Vulvovaginitis

Vulvovaginitis

Vulvovaginitis is the spectrum of conditions that cause vaginal or vulvar symptoms such as itching,burning, irritation, and abnormal discharge. Vaginal and vulvar symptoms are among the most common reasons for patient visits to obstetrician–gynecologists. Symptoms may be acute or subacute, and may range in intensity from mild to severe. Vulvovaginitis may have important conse-quences in terms of discomfort and pain, days lost from school or work, sexual functioning, and self-image. Depend-ing on etiology, vulvovaginitis may also be associated with adverse reproductive outcomes in pregnant and nonpreg-nant women.

Vulvovaginitis has a broad differential diagnosis, and successful treatment frequently depends on accurately iden-tifying its cause. The most common causes of vaginitis are bacterial vaginosis (22%–50% of symptomatic women), vulvovaginal candidiasis (17%–39%), and trichomoniasis (4%–35%). Common vaginal infections often present with characteristic patterns (Table 26.1). The vulva and vagina are also sites of symptoms and lesions of several sexually transmitted infections, such as herpes genitalis, human pa-pillomavirus, syphilis, chancroid, granuloma inguinale, lym-phogranuloma venereum, and molluscum contagiosum. It is estimated that up to 70% of women with vaginitis remain undiag-nosed. In this undiagnosed group, symptoms may be caused by a broad array of conditions, including atrophic vaginitis, various vulvar dermatologic conditions, and vulvodynia.

Although sexually transmitted and other infections are common etiologies of vulvovaginitis, the patient’s his-tory and symptoms may point to chemical, allergic, or other noninfectious causes. Evaluation of women with vulvovaginitis should include a focused history about the entire spectrum of vaginal symptoms, including change in discharge, vaginal malodor, itching, irritation, burning, swelling, dyspareunia, and dysuria. Questions about the location of symptoms (vulva, vagina, anus), duration, the relation to the menstrual cycle, the response to prior treat-ment including self-treatment and douching, and a sexual history can yield important insights into the likely etiol-ogy. In patients with vulvar symptoms, the physical exam-ination should begin with a thorough evaluation of the vulva. However, evaluation may be compromised by pa-tient self-treatment with nonprescription medications.

A variety of laboratory tests are available to aid in di-agnosing the cause of vulvovaginitis. Samples obtained dur-ing speculum examination can be tested for vaginal pH, amine (“whiff”) test, and saline (wet mount) and 10% potas-sium hydroxide (KOH) microscopy. Tests for diagnosing vaginal infection, such as rapid tests for enzyme activity from bacterial vaginosis-associated organisms, Trichomonasvaginalis antigen, and point-of-care testing for DNA of Gardnerella vaginalis, Trichomonas vaginalis, and Candida species are also available, although the role of these tests in the proper management of patients with vulvovaginitis is unclear. Depending on risk factors, DNA amplification tests can be obtained for Neisseria gonorrhoeae and Chlamydiatrachomatis.