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 ), 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
An intravaginal foreign body (eg, a forgotten tampon or vaginal pessary)
Etiology of Vaginal Itching and Discharge
The most common causes of vaginal itching and discharge vary by patient age (see table Some Causes of Vaginal Pruritus and Discharge Some Causes of Vaginal Pruritus 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).... read more ).
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 , 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.
Less commonly, a vaginal discharge in children results from sexual abuse Sexual abuse Child maltreatment is behavior toward a child that is outside the norms of conduct and entails substantial risk of causing physical or emotional harm. Four types of maltreatment are generally... read more .
Women of reproductive age
Vaginitis is also a common cause in women of reproductive age; it is usually infectious. The most common types are
Sometimes another infection (eg, gonorrhea Gonorrhea Gonorrhea is caused by the bacteria Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent discharge... read more , chlamydial infection) Chlamydial, Mycoplasmal, and Ureaplasmal Mucosal Infections Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis not due to gonorrhea are caused predominantly by chlamydiae and infrequently by mycoplasmas or Ureaplasma sp. Chlamydiae... read more causes a discharge. These infections often also cause pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more .
Genital herpes Genital Herpes Genital herpes is a sexually transmitted disease caused by human herpesvirus 1 or 2. It causes ulcerative genital lesions. Diagnosis is clinical with laboratory confirmation by culture, polymerase... read more sometimes causes vaginal itching but typically manifests with pain and ulceration.
Vaginitis may also result from foreign bodies (eg, a forgotten tampon). Inflammatory noninfectious vaginitis is uncommon.
In postmenopausal women Geriatrics Essentials Vaginal itching (pruritus), discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa (vaginitis), often with inflammation of the vulva (vulvovaginitis).... read more , atrophic vaginitis is a common cause.
Other causes of discharge include vaginal cancer Vaginal Cancer Vaginal cancer is usually a squamous cell carcinoma, most often occurring in women > 60. The most common symptom is abnormal vaginal bleeding. Diagnosis is by biopsy. Treatment for many small... read more , cervical cancer Cervical Cancer Cervical cancer is usually a squamous cell carcinoma caused by human papillomavirus infection; less often, it is an adenocarcinoma. Cervical neoplasia is asymptomatic; the first symptom of early... read more , and endometrial cancer Endometrial Cancer Endometrial cancer is usually endometrioid adenocarcinoma. Typically, postmenopausal vaginal bleeding occurs. Diagnosis is by biopsy. Staging is surgical. Treatment requires hysterectomy, bilateral... read more 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)
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.
Evaluation of Vaginal Itching 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 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 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).
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 Some Causes of Vaginal Pruritus 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).... read more ), 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 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 , 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 Bacterial Vaginosis (BV) Bacterial vaginosis is vaginitis due to a complex alteration of vaginal flora in which lactobacilli decrease and anaerobic pathogens overgrow. Symptoms include a gray, thin, fishy-smelling vaginal... read more produces a thin, gray discharge with a fishy odor.
A trichomonal infection Trichomoniasis Trichomoniasis is infection of the vagina or male genital tract with Trichomonas vaginalis. It can be asymptomatic or cause urethritis, vaginitis, or occasionally cystitis, epididymitis, or... read more produces a frothy, yellow-green vaginal discharge and causes vulvovaginal soreness.
Candidal vaginitis Candidal Vaginitis Candidal vaginitis is vaginal infection with Candida species, usually C. albicans. (See also Overview of Vaginitis.) Most fungal vaginitis is caused by C. albicans (candidiasis), which colonizes... read more 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 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 (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 Psoriasis Psoriasis is an inflammatory disease that manifests most commonly as well-circumscribed, erythematous papules and plaques covered with silvery scales. Multiple factors contribute, including... read more , lichen sclerosus Lichen Sclerosus Lichen sclerosus is an inflammatory dermatosis of unknown cause, possibly autoimmune, that usually affects the anogenital area. The earliest signs are skin fragility, bruising, and sometimes... read more , tinea versicolor Tinea Versicolor Tinea versicolor is skin infection with Malassezia furfur that manifests as multiple asymptomatic scaly patches varying in color from white to tan to brown to pink. Diagnosis is based on clinical... read more ), which can usually be differentiated by history and skin findings.
Discharge that is watery, bloody, or both may result from vulvar cancer Vulvar Cancer Vulvar cancer is usually a squamous cell skin cancer, most often occurring in older women. It usually manifests as a palpable lesion. Diagnosis is by biopsy. Treatment typically includes excision... read more , vaginal cancer Vaginal Cancer Vaginal cancer is usually a squamous cell carcinoma, most often occurring in women > 60. The most common symptom is abnormal vaginal bleeding. Diagnosis is by biopsy. Treatment for many small... read more , or cervical cancer Cervical Cancer Cervical cancer is usually a squamous cell carcinoma caused by human papillomavirus infection; less often, it is an adenocarcinoma. Cervical neoplasia is asymptomatic; the first symptom of early... read more ; cancers can be differentiated from vaginitis by examination and biopsy.
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.
All patients require the following in-office testing:
Potassium hydroxide (KOH) preparation
Testing for gonorrhea Diagnosis Gonorrhea is caused by the bacteria Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or conjunctivae, causing irritation or pain and purulent discharge... read more and chlamydial infections Diagnosis Sexually transmitted urethritis, cervicitis, proctitis, and pharyngitis not due to gonorrhea are caused predominantly by chlamydiae and infrequently by mycoplasmas or Ureaplasma sp. Chlamydiae... read more 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% 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).
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.
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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