Vaginitis and Vulvar Conditions

Abstract

Women with vaginitis often present to primary care settings. The most common types of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Less commonly, vaginitis results from a noninfectious etiology. In addition to vaginitis, a woman presenting with vaginal discharge may have physiologic discharge, cervicitis, or pelvic inflammatory disease; it is critical to exclude an upper genital tract infection in women presenting with vaginal discharge. Clinical assessment includes a combination of history, exam, assessment of vaginal pH, the whiff test, microscopy, and/or point-of-care testing for the three common infectious causes. Yeast vaginitis and bacterial vaginosis often recur, necessitating review of contributing factors and consideration of long-term management. Although vulvar symptoms more commonly result from discharge originating from the vagina or cervix, primary vulvar processes also occur and can present with pruritus, burning pain, dyspareunia, dysuria, or rarely with bleeding or a palpable mass. Primary vulvar conditions include contact and allergic dermatitis, chronic vulvar dermatoses, vulvar malignancies, and vulvodynia.

Review Questions

• 1. Tamara is a 34-year-old woman who calls your office complaining of vaginal discharge that started 2 days ago. She tells you the discharge is thin, yellow, and malodorous. She denies dysuria and dyspareunia, but notes mild associated pruritus. She tells you she is sexually active with only her husband, and they do not use condoms. She also says that her symptoms are similar to when she had a bacterial vaginosis infection earlier this year, and you confirm in the medical record that she was diagnosed with bacterial vaginosis 6 months ago. She requests a prescription for oral metronidazole. What do you advise?

  • A. An office visit is not required; prescribe metronidazole 500 mg orally twice daily for 7 days

  • B. An office visit is not required; prescribe metronidazole vaginal gel 0.75%, 5 g intravaginally once nightly for 5 days

  • C. An office visit is not required; prescribe clindamycin 2% cream, 1 applicatorful once nightly for 7 days

  • D. Advise her to come to the office to be evaluated

  The correct answer is D: Advise her to come to the office to be evaluated [1]. Bacterial vaginosis (BV) is typically associated with a thin, homogenous, malodorous discharge. It is not usually associated with any pain or pruritus. However, none of these symptoms are diagnostic of BV. While choices A and B are recommended treatment regimens for a confirmed diagnosis of BV, a proper evaluation that includes history, pelvic exam, and office microscopy is required to confirm the diagnosis and rule out cervicitis and PID. Choice C is an alternative treatment regimen for BV.

• 2. Sweta is a 37-year-old woman presenting for vaginal discharge. She complains of thick, white discharge associated with pruritus. She is not sexually active. She reports having three “yeast infections” in the last year and believes this is another one. You perform a pelvic exam and prepare a wet mount, confirming a diagnosis of vulvovaginal candidiasis. Sweta is frustrated by the recurrent infections and wants to know what can be done. What do you advise?

  • A. Prescribe a single dose of oral fluconazole 150 mg; suppressive therapy is not indicated

  • B. Prescribe three doses of oral fluconazole 150 mg separated by 72 h; suppressive therapy is not indicated

  • C. Prescribe 10 days of a topical azole or oral fluconazole 150 mg, followed by oral fluconazole 150 mg once per week for 6 months

  • D. Prescribe a single dose of oral fluconazole 150 mg, followed by oral fluconazole 150 mg once per week for 6 weeks

  The correct answer is choice C. Prescribe 10 days of a topical azole or oral fluconazole 150 mg, followed by oral fluconazole 150 mg once per week for 6 months. This woman has complicated and recurrent VC, defined as ≥4 episodes per year. Given that she is frustrated by the frequent symptoms she should be offered a course of chronic therapy. For the management of recurrent VC, the Infectious Diseases Society of America recommends 10–14 days of induction therapy with a topical azole or oral fluconazole followed by 6 months of maintenance therapy consisting of oral fluconazole 150 mg once weekly [44]. A single dose of oral fluconazole (Choice A) would be the correct choice if this was an uncomplicated vulvovaginal candidiasis (VC) infection (e.g. ≤3 episodes per year, mild to moderate symptoms), and choice B would be the correct answer if this was only complicated VC and Sweta was not bothered by her symptoms.

• 3. A 20-year-old woman presents complaining of 5 days of severe vulvar pruritus. Following full evaluation, the two of you determine that it is from an allergic dermatitis resulting from an allergy to the deodorant in her feminine pads, which she used for the first time beginning 1 week ago. What do you recommend?

  • A. She should soak in very warm baths for relief

  • B. She should use a strong liquid soap to remove any residual antigen

  • C. She should immediately cease and permanently avoid using this product (and perhaps all feminine products that contain deodorant)

  • D. She should take diphenhydramine around-the-clock for relief of pruritus

  The correct answer is C. Immediate and permanent avoidance of the culprit antigen is the cornerstone of treating allergic contact dermatitis. In addition, topical steroid ointments and, if needed, oral antihistamines are used. Warm baths would aggravate the pruritus; cool Sitz baths and compresses are helpful. Harsh soaps are never recommended on the vulva. Diphenhydramine would be too sedating for daytime use; the preferred antihistamines for pruritus are cetirizine in the daytime and hydroxyzine at night.

• 4. A 55-year-old woman presents for a “routine Pap smear.” She reports mild vulvar itching for the past year or two. Her vulva appears abnormal with diffuse pallor and thinning, and her labia minora appear markedly shrunken. You recommend:

  • A. Referral to dermatology or gynecology

  • B. Waiting for the results of her cervical cytology to determine the next step

  • C. A trial of watchful waiting

  • D. A trial of topical estrogen

  The correct answer is A. This presentation is classic for lichen sclerosus, which presents with focal or diffusely pale vulvar mucosa that is either abnormally thick (early stage) or thin (later stage). LS requires treatment using ultrapotent topical corticosteroids plus close monitoring for the possible development of vulvar cancer. For this reason, patients with LS are usually managed by dermatologists or gynecologists. Cervical cytology has no bearing on the patient’s vulvar problem. Watchful waiting is inappropriate since without treatment the destruction of her vulvar anatomy will progress and the risk of vulvar cancer is increased. The patient’s exam findings, particularly the changes to her labia minora, are too dramatic to be consistent with the genitourinary syndrome of menopause.

• 5. A 75-year-old healthy woman presents complaining of several months of progressive burning “in my private parts.” Her exam is notable for erosions with white borders on her labia minora as well as in her vagina. The most likely etiology is:

  • A. Genital psoriasis

  • B. Lichen sclerosus

  • C. Lichen simplex chronicus

  • D. Lichen planus

  The correct answer is D. The erosive form of lichen planus is the only chronic dermatosis of the vulva that also involves the vagina, and erosions with surrounding white reticular borders are characteristic. Psoriasis involves plaques (not erosions). Lichen sclerosus presents with pale mucosa that is either abnormally thick or thin. Lichen simplex chronicus presents with plaques, lichenification, excoriations, and broken-off hairs that all result from excessive scratching.

• 6. A 50-year-old healthy woman presents with vulvar pruritus. Her pelvic exam reveals several symmetric erythematous plaques with rounded borders on the outer (hair-bearing) aspects of the labia majora. No scale is seen. Which of the following is true?

  • A. Examination of the scalp, gluteal cleft, umbilicus, and nails might uncover findings that support the diagnosis

  • B. This cannot be psoriasis since no silvery scale is present

  • C. Biopsy is needed to confirm the diagnosis

  • D. These lesions are most likely malignant

  The correct answer is A. The findings described are classic for psoriasis on the vulva; uncovering psoriasis elsewhere on the body would be supportive of the diagnosis. Due to the apposition of the skin and overall moist environment of the vulva, scale is frequently absent at this location. Biopsy is rarely needed to make the diagnosis of psoriasis, even when isolated to the vulva. Although malignancies on the vulva may present in any of a myriad of presentations, the symmetry of lesions makes this unlikely.

• 7. Your next patient is a 24-year-old woman who is new to you. In eliciting her medical history, you learn that she quit using contraception because she and her husband have not had intercourse in nearly a year due to entrance dyspareunia. She tearfully explains that she has seen two physicians for this problem but was told “everything is normal.” She has no other genital complaints and she is healthy overall. You advise:

  • A. A referral for individual psychotherapy

  • B. Couple’s counseling

  • C. Diagnostic pelvic exam

  • D. A trial of amitriptyline or gabapentin

  The correct answer is C. This patient describes provoked vestibulodynia. Although the mucosa of the vaginal vestibule appears normal in women with this condition, gentle application of a cotton-tipped applicator to the vestibule may reproduce the patient’s pain, and this maneuver should be performed during the pelvic exam to make the diagnosis. Histologic studies indicate an increased number of nociceptors at the vestibule of affected women, and an important component of patient counseling is communicating that the condition is real. Treatment includes topical anesthetics applied to the vestibule 15–20 min before intercourse then washed off immediately prior to penetration. Referral for individual or couples’ counseling is premature given that any mood or relationship problems might promptly resolve with treatment of her vestibulodynia. Chronic pain medications are used for unprovoked vulvar pain, typically generalized unprovoked vulvodynia.