Chapter 102: Vulvovaginitis

INTRODUCTION

Vulvovaginitis, or vulvovaginal inflammation, results from infectious and noninfectious processes that cause symptoms that include burning, irritation, itching, odor, and abnormal vaginal discharge. The factors associated with acute vaginitis are listed in Table 102-1.

The clinical diagnosis may be challenging because more than one disease can be present, signs and symptoms are nonspecific to a single cause, and polymicrobial infection is common. In approximately 30% of women with vaginal complaints, no etiology is determined even after comprehensive testing.^1-3

Although infectious vaginitis rarely requires hospitalization, it can lead to serious sequelae. Both bacterial vaginosis (BV) and trichomoniasis are associated with premature rupture of membranes, preterm labor, and low infant birth weight.^4,5 Trichomonas vaginitis increases the risk of human immunodeficiency virus (HIV) acquisition and transmission due to the loss of the protective effect found with normal vaginal lactobacilli and is also associated with pelvic inflammatory disease in patients who are known to be HIV positive.^6,7

PATHOPHYSIOLOGY

In females of childbearing age, estrogen helps develop a thick vaginal epithelium with a large number of superficial glycogen-containing cells that serves a protective function. Normal flora, such as lactobacilli and acidogenic corynebacteria, use glycogen to form lactic and acetic acids. The resulting acidic environment favors the normal flora, discouraging growth of pathogenic bacteria. Low estrogen levels in postmenopausal women result in atrophy due to loss of the protective glycogen-containing superficial cells and the altered pH environment.

Normal vaginal secretions vary in consistency from thin and watery to thick, white, and opaque. The volume may also vary from a scant to a copious amount. Secretions are odorless and produce no symptoms. 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.

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 (e.g., bubble bath), poor hygiene, front-to-back wiping, short distance between the ...