Vulvovaginitis in Emergency Medicine Clinical Presentation

  • Author: Mark J Leber, MD, MPH; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Apr 16, 2012
 

History

Different historical aspects should be ascertained depending on what vulvovaginitis category the patient may have.

  • Premenarchal[8]
    • Wiping the anus from posterior to anterior, wearing tight-fitting synthetic undergarments, and using vaginal irritants such as bubble baths
    • Recent upper respiratory infection or pharyngitis can lead to group A beta-hemolytic streptococci (GABHS) vaginitis.[8]
    • Vaginal pruritus, especially at night, suggests pinworm infection.[8, 13]
    • Itching, soreness, bleeding, and vaginal discharge; bloody and foul-smelling discharge may suggest a vaginal foreign body.
    • Vulvovaginitis may be secondary to sexual abuse of the child. Parents often equate vulvovaginitis with abuse, although this is not justified in most cases.
    • Asymptomatic vaginal discharge often occurs in the months prior to menarche and represents a physiologic response to increasing estrogen levels.
    • Skin conditions (ie, eczema, psoriasis, seborrhea) occasionally involve the vagina, and a history of these conditions should be sought.
  • In obtaining a history of women in childbearing age, record a complete sexual history, last menstrual period, number of sexual partners, and methods of birth control. A new sexual partner increases the risk of STD and pregnancy. Inquire about antibiotics, high estrogen oral contraceptive pills, and any abdominal pain; ask about the patient's hygienic practices (daily use of panty liners and feminine products).[3]
    • Irritants such as soaps, baths, spermicides, perfumes, douches, and creams can cause vulvovaginitis. Tight-fitting, synthetic undergarments can increase moisture, exacerbating this condition.[8]
    • Vulvovaginitis is usually related to infections secondary to Gardnerella, Trichomonas, or Candida species. Vaginal discharge, pruritus, burning sensation, foul-smelling odor, superficial dyspareunia, and dysuria may be the presenting complaint.[4] With candidiasis, the patient may describe a thick, white, cottage cheese–like discharge associated with pruritus.[8, 10, 3]
  • Inquire about social stressors including homelessness, threats to personal safety, and insufficient resources, which appear to increase the risk.[3]
  • In postmenopausal women, inquire about vaginal bleeding or spotting, dysuria, pruritus, watery discharge, or dyspareunia and decreased sexual activity.
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Physical

  • Premenarchal
    • Genital examination of a prepubertal girl may produce a great deal of anxiety. Explaining the examination to the child and parent, keeping the parent at the patient's side, and explaining the difference between allowing a clinician or anyone else to examine her genitals may make the examination less traumatic. Sedation rarely is necessary.[14]
    • Cultures are not necessary most of the time. History and physical examination should indicate when to obtain a culture from the patient. If there is a history of trauma, sexual abuse, or vaginal discharge, then endocervical and urethral specimens should be obtained. Urine specimens are not as accurate.[8] Only cultures are accepted and not nucleic acid amplification techniques (NAAT) as legal evidence of child sexual abuse.[8]
  • Childbearing age
    • A complete pelvic examination is needed to evaluate possible upper genital tract infection.
    • Specific clinical descriptions and physical examination findings have been described for each of the 3 etiologies (Gardnerella, Trichomonas, and Candida species), yet these often overlap.
    • More than one infection may be present simultaneously. This usually necessitates additional diagnostic testing to confirm the diagnosis.
    • Pathologic vaginal discharge may be odor producing and may adhere to the vaginal walls, unlike odorless physiologic discharge found in the dependent areas of the vagina.
    • Bacterial vaginosis typically presents with an unpleasant fishy-smelling discharge that is more noticeable after unprotected intercourse.[9] A thin, gray-white vaginal discharge that is homogeneous may adhere to the vaginal walls and be present at the introitus. The discharge is usually moderate to profuse.[15] Pruritus and inflammation are unusual in bacterial vaginosis. The absence of inflammation is the basis for the term vaginosis rather than vaginitis.[10, 6]
    • Trichomonal infection may be asymptomatic or may produce a profuse, frothy, yellow-gray, homogenous discharge.[15] This discharge may adhere to the vaginal walls and may not be present at the vaginal introitus. In contrast to bacterial vaginosis, vulvar and vaginal erythema and edema with Trichomonas species often are present. Punctate hemorrhages may be visible on the vagina and cervix (2% of cases).[8, 3, 9]
    • Candida species infection typically is found as an isolated infection, heralded by pruritus. A thick, odorless, white, cottage cheese–like discharge often is found adhering to the vagina.[10, 2, 15] Erythema, edema, and excoriation may be present. Dysuria and urinary frequency occasionally may be present. Candida can occur in women who are not sexually active.[8]
  • Postmenarchal[7]
    • Vaginal mucosa is thin with diffuse erythema, occasional petechiae or ecchymoses, and few or no vaginal folds.
    • Hair loss may occur over the mons and labia majora.
    • Loss of rugae may occur.
    • Thinned mucosa may become friable.
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Causes

  • Premenarchal[8, 4]
    • Nonspecific - No defined etiologic agent or poor perineal hygiene
    • Chemical irritants (eg, bubble baths, lotions)
    • Vaginal foreign bodies
    • Pinworm infection
    • GABHS infection
    • Skin conditions - Eczema, psoriasis, seborrhea
    • Etiologies usually associated with women of childbearing age - Bacterial vaginosis, Trichomonas species, Candida species, and gonorrhea (Many of these are associated with sexual abuse.)
  • Childbearing age
    • Sexual contact especially with multiple sexual contacts
    • No method of birth control
    • History of STD
    • Bacterial or fungal infections such as G vaginalis (bacterial vaginosis), Candida species, and Trichomonas species
    • Chemical irritants[8]
    • Recent broad-spectrum antibiotics such as tetracycline, ampicillin, and cephalosporins
    • Pregnancy
  • Postmenarchal - Atrophic vaginitis (most common cause of vulvovaginitis in postmenarchal women)
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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

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.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Reza Keshavarz, MD, to the development and writing of this article.

References

  1. B Angotti L, C Lambert L, E Soper D. Vaginitis: making sense of over-the-counter treatment options. Infect Dis Obstet Gynecol. 2007;2007:97424. [Medline].

  2. Nyirjesy P. Vulvovaginal candidiasis and bacterial vaginosis. Infect Dis Clin North Am. Dec 2008;22(4):637-52, vi. [Medline].

  3. Katz. Vaginitis. In: Mosby. Katz:Comprehensive Gynecology. 5th ed. Elsevier; 2007:588-596.

  4. Szumigala JA, Alveredo R. Vulvovaginitis. In: Mosby. Ferri: Ferri's Clinical Advisor 2009. ed. Elsevier; 2009:155,1008-1012.

  5. [Guideline] Workowski KA, Berman SM. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. 2009;[Full Text].

  6. Eckert LO. Clinical practice. Acute vulvovaginitis. N Engl J Med. Sep 21 2006;355(12):1244-52. [Medline].

  7. Margesson LJ. Vulvar disease pearls. Dermatol Clin. Apr 2006;24(2):145-55, v. [Medline].

  8. Braverman Paula k. Urethritis, Vulvovaginitis, and Cervicitis. In: Churchill Livingstone. Principals and Practice of Pediatric Infectious Diseases. 3rd ed. Elsevier; 2008:55.

  9. Farage MA, Miller KW, Ledger WJ. Determining the cause of vulvovaginal symptoms. Obstet Gynecol Surv. Jul 2008;63(7):445-64. [Medline].

  10. Biggs WS, Williams RM. Common gynecologic infections. Prim Care. Mar 2009;36(1):33-51, viii. [Medline].

  11. Hampton T. High prevalence of lesser-known STDs. JAMA. Jun 7 2006;295(21):2467. [Medline].

  12. Helms DJ, Mosure DJ, Metcalf CA, Douglas JM Jr, Malotte CK, Paul SM, et al. Risk factors for prevalent and incident Trichomonas vaginalis among women attending three sexually transmitted disease clinics. Sex Transm Dis. May 2008;35(5):484-8. [Medline].

  13. Jasper J. Vulvovaginitis in the prepubertal child. Clin Pediatr Emerg Med. Mar 2009;10.

  14. Freeto JP, Jay MS. "What's really going on down there?" A practical approach to the adolescent who has gynecologic complaints. Pediatr Clin North Am. Jun 2006;53(3):529-45, viii. [Medline].

  15. 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. Sep 2008;52(3):294-7. [Medline].

  16. 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. Jul-Aug 2006;19(4):368-73. [Medline].

  17. Kulp JL, Chaudhry S, Wiita B, Bachmann G. The accuracy of women performing vaginal pH self-testing. J Womens Health (Larchmt). May 2008;17(4):523-6. [Medline].

  18. 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. Apr 2007;196(4):309.e1-4. [Medline].

  19. Hollier LM, Workowski K. Treatment of sexually transmitted infections in women. Infect Dis Clin North Am. Dec 2008;22(4):665-91, vi. [Medline].

  20. Pillay A, Radebe F, Fehler G, Htun Y, Ballard RC. Comparison of a TaqMan-based real-time polymerase chain reaction with conventional tests for the detection of Trichomonas vaginalis. Sex Transm Infect. Apr 2007;83(2):126-9. [Medline].

  21. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. Feb 17 2006;5:4. [Medline].

  22. Heller DS, Maslyak S, Skurnick J. Is the presence of Trichomonas on a Pap smear associated with an increased incidence of bacterial vaginosis?. J Low Genit Tract Dis. Jul 2006;10(3):137-9. [Medline].

  23. [Guideline] Huntzinger A. Practice Guideline Briefs. American Family Physician. Nov 2006;74.

  24. Mania-Pramanik J, Kerkar SC, Mehta PB, Potdar S, Salvi VS. Use of vaginal pH in diagnosis of infections and its association with reproductive manifestations. J Clin Lab Anal. 2008;22(5):375-9. [Medline].

  25. Schwebke JR, Desmond R. A randomized trial of metronidazole in asymptomatic bacterial vaginosis to prevent the acquisition of sexually transmitted diseases. Am J Obstet Gynecol. Jun 2007;196(6):517.e1-6. [Medline].

  26. Schwebke JR, Desmond RA. A randomized trial of the duration of therapy with metronidazole plus or minus azithromycin for treatment of symptomatic bacterial vaginosis. Clin Infect Dis. Jan 15 2007;44(2):213-9. [Medline].

  27. Swadpanich U, Lumbiganon P, Prasertcharoensook W, Laopaiboon M. Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery. Cochrane Database Syst Rev. Apr 16 2008;CD006178. [Medline].

  28. Carey JC, Klebanoff MA, Hauth JC, et al. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. Feb 24 2000;342(8):534-40. [Medline].

  29. Nailor MD, Sobel JD. Tinidazole for the treatment of vaginal infections. Expert Opin Investig Drugs. May 2007;16(5):743-51. [Medline].

  30. Marrazzo J. Vulvovaginal candidiasis. BMJ. Sep 14 2002;325(7363):586. [Medline].

  31. Mann JR, McDermott S, Zhou L, Barnes TL, Hardin J. Treatment of trichomoniasis in pregnancy and preterm birth: an observational study. J Womens Health (Larchmt). Apr 2009;18(4):493-7. [Medline].

  32. [Best Evidence] Buckling J. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst. Rev. 2006;4:[Medline].

  33. 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. Dec 2008;199(6):613.e1-9. [Medline].

  34. Van Der Pol B, Kwok C, Pierre-Louis B, Rinaldi A, Salata RA, Chen PL, et al. Trichomonas vaginalis infection and human immunodeficiency virus acquisition in African women. J Infect Dis. Feb 15 2008;197(4):548-54. [Medline].

  35. Gabbe SG. Vaginal infections. In: Obstetrics - Normal and Problem Pregnancies. 4th ed. 2002.

  36. Johns Hopkins. Diagnostic features and management of vaginal infections. In: The Harriet Lane Handbook: A Manual for Pediatric House Officers. 17th ed. 2005.

  37. Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. Dec 1 2004;70(11):2125-32. [Medline].

  38. Sobel JD. Vaginitis, vulvitis, cervicitis and cutaneous vulval lesions. In: Infectious Diseases. 2nd ed. Cohen & Powderly; 2004.

 
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The photomicrograph reveals bacteria adhering to vaginal epithelial cells known as clue cells. The presence of clue cells is a sign that the patient has bacterial vaginosis. Source CDC Phil/ M.Rein.
Candida albicans photomicrograph. Source CDC.
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