Vulvovaginitis: Find the cause to treat it
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.
NONINFECTIOUS CAUSES
Desquamative inflammatory vaginitis
Desquamative inflammatory vaginitis is a chronic vaginal disorder of unknown cause. It is a diagnosis of exclusion, and some patients may have a superimposed bacterial infection. It occurs mostly in perimenopausal woman and is often associated with low estrogen levels.
Diagnosis. Patients may report copious green-yellow mucoid discharge, vulvar or vaginal pain, and dyspareunia. On examination, the vulva may be erythematous, friable, and tender to the touch. The vagina may have ecchymoses, be diffusely erythematous, and have linear lesions. Mucoid or purulent discharge may be seen.
The vaginal pH is greater than 4.5.
Saline microscopy shows increased parabasal cells and leukorrhea (Figure 5).
Diagnosis is based on all of the following:
- At least 1 symptom (ie, vaginal discharge, dyspareunia, pruritus, pain, irritation, or burning)
- Vaginal inflammation on examination
- pH higher than 4.5
- Presence of parabasal cells and leukorrhea on microscopy (a ratio of leukocytes to vaginal epithelial cells > 1:1).36
Treatment involves use of 2% intravaginal clindamycin or 10% intravaginal compounded hydrocortisone cream for 4 to 6 weeks. Patients who are not cured with single-agent therapy may benefit from compounded clindamycin and hydrocortisone, with estrogen added to the formulation for hypoestrogenic patients.
Atrophic vaginitis
Atrophic vaginitis is often seen in menopausal or hypoestrogenic women. Presenting symptoms include vulvar or vaginal pain and dyspareunia.
Diagnosis. On physical examination, the vulva appears pale and atrophic, with narrowing of the introitus. Vaginal examination may reveal a pale mucosa that lacks elasticity and rugation. The examination should be performed with caution, as the vagina may bleed easily.
The vaginal pH is usually elevated.
Saline microscopy may show parabasal cells and a paucity of epithelial cells. (Figure 6).
The Vaginal Maturation Index is an indicator of the maturity of the epithelial cell types being exfoliated; these normally include parabasal (immature) cells, intermediate, and superficial (mature) cells. A predominance of immature cells indicates a hypoestrogenic state.
Infection should be considered and treated as needed.
Treatment. Patients with no contraindication may benefit from systemic hormone therapy or topical estrogen, or both.
Contact dermatitis
Contact dermatitis is classified into two types:
Irritant dermatitis, caused by the destructive action of contactants, eg, urine, feces, topical agents, feminine wipes
Allergic dermatitis, also contactant-induced, but immunologically mediated.
If a diagnosis cannot be made from the patient history and physical examination, biopsy should be performed.
Treatment of contact dermatitis involves removing the irritant, hydrating the skin with sitz baths, and using an emollient (eg, petroleum jelly) and midpotent topical steroids until resolution. Some patients benefit from topical immunosuppressive agents (eg, tacrolimus). Patients with severe symptoms may be treated with a tapering course of oral steroids for 5 to 7 days. Recalcitrant cases should be referred to a specialist.
Lichen planus
Lichen sclerosus is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning, and distinctive dermal changes accompanied by pruritus and pain (Figures 7 and 8).
Treatment. High-potency topical steroids are the mainstay of therapy for lichen disease. Although these are not infectious processes, superimposed infections (mostly bacterial and fungal) may also be present and should be treated.
