Chapter 102: Vulvovaginitis

INTRODUCTION

Vaginal discharge is caused by a wide variety of disorders, including vaginitis, cervicitis, and pelvic inflammatory disease.¹ Vaginitis is a spectrum of diseases that cause vulvovaginal symptoms including burning, irritation, itching, odor, and abnormal discharge. The factors associated with acute vaginitis are listed in Table 102–1. The most common infectious causes of vaginitis in symptomatic premenopausal women are bacterial vaginosis (40% to 45%), vulvovaginal candidiasis (20% to 25%), and trichomoniasis (15% to 20%). Vulvovaginal candidiasis, contact vaginitis, and atrophic vaginitis may occur in virgins and postmenopausal women; however, the other forms of infectious vulvovaginitis are generally found in sexually active women. In approximately 30% of women with vaginal complaints, the disorder remains undiagnosed even after comprehensive testing.^2,3,4

The clinical diagnosis may be challenging, because women may have more than one disease, and signs and symptoms are frequently not specific to a particular cause. Polymicrobial infection is not uncommon.

Although infectious vaginitis rarely requires hospitalization, it may have serious sequelae. Both bacterial vaginosis and trichomoniasis have been shown to be associated with premature rupture of membranes, preterm labor, and low infant birth weight.^5,6 Trichomoniasis is associated with pelvic inflammatory disease in patients infected with human immunodeficiency virus and increases risk of human immunodeficiency virus acquisition and transmission.^7,8 When overgrowth of certain bacteria occurs, the protective effect of vaginal lactobacilli strains, which inhibit the growth of bacteria and destroy human immunodeficiency virus in vitro, is lost.¹

PHYSIOLOGY

In females of childbearing age, estrogen causes the development of a thick vaginal epithelium with a large number of superficial glycogen-containing cells and serves a protective function. Glycogen is used by the normal flora, such as lactobacilli and acidogenic corynebacteria, to form lactic and acetic acids. The resulting acidic environment favors the normal flora and discourages the growth of pathogenic bacteria. Lack of estrogen or a dominance of progesterone results in an atrophic condition, with loss of the protective superficial cells and their contained glycogen, and subsequent loss of the acidic environment.

Normal vaginal secretions vary in consistency from thin and watery to thick, white, and opaque. The quantity may also vary from a scant to a rather copious amount. Secretions are odorless and produce no symptoms. The normal vaginal pH varies between 3.8 and 4.5. Alkaline secretions from the cervix before and during menstruation, as well as alkaline semen, reduce acidity and predispose to infection. Before menarche and after menopause, the vaginal pH varies between 6 and 7. Because of scant nerve endings ...