Vulvovaginitis

Vulvovaginitis is inflammation of the vulva and vagina with itching, discharge, soreness or odour. It has infective, irritant, allergic and atrophic causes.

• In women of reproductive age the commonest causes are vulvovaginal candidiasis, bacterial vaginosis and trichomoniasis.
• In prepubertal girls the vulval skin is thin and unprotected by oestrogen, so hygiene, threadworms and bacterial infection predominate.
• Treatment must match the cause, so diagnosis comes first.

Vulval itching, burning, dysuria (external), dyspareunia and abnormal discharge.

• Candidiasis: thick white curdy discharge, erythema, fissures, satellite lesions.
• Bacterial vaginosis: thin grey fishy discharge without much inflammation.
• Trichomoniasis: frothy yellow-green discharge, strawberry cervix, dysuria.
• Prepubertal girls: redness, discharge, soreness, bedwetting or itching at night (threadworms).
• Differential diagnosis: lichen sclerosus, lichen planus, contact dermatitis, herpes genitalis, vaginal foreign body, aerobic vaginitis, atrophic vaginitis, cervicitis, sexual abuse in children.
• Complications: pelvic inflammatory disease, preterm birth in pregnancy, increased HIV acquisition, chronic vulval pain, secondary bacterial infection.

Diagnosis uses examination, vaginal pH and microscopy.

• Vaginal pH: 4.5 or below in candidiasis, above 4.5 in bacterial vaginosis and trichomoniasis.
• Wet mount: yeast and pseudohyphae (candidiasis), clue cells (bacterial vaginosis), motile trichomonads.
• Gram stain with Nugent score and amine test if available; potassium hydroxide 10 percent preparation for yeast.
• NAAT or culture for trichomonas, gonorrhoea and chlamydia; HIV and syphilis tests; random blood glucose in recurrent candidiasis.
• In children, perineal swab for culture and a tape test for threadworm eggs.

Treat the cause.

• Supportive: avoid soaps, douching, scented products and tight synthetic clothing; wash with water or a soap substitute; cotton underwear; wipe front to back; cool compress for itch.
• Pharmacological: vulvovaginal candidiasis: fluconazole 150 mg oral single dose, or clotrimazole 500 mg pessary intravaginal single dose at night, or clotrimazole 100 mg pessary nightly for 6 nights. Severe or recurrent candidiasis: fluconazole 150 mg oral on days 1, 4 and 7 then 150 mg weekly for 6 months. Bacterial vaginosis: metronidazole 400 mg oral 12-hourly for 7 days, or clindamycin 2 percent cream 5 g intravaginal nightly for 7 days. Trichomoniasis: metronidazole 2 g oral single dose or 400 mg oral 12-hourly for 7 days; treat all sexual partners at the time and avoid alcohol during treatment and for 48 hours afterwards. Prepubertal bacterial vulvovaginitis: amoxicillin 15 mg/kg oral 8-hourly for 7 to 10 days (maximum 500 mg per dose). Threadworm: albendazole 400 mg oral single dose (children aged 2 years and over), repeated after 2 weeks, with treatment of the household.
• Procedures: none. Remove a vaginal foreign body under sedation or anaesthesia in children.
• Special groups: in pregnancy avoid oral fluconazole; use clotrimazole 100 mg pessary nightly for 7 days; metronidazole 400 mg oral 12-hourly for 7 days is safe in all trimesters. In diabetes tighten glycaemic control.
• Red flags: genital ulceration, blood-stained discharge, signs of pelvic inflammatory disease, suspected abuse in a child, treatment failure after two courses.
• Follow-up: review after treatment if symptoms persist; test of cure for trichomoniasis at 3 months; retest HIV and syphilis as indicated.