Gynecology Topic 17. Inflammatory disorders of the vulva and vagina

I. Vulvovaginitis: General Approach

Definition

• Vulvovaginitis: inflammation affecting vagina and vulva due to infection or change in normal vaginal flora.
• Normal flora: Lactobacillus-dominant, acidic pH usually < 4.5.
• Main causes: bacterial vaginosis, candidiasis, trichomoniasis; also consider cervicitis/STIs.
• Noninfectious mimics: atrophy/GSM, irritant/allergic vaginitis, foreign body, lichen disease, neoplasm.

Clinical Features

• Vaginal discharge: change in color, volume, consistency or odor.
• Pruritus, burning, irritation.
• Vulvar/vaginal erythema, edema, excoriation.
• Dysuria: often external dysuria from urine touching inflamed vulva.
• Dyspareunia.
• History clues: pregnancy, STI risk, antibiotics, diabetes, immunosuppression, douching, IUD, new/multiple partners.

Diagnosis

1. History and physical examination.
2. Speculum examination: discharge, cervix, vaginal/vulvar inflammation, foreign body, lesions.
3. Vaginal pH testing.
4. Wet mount in saline: clue cells, WBCs, motile trichomonads.
5. KOH preparation: yeast/pseudohyphae; whiff test for amine odor.
6. Culture, Gram stain, rapid antigen test or NAAT/PCR when unclear or STI suspected.

II. Bacterial Vaginosis

Etiology

• Bacterial vaginosis (BV): vaginal dysbiosis, not a classic STI.
• Mechanism: decreased Lactobacillus → increased pH → overgrowth of mixed anaerobes.
• Organisms: Gardnerella vaginalis, Bacteroides, Mycoplasma hominis and other anaerobes.
• Associations: new/multiple partners, douching, copper IUD, pregnancy.

Clinical Features

• Thin, homogeneous, greyish-white vaginal discharge.
• Fishy/malodorous odor, often worse after intercourse or menses.
• Vaginal pH increased, usually > 4.5.
• Mild itching/erythema may occur, but marked inflammation is usually absent.
• Dyspareunia is usually absent.

Diagnosis

• Clinical pattern: discharge + increased pH.
• Whiff test positive: fishy odor after 10% KOH added to vaginal fluid.
• Microscopy: clue cells = epithelial cells covered with bacteria.
• Gram stain: decreased Lactobacillus/large gram-positive rods + increased small gram-variable rods/anaerobes.
• Amsel logic: thin discharge + pH > 4.5 + positive whiff + clue cells.

Treatment and Complications

• First-line: metronidazole.
• Alternative: clindamycin.
• Routine male partner treatment is not recommended.
• Pregnancy: treat symptomatic pregnant women; BV is associated with PROM, preterm birth and STI susceptibility.
• Other risks: PID, postoperative/postabortal infection; recurrence is common.

III. Vulvovaginal Candidiasis

Etiology and risk factors

• Pathogen: Candida species, most commonly Candida albicans; yeast.
• Not considered an STI; Candida can be part of normal flora.
• Risk factors: antibiotic use, pregnancy, diabetes, immunosuppression, high-estrogen state/OCP use.

Clinical Features

• Thick, white, clumpy "cottage cheese-like" discharge.
• Marked vulvar itching/pruritus, burning, erythema, edema.
• External dysuria and dyspareunia.
• Vaginal pH usually normal, 4.0-4.5 → key difference from BV/trichomoniasis.

Diagnosis

• Clinical picture + normal pH supports diagnosis.
• KOH microscopy: budding yeast, pseudohyphae or hyphae.
• Culture/PCR: recurrent, resistant, complicated, or negative microscopy with persistent symptoms.
• Do not treat asymptomatic Candida colonization.

Treatment

• Uncomplicated: topical azole, e.g. miconazole/clotrimazole.
• Oral fluconazole: option outside pregnancy; useful if persistent/resistant according to context.
• Pregnancy: topical azole for 7 days; avoid oral fluconazole.
• Recurrent/resistant: confirm species; longer induction and suppression may be needed.
• Partner treatment is not routine unless male partner has symptomatic balanitis.

IV. Trichomoniasis and Differential Points

Trichomoniasis: Etiology

• Pathogen: Trichomonas vaginalis, flagellated protozoan.
• Transmission: sexually transmitted infection.
• Men are often asymptomatic but may have urethritis.
• Screen for other STIs when risk is present.

Clinical Features

• Can be asymptomatic.
• Profuse, yellow-green, frothy or purulent, foul-smelling discharge.
• Vaginal/vulvar erythema and pruritus.
• Cervix: spotted erythema / "strawberry cervix".
• Vaginal pH increased, usually > 4.5, often around 5-6.

Diagnosis

• Clinical pattern: discharge + strawberry cervix + increased vaginal pH.
• Wet mount microscopy: motile flagellated trichomonads + many WBCs.
• NAAT/PCR: high sensitivity; useful if suspected or wet mount negative.
• Rapid antigen tests may be used where available.
• Test for other STIs as indicated: chlamydia, gonorrhea, HIV, syphilis.

Treatment

• Metronidazole: standard treatment; 7-day regimen preferred for women.
• Alternative: tinidazole 2 g PO single dose.
• Treat all sexual partners → prevents reinfection / "ping-pong" infection.
• Abstain from sex until patient and partners complete treatment and symptoms resolve.
• Retest sexually active women because reinfection is common.

Fast Differential

• BV: thin grey-white fishy discharge + pH > 4.5 + clue cells + positive whiff test; little inflammation.
• Candidiasis: thick white clumpy discharge + intense pruritus + normal pH + yeast/pseudohyphae.
• Trichomoniasis: yellow-green frothy foul discharge + pH > 4.5 + strawberry cervix + motile protozoa/NAAT positive.
• Atrophic vaginitis/GSM: postmenopause, dryness, dyspareunia, burning, recurrent UTI; thin pale mucosa.
• Cervicitis: mucopurulent cervical discharge, contact bleeding, cervical motion tenderness risk → test for chlamydia/gonorrhea.