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Vaginal Itching and Discharge

By

David H. Barad

, MD, MS, Center for Human Reproduction

Last full review/revision Mar 2020| Content last modified Mar 2020
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Vaginal itching (pruritus), discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa (vaginitis Overview of Vaginitis Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema... read more Overview of 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 of Vaginal Itching and Discharge

Some vaginal discharge is normal, particularly when estrogen levels are high. Estrogen levels are high in the following situations:

  • A few days before ovulation

  • During the first 2 weeks of life (because maternal estrogens are transferred before birth)

  • During the few months before menarche and during pregnancy (when estrogen production increases)

  • 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 species 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

  • An intravaginal foreign body (eg, a forgotten tampon or vaginal pessary)

Etiology of Vaginal Itching and Discharge

Children

In children, a common cause is vaginitis Overview of Vaginitis Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema... read more Overview of Vaginitis , usually due to infection with gastrointestinal (GI) tract flora (nonspecific vulvovaginitis). A common contributing factor in girls aged 2 to 6 years 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 also a common cause in women of reproductive age; it is usually infectious. The most common types are

Vaginitis may also result from foreign bodies (eg, a forgotten tampon). Inflammatory noninfectious vaginitis is uncommon.

Postmenopausal women

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)

  • 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.

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Evaluation of Vaginal Itching and Discharge

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 the following:

  • Fever or chills and abdominal or suprapubic pain: Pelvic inflammatory disease (PID) or cystitis

  • Polyuria and polydipsia: New-onset diabetes

Past medical history should note risk factors for the following:

  • Candidal infection (eg, recent antibiotic use, diabetes, HIV infection, other immunosuppressive disorders)

  • Fistulas (eg, Crohn disease, genitourinary or gastrointestinal cancer, pelvic or rectal surgery, lacerations during delivery)

  • Sexually transmitted diseases (eg, unprotected intercourse, multiple partners)

If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced event and improves the quality of information obtained.

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

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 Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include vaginal discharge, vaginal bleeding, and cervical erythema and friability. Women are tested for infectious... read more 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:

Contact irritant or allergic reactions cause significant irritation and inflammation with comparatively minimal discharge.

In atrophic vaginitis, discharge is scant and may be watery and thin or thick and yellowish. Dyspareunia is common, and vaginal tissue appears thin and dry.

Testing

All patients require the following in-office testing:

  • pH

  • Wet mount

  • Potassium hydroxide (KOH) preparation

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% sodium chloride 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 of Vaginal Itching and Discharge

Any specific cause of the itching or discharge 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. Flushing the genital area with lukewarm water may also provide relief. If chronic vulvar inflammation is due to being bedbound or incontinent, better vulvar hygiene may help.

Women should be advised not use douches.

If symptoms are moderate or severe or do not respond to other measures, drugs may be needed. For pruritus, topical corticosteroids (eg, 1% hydrocortisone twice a day as needed) 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 is scant and 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 symptoms related to itching and/or discharge are often nonspecific.

  • Causes of vaginal pruritus and itching vary depending on the patient’s age.

  • For most patients, measure vaginal pH and obtain a sample of secretions for microscopic examination and testing; if needed, do culture for sexually transmitted organisms.

  • In postmenopausal women, promptly evaluate any vaginal discharge.

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