Chapter 102: Vulvovaginitis

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

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 in the vagina, the patient usually does not have symptoms until both the vagina and vulva are involved in an inflammatory or irritant process.

Vulvovaginal inflammation is the most common gynecologic disorder in prepubertal girls and includes both infectious causes (e.g., bacterial, fungal, pinworm) and noninfectious causes (e.g., contact/irritant, lichen sclerosis, foreign body). Factors thought to contribute to vaginitis in prepubertal females include less protective covering of the vestibule by the labia minora, low estrogen concentration resulting in a thinner epithelium, exposure to chemical irritants such as bubble bath, poor hygiene, front-to-back wiping and the short distance between the vagina and anus, foreign bodies, chronic medical conditions (eczema, seborrhea, and other chronic diseases), and sexual abuse. Infectious causes include respiratory and enteric bacterial organisms such as Haemophilus influenzae, Staphylococcus aureus, group A streptococci and Streptococcus pneumoniae, Escherichia coli, Shigella flexneri, Neisseria gonorrhoeae, and Chlamydia, as well as Candida and pinworms. Infectious causes may be more common in adolescents, especially those who are sexually active.⁴

Obtain a detailed gynecologic history and perform a pelvic examination. History should include details of vaginal discharge, odor, irritation, itching, burning, bleeding, dysuria, and dyspareunia. Inquire about associated abdominal pain, new sexual partners, use of barrier protection during intercourse, relationship of symptoms to menses, use of antibiotics and contraceptives, and hygiene practices. Note the presence of vulvar edema or erythema, vaginal discharge, cervical inflammation, and abdominal and cervical motion tenderness.

During speculum examination, obtain a swab of the discharge and test for gonorrhea and chlamydial infection. If a patient refuses pelvic examination or it is not feasible, the patient may submit a self-swab of vaginal secretions or a urine sample.⁹

Microscopic examination of secretions and evaluation of pH are useful diagnostic tools. However, microscopes and reagents are not available in all EDs, microscopic examination is time consuming and tedious, and results depend on operator skill. To test pH, obtain a sample from the mid portion of the vaginal sidewall to avoid false elevations in pH caused by mucus. Sampling from the posterior fornix may yield inaccurate results because cervical mucus, blood, semen, douches, and vaginal medications can elevate the pH. Microscopic evaluation of fresh vaginal secretions using both normal saline solution and 10% potassium hydroxide slide preparation and fishy odor on whiff test help provide evidence for a diagnosis¹⁰ (Tables 102–2 and 102–3). Signs of vulvar inflammation and minimal discharge suggest the possibility of mechanical, chemical, allergic, or other noninfectious causes of vulvovaginitis.

Bacterial vaginosis is the most common cause of vaginitis and accounts for up to 50% of cases in acutely symptomatic women. However, up to 50% of women who meet clinical criteria for this diagnosis are asymptomatic.

Bacterial vaginosis is a polymicrobial infection that occurs when the normal hydrogen peroxide–producing lactobacilli are replaced by other species including Gardnerella vaginalis, Ureaplasma, Mycoplasma, and various anaerobes. Risk factors include multiple sexual partners, intercourse with an uncircumcised male partner, vaginal intercourse immediately after receptive anal intercourse, lack of condom use, douching, and absence of peroxide-producing lactobacilli in the vaginal flora.^1,11 Women who have never been sexually active are less commonly affected. Bacterial vaginosis is not classified as a sexually transmitted infection, but it is generally agreed upon that sexual activity plays a role in transmission and may promote infection.¹²

DIAGNOSIS

The most common clinical presentation of women with bacterial vaginosis is vaginal discharge and odor. Classically, a thin, whitish-gray discharge is present, generally with an increase in discharge volume. The absence of discharge or the presence of only a mild discharge makes the diagnosis less likely. When an odor is present, it may be described as a fishy smell. Introital or vaginal irritation, such as redness, tissue fissures, excoriations, or edema, is not common with bacterial vaginosis.

The diagnosis is based on history, speculum vaginal examination, microscopic evaluation of vaginal secretions, and point-of-care testing. Obtain secretions from the mid sidewall of the vagina, and mix with one to two drops of 0.9% normal saline. Cover with a coverslip for microscopic evaluation for clue cells; to check for fishy or amine odor, add one drop of 10% potassium hydroxide and assess vapors for fishy (amine) smell (see additional methods for amine testing below). To check pH, apply a small amount of secretions directly onto pH paper. The presence of three of the following four criteria makes the diagnosis:

1. A thin, homogeneous vaginal discharge

2. More than 20% clue cells on a wet mount (Figure 102–1)

3. Positive results on test for amine release, or whiff test

4. A vaginal pH level >4.5

The criterion with the highest sensitivity (89%) is vaginal pH, whereas that with the highest specificity (93%) is the amine odor, or positive result on whiff test. If vaginal pH is >4.5 and there is an amine odor, the diagnosis of bacterial vaginosis can be made with confidence.¹⁴ A colorimetric card test for bacterial vaginosis detects a vaginal pH of ≥4.7 and volatile vaginal fluid amines. Commercially available tests that might be useful for the diagnosis of bacterial vaginosis include card tests for proline aminopeptidase (Pip Activity TestCard; Quidel, San Diego, CA), a DNA probe–based test for high concentrations of G. vaginalis (Affirm VP III; Becton Dickinson, Sparks, MD), and the OSOM BVBlue test (Sekisui Diagnostics, Lexington, MA), all of which have performance characteristics that are comparable to Gram stain. Cards are available for the detection of elevated pH and trimethylamine; however, they have a low sensitivity and specificity and thus are no longer recommended. Cultures of vaginal discharge are not beneficial, because Gardnerella organisms are part of the normal vaginal flora. Polymerase chain reaction for various organisms is being used in research but is not clinically relevant at this time.¹

The combination of bacterial vaginosis and leukorrhea (more WBCs than epithelial cells seen on a wet mount) is associated with a positive test result for Chlamydia (odds ratio = 3.8).¹⁵ For this reason, women who complain of vaginal discharge should be screened for and, depending on clinical suspicion, treated presumptively for N. gonorrhoeae and Chlamydia infection at the initial visit (Table 102–2). The Centers for Disease Control and Prevention also recommends syphilis testing for women engaged in high-risk sexual behavior, such as those having multiple sexual partners or a new sexual partner or engaging in unprotected intercourse. Finally, women of childbearing age should be screened for pregnancy, because this may impact medical treatment.

TREATMENT

Recommended treatment regimens are listed in Table 102–4. The use of Lactobacillus intravaginal suppositories and probiotics to restore the normal vaginal flora is an ongoing area of research. Treating male sexual partners is not beneficial for preventing recurrence, but consider treating female partners, particularly with frequent recurrences, because bacterial vaginosis can spread between female partners.² Counsel patients receiving metronidazole against consuming alcoholic beverages during the treatment period and for the following 24 hours to avoid a disulfiram-like reaction. Advise patients to refrain from intercourse or to use condoms during treatment.¹

Overall cure rates 4 weeks after treatment do not differ significantly for a 7-day regimen of oral metronidazole, metronidazole vaginal gel, and clindamycin vaginal cream. Metronidazole vaginal gel has fewer side effects (i.e., GI disturbance and unpleasant taste) but should not be used in women who are allergic to the oral preparation.

Recurrence of symptoms is seen within 3 months in 30% of treated patients who initially show a response. The reasons for this are unclear but could be from sexual transmission.¹⁵ Metronidazole gel 0.75% twice weekly for 4 to 6 months prevents recurrence.¹

BACTERIAL VAGINOSIS COMPLICATIONS

Bacterial vaginosis has been associated with several adverse health outcomes, including facilitation of co-infection with sexually transmitted infections such as human immunodeficiency virus, herpes simplex virus-2, Chlamydia trachomatis, and N. gonorrhoeae by decreasing local secretory leukocyte protease inhibitor levels.^1,12 Bacterial vaginosis is also linked to complications related to pregnancy and surgical procedures, such as spontaneous abortion, premature rupture of membranes, amniotic fluid infection, chorioamnionitis, preterm delivery, postpartum endometritis, pelvic inflammatory disease, postoperative wound infection, and infection after vaginal and abdominal hysterectomy.¹⁶

PREGNANT WOMEN

The Centers for Disease Control and Prevention recommends treating all symptomatic pregnant women. Recommended treatment regimens are listed in Table 102–4. The Centers for Disease Control and Prevention no longer recommends routine screening of asymptomatic pregnant women.¹ Pregnant women who are at high risk for preterm labor should be considered for treatment to avoid preterm labor and other adverse outcomes of pregnancy.⁵ However, studies have not been able to demonstrate clear benefit in preventing adverse outcomes of pregnancy.^1,17,18,19Topical clindamycin preparations should not be used in the second half of pregnancy because of an increased association of adverse events, including low infant birth weight and neonatal infections.

Candida species are the second most common cause of infectious vaginitis.²⁰ Prevalence data for vulvovaginal candidiasis vary because the disease is not reportable, many women self-medicate with over-the-counter preparations, and as many as half the women in whom candidiasis is diagnosed also have other conditions.²⁰ The Centers for Disease Control and Prevention estimates that 75% of women will have at least one episode of vulvovaginal candidiasis in their lifetime.¹

The organism is isolated in up to 20% of asymptomatic, healthy women of childbearing age, some of whom are celibate. Some women remain entirely asymptomatic despite being heavily colonized with Candida species.

Vulvovaginal candidiasis is rare in nonestrogenized premenarchal girls but does occur and is common under 2 years of age. Consider undiagnosed juvenile diabetes or other forms of immunosuppression if Candida is diagnosed in a toilet-trained child.⁴ Incidence decreases after menopause unless replacement estrogen is being used, which further emphasizes the hormonal dependence of the infection.

Candidiasis can be classified as either an uncomplicated or complicated infection. Uncomplicated infections are sporadic, produce mild to moderate symptoms, are the result of Candida albicans, and occur in the nonpregnant, immunocompetent host. Complicated infections are recurrent (four or more infections per year), produce severe symptoms or findings, are the result of suspected or proven non-albicans candidiasis, and occur in an abnormal host (women who have uncontrolled diabetes, debilitation, or immunosuppression, or are pregnant). Approximately 10% to 20% of women have complicated disease. Recurrent vulvovaginal candidiasis occurs in <5% of women.^1,21

C. albicans strains account for 85% to 92% of Candida organisms isolated from the vagina. Candida glabrata and Candida tropicalis are the most common non-albicans strains and are often more resistant to conventional therapy.

Candidal organisms gain access to the vaginal lumen and secretions predominantly from the adjacent perianal area. Candidal organisms must first adhere to the vaginal epithelial cells for colonization to take place, and C. albicans adheres in greater numbers than other species.

The growth of Candida is held in check by the normal vaginal flora, and symptoms of vaginitis usually occur only when the normal balance is upset. Increased colonization by Candida resulting in subsequent symptomatic infection may be caused by conditions that (1) inhibit the growth of normal vaginal flora, particularly Lactobacillus species (e.g., systemic antibiotics); (2) diminish the glycogen stores in vaginal epithelial cells (e.g., diabetes mellitus, pregnancy, oral contraceptive use, and hormonal replacement therapy); or (3) increase the pH of vaginal secretions (e.g., menstrual blood or semen). Factors that favor increased rates of vaginal colonization include pregnancy, oral contraceptive use, uncontrolled diabetes mellitus, and frequent visits to sexually transmitted infection clinics (perhaps as a result of antimicrobial therapy). This infection is not considered a sexually transmitted infection, although it can be transmitted by sexual intercourse. The wearing of tight-fitting, particularly synthetic, undergarments may also contribute to the problem because of increased temperature. Although all of these factors are thought to be associated with symptomatic disease, there is poor evidence to prove that any of them is causative.²⁰ Evidence supporting an association between antibiotic use and vulvovaginal candidiasis is limited. However, antibiotics are thought to increase the risk of vulvovaginal candidiasis by killing endogenous normal flora.

DIAGNOSIS

Clinical symptoms include leukorrhea, severe vaginal pruritus, external dysuria, and dyspareunia. Vaginal pruritus is the most common and specific symptom. Complaints of discharge vary from little to copious white vaginal discharge. Symptoms vary in severity, but exacerbation is frequently seen in the week prior to menses or with coitus, perhaps because these factors cause the pH to become more alkaline. Odor is unusual and, if present, favors a diagnosis of bacterial vaginosis rather than candidiasis.

Gynecologic examination may reveal vulvar erythema and edema, vaginal erythema, and discharge. Discharge varies from none to watery to homogeneously thick and "cottage cheese–like." Discharge often adheres to the vaginal walls.

The diagnosis is confirmed with a normal vaginal pH (4.0 to 4.5) and visualization of budding yeast and pseudohyphae on slide preparation of vaginal secretions (Figure 102–2). The sensitivity of microscopic examination using a sample prepared with normal saline is only 40% to 60%. Adding two drops of 10% potassium hydroxide to the vaginal secretions dissolves the vaginal epithelial cells while leaving yeast buds and pseudohyphae intact. This increases the sensitivity of microscopic examination to 80% and yields almost 100% specificity. Empiric treatment is suggested for symptomatic patients with negative findings on microscopic examination if Candida cultures cannot be obtained.¹

TREATMENT

Recommended treatment regimens are listed in Table 102–5. Therapy regimens are effective in treating over 80% of cases of uncomplicated vaginal candidiasis. Topically applied azole drugs are more effective than nystatin, with relief of symptoms in 80% to 90% of patients who complete treatment. Consider patient preference because creams, lotions, sprays, vaginal tablets, suppositories, and coated tampons are all equally efficacious.²²

The azole drugs are all available over the counter in treatment regimens of 1, 3, or 7 days. Uncomplicated vulvovaginal candidiasis responds to all azoles, including single-dose therapy.²³ Other than initial burning and irritation, side effects of topical agents are unusual.

Single-dose treatment with oral fluconazole is as effective as topical therapy in the treatment of uncomplicated vulvovaginal candidiasis. Patient preference should be considered, because oral therapy is often more convenient, although insurance and cultural variables can influence preference.²⁴ Oral treatment may occasionally cause GI symptoms, headache, and rash.²⁵ Ketoconazole can cause liver toxicity, and therefore, it as been removed from many formularies. The oral azoles can interact with a variety of other medications, including astemizole, calcium channel antagonists, cisapride, warfarin, cyclosporine A, oral hypoglycemic agents, phenytoin, protease inhibitors, tacrolimus, terfenadine, theophylline, trimetrexate, and rifampin.

Sexual partners should not be treated unless the woman has frequent recurrences.

Self-medication is sometimes advised in women with recurrence of previously diagnosed vulvovaginal candidiasis; however, studies demonstrate poor ability to accurately self-diagnose candidiasis even with a prior history of the disease.^5,26 Therefore women who fail to respond to over-the-counter therapy or have recurrence within 2 months should be evaluated by a physician.

The treatment of complicated vulvovaginal candidiasis (both severe and recurrent cases) requires longer duration of therapy with topical and oral azoles or alternative therapies. In severe cases, consider treating with a topical azole for 7 to 14 days or treatment with oral fluconazole, 150 milligrams on days 1 and 3 for a total of two doses. In cases of recurrence, consider treating with a topical azole for 7 to 14 days or fluconazole, 100, 150, or 200 milligrams on days 1, 4, and 7 for a total of three doses.^1,25,26

CANDIDIASIS COMPLICATIONS

Vaginal and microscopic examinations should be performed if symptoms persist or recur within 2 months, and precipitating factors, such as high blood glucose levels, should be controlled. However, most women with recurrences do not have obvious precipitating causes. Vaginal cultures should be obtained to confirm clinical diagnosis but also to indentify any unusual species such as C. glabrata. Azoles are not very effective in treating vaginitis caused by C. glabrata.

Management of women with frequent recurrence is aimed at control with a long-term suppressive prophylactic regimen, rather than cure. The reason that some women, many of whom have no underlying pathology, experience frequent recurrences of infection with resulting morbidity is not fully understood. Current views suggest that local vaginal immune mechanisms may be responsible for frequent relapses. Maintenance regimens with oral fluconazole (100-, 150-, or 200-milligram doses weekly for 6 months) are the first line of treatment.¹

Trichomonas vaginalis is the most common nonviral sexually transmitted infection and accounts for 15% to 20% of cases of acute vaginitis. There are an estimated 3.7 million Americans infected with T. vaginalis, more than N. gonorrhoeae and Chlamydia combined.²⁷ Both men and women can be infected, and it is spread through sexual contact. Infection is more common in certain racial and ethnic groups. Incidence is highest among black women at 13.3%, compared with 1.8% of Hispanic women and 1.3% of white women.²⁸ The prevalence of T. vaginalis infection increases with age,¹ unlike other sexually transmitted infections, such as Chlamydia and N. gonorrhoeae, for which the prevalence is highest among adolescents and young adults. Risk of T. vaginalis infection is associated with increasing numbers of sexual partners (recent or remote), early initiation of sexual activity, lower educational levels (high school or below), and poverty.

Trichomoniasis is a parasitic infection with the single-celled protozoan T. vaginalis, a flagellated organism (Figure 102–3). Infection can produce local inflammation when the organism attaches to the vaginal mucosa. As many as 50% of women are asymptomatic. Clinically symptomatic women with Trichomonas vaginitis present with vaginal discharge, pruritus, and irritation. The classic discharge is described as frothy and malodorous. Symptoms generally develop within 5 to 28 days; however, untreated infections can last for months to years and produce symptoms at any time.²⁹

DIAGNOSIS

Clinical diagnosis of Trichomonas vaginitis traditionally relies on microscopic examination of the vaginal secretions and visualization of motile trichomonads (Figure 102–3). Microscopy should be performed immediately following sample collection or the organism will lose motility. The sensitivity of microscopic identification of trichomonads is 60% to 70%.¹ Although associated with low cost and immediate results, there are several disadvantages to this method, including operator error and overall poor sensitivity. Culture is 95% sensitive and considered the gold standard in diagnosis. However, results may not be available for 2 to 5 days. There are several newer testing options, including two different point-of-care diagnostic tests. Results of the immunochromatographic capillary flow dipstick technology test, OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, MA), and the nucleic acid probe test, Affirm VP III (Becton Dickinson, San Jose, CA), are available in 10 minutes and 45 minutes, respectively. Both have a sensitivity of >83% and specificity of >97%.^1,30,31 The U.S. Food and Drug Administration–cleared polymerase chain reaction assay for N. gonorrhoeae and Chlamydia infection, Amplicor (Roche Diagnostics, Indianapolis, IN), has been modified for T. vaginalis detection in both vaginal and endocervical swabs, as well as urine. The sensitivity ranges from 88% to 97%, and the specificity ranges from 98% to 99%. APTIMA T. vaginalis Analyte Specific Reagents are available for RNA-mediated amplification testing using the instrumentation platform APTIMA Combo2 (Gen-Probe, Bedford, MA) currently used to diagnose N. gonorrhoeae and Chlamydia infections. The sensitivity ranges from 74% to 98%, and the specificity ranges from 87% to 98%.¹

TREATMENT

Treatment regimens for acute Trichomonas vaginitis are listed in Table 102–6. The nitroimidazoles, metronidazole and tinidazole, are the only medications effective in treating trichomoniasis. Metronidazole gel is considerably less effective (<50%) than oral metronidazole preparations, and so the gel is not recommended. Single-dose treatment is preferable because of lower cost, fewer side effects, and greater patient adherence to the regimen. However, patients whose infection is not responsive to single-dose therapy may require a 7-day course of therapy. There is a 90% cure rate with either the single- or multiple-dose regimen. Cure rates increase to >90% when sexual partners are treated simultaneously. Patients with a true allergy can undergo desensitization in consultation with a specialist.¹

Counsel patients to abstain from sexual intercourse until drug therapy has been completed and the patient and their partner(s) are asymptomatic and to avoid alcohol use during therapy and for 24 hours after completion of drug therapy with metronidazole to avoid a disulfiram-like reaction.

TRICHOMONIASIS COMPLICATIONS

The spread of Trichomonas infection is difficult to control, because up to 50% to 75% of those infected are asymptomatic and reinfection is common. Recurrence of disease is frequent and may necessitate multiple courses of treatment.

T. vaginalis infection is associated with several adverse health outcomes, including preterm birth, delivery of low-birth-weight infants, and pelvic inflammatory disease. It has also been associated with increased transmission of several other infections, including human immunodeficiency virus, herpes simplex virus, and human papillomavirus infection. Not only does Trichomonas infection increase the likelihood of human immunodeficiency virus acquisition, but it also promotes human immunodeficiency virus transmission and viral shedding.^32,33

SPECIAL POPULATIONS

Human immunodeficiency virus–positive individuals are more likely to become infected with T. vaginalis and have higher complication rates. Consider 7-day therapy for human immunodeficiency virus–positive individuals because studies have indicated that single-dose therapy is less effective.¹

Due to the potential adverse outcomes, pregnant women should receive treatment with oral metronidazole. Women can be safely treated with single-dose metronidazole therapy at any stage of pregnancy. Tinidazole safety in pregnancy is not well studied. Breastfeeding mothers should withhold nursing during treatment with metronidazole and for 12 to 24 hours after the last dose. If treated with tinidazole, patients should hold breastfeeding for 3 days after the last dose.

Contact dermatitis results from the exposure of the vulvar epithelium and vaginal mucosa to a primary chemical irritant or an allergen. Irritant dermatitis is more common than allergic dermatitis.³⁴ Common irritants and/or allergens include chemically scented douches, soaps, bubble baths, and deodorants; perfumes, dyes, and scents in toilet paper, tampons, pads, and feminine hygiene products; topical vaginal antibiotics; laundry detergents, dryer sheets, and fabric softeners; and tight slacks, pantyhose, and synthetic underwear. Benzocaine, used by women to control vulvar discomfort, can also cause a particularly severe contact dermatitis.

DIAGNOSIS AND TREATMENT

Diagnosis may be difficult due to variation in severity of symptoms and presence of other preexisting conditions. Clinically, patients report local swelling and itching or a burning sensation. Physical findings range from local erythema and edema to excoriation, ulceration, and secondary infection. Local vesiculation and ulceration are more common with allergens or with primary irritants used in strong concentrations. Also consider herpes infections if vesicles are present. Vaginal pH changes may promote colonization and infection with C. albicans, which can obscure the primary cause.

Diagnosis of contact vulvovaginitis is made by ruling out an infectious cause and identifying the offending agent. Most cases of mild vulvovaginal contact dermatitis resolve spontaneously when the causative agent is withdrawn. Cool sitz baths and application of wet compresses of dilute boric acid or Burow's solution may afford relief for patients with severe painful reactions. A few days of therapy with topical corticosteroids, such as hydrocortisone acetate (0.5% to 2.5%), fluocinolone acetonide (0.01% to 0.2%), or triamcinolone acetonide (0.025%), applied two or three times daily, provide symptomatic relief and promote healing. Oral antihistamines may be helpful if a true allergic reaction is present. Superinfection with C. albicans should be treated as previously described in the section on Candida vaginitis.

Vaginal atrophy, present in 60% of women 4 years after menopause, can result in atrophic vaginitis.³⁵ Decreases in ovarian steroid production that occur in the menopausal woman lead to profound changes in the vulva, vagina, cervix, urethra, and bladder. The changes vary widely from one patient to another. The vagina loses its normal rugae, and the vaginal mucosa becomes attenuated, pale, and almost transparent as a result of decreased vascularity. The squamous epithelium atrophies, the glycogen content of the cells decreases, and the vaginal pH ranges from 5.5 to 7.0. The upper one third of the vagina constricts, and the entire vagina becomes shorter in length and loses its elasticity. The mucosa is only three or four cells thick and is less resistant to minor trauma and infection. The cervix atrophies and retracts and may become flush with the apex of the vault.

DIAGNOSIS AND TREATMENT

Symptoms include vaginal dryness, soreness, itching, dyspareunia, and occasional spotting or discharge. Discharge is thin, scant, and yellowish or pink. The vaginal epithelium appears thin, inflamed, and even ulcerated.

A clinical vaginal infection with copious purulent discharge may develop due to increased vaginal pH, which permits growth of nonacidophilic coliform organisms and the disappearance of Lactobacillus species. Candida and Trichomonas infections are rare in the postmenopausal woman unless estrogenic replacement therapy is used.

Wet preparations demonstrate erythrocytes, increased polymorphonuclear neutrophils, and small, round epithelial cells, which are immature squamous cells that have not been exposed to sufficient estrogen.

Treatment of atrophic vaginitis consists primarily of topical vaginal estrogen. Creams, pessaries, tablets, and the estradiol vaginal ring are all effective in treating the symptoms.³⁵ Side effects of treatment may include uterine bleeding, breast pain, perineal pain, and endometrial hyperstimulation. Estrogen should not be prescribed to patients with a history of cancer of any of the reproductive organs. Atrophic vaginitis is usually not seen in patients who are already taking systemic estrogen replacement therapy.

Patients should be referred to their own doctors or a clinic for treatment and follow-up to monitor therapy, because all formulations of estrogen, even at low dosages, show systemic absorption and have potentially harmful side effects.³⁶ In addition, any patient with postmenopausal bleeding, either by history or physical examination, should be referred to a gynecologist to rule out carcinoma.

Bartholin glands are located in the labia minora. The ducts of the glands drain into the posterior vestibule at the 4 o'clock and 8 o'clock positions. Normally the glands are pea sized, but may form a cyst or abscess. The glands begin to function at puberty to provide moisture for the vestibule and involute as women age. Obstruction of the duct may result in a cyst or abscess. A cyst does not need to be present for an abscess to develop. Abscesses may become quite large and cause extreme pain. Bartholin gland abscesses tend to be polymicrobial, although N. gonorrhoeae and C. trachomatis have been implicated.³⁷

DIAGNOSIS AND TREATMENT

Bartholin gland abscess is characterized as a mass in the posterior introitus near the 4 o'clock or 8 o'clock position that has developed over several days. If the abscess was preceded by a cyst, the abscess may develop over a longer period of time. Pain, induration, and fluctuance are usually present. Systemic symptoms such as fever and chills are rarely present.

Incision and drainage of an abscess is usually necessary but should not be performed until the abscess is a well-defined, walled-off structure. If the abscess is not ready for incision and drainage, give the patient broad-spectrum antibiotics and analgesics, and advise warm sitz baths. Most patients present with an exquisitely tender, hyperemic, fluctuant mass that needs drainage.

Provide analgesia with a local injection of 2 to 4 mL of 1% lidocaine. To drain the abscess, make a stab incision with a #11 scalpel on the mucosal surface of the vestibule, just lateral to the hymenal ring in the region of the Bartholin gland, where the abscess cavity is closest to the mucosal surface. Extend the stab incision only for a few millimeters—an incision that is too large will result in displacement of the Word catheter. A Word catheter (Figure 102–4) is the size of a #10 Foley catheter with a 1-in (2.5-cm) stem and an inflatable balloon. Insert the Word catheter into the incision site, and inflate the balloon with 2 to 4 mL of water. Tuck the end of the catheter into the vagina. The catheter should remain in place for 4 to 6 weeks to avoid recurrence.³⁸ Case reports describe using plastic tubing (Figure 102–5) and pediatric Foley catheters for abscess drainage when a Word catheter is not available.^39,40 Prescribe analgesics and broad–spectrum antibiotics, and give instructions for follow-up care. If N. gonorrhoeae and C. trachomatis infection are possible, direct antibiotic coverage accordingly (Table 102–2). Patients with recurrent abscess may require definitive surgical care and should be provided with specialty referral.

Consider a vaginal foreign body in patients with chronic vaginal discharge. Objects removed in the ED include retained tampons and toilet tissue, items used for sexual stimulation, packets of illegal drugs, and various other items.

Premenarchal children presenting with vaginal discharge, especially if bloody or brown, should be evaluated for a vaginal foreign body, which is found in 4% to 10% of such cases. The discharge associated with a foreign body occurs daily and is often malodorous.⁴ Potential foreign bodies include small pieces of toilet paper or cloth and small toys/objects.

Vaginal irrigation with 0.9% normal saline can be attempted to visualize and remove a foreign body in cooperative children >7 years of age. Vaginoscopy under anesthesia in the operating room may be necessary in younger children.

The use of imaging modalities is limited by the composition of the foreign body. Radiolucent foreign bodies are not seen on plain radiographs and may not be detected by pelvic ultrasound. MRI may aid in the localization of nonmetallic objects but is not always available and is not necessarily conclusive.

Treatment of vaginal foreign bodies is removal either manually or by irrigation.

Patients with pinworms (Enterobius vermicularis) complain of anal and/or vaginal pruritus, which is more intense at night (when the gravid female pinworms pass out from the intestinal tract to lay eggs on the perineal skin). The worms may migrate from the anus to the vagina in children.

The diagnosis is made by visualization of 1-cm-long, thin white worms exiting the anus. Alternately, a sample can be obtained on cellophane tape and used for identification of ova, which are large and double-walled in appearance, on microscopy.

Treat the child and all family members with an antiparasitic agent (Table 102–7). Treatments are repeated, because mature worms are more vulnerable to treatment than young worms.⁴

Nonobstetric vulvar trauma is uncommon; however, it is associated with significant physical and psychological consequences. Various types of trauma can be seen including injuries sustained during consensual and nonconsensual sexual activity, accidental injuries including straddle-type injuries, other forms of physical assault, and self-mutilation. Patients may present with abrasions, tears, lacerations, hematomas, burns, and bite wounds. Depending on the situation, gynecologic consultation and examination under anesthesia may be necessary.

Evaluate patients with vulvar trauma for associated vaginal, urethral, anal, and bony pelvis injuries, and treat accordingly.⁴¹

Acknowledgement: The authors wish to thank Drs. Gloria Kuhn and Robert Wahl who contributed to this chapter in the previous edition.