Vulvovaginitis

Background

Labeled vulva, showing external and internal views.

Pelvic anatomy including organs of the female reproductive system.

• Definition: inflammation of the vulva and vagina
• Candida Vaginitis and Contact Vulvovaginitis may occur in pre-pubertal and non-sexually active people
• Atrophic vaginitis may occur in postmenopausal women

Vulvovaginitis

• Bacterial vaginosis
• Candida vaginitis
• Trichomonas vaginalis
• Contact vulvovaginitis
  • Bubble baths and soaps
  • Deodorants, powders, and douches
  • Clothing
• Atrophic vaginitis due to lack of estrogen (AKA Vulvovaginal atrophy)
• Lichen sclerosus
• Tinea cruris
• Chlamydia/Gonorrhea infection
• Pinworms
• Vaginal foreign body
  • Toilet paper
  • Other
• Genitourinary syndrome of menopause
• Foreign body
• Allergic reaction
• Normal physiologic discharge

Clinical Features

• Nonspecific
  • Discharge
  • Itching
  • Erythema or rash
  • Dysuria
  • Odor
  • Pain with intercourse

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervical Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Evaluation

Workup

• History and GU exam are required
• Evaluate for infectious causes with cultures and wet mount
  • Respiratory or enteric flora may be seen in vaginal cultures from pre-puberal females
    • Respiratory: Staph, Strep, H. Influenza, Moraxella and N. Meningitidis
    • Enteric: E. Coli, Proteus, Klebsiella, Shigella etc.
  • STIs are less common
  • Candida and Gardnerella may be see on wet mount
• Consider O&P
  • Pinworms may cause vulvovaginitis

Management

• Treat infectious etiologies based on wet mount, PCR, and culture results as indicated
• Hygienic measures for non-specific vulvovaginitis particularly in pre-pubertal females
• OTC Vaginal lubrication products for post-menopausal women
• Consider hormone replacement therapy in post-menopausal women
  • Best provided by a primary care provider

Disposition

• Virtually all patients can be discharges with PCP or Gyn follow up
• Any test sent should be followed for results

See Also

• Pelvic Pain