Vulvovaginitis

Definition

• Vulvovaginitis is inflammation of the vulva and vagina, presenting with a range of symptoms including irritation and discharge

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Differential Diagnoses

• Infectious causes

  • Candidiasis: Thick, white discharge; intense itching; may be associated with dysuria and dyspareunia

  • Bacterial vaginosis: Thin, grey discharge; fishy odour (often more pronounced after intercourse)

  • Trichomoniasis: Frothy, yellow-green discharge; vaginal irritation; possible cervical motion tenderness

• Dermatological conditions

  • Lichen sclerosus: White, atrophic patches; severe itching; potential risk for squamous cell carcinoma if untreated

  • Eczema/dermatitis: Erythema and scaling; pruritus; may be related to irritants

  • Psoriasis: Well-demarcated erythematous plaques; silvery scales; typically chronic with variable severity

• Other causes

  • Atrophic vaginitis: Due to oestrogen deficiency in postmenopausal women; dryness, itching, dyspareunia

  • Allergic or irritant reactions: Triggered by soaps, detergents, sanitary products or spermicides

  • Foreign bodies: Retained tampon or other objects causing persistent discharge and irritation

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History

• Document onset, duration and severity of symptoms

• Characterise discharge by colour, consistency and odour

• Ask about associated symptoms such as itching, burning, dyspareunia, and dysuria

• Review recent antibiotic use, new hygiene or cosmetic products, and changes in sexual activity

• Inquire about menstrual history and previous episodes of vulvovaginitis or dermatological conditions

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Examination

• Perform a thorough vulval examination to inspect for erythema, swelling, fissuring or lichenification

• Check for signs of atrophy in postmenopausal women

• Evaluate for signs of foreign bodies or trauma

• Consider a pelvic examination if deeper pathology is suspected

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Investigations

• Obtain a high vaginal swab for microscopy, culture, and nucleic acid amplification testing (NAAT) to confirm the diagnosis

• Use Gram stain for detection of clue cells in bacterial vaginosis or budding yeast and hyphae in candidiasis

• Consider pH testing of vaginal secretions (vaginal pH >4.5 supports bacterial vaginosis)

• In cases of persistent or recurrent symptoms, further evaluation including biopsy may be warranted

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Management

• General measures

  • Advise avoidance of irritants such as douches, perfumed products and tight clothing

  • Recommend the use of soap-free cleansers and loose, cotton underwear to reduce moisture

  • Instruct on gentle drying after bathing and to avoid excessive washing

• Specific treatments

  • Candidiasis: Treat with topical antifungals (e.g. clotrimazole 1% cream or pessaries for six nights) or, if severe, consider oral antifungals (fluconazole 150 mg single dose, noting contraindications in pregnancy)

  • Bacterial vaginosis: Treat with oral or topical metronidazole (400 mg twice daily for five to seven days) or clindamycin (oral or 2% cream at night for seven days)

  • Trichomoniasis: Treat with oral metronidazole (2 g single dose or 400 mg twice daily for 5–7 days); ensure partner treatment

  • Dermatological conditions: Manage with appropriate topical corticosteroids or immunomodulators as indicated

  • Atrophic vaginitis: Use topical oestrogen therapy to alleviate symptoms and improve vaginal health

• Patient education

  • Emphasise proper genital hygiene and avoidance of known irritants

  • Provide advice on lifestyle modifications to reduce recurrence

  • In cases of recurrent or persistent symptoms, consider referral for specialist evaluation

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Notes

• Confirm diagnosis with appropriate laboratory investigations including microscopy, culture, and NAAT before initiating treatment

• Persistent or recurrent symptoms warrant further evaluation to rule out alternative or coexisting pathology

• Treatment choices may be influenced by patient preference, cost considerations, and pregnancy status

• Individualised treatment plans are essential for optimal patient outcomes and long-term symptom control