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Vaginal Itching and Discharge

by David H. Barad, MD, MS

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.

Pathophysiology

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

  • Use of antibiotics (which may decrease lactobacilli)

  • Alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli

  • Poor hygiene

  • Frequent douching

  • Pregnancy

  • Diabetes mellitus

Etiology

The most common causes vary by patient age (see Table: Some Causes of Vaginal Pruritus and Discharge).

Children

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.


Women of reproductive age

Vaginitis is usually infectious. The most common types are

  • Bacterial vaginosis

  • Candidal vaginitis

  • Trichomonal vaginitis (usually sexually transmitted)

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.


Postmenopausal women

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.


Women of all ages

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

Cause

Suggestive Findings

Diagnostic Approach*

Children

Poor perineal hygiene

Pruritus, vulvovaginal erythema, vaginal odor, sometimes dysuria, no discharge

Diagnosis of exclusion

Chemical irritation (eg, soaps, bubble baths)

Vulvovaginal erythema and soreness, often recurrent and accompanied by pruritus and dysuria

Clinical evaluation

Foreign bodies (often toilet paper)

Vaginal discharge, usually with a foul odor and vaginal spotting

Clinical evaluation (may require a topical anesthetic or procedural sedation)

Infections (eg, candidal, pinworm, streptococcal, staphylococcal)

Pruritus and vaginal discharge with vulvar erythema and swelling, often with dysuria

Worsening of pruritus at night (suggesting pinworm infection)

Significant erythema and vulvar edema with discharge (suggesting streptococcal or staphylococcal infection)

Microscopic examination of vaginal secretions for yeast and hyphae and culture to confirm

Examination of vulva and anus for pinworms

Sexual abuse

Vulvovaginal soreness, bloody or malodorous vaginal discharge

Often, vague and nonspecific medical complaints (eg, fatigue, abdominal pain) or behavior changes (eg, temper tantrums)

Clinical evaluation

Cultures or PCR for sexually transmitted diseases

Measures to ensure the child’s safety and a report to state authorities if abuse is suspected

Women of reproductive age

Bacterial vaginosis

Malodorous (fishy), thin, gray vaginal discharge with pruritus and irritation

Erythema and edema uncommon

Criteria for diagnosis (3 of 4):

  • Gray discharge

  • Vaginal secretion pH > 4.5

  • Fishy odor to discharge

  • Clue cells seen during microscopic examination

Candidal infection

Vulvar and vaginal irritation, edema, pruritus

Discharge that resembles cottage cheese and adheres to the vaginal wall

Sometimes worsening of symptoms after intercourse and before menses

Sometimes recent antibiotic use or history of diabetes

Clinical evaluation plus

  • Vaginal pH < 4.5

  • Yeast or hyphae identified on a wet mount or KOH preparation

Sometimes culture

Trichomonal infection

Yellow-green, frothy vaginal discharge, often with a fishy odor

Often soreness, erythema, and edema of the vulva and vagina

Sometimes dysuria and dyspareunia

Sometimes punctate, red “strawberry” spots on the vaginal walls or cervix

Mild cervical motion tenderness often detected during bimanual examination

Motile, pear-shaped flagellated organisms seen during microscopic examination

Rapid diagnostic assay for Trichomonas, if available

Foreign bodies (often a forgotten tampon)

Extremely malodorous, often profuse vaginal discharge, often with vaginal erythema, dysuria, and sometimes dyspareunia

Object visible during examination

Clinical evaluation

Pelvic inflammatory disease

Abdominal or pelvic pain

Fever

Cervical motion and/or adnexal tenderness

Cultures or PCR for sexually transmitted diseases

Postmenopausal women

Atrophic (inflammatory) vaginitis

Dyspareunia, scant discharge, thin and dry vaginal tissue

Clinical evaluation plus

  • Vaginal pH > 6

  • No fishy odor to discharge

  • Increased number of neutrophils, parabasal cells, and cocci and decreased number of bacilli seen during microscopic examination

Cancer of the vagina, cervix, or endometrium

Gradual onset of pain, a watery or bloody vaginal discharge (which precedes bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia)

Often no other symptoms until the cancer is advanced

Sometimes weight loss

Rarely, a palpable pelvic mass

Pelvic ultrasonography

Biopsy

Chemical vulvitis due to irritation from urine or feces

Diffuse redness

Risk factors (eg, incontinence, restriction to bed rest)

Clinical evaluation

All ages

Hypersensitivity reactions

Vulvovaginal erythema, edema, pruritus (often intense), vaginal discharge

History of recent use of hygiene sprays or perfume, bath water additives, topical treatment for candidal infections, fabric softeners, bleaches, or laundry soaps

Clinical evaluation

Trial of avoidance

Inflammatory (eg, pelvic radiation, oophorectomy, chemotherapy)

Purulent vaginal discharge, dyspareunia, dysuria, irritation

Sometimes pruritus, erythema, burning pain, mild bleeding

Thin, dry vaginal tissue

Diagnosis of exclusion based on history and risk factors

Vaginal pH >6

Negative whiff test

Granulocytes and parabasal cells seen during microscopic examination

Enteric fistulas (complication of delivery, pelvic tumors, pelvic surgery, or inflammatory bowel disease)

Malodorous vaginal discharge with passage of feces from vagina

Direct visualization or palpation of the fistula in the lower part of the vagina

Skin disorders (eg, psoriasis, lichen sclerosus, tinea versicolor)

Characteristic genital and extragenital skin findings

Clinical evaluation

*If discharge is present, microscopic examination of a saline wet mount and KOH preparation and cultures or PCR for sexually transmitted organisms are done (unless a noninfectious cause such as allergy or a foreign body is obvious).

Such inflammatory conditions are an uncommon cause of vaginitis.

KOH = K hydroxide.


Evaluation

History

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

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).


Red flags

The following findings are of particular concern:

  • Trichomonal vaginitis in children (suggesting sexual abuse)

  • Fecal discharge (suggesting a fistula, even if not seen)

  • Fever or pelvic pain

  • Bloody discharge in postmenopausal women


Interpretation of findings

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.


Testing

All patients require the following in-office testing:

  • pH

  • Wet mount

  • K hydroxide (KOH) preparation

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.


Treatment

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).

Geriatrics Essentials

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.

Key Points

  • 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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