Acute Vulvovaginitis

Acute vulvovaginitis is inflammation of the vagina and vulva causing discharge, itching, irritation, burning, odour or dyspareunia.

• Infective causes: vulvovaginal candidiasis (Candida albicans in 85 to 90 percent), bacterial vaginosis (polymicrobial, Gardnerella, anaerobes), trichomoniasis (Trichomonas vaginalis), group A streptococcus and other bacteria (children), herpes simplex virus, sexually transmitted cervicitis with vaginal discharge (gonorrhoea, chlamydia), pinworms, and foreign bodies.
• Non-infective causes: atrophic vaginitis (low oestrogen), irritant or allergic contact dermatitis (soaps, douches, spermicides, latex), lichen sclerosus, desquamative inflammatory vaginitis, and poor hygiene.
• Risk factors: diabetes, pregnancy, antibiotics, immunosuppression, HIV, steroid use, new sexual partners, intrauterine device, douching, tight synthetic clothing, and in girls poor hygiene and anatomy (hypo-oestrogenic mucosa).

Candidiasis: thick white curd-like discharge, intense itching, vulval erythema, oedema, fissures, dysuria, dyspareunia, no odour.

• Bacterial vaginosis: thin grey-white homogeneous discharge, fishy odour (worse after intercourse), little inflammation.
• Trichomoniasis: copious frothy yellow-green discharge, offensive odour, vulval irritation, dysuria, strawberry cervix (colpitis macularis).
• Atrophic: dryness, burning, dyspareunia, spotting.
• Children: redness, discharge, itching, dysuria, soiling; always consider foreign body and abuse.
• Differential diagnosis: cervicitis, pelvic inflammatory disease, genital herpes, lichen planus or sclerosus, contact dermatitis, vaginal cancer, vulvodynia, retained tampon, fistula.
• Complications: recurrent infection (four or more episodes yearly), pelvic inflammatory disease, preterm labour and low birth weight (bacterial vaginosis, trichomoniasis in pregnancy), increased HIV and sexually transmitted infection risk, post-procedure infection, psychosexual harm.

Examination of vulva, speculum examination of vagina and cervix; vaginal pH (4.5 or below is normal; above 4.5 in bacterial vaginosis and trichomoniasis, below 4.5 in candidiasis).

• Saline and 10 percent potassium hydroxide wet mount (budding yeast and hyphae, clue cells, motile trichomonads, leucocytes), whiff test (amine odour in bacterial vaginosis), Gram stain, culture, and nucleic acid amplification tests (trichomonas, gonorrhoea, chlamydia).
• Screen for HIV, syphilis and other sexually transmitted infections where relevant; glucose in recurrent candidiasis; pregnancy test.
• Biopsy for non-resolving vulval lesions.

Supportive: avoid soaps, douches and perfumed products, wear cotton underwear, wash with water, avoid irritants; sitz baths; partner counselling.

Pharmacological

• Uncomplicated candidiasis: fluconazole 150 mg single dose, or clotrimazole 500 mg pessary single dose, clotrimazole 200 mg pessary nightly for 3 days, clotrimazole 1 percent cream 5 g nightly for 7 days; miconazole 2 percent cream 5 g nightly for 7 days.
• Severe or complicated candidiasis (diabetes, immunosuppression, pregnancy): fluconazole 150 mg repeated after 72 hours, or topical therapy for 7 to 14 days; recurrent (four or more yearly): induction with fluconazole 150 mg every 72 hours for 3 doses then maintenance 150 mg weekly for 6 months.
• Non-albicans species: boric acid 600 mg vaginal capsule nightly for 14 days or nystatin pessary 100,000 units nightly for 14 days.
• Bacterial vaginosis: metronidazole 400 to 500 mg twice daily for 7 days, or metronidazole gel 0.75 percent 5 g intravaginally nightly for 5 days, or clindamycin cream 2 percent 5 g nightly for 7 days, or tinidazole 2 g daily for 2 days; recurrent: metronidazole gel twice weekly for 4 to 6 months.
• Trichomoniasis: metronidazole 2 g single dose or 500 mg twice daily for 7 days (preferred in women), or tinidazole 2 g single dose; treat all partners simultaneously; abstain from sex until treatment is complete and symptoms resolved; avoid alcohol for 24 to 72 hours.
• Atrophic vaginitis: vaginal oestradiol 10 microgram tablet daily for 2 weeks then twice weekly, or estriol 0.5 mg cream.
• Pregnancy: clotrimazole pessary 100 mg nightly for 7 days (avoid oral fluconazole), metronidazole 400 mg twice daily for 5 to 7 days for bacterial vaginosis or trichomoniasis (after the first trimester or if clearly indicated).
• Children: treat the specific cause; sitz baths, barrier cream (zinc oxide); amoxicillin 25 mg/kg twice daily for 7 to 10 days for group A streptococcus; mebendazole 100 mg single dose for pinworms (repeat after 2 weeks); remove foreign body under anaesthesia.
• Syndromic management where tests are unavailable (cervicitis plus discharge): cover for gonorrhoea and chlamydia in addition to vaginal infections.

Special groups: HIV (no change in drugs or doses; recurrent candidiasis responds to antiretroviral therapy), diabetes (glycaemic control), pregnancy, postmenopausal women (oestrogen), girls (hygiene and cause-directed therapy).

Red flags: fever, pelvic pain, foul discharge with retained foreign body, vaginal bleeding, non-healing lesions, recurrent infections despite treatment.

Follow-up: review if symptoms persist beyond 7 days or recur within 2 months; test of cure for trichomoniasis in high risk women at 3 months; repeat screening in pregnancy.