Chapter 63. Vulvovaginitis

Causes of vulvovaginitis include infections, irritants, allergies, reaction to foreign bodies, and atrophy. The normal vaginal flora helps maintain an acidic pH between 3.8 and 4.5, which decreases pathogen growth.

Bacterial vaginosis (BV) is the most common cause of malodorous vaginal discharge. However, many infected women are asymptomatic. BV occurs when vaginal lactobacilli are replaced by anaerobes, Gardnerella vaginalis, and Mycoplasma hominis.

Clinical Features

The most common symptom is malodorous or “fishy smelling” vaginal discharge. Vaginal irritation, excoriation, and fissures are less common. Examination findings range from mild vaginal redness to a frothy gray-white or yellow discharge.

Diagnosis and Differential

The diagnosis can be made if 3 of the following 4 criteria are present: (a) vaginal discharge, (b) vaginal pH greater than 4.5, (c) positive amine test (fishy odor when 10% KOH is added to the discharge), (d) clue cells seen on saline wet preparation. Often, the diagnosis of BV is suspected from the history.

Emergency Department Care and Disposition

Treat with metronidazole 500 milligrams PO twice daily for 7 days. Clindamycin 300 milligrams PO twice daily for 7 days is an alternative. Treatment is not recommended for male partners or asymptomatic women. All patients treated with metronidazole should refrain from alcohol use during treatment and for 24 hours after ending treatment, to avoid a disulfram-like reaction.

Pregnant women at high risk of preterm labor should be considered for treatment, and all symptomatic pregnant women should be treated. The recommended treatment in pregnancy is metronidazole 250 milligrams PO twice daily for 7 days. Routine treatment of asymptomatic pregnant women with BV is not recommended.

Candida albicans is a common cause of vaginitis. Conditions that promote Candida vaginitis include systemic antibiotics, diabetes, pregnancy, and birth control pills. Incidence is decreased in postmenopausal patients. Candidiasis is not considered a sexually transmitted disease, though it can be transmitted sexually.

Clinical Features

The most common symptom of Candida vaginitis is pruritus. Other symptoms include vaginal discharge, external dysuria, and dyspareunia. Signs include vulvar and vaginal edema, erythema, and a thick “cottage cheese” discharge.

Diagnosis and Differential

Examine vaginal secretions microscopically in a few drops of saline solution or make a KOH preparation. Ten percent KOH dissolves vaginal epithelial cells, leaving yeast buds and pseudohyphae intact and easier to see. The sensitivity of the KOH technique is 80%, with a specificity approaching 100%.

Emergency Department Care and Disposition

Almost all topically applied azoles are equally efficacious. Treatment options include clotrimazole 100 milligram intravaginal tablet (2 tablets for 3 days), butoconazole 2% cream 1 vaginal applicator daily for 3 days, miconazole 200 milligrams vaginal suppository for 3 days. Pregnant patients are treated with intravaginal agents for 7 days. Single-dose treatment with fluconazole, 150 milligrams PO, is as effective as topical treatments but oral fluconazole may not be used in pregnancy. For nonpregnant patients with complicated candidiasis, fluconazole 150 milligrams PO is given on days 1 and 3.

Trichomoniasis is a common sexually transmitted disease caused by the protozoan T vaginalis.

Clinical Features

Presenting symptoms include a frothy, malodorous vaginal discharge, vaginal erythema and vulvar irritation. However, up to 50% of women harboring the organism are asymptomatic.

Diagnosis and Differential

Saline wet prep shows motile, pear-shaped, flagellated trichomonads. Microscopy should be performed within 20 min of obtaining the sample or the organisms may lose motility. The sensitivity of microscopy is 60% to 70%. The sensitivity of culture is 95% but results are not readily available in the ED.

Emergency Department Care and Disposition

The treatment of choice for trichomoniasis is metronidazole 2 grams single oral dose or tinidazole 2 grams single oral dose. Metronidazole 500 milligrams twice daily for 7 days is recommended for patients who fail single-dose therapy. Metronidazole gel is much less efficacious and thus not recommended for use. Male partners should be treated to avoid retransmission of disease. Patients should be advised to abstain from alcohol intake until 24 hours after completing metronidazole and 72 hours after completing tinidazole therapy. They should also be counseled to abstain from sexual activity until treatment course is completed and they are asymptomatic.

Common causes of contact vulvovaginitis include douches, soaps, bubble baths, deodorants, perfumes, feminine hygiene products, topical antibiotics, and tight undergarments. Patients complain of perineal burning, itching, swelling, and often dysuria. The examination shows a red and swollen vulvovaginal area. In severe cases, vesicles and ulceration may be present. Vaginal pH changes may promote overgrowth of Candida, obscuring the primary problem.

Try to identify the precipitating agent and rule out infectious causes. Most cases resolve spontaneously when the precipitant is withdrawn. For more severe reactions, cool sitz baths, compresses with Burow's solution, and topical corticosteroids may help. Oral antihistamines are drying but may be helpful if a true allergy is identified. Concomitant Candida infections should be treated as previously discussed.

In younger girls, common items include toilet paper, toys, and small household objects. Later, a forgotten or irretrievable tampon or items used for sexual stimulation are more often seen. Patients present with a foul-smelling or bloody discharge. Removal of the object is usually curative.

After menopause, the lack of estrogen stimulation leads to vaginal mucosal atrophy. The epithelium becomes pale, thin, and less resistant to minor trauma or infection. Bleeding can occur. The vaginal pH also increases, and subsequent changes in the vaginal flora can predispose to bacterial infection with purulent discharge. Treatment consists primarily of topical estrogen creams. Estrogen creams should not be prescribed in the emergency department for women with prior reproductive tract cancer or postmenopausal bleeding.