B8. Vulvar and vaginal inflammatory disorders and their treatment

Vulvovaginitis is an inflammation of the vulva and vagina. It’s a common condition, and it’s one of the most common gynaecological disorders in children.

Etiology

• Infectious vulvovaginitis (90% of cases)
  • Bacterial vulvovaginitis (bacterial vaginosis) (50% of cases)
  • Vulvovaginal candidiasis
  • Trichomoniasis
• Non-infectious vulvovaginitis
  • Atrophic vaginitis
  • Allergic vulvovaginitis
  • Mechanical vulvovaginitis

Bacterial vaginosis is caused by disturbance of the local microbial flora (intercourse, overenthusiastic washing), which leads to overgrowth of Gardnerella vaginalis. Bacterial vulvovaginitis can also be due to other bacteria, like E. coli, Streptococci, Staphylococci.

Trichomoniasis is a sexually transmitted infection caused by trichomonas vaginalis.

Atrophic vaginitis is caused by vaginal mucosal atrophy due to decreased lower oestrogen levels. It mostly occurs after menopause.

Allergic vulvovaginitis can occur due to laundry detergents, condoms, certain textiles, etc.

Mechanical vulvovaginitis can occur due to chronic itching (due to other types of vulvovaginitis, etc.), due to tight clothing, etc.

Children have a higher risk of vulvovaginitis, due to:

• Decreased oestrogen -> thin vulvar skin and vaginal mucosa -> increased susceptibility
• Poor hygiene
• Tendency to insert foreign bodies

Clinical features

The exact clinical features depend on the cause, but symptoms generally include:

• Vaginal discharge, sometimes with odour or altered colour
  • Bacterial vaginosis -> fishy odour, milky colour
  • Trichomoniasis -> foul-smelling, yellow-green colour
  • Candida -> cottage cheese-like discharge
• Soreness, pain
• Dyspareunia
• Itchiness
  • Especially in bacterial and allergic
• Redness

In bacterial vaginosis, the main complaint is a fishy odour and milky discharge. There is no pain, itching, or hyperaemia and the symptoms worsen in cases where the pH is increased, like intercourse or menstruation.

Vulvovaginal candidiasis causes itching, burning pain, and cottage cheese-like discharge which does not smell. There is visible hyperaemia.

Diagnosis and evaluation

History to look for possible causes is important. Physical examination may reveal characteristic appearance or odour.

The Whiff test or Amine test is used to diagnose bacterial vaginosis. It’s positive if, after adding a few drops of 10% KOH to a sample of vaginal fluid, intensification of the fishy odour occurs.

pH measurement is also important. The pH of the vagina is normally 4 – 4,5, but in case of bacterial vaginosis or trichomoniasis, the pH is > 4,5.

Vaginal smear, the examination of vaginal fluid under the microscope, may also be performed. For trichomoniasis, motile organisms with multiple flagella are visible. “Clue cells” (squamous cells surrounded by bacteria) may be present in bacterial vaginosis. When KOH is added, pseudohyphae are visible in candidiasis.

Treatment

Treatment depends on the underlying cause:

• Bacterial vaginosis – oral metronidazole or vaginal clindamycin
• Trichomoniasis – oral metronidazole
• Vulvovaginal candidiasis – topical azoles (clotrimazole) or single dose oral fluconazole
• Atrophic vaginitis – moisturizer, topical oestrogen cream
• Allergic vulvovaginitis – avoid allergen
• Foreign body – irrigation of the vagina