eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Vulvovaginitis: Treatment & Medication
Updated: Aug 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
- Prehospital care rarely is needed.
- Some women with recurrent candidal infections opt for treatment with over-the-counter (OTC) medications that generally are highly effective for candidiasis. Preparations for intravaginal administration of butoconazole, clotrimazole, miconazole, and tioconazole are available OTC. Self-medication with OTC preparations should be advised only for women who have been diagnosed previously with vulvovaginal candidiasis and who have a recurrence of the same symptoms. Any woman whose symptoms persist after using an OTC preparation or who has a recurrence of symptoms within 2 months should seek medical care.23 Unnecessary or inappropriate use of OTC preparations is common and can lead to delay of treatment of other etiologies of vulvovaginitis that could result in adverse clinical outcomes. Studies on women treating themselves for candidiasis revealed a 28% accuracy rate.3
Emergency Department Care
- No specific ED care is needed.
- If sexual abuse of a child is suspected, call upon further resources, such as a social work and child welfare agency.
- Medical treatment should be tailored to the suspected pathogen.
Consultations
- Consultations are not necessary for most patients.
- Suspected child sexual abuse must be reported to the child welfare agency and police. Strongly consider consultation with a clinician experienced in the area of child abuse, if available.
- A patient with a vaginal foreign body that is difficult to observe or remove may require sedation or referral to a gynecologist for examination under general anesthesia.
- Patients with infections that are difficult to treat or that are recurrent occasionally require gynecologic consultation.
Medication
Treatment should be aimed at bacterial, parasitic, or fungal infection.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.25
A 7-day oral course yields a 90% cure, and single oral dose therapy yields an 80% cure. Relapses are common requiring a longer duration of treatment.26 Combinations of antibiotics have no benefit.25,26 If single oral dose therapy is ineffective, either administer a second oral dose in 48 hours or initiate weeklong therapy. Some patients prefer intravaginal medication.10 Treatment of bacterial vaginosis before 20 weeks' gestation may decrease preterm delivery.27 Only those women who are symptomatic from bacterial vaginosis should be screened.10,28,5 Topical metronidazole gel poorly achieves therapeutic concentration in the urethra and Skene's gland and therefore is not indicated in Trichomonas infections.19 Tinidazole may have less side effects than metronidazole and can be used in the rare case of metronidazole resistance.29
Metronidazole (Metro-Gel, Noritate)
Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Indicated for treatment of bacterial vaginosis (formerly referred to as Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, anaerobic vaginosis).
Adult
2 g PO once or 500 mg PO bid for 7 d for Trichomonas
For bacterial vaginosis: 500 mg PO bid for 7 d
Alternatively: Metronidazole gel 0.75%, 1 applicatorful (5 g) intravaginally qd for 5 d effective as oral metronidazole
Less efficacious (<50% cure for Trichomonas)
Pregnancy: 500 mg PO bid for 7 d or 250 mg PO tid for 7 days or 2 g PO once for T vaginalis
Pediatric
15-30 mg/kg/d PO divided bid for 7 d; not to exceed 500 mg or 40 mg/kg PO once
Alternatively: Insert 1 applicatorful as in adults
Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; avoid alcohol during treatment and 24 h after that
Documented hypersensitivity; use of alcohol
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; known or previously unrecognized vaginal candidiasis may present more prominent symptoms during metronidazole vaginal gel therapy; more than 6% of patients have developed symptomatic candidal vaginitis during or immediately after therapy
Avoid alcohol 24 h before therapy and 72 h after therapy
Penicillin VK (Veetids, Beepen-VK)
Indicated when the offending organism is group A streptococci. Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.
Adult
500 mg PO q6h for 10 d
Pediatric
<12 years: 40-50 mg/kg/d PO divided tid/qid; not to exceed 3 g/d
>12 years: Administer as in adults
Probenecid can increase penicillin effectiveness by decreasing its clearance; conversely, coadministration of tetracyclines can decrease penicillin effectiveness
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Tinidazole (Tindamax)
5-Nitroimidazole derivative used for susceptible protozoal infections. The mechanism by which tinidazole exhibits activity against Giardia and Entamoeba species is not known.
Adult
500 mg PO bid for 5 d
Alternatively, 2 g PO one dose for Trichomonas
Pediatric
<3 years: Not established
>3 years: 50 mg/kg PO qd for 3 d with food; not to exceed 2 g/dose
Limited data exist; interaction information based on experience with other nitroimidazole derivatives (ie, metronidazole); may prolong PT when coadministered with warfarin; avoid alcoholic beverages and preparations containing ethanol or propylene glycol during and 3 d following administration (may cause disulfiramlike reaction); may increase serum levels of lithium, phenytoin, cyclosporine, tacrolimus, and fluorouracil; CYP450 inducers (eg, phenobarbital, rifampin, phenytoin) may increase elimination; CYP450 inhibitors (eg, cimetidine, ketoconazole) may decrease elimination; concurrent administration with cholestyramine may decrease oral bioavailability; oxytetracycline may antagonize effect
Documented hypersensitivity; first trimester of pregnancy; breastfeeding women (recommend interruption during therapy and for 3 d following last dose)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in blood dyscrasias, organic neurological dysfunction, late trimesters of pregnancy, seizure disorders, and hepatic and renal impairment
Carcinogenicity has been observed in mice and rats treated chronically with metronidazole (another nitroimidazole), although not observed with tinidazole, use cautiously; may cause metallic/bitter taste, nausea, anorexia, vomiting, weakness, fatigue, dizziness, or headache; if administered on day of hemodialysis, administer additional dose equivalent to one-half of recommended dose following dialysis
Erythromycin (EES, E-Mycin, Ery-Tab)
DOC for penicillin-allergic patients with infections caused by susceptible strains of microorganisms, including group A streptococci. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes, which inhibits bacterial growth.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
250 mg erythromycin stearate/base, or 400 mg ethylsuccinate PO q6h 1 h ac or 500 mg q12h for 10 d
Pediatric
30-50 mg/kg/d PO divided q6-8h for 10 d, not to exceed 2 g/d; double dose for severe infections
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs
Clindamycin (C/T/S, Clinda-Derm, Cleocin HCl)
Useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition. Has a 90% cure rate and is used as an alternative to metronidazole.
Adult
Cream 2%: 1 applicatorful (5 g)intravaginally hs for 7 d
Alternatively: Administer 300 mg PO bid for 7 d or clindamycin ovules 100 g intravaginally qhs for 3 d
Pediatric
20-30 mg/kg/d PO divided tid/qid for 7 d
None reported
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid contact with eyes; vaginal cream contains ingredients that cause burning and irritation of the eye; in event of accidental contact, rinse eye with copious amounts of cool tap water; use of clindamycin vaginal cream may result in overgrowth of nonsusceptible organisms, particularly yeasts, in vagina; clindamycin cream and ovules are oil-based and might weaken latex condoms and diaphragms; antibiotic-associated colitis has been reported with both oral and topical clindamycin
Corticosteroids
These agents are used to treat extreme vaginal pruritus. Cream is for symptomatic relief, especially in pediatric vulvovaginitis.
These agents are adrenocorticosteroid derivatives incorporated into a vehicle suitable for application to skin or external mucous membranes.
Hydrocortisone (Cortef Feminine Itch, Delcort)
DOC because of its mineralocorticoid activity and glucocorticoid effects.
Primary therapeutic effects of topical corticosteroids are from their anti-inflammatory activity, which is nonspecific (ie, they act against most causes of inflammation including mechanical, chemical, microbiological, immunological).
Do not use very high or high-potency agents on the face, groin, or axilla.
Adult
Apply sparingly bid to vagina in affected areas
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Prolonged use, applying over large surface areas, applying potent steroids, and using occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Antifungal agents
These agents are used to treat candidal vulvovaginitis. Topical azole antifungals achieve cure rates of 85-95%. Nystatin demonstrates a 75-80% cure rate. Oral fluconazole has a cure rate comparable to topical azole antifungals.30 It may be preferred by patients because of the ease of one-time dosing.
Intravaginal and topical therapies with a variety of antifungals, such as clotrimazole, miconazole, terconazole, and tioconazole, are highly effective. Many of the preparations are now available OTC. 1-, 3-, and 7-day regimens can be used. Cure rates of 90% are reported with longer courses.
Butoconazole (Femstat)
Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
3-d therapy:
2% cream: Insert 5 g, 1 applicatorful, intravaginally qhs for 3 d
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes
Tioconazole (Vagistat)
Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
1-d therapy:
6.5% ointment: Insert 5 g, 1 applicatorful, intravaginally once
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes
Clotrimazole (Mycelex-7)
Broad-spectrum antifungal agents that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
1-d therapy:
500-mg tab: Insert 1 applicatorful intravaginally once
3-d therapy:
100-mg tab: Insert 2 tab intravaginally qhs for 3 d
7-d therapy:
Applicator: Insert 5 g, 1 applicatorful, of 1% vaginal cream intravaginally qhs for 7-14 d
Vaginal tab: Insert 1 tab (100 mg) intravaginally qhs for 7 d
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If irritation (5%-10% will have local burning)or sensitization occurs, discontinue use; chronic or recurrent candidiasis may be a symptom of unrecognized diabetes mellitus or a damaged immune system (including HIV infection); persistently resistant infections may be re-infections, thus evaluate sources of re-infection; if lack of response, repeat microbiologic studies to confirm diagnosis and exclude other pathogens before re-instituting antifungal therapy; do not use creams in mouth or eyes; no well-controlled studies have been performed during first trimester of pregnancy; these products may compromise condoms and diaphragms
Fluconazole (Diflucan)
Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. Consider ease of use, although direct cost may be a limiting factor. Do not recommend PO antifungals in pregnancy.
Adult
1-d therapy:
150 mg PO once may repeat on the third day if infection not improved
Pediatric
3-6 mg/kg PO qd for 14-28 d, depending on severity of infection
Levels may increase with hydrochlorothiazides; levels may decrease with chronic coadministration of rifampin; coadministration of fluconazole may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine concentrations may occur when administered concurrently
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor closely if rashes develop and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS or a malignancy and while taking multiple concomitant medications; not recommended for women who are breastfeeding
Miconazole (Monistat Vaginal)
Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
3-d therapy:
200-mg vaginal suppository: Insert 1 supp intravaginally qhs for 3 d
7-d therapy:
2% cream: Instill 5 g, 1 applicatorful, intravaginally qhs for 7 d
100-mg vaginal supp: Insert 1 supp intravaginally qhs for 7 d
Pediatric
Administer as in adults
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; adverse effects include vaginal burning, irritation, and dyspareunia
Terconazole (Terazol 3, Terazol 7)
Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
3-d therapy:
0.8% cream: Insert 5 g, 1 applicatorful, intravaginally qhs for 3 d
80-mg vaginal supp: Insert 1 supp intravaginally qhs for 3 d
7-d therapy:
0.4% cream: Insert 5 g, 1 applicatorful, intravaginally for 7 d
Tab: Insert 2 tab (100 mg each) intravaginally qhs for 3 d or a 500-mg tab intravaginally once
1% vaginal cream: Apply to external genitalia bid
Pediatric
Not established
May impair barrier contraceptives
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; high doses may cause fever or flulike symptoms
Ketoconazole (Kuric 2%, Xolegel 2%)
Broad-spectrum antifungal agents that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
2% cream: Rub gently into affected area qd/bid
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
If sensitivity or irritation develops, discontinue use; for external use only; avoid contact with eyes
Nystatin
Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death.
Adult
Insert 1 vaginal tab (100,000 U) qhs for 2 wk
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat systemic mycoses
Estrogens
These agents are used in treatment of atrophic vaginitis in postmenopausal women. Oral estrogen replacement also is effective and has other health benefits. Oral estrogen therapy generally should be initiated by a primary care provider rather than an ED clinician.
Conjugated estrogens (Premarin)
Several topical steroid preparations are available, including equine estrogen, estradiol, and dienestrol. Estrogens are indicated for atrophic vaginitis and atrophic urethritis associated with menopause.
Adult
0.3-1.25 mg PO qd, depending on tissue response of patient
Topical: Insert 2-4 g, 0.5-1 applicatorful intravaginally qhs
Recommendation: Cyclical administration consisting of 3 wk of daily estrogen and 1 wk off
Pediatric
Not established
May reduce hypoprothrombinemic effects of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins
Documented hypersensitivity; known or suspected pregnancy; breast cancer; undiagnosed abnormal genital bleeding; active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, such as abnormal or excessive uterine bleeding or mastodynia; estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia
Anthelmintics
These agents are used to treat parasitic infections. Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.
Mebendazole (Vermox)
Indicated drug to treat pinworm. Kills worms by selectively and irreversibly blocking glucose uptake and other nutrients in the susceptible adult intestine where helminths dwell.
Adult
100 mg PO once
Alternatively: Administer 100 mg PO bid on 3 consecutive days; second course may be administered if patient is not cured within 3-4 wk
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Carbamazepine and phenytoin may increase mebendazole metabolism, decreasing its efficacy; conversely, cimetidine may increase mebendazole levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in pregnancy, especially during first trimester; may need to adjust dose in hepatic impairment
Pyrantel (Pin-Rid, Pin-X, Reese Pinworm)
Used as an alternative to mebendazole; a depolarizing neuromuscular blocking agent that inhibits cholinesterases, resulting in spastic paralysis of the worm. Active against E vermicularis (ie, pinworm) and Ascaris lumbricoides (ie, roundworm). Also effective against Ancylostoma duodenale (ie, hookworm). Purging is not necessary; may be taken with milk or fruit juices.
Adult
11 mg/kg (5 mg/lb) PO not to exceed 1 g once without regard to ingestion of food or time of day
Pediatric
<2 years: Not established
>2 years: Administer as in adults
In ascariasis, pyrantel and piperazine are mutually antagonistic and should not be used concomitantly; theophylline serum levels may increase in pediatric patients following pyrantel pamoate administration
Documented hypersensitivity; hepatic disease
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in liver impairment, anemia, and malnutrition
Estrogen receptor antagonists
These agents competitively bind to estrogen receptor, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects.
Tamoxifen (Nolvadex)
May be used for women who are very concerned about estrogen exposure. Known to have both estrogen antagonist and agonist effects, depending on target tissue.
Adult
10-20 mg PO bid
Pediatric
Not established
May exacerbate hepatotoxic effects of allopurinol; may increase cyclosporine serum levels; increases anticoagulant effects of warfarin; aminoglutethimide reduces serum concentration of tamoxifen; cyclophosphamide, methotrexate, and 5-FU increase thrombotic risk of tamoxifen
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in leukopenia, thrombocytopenia, and hyperlipidemia; decreased visual acuity, corneal changes, and retinopathy may occur with >1 y of use; may induce ovulation
More on Vulvovaginitis |
| Overview: Vulvovaginitis |
| Differential Diagnoses & Workup: Vulvovaginitis |
 Treatment & Medication: Vulvovaginitis |
| Follow-up: Vulvovaginitis |
| Multimedia: Vulvovaginitis |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
vulvovaginitis, vaginitis, vaginal yeast infection, vaginosis, bacterial vaginosis, lactobacillus, inflammation of vagina, inflammation of vulva, vaginal discharge, vaginal itching, vaginal irritation, vaginal fluid, vaginal pH, Gardnerella vaginalis, G vaginalis, Staphylococcus epidermis, S epidermis, Trichomonas vaginalis, T vaginalis, vulvovaginal candidiasis, VVC, candidal vulvovaginitis, desquamative inflammatory vaginitis, atrophic vaginitis, trichomoniasis
