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Vulvovaginitis: Find the cause to treat it

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ABSTRACT

Vulvar and vaginal disorders are among the most common problems seen in ambulatory care. The cause is usually infectious, but noninfectious causes should also be considered, and differentiating them can be challenging. Accurate diagnosis based on patient history, physical examination, and laboratory testing is necessary so that effective therapy can be chosen.

KEY POINTS

  • Typical presenting symptoms of vulvovaginitis are itching, burning, and abnormal discharge.
  • Evaluating vaginal secretions with simple office-based tools is often sufficient for diagnosis, although DNA testing is also available.
  • Depending on the cause, vulvovaginitis is generally treated with a course of oral or topical antibiotics, antiviral or antifungal drugs, anti-inflammatory agents, or hormonal therapy.
  • Cases that do not resolve may require maintenance therapy. Patients who have persistent or unusual symptoms should be referred to a specialist.


 

References

Although vulvovaginitis has several possible causes, the typical presenting symptoms are similar regardless of the cause: itching, burning, and vaginal discharge. Physical examination often reveals atrophy, redness, excoriations, and fissures in the vulvovaginal and perianal areas. Determining the cause is key to successful treatment.

This article reviews the diagnosis and treatment of many common and less common infectious and noninfectious causes of vulvovaginitis, the use of special tests, and the management of persistent cases.

DIAGNOSIS CAN BE CHALLENGING

Common causes of vulvovaginitis

Vulvar and vaginal symptoms are most commonly caused by local infections, but other causes must be also be considered, including several noninfectious ones (Table 1). Challenges in diagnosing vulvovaginitis are many and include distinguishing contact from allergic dermatitis, recognizing vaginal atrophy, and recognizing a parasitic infection. Determining whether a patient has an infectious process is important so that antibiotics can be used only when truly needed.

Foreign bodies in the vagina should also be considered, especially in children,1 as should sexual abuse. A 15-year retrospective review of prepubertal girls presenting with recurrent vaginal discharge found that sexual abuse might have been involved in about 5% of cases.2

Systemic diseases, such as eczema and psoriasis, may also present with gynecologic symptoms.

Heavy vaginal discharge may also be normal. This situation is a diagnosis of exclusion but is important to recognize in order to allay the patient’s anxiety and avoid unnecessary treatment.

SIMPLE OFFICE-BASED ASSESSMENT

A thorough history and physical examination are always warranted.

Vaginal secretion test results for common causes of vulvovaginitis

Simple tests of vaginal secretions can often determine the diagnosis (Table 2). Vaginal secretions should be analyzed in the following order:

Testing the pH. The pH can help determine likely diagnoses and streamline further testing (Figure 1).

Using pH as a diagnostic tool in vulvovaginitis.

Figure 1. Using pH as a diagnostic tool in vulvovaginitis.

Saline microscopy. Some of the vaginal discharge sample should be diluted with 1 or 2 drops of normal saline and examined under a microscope, first at × 10 magnification, then at × 40. The sample should be searched for epithelial cells, blood cells, “clue” cells (ie, epithelial cells with borders studded or obscured by bacteria), and motile trichomonads.

10% KOH whiff test and microscopy. To a second vaginal sample, a small amount of 10% potassium hydroxide should be added, and the examiner should sniff it. An amine or fishy odor is a sign of bacterial vaginosis.

Potassium hydroxide 10% added to a vaginal sample and microscopy performed at × 40 magnification reveals yeast.

Figure 2. Potassium hydroxide 10% added to a vaginal sample and microscopy performed at × 40 magnification reveals yeast.

The sample should next be examined under a microscope for fungal elements (Figure 2). However, not finding trichomonads or fungal elements by either saline or 10% KOH microscopy does not rule out such infections.

If pH paper, KOH, and a microscope are unavailable, other point-of-care tests can be used for specific conditions as discussed below.

INFECTIOUS CAUSES

Infectious causes of vulvovaginitis include bacterial vaginosis, candidiasis, trichomoniasis, and herpes simplex virus (HSV) infection.

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