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Vulvovaginitis Clinical Presentation

  • Author: Jill M Krapf, MD, FACOG; Chief Editor: Christine Isaacs, MD  more...
 
Updated: Mar 29, 2015
 

History and Physical Examination

Vulvovaginal candidiasis

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.[25]

Atrophic vaginitis

Most women with mild to moderate vaginal atrophy (60-90%) are asymptomatic or have symptoms that cause no distress. Clinical symptoms include the following:

  • Vaginal soreness
  • Postcoital burning
  • Dyspareunia
  • Burning leukorrhea
  • Occasional spotting

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.

Vulvar vestibulitis

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.[26]

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.

Contact dermatitis

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.

 
 
Contributor Information and Disclosures
Author

Jill M Krapf, MD, FACOG Assistant Professor, Department of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences; Assistant Director, Obstetrics and Gynecology Clerkship, Center for Sexual Health, Women’s Services

Jill M Krapf, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, American Congress of Obstetricians and Gynecologists, International Society for the Study of Women’s Sexual Health

Disclosure: Nothing to disclose.

Specialty Editor Board

Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Chief Editor

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Acknowledgements

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Emergency Medicine Residency Program Director Emeritus, Head, Phemister Society, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Reza Keshavarz, MD, MPH Clinical Assistant Professor, Departments of Pediatrics and Emergency Medicine, Mount Sinai School of Medicine; Director of Pediatric Emergency Medicine, Mount Sinai Hospital

Disclosure: Nothing to disclose.

Mark J Leber, MD, MPH Assistant Professor of Emergency Medicine in Clinical Medicine, Weill Cornell Medical College; Attending Physician, Lincoln Medical and Mental Health Center

Mark J Leber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians

Disclosure: Nothing to disclose.

Deslyn M Mancini, MD Instructor, Department of Obstetrics and Gynecology, MCP Hahnemann University

Disclosure: Nothing to disclose.

Bruce A Meyer, MD, MBA Executive Vice President for Health System Affairs, Executive Director, Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School

Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Omnia M Samra-Latif, MD Clinical Faculty, Department of Obstetrics and Gynecology, Robert Wood Johnson University, Hamilton Hospital

Omnia M Samra-Latif, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Anuritha Tirumani, MD Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center

Disclosure: Nothing to disclose.

Ellen Wood, DO, FACOOG Voluntary Assistant Professor, University of Miami, Leonard M Miller School of Medicine

Ellen Wood, DO, FACOOG is a member of the following medical societies: American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

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Candida albicans photomicrograph. Courtesy of Centers for Disease Control and Prevention (CDC).
Table 1. Suggested Treatment Options as Cited in the US Centers for Disease Control and Prevention (CDC) Guidelines for Treatment
Option Treatment
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
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