Vulvovaginitis

(Redirected from Vaginal discharge)

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

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

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Evaluation

Workup

Diagnosis

Management

Empiric Treatment

  • Acceptable when clinically suspecting BV, vaginal candidiasis, or a non-infectious etiology
  • If signs/symptoms are equivocal for a specific diagnosis or if they suggest possible trichomoniasis, diagnostic testing should first be performed prior to treatment.

Non-Infectious Etiology Treatment

  • Hygienic measures for non-specific vulvovaginitis particularly in pre-pubertal females
  • OTC Vaginal lubrication products for post-menopausal women with vulvovaginal atrophy symptoms [3]
  • Consider hormone replacement therapy in post-menopausal women
    • Best provided by a primary care provider

Treatment for Test-Positive Patients based on Organism and Symptomatology

Positive Organism Symptomatic Asymptomatic Test of cure needed? Treat sexual partner(s)?
BV Treat Do not treat No, unless persistent symptoms No
Vaginal candidiasis Treat Do not treat No, unless persistent symptoms No
Trichomoniasis Treat Treat Yes (in 3 months; use NAAT) Yes

Bacterial vaginosis

First Line Therapy[4]

  • Metronidazole 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

  • Tinidazole 2 g PO qd for 2 days OR
  • Tinidazole 1 g PO qd for 5 days OR
  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)

Pregnant

Prophylaxis (Sexual Assault)

Candida vulvovaginitis

Uncomplicated

There is little resistance to azole medications; treatment often dictated by patient preference.

  • Fluconazole 150mg PO once (preferred)[6]
    • A second dose at 72hrs may be given if patient is still symptomatic
  • Intravaginal therapy
    • Clotrimazole 1 % cream applied vaginally for 7 days OR
    • Clotrimazole 2% applied vaginally for 3 days
    • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
    • Butoconazole 2% applied vaginally x 3 days
    • Tioconazole 6.5% applied vaginally x 1

Complicated

Severe or immunosuppressed

Non-albicans species

  • For example, C. glabrata, C. krusei and other atypical Candida spp.
  • Boric acid vaginal suppository intravaginal qday x ≥14 days
    • Can be fatal if taken orally
  • If empirically treated and later is found to have non-albicans Candida spp., no change in therapy is needed if patient is improving (otherwise switch to boric acid.

Recurrent (≥ 4 infections in a year)

  • Treat as for uncomplicated (see above)
  • Once therapy completed, prescribe long-term treatment
    • Fluconazole 150mg PO qweek x 6 months, OR
    • Intravaginal medication, such as clotrimazole 500mg PV qweek or 200mg PV twice a week

Pregnant Patients

  • Intravaginal clotrimazole or miconazole are the only recommended treatments
  • Duration is 7 days
  • PO fluconazole associated with congenital malformations and spontaneous abortions[7]

[[Trichomonas vaginalis

Non-Pregnant

Pregnant

Only treat if the patient is symptomatic and avoid breast feeding until 24-hrs after last dose

Sexual Partner Treatment

Disposition

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

See Also

External Links

  • ACOG patient information for vaginitis [1]

References

  1. Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  2. Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
  3. Alvisi S, Gava G, Orsili I, Giacomelli G, Baldassarre M, Seracchioli R, Meriggiola MC. Vaginal Health in Menopausal Women. Medicina (Kaunas). 2019 Sep 20;55(10):615. doi: 10.3390/medicina55100615. PMID: 31547180; PMCID: PMC6843679.
  4. Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  5. 5.0 5.1 5.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  6. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1.
  7. Molgaard-Nielsen D et al. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67.
  8. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  9. CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  10. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon