Vulvovaginitis Clinical Presentation
- Author: Jill M Krapf, MD, FACOG; Chief Editor: Christine Isaacs, MD more...
History and Physical Examination
Acute vulvovaginal candidiasis
In acute vulvovaginal candidiasis, vulvar pruritus and burning are the main symptoms. Patients commonly complain of both symptoms after intercourse or upon urination. Dyspareunia may develop and become severe enough to lead to intolerance of intercourse.
Physical findings include erythema and edema of the vestibule and of the labia majora and minora. The rash may extend to the thighs and perineum. Thrush patches are usually found loosely adherent to the vulva. A thick, white, curdlike vaginal discharge is usually present.[21, 22, 23, 24]
Chronic vulvovaginal candidiasis
The clinical picture of chronic, persistent vulvovaginal candidiasis differs in that it includes marked edema and lichenification of the vulva with poorly defined margins. Often, a grayish sheen made up of epithelial cells and organism covers the area. Symptoms include severe pruritus, burning, irritation, and pain. Patients with chronic candidiasis are usually older and obese and often have long-standing diabetes mellitus.
Most women with mild to moderate vaginal atrophy (60-90%) are asymptomatic or have symptoms that cause no distress. Clinical symptoms include the following:
Pronounced symptoms of atrophic vaginitis generally appear only after estrogen levels have been low for an extended period of time.
Early on, women may notice a slight decrease in vaginal lubrication upon arousal, which is one of the first signs of estrogen insufficiency. As the hypoestrogenic state becomes chronic, additional symptoms arise. The most common symptom is vaginal spotting, which usually results from a break in the thin vaginal mucosa. Dyspareunia may result from ulceration of the vulvovaginal epithelium.
The vagina is noted to be thin, with occasional petechia and diffuse redness and with few or no vaginal folds. A serosanguineous discharge may be present, with a pH of 5-7. A wet mount often shows white blood cells and a paucity of Lactobacillus.
Women who are first affected are usually young, sexually active, and of Caucasian origin. Most patients have endured their symptoms for several months and have empirically tried various remedies with no improvement.
Vulvar vestibulitis can be divided into primary and secondary forms, as follows:
Primary vulvar vestibulitis (20% of cases) - Introital dyspareunia that starts from initiation of sexual activity or intolerable pain consistently present upon insertion of a tampon or vaginal speculum in women who have never been sexually active
Secondary vulvar vestibulitis - Introital dyspareunia that develops after a period of comfortable sexual relations, tampon use, or speculum examinations
Usual symptoms include pain, soreness, burning, and a feeling of rawness that is aggravated by stress, exercise, tight clothing, coitus, and tampon use. The pain is usually not considered constant but is elicited by any attempt to enter the vagina.
Many patients complain of an irritating vaginal discharge and a vulvar burning sensation. Examination may reveal small spots of erythema around the vestibular glands, with rare ulceration. Lesions are predominantly found in the lower portion of the vestibule.
Unfortunately, standard pelvic examination typically reveals no physical findings. Gentle pressure with a cotton-tipped applicator around the base of the hymenal ring and posterior fourchette usually elicits the pain.
The diagnosis usually is based on the patient's history and physical examination. Clinical symptoms consist of varying degrees of tenderness, pain, burning, and pruritus. Urinary retention may occur in severe cases.
Pruritus is the cardinal symptom. However, an acute reaction may develop as a result of exposure to a potent irritant that involves the mucosa, leading to burning, rawness, and pain. This initially presents as red and edematous skin followed by exudation and weeping, which may lead to secondary infections. The irritant also may be potent enough to cause erosion, ulceration, or necrosis.
Repetitive exposure to weak irritants with an insufficient period of healing and restoration of skin integrity between each exposure characterizes chronic contact dermatitis. Contact dermatitis of long duration may include lichenification, scaling, thickening of the skin, and white plaques.
When the mechanism is an allergen, the symptoms may not be apparent until 24-48 hours after contact, while an irritant will elicit immediate symptoms.
Chatwani AJ, Mehta R, Hassan S, Rahimi S, Jeronis S, Dandolu V. Rapid testing for vaginal yeast detection: a prospective study. Am J Obstet Gynecol. 2007 Apr. 196(4):309.e1-4. [Medline].
Donders G, Bellen G, Byttebier G, Verguts L, Hinoul P, Walckiers R, et al. Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial). Am J Obstet Gynecol. 2008 Dec. 199(6):613.e1-9. [Medline].
Katz. Vaginitis. Katz. Comprehensive Gynecology. 5th ed. Mosby; Elsevier; 2007. 588-596.
Horowitz BJ, Edelstein SW, Lippman L. Sexual transmission of Candida. Obstet Gynecol. 1987 Jun. 69(6):883-6. [Medline].
Ip WK, Lau YL. Role of mannose-binding lectin in the innate defense against Candida albicans: enhancement of complement activation, but lack of opsonic function, in phagocytosis by human dendritic cells. J Infect Dis. 2004 Aug 1. 190(3):632-40. [Medline].
Lillegard JB, Sim RB, Thorkildson P, Gates MA, Kozel TR. Recognition of Candida albicans by mannan-binding lectin in vitro and in vivo. J Infect Dis. 2006 Jun 1. 193(11):1589-97. [Medline].
Liu F, Liao Q, Liu Z. Mannose-binding lectin and vulvovaginal candidiasis. Int J Gynaecol Obstet. 2006 Jan. 92(1):43-7. [Medline].
Giraldo PC, Babula O, Gonçalves AK, Linhares IM, Amaral RL, Ledger WJ, et al. Mannose-binding lectin gene polymorphism, vulvovaginal candidiasis, and bacterial vaginosis. Obstet Gynecol. 2007 May. 109(5):1123-8. [Medline].
Fong IW. The value of treating the sexual partners of women with recurrent vaginal candidiasis with ketoconazole. Genitourin Med. 1992 Jun. 68(3):174-6. [Medline]. [Full Text].
Pandit L, Ouslander JG. Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci. 1997 Oct. 314(4):228-31. [Medline].
Pyka RE, Wilkinson EJ, Friedrich EG Jr, Croker BP. The histopathology of vulvar vestibulitis syndrome. Int J Gynecol Pathol. 1988. 7(3):249-57. [Medline].
Woodruff JD, Parmley TH. Infection of the minor vestibular gland. Obstet Gynecol. 1983 Nov. 62(5):609-12. [Medline].
Bergeron C, Moyal-Barracco M, Pelisse M, Lewin P. Vulvar vestibulitis. Lack of evidence for a human papillomavirus etiology. J Reprod Med. 1994 Dec. 39(12):936-8. [Medline].
Turner ML, Marinoff SC. Association of human papillomavirus with vulvodynia and the vulvar vestibulitis syndrome. J Reprod Med. 1988 Jun. 33(6):533-7. [Medline].
Marinoff SC, Turner ML. Vulvar vestibulitis syndrome. Dermatol Clin. 1992 Apr. 10(2):435-44. [Medline].
Westrom LV, Willen R. Vestibular nerve fiber proliferation in vulvar vestibulitis syndrome. Obstet Gynecol. 1998 Apr. 91(4):572-6. [Medline].
Szumigala JA, Alveredo R. Vulvovaginitis. Ferri. Ferri's Clinical Advisor 2009. Mosby; Elsevier; 2009. 155, 1008-1012.
Eckert LO. Clinical practice. Acute vulvovaginitis. N Engl J Med. 2006 Sep 21. 355(12):1244-52. [Medline].
Margesson LJ. Vulvar disease pearls. Dermatol Clin. 2006 Apr. 24(2):145-55, v. [Medline].
Foxman B, Muraglia R, Dietz JP, Sobel JD, Wagner J. Prevalence of recurrent vulvovaginal candidiasis in 5 European countries and the United States: results from an internet panel survey. J Low Genit Tract Dis. 2013 Jul. 17(3):340-5. [Medline].
Nyirjesy P. Vulvovaginal candidiasis and bacterial vaginosis. Infect Dis Clin North Am. 2008 Dec. 22(4):637-52, vi. [Medline].
Braverman PK. Urethritis, vulvovaginitis, and cervicitis. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Churchill Livingstone; Elsevier; 2008. 55.
Biggs WS, Williams RM. Common gynecologic infections. Prim Care. 2009 Mar. 36(1):33-51, viii. [Medline].
Johnson E, Berwald N. Evidence-based emergency medicine/rational clinical examination abstract. Diagnostic utility of physical examination, history, and laboratory evaluation in emergency department patients with vaginal complaints. Ann Emerg Med. 2008 Sep. 52(3):294-7. [Medline].
Nyirjesy P, Leigh RD, Mathew L, Lev-Sagie A, Culhane JF. Chronic vulvovaginitis in women older than 50 years: analysis of a prospective database. J Low Genit Tract Dis. 2012 Jan. 16(1):24-9. [Medline].
Halperin R, Zehavi S, Vaknin Z, Ben-Ami I, Pansky M, Schneider D. The major histopathologic characteristics in the vulvar vestibulitis syndrome. Gynecol Obstet Invest. 2005. 59(2):75-9. [Medline].
Esim Buyukbayrak E, Kars B, Karsidag AY, Karadeniz BI, Kaymaz O, Gencer S, et al. Diagnosis of vulvovaginitis: comparison of clinical and microbiological diagnosis. Arch Gynecol Obstet. 2010 Nov. 282(5):515-9. [Medline].
Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. 2006 Feb 17. 5:4. [Medline]. [Full Text].
[Guideline] Workowski KA, Berman S. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR. Dec 17 2010;59(RR-12). Centers for Disease Control and Prevention. Available at http://www.cdc.gov/std/treatment/2010/default.htm. Accessed: August 22, 2013.
Ferris DG, Francis SL, Dickman ED, Miler-Miles K, Waller JL, McClendon N. Variability of vaginal pH determination by patients and clinicians. J Am Board Fam Med. 2006 Jul-Aug. 19(4):368-73. [Medline].
Kulp JL, Chaudhry S, Wiita B, Bachmann G. The accuracy of women performing vaginal pH self-testing. J Womens Health (Larchmt). 2008 May. 17(4):523-6. [Medline].
[Guideline] Huntzinger A. Guideline Briefs. Practice American Family Physician. Nov 2006. 74.
Sobel JD, Wiesenfeld HC, Martens M, Danna P, Hooton TM, Rompalo A, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med. 2004 Aug 26. 351(9):876-83. [Medline].
Sobel JD, Chaim W. Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy. Clin Infect Dis. 1997 Apr. 24(4):649-52. [Medline].
Nachtigall LD. Use of low-dose premarin, estrace, and estring vaginally. Obstetrical and Gynecological Survey. 1998. 53(10S):62S-65S.
Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006 Oct 18. CD001500. [Medline].
The North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007 May-Jun. 14(3 pt 1):355-69; quiz 370-1. [Medline].
Henriksson L, Stjernquist M, Boquist L, Cedergren I, Selinus I. A one-year multicenter study of efficacy and safety of a continuous, low-dose, estradiol-releasing vaginal ring (Estring) in postmenopausal women with symptoms and signs of urogenital aging. Am J Obstet Gynecol. 1996 Jan. 174(1 Pt 1):85-92. [Medline].
Ayton RA, Darling GM, Murkies AL, Farrell EA, Weisberg E, Selinus I, et al. A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol. 1996 Apr. 103(4):351-8. [Medline].
Eriksen PS, Rasmussen H. Low-dose 17 beta-estradiol vaginal tablets in the treatment of atrophic vaginitis: a double-blind placebo controlled study. Eur J Obstet Gynecol Reprod Biol. 1992 Apr 21. 44(2):137-44. [Medline].
Brossfield J. Herbal Therapies for Menopause. The Resident Reporter. 2000. 5(6):26-30.
Hirata JD, Swiersz LM, Zell B, Small R, Ettinger B. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril. 1997 Dec. 68(6):981-6. [Medline].
Lieberman S. A review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause. J Womens Health. 1998 Jun. 7(5):525-9. [Medline].
Nachtigall LB, LaGrega L, Lee WW. The effects of isoflavones derived from red clover on vasomotor symptoms and endometrial thickness. 9th International Menopause Society World Congress on Menopause. 1999.
Punyahotra S, Dennerstein L, Lehert P. Menopausal experiences of Thai women. Part 1: Symptoms and their correlates. Maturitas. 1997 Jan. 26(1):1-7. [Medline].
Chen J, Geng L, Song X, Li H, Giordan N, Liao Q. Evaluation of the efficacy and safety of hyaluronic acid vaginal gel to ease vaginal dryness: a multicenter, randomized, controlled, open-label, parallel-group, clinical trial. J Sex Med. 2013 Jun. 10(6):1575-84. [Medline].
Bergeron S, Binik YM, Khalifé S, Pagidas K. Vulvar vestibulitis syndrome: a critical review. Clin J Pain. 1997 Mar. 13(1):27-42. [Medline].
Solomons CC, Melmed MH, Heitler SM. Calcium citrate for vulvar vestibulitis. A case report. J Reprod Med. 1991 Dec. 36(12):879-82. [Medline].
Horowitz BJ. Interferon therapy for condylomatous vulvitis. Obstet Gynecol. 1989 Mar. 73(3 Pt 1):446-8. [Medline].
Harris G, Horowitz B, Borgida A. Evaluation of gabapentin in the treatment of generalized vulvodynia, unprovoked. J Reprod Med. 2007 Feb. 52(2):103-6. [Medline].
Marrazzo J. Vulvovaginal candidiasis. BMJ. 2002 Sep 14. 325(7364):586. [Medline]. [Full Text].
|Butoconazole||2% cream, 5 g intravaginally for 3 days|
|Butoconazole||2% cream, 5 g (butoconazole 1-sustained release), single intravaginal application|
|Clotrimazole||1% cream, 5 g intravaginally for 7–14 days|
|Clotrimazole||100 mg vaginal tablet for 7 days|
|Clotrimazole||100 mg vaginal tablet, 2 tablets for 3 days|
|Miconazole||2% cream 5 g intravaginally for 7 days|
|Miconazole||100 mg vaginal suppository, 1 suppository for 7 days|
|Miconazole||200 mg vaginal suppository, 1 suppository for 3 days|
|Miconazole||1200 mg vaginal suppository, 1 suppository for 1 day|
|Nystatin||100,000-unit vaginal tablet, 1 tablet for 14 days|
|Tioconazole||6.5% ointment 5 g intravaginally in a single application|
|Terconazole||0.4% cream 5 g intravaginally for 7 days|
|Terconazole||0.8% cream 5 g intravaginally for 3 days|
|Terconazole||80 mg vaginal suppository, 1 suppository for 3 days|
|Fluconazole||150 mg oral tablet, 1 tablet in single dose|