Vulvovaginitis

Background

• Vulvovaginitis (also called vaginitis or vulvitis) refers to pruritus, irritation, and/or erythema of the vulvovaginal area, particularly with the presence of a vaginal discharge.
• The 3 most common causes of vulvovaginitis are:
  • bacterial vaginosis
  • vulvovaginal candidiasis
  • trichomoniasis
• Other causes of vulvovaginitis include:
  • atrophic vaginitis
  • dermatologic causes, such as
    • contact dermatitis
    • lichen sclerosis
    • lichen planus
    • lichen simplex chronicus
  • aerobic vaginitis (desquamative inflammatory vaginitis)
  • mucopurulent cervicitis (for example, resulting from Chlamydia trachomatis, Mycoplasma genitalium or Neisseria gonorrhea)
  • herpes simplex virus

Evaluation

• The history and physical exam may suggest a specific cause
  • Obtain sexual history
  • Ask about vaginal discharge characteristics
    • itching may suggest (partial list)
      • candidiasis
      • trichomoniasis
      • erosive lichen planus
      • contact dermatitis
    • odor may suggest
      • bacterial vaginosis (fishy odor)
      • trichomoniasis
      • aerobic vaginitis
    • pain may suggest (partial list)
      • trichomoniasis
      • vulvovaginal candidiasis
      • aerobic or atrophic vaginitis
    • postcoital bleeding may suggest cervicitis, erosive lichen planus, or cervical neoplasm
  • Due to low sensitivities and specificities, history and physical are usually inadequate for definitive diagnosis.
• A vaginal specimen may be adequate for making a specific diagnosis and may be collected without a speculum exam in females aged 12-22 years.
• Diagnostic testing may include vaginal pH, wet mount, nucleic acid amplification test (NAAT), multiplex polymerase chain reaction (PCR) testing, and DNA or antigen testing.
• Biopsy of vulvar lesions typically performed in select circumstances, including suspicion of neoplasia.

Management

• Treatment options for selected causes of vulvovaginitis:
  • uncomplicated vulvovaginal candidiasis:
    • topical antifungal agent (such as butoconazole, clotrimazole, miconazole, tioconazole, or terconazole) once daily as cream, tablet, or suppository (Strong recommendation)
    • fluconazole (Diflucan) 150 mg orally in single dose (Strong recommendation)
    • see Vulvovaginal candidiasis for details and additional information
  • complicated vulvovaginal candidiasis:
    • oral fluconazole (Diflucan) 150 mg orally every 72 hours for 2-3 doses
    • see Vulvovaginal candidiasis for details and additional information
  • bacterial vaginosis:
    • first-line therapy for symptomatic women, including women with HIV and pregnant women, includes 1 of 3 antimicrobial regimens:
      • metronidazole 500 mg orally twice daily for 7 days
      • metronidazole gel 0.75% 1 full applicator (5 g) intravaginally once daily for 5 days
      • clindamycin cream 2% 1 full applicator (5 g) intravaginally once daily at bedtime for 7 days
    • Alternative regimens include the following:
      • secnidazole 2 g oral granules mixed in apple sauce, yogurt, or pudding in a single dose or tinidazole 2 g orally once daily for 2 days or tinidazole 1 g orally once daily for 5 days
      • clindamycin 300 mg orally twice daily for 7 days or clindamycin ovules 100 mg intravaginally once daily at bedtime for 3 days
    • Use of tinidazole or secnidazole is not recommended during pregnancy.
    • see Bacterial vaginosis (BV) for details, information on recurrent BV, and additional information
  • trichomoniasis:
    • recommended treatment in women is metronidazole 500 mg orally twice daily for 7 days
    • recommended treatment in men is metronidazole 2 g orally in single dose
    • alternative treatment in women and men is tinidazole 2 g orally in single dose
    • recommended treatment in pregnant patients with symptomatic infection is metronidazole 500 mg orally twice daily for 7 days, but patients should be counseled regarding the potential risks and benefits of treatment
• Other causes of vulvovaginitis require different management strategies.