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Vaginal Itching and Discharge
Vaginal itching (pruritus), discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa (vaginitis), often with inflammation of the vulva (vulvovaginitis). Symptoms may also include irritation, burning, erythema, and sometimes dysuria and dyspareunia. Symptoms of vaginitis are one of the most common gynecologic complaints.
Some vaginal discharge is normal, particularly when estrogen levels are high a few days before ovulation. Estrogen levels are also high during the first 2 wk of life (because maternal estrogens are transferred before birth), during the few months before menarche and during pregnancy (when estrogen production increases), and with use of drugs that contain estrogen or that increase estrogen production (eg, some fertility drugs). However, irritation, burning, and pruritus are never normal.
Normally in women of reproductive age, Lactobacillus sp is the predominant constituent of normal vaginal flora. Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of pathogenic bacteria. Also, high estrogen levels maintain vaginal thickness, bolstering local defenses.
Factors that predispose to overgrowth of bacterial vaginal pathogens include
The most common causes vary by patient age (see Table: Some Causes of Vaginal Pruritus and Discharge).
Vaginitis usually involves infection with GI tract flora (nonspecific vulvovaginitis). A common contributing factor in girls aged 2 to 6 yr is poor perineal hygiene (eg, wiping from back to front after bowel movements, not washing their hands after bowel movements). Chemicals in bubble baths or soaps may cause inflammation and pruritus of the vulva, which often recur. Foreign bodies may cause nonspecific vaginitis, often with a scant bloody discharge.
Vaginitis is usually infectious. The most common types are
Sometimes another infection (eg, gonorrhea, chlamydial infection) causes a discharge. These infections often also cause pelvic inflammatory disease.
Genital herpes sometimes causes vaginal itching but typically manifests with pain and ulceration (see Herpesviruses:Mucocutaneous infection).
Vaginitis may also result from foreign bodies (eg, a forgotten tampon). Inflammatory noninfectious vaginitis is uncommon.
In postmenopausal women (see also Vaginal Itching and Discharge : Geriatrics Essentials), atrophic vaginitis is a common cause.
Other causes of discharge include vaginal, cervical, and endometrial cancers and, in women who are incontinent or bedbound, chemical vulvitis.
At any age, conditions that predispose to vaginal or vulvar infection include fistulas between the intestine and genital tract (which allow intestinal flora to seed the genital tract) and pelvic radiation or tumors (which break down tissue and thus compromise normal host defenses). Fistulas are usually obstetric in origin (due to vaginal birth trauma or a complication of episiotomy infection) but are sometimes due to inflammatory bowel disease or pelvic tumors or occur as a complication of pelvic surgery (eg, hysterectomy, anal surgery).
Noninfectious vulvitis accounts for up to 30% of vulvovaginitis cases. It may result from hypersensitivity or irritant reactions to various agents, including hygiene sprays or perfumes, menstrual pads, laundry soaps, bleaches, fabric softeners, and sometimes spermicides, vaginal creams or lubricants, latex condoms, vaginal contraceptive rings, and diaphragms.
Some Causes of Vaginal Pruritus and Discharge
History of present illness includes nature of symptoms (eg, pruritus, burning, pain, discharge), duration, and intensity. If vaginal discharge is present, patients should be asked about the color and odor of the discharge and any exacerbating and remitting factors (particularly those related to menses and intercourse). They should also be asked about use of hygiene sprays or perfumes, spermicides, vaginal creams or lubricants, latex condoms, vaginal contraceptive rings, and diaphragms.
Review of systems should seek symptoms suggesting possible causes, including fever or chills and abdominal or suprapubic pain (pelvic inflammatory disease [PID] or cystitis) and polyuria and polydipsia (new-onset diabetes).
Past medical history should note risk factors for candidal infection (eg, recent antibiotic use, diabetes, HIV infection, other immunosuppressive disorders), fistulas (eg, Crohn disease, GU or GI cancer, pelvic or rectal surgery, lacerations during delivery), and sexually transmitted diseases (eg, unprotected intercourse, multiple partners).
Physical examination focuses on the pelvic examination.
The external genitals are examined for erythema, excoriations, and swelling. A water-lubricated speculum is used to check the vaginal walls for erythema, discharge, and fistulas. The cervix is inspected for inflammation (eg, trichomoniasis) and discharge. Vaginal pH is measured, and samples of secretions are obtained for testing. A bimanual examination is done to identify cervical motion tenderness and adnexal or uterine tenderness (indicating PID).
Often, the history and physical examination help suggest a diagnosis (see Table: Some Causes of Vaginal Pruritus and Discharge), although there can be much overlap.
In children, a vaginal discharge suggests a foreign body in the vagina. If no foreign body is present and children have trichomonal vaginitis, sexual abuse is likely. If they have unexplained vaginal discharge, cervicitis, which may be due to a sexually transmitted disease, should be considered. Nonspecific vulvovaginitis is a diagnosis of exclusion.
In women of reproductive age, discharge due to vaginitis must be distinguished from normal discharge. Normal vaginal discharge is commonly milky white or mucoid, odorless, and nonirritating; it can result in vaginal wetness that dampens underwear.
Bacterial vaginosis produces a thin, gray discharge with a fishy odor. A trichomonal infection produces a frothy, yellow-green vaginal discharge and causes vulvovaginal soreness. Candidal vaginitis produces a white discharge that resembles cottage cheese, often increasing the week before menses; symptoms worsen after sexual intercourse.
Contact irritant or allergic reactions cause significant irritation and inflammation with comparatively minimal discharge.
Discharge due to cervicitis (eg, due to PID) can resemble that of vaginitis. Abdominal pain, cervical motion tenderness, or cervical inflammation suggests PID.
In women of all ages, vaginal pruritus and discharge may result from skin disorders (eg, psoriasis, lichen sclerosus, tinea versicolor), which can usually be differentiated by history and skin findings.
Discharge that is watery, bloody, or both may result from vulvar, vaginal, or cervical cancer; cancers can be differentiated from vaginitis by examination and Papanicolaou (Pap) tests.
In atrophic vaginitis, discharge is scant, dyspareunia is common, and vaginal tissue appears thin and dry.
All patients require the following in-office testing:
Testing for gonorrhea and chlamydial infections is typically done unless a noninfectious cause (eg, allergy, foreign body) is obvious.
Vaginal secretions are tested using pH paper with 0.2 intervals from pH 4.0 to 6.0. Then, a cotton swab is used to place secretions on 2 slides; secretions are diluted with 0.9% NaCl on one slide (saline wet mount) and with 10% KOH on the other (KOH preparation).
The KOH preparation is sniffed (whiff test) for a fishy odor, which results from amines produced in trichomonal vaginitis and bacterial vaginosis. The slide is examined using a microscope; KOH dissolves most cellular material except yeast hyphae, making identification easier.
The saline wet mount is examined using a microscope as soon as possible to detect motile trichomonads, which can become immotile and more difficult to recognize within minutes after slide preparation.
If clinical criteria and in-office test results are inconclusive, the discharge may be cultured for fungi and trichomonads.
Any specific cause is treated.
The vulva should be kept as clean as possible. Soaps and unnecessary topical preparations (eg, feminine hygiene sprays) should be avoided. If a soap is needed, a hypoallergenic soap should be used. Intermittent use of ice packs or warm sitz baths (with or without baking soda) may reduce soreness and pruritus. If chronic vulvar inflammation is due to being bedbound or incontinent, better vulvar hygiene may help.
If symptoms are moderate or severe or do not respond to other measures, drugs may be needed. For pruritus, topical corticosteroids (eg, 1% hydrocortisone bid prn) can be applied to the vulva but not into the vagina. Oral antihistamines lessen pruritus and cause drowsiness, helping patients sleep.
Prepubertal girls should be taught good perineal hygiene (eg, wiping front to back after bowel movements and voiding, washing their hands, avoiding fingering the perineum).
In postmenopausal women, a marked decrease in estrogen causes vaginal thinning (atrophic vaginitis), increasing vulnerability to infection and inflammation. Other common causes of decreased estrogen in older women include oophorectomy, pelvic radiation, and certain chemotherapy drugs.
In atrophic vaginitis, inflammation often results in an abnormal discharge, which may be watery and thin or thick and yellowish. Dyspareunia is common, and vaginal tissue appears thin and dry.
Poor hygiene (eg, in patients who are incontinent or bedbound) can lead to chronic vulvar inflammation due to chemical irritation by urine or feces.
Bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis are uncommon among postmenopausal women but may occur in those with risk factors.
After menopause, risk of cancer increases, and a bloody or watery discharge is more likely to be due to cancer; thus, any vaginal discharge in postmenopausal women should be promptly evaluated.
Vaginal complaints are often nonspecific.
Causes vary depending on the patient’s age.
Most patients require measurement of vaginal pH and microscopic examination of secretions; if needed, culture for sexually transmitted organisms is done.
In postmenopausal women, any vaginal discharge should be promptly evaluated.
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