What are the symptoms and treatment options for vulvovaginitis?

Symptoms and Treatment of Vulvovaginitis

The typical symptoms of vulvovaginitis include pruritus (itching), vaginal discharge, vaginal soreness, vulvar burning, dyspareunia (painful intercourse), and external dysuria (painful urination). 1

Common Symptoms

• Pruritus (itching) in the vulvovaginal area is the most characteristic symptom 1
• Vaginal discharge, which varies depending on the cause 1
• Vaginal soreness and vulvar burning 1
• Dyspareunia (painful sexual intercourse) 1
• External dysuria (pain during urination) 1
• Erythema (redness) in the vulvovaginal area 1
• Vulvar irritation, especially with trichomoniasis 1

Types of Vulvovaginitis and Their Specific Symptoms

Vulvovaginal Candidiasis (VVC)

• White, thick discharge that may resemble cottage cheese 1
• Normal vaginal pH (≤4.5) 1
• Intense vulvar itching and burning 1
• Erythema and swelling of vulvovaginal tissues 1
• Affects approximately 75% of women at least once in their lifetime 1

Bacterial Vaginosis

• Milky, homogeneous discharge 2
• Fishy odor, especially after sexual intercourse or with alkaline substances 2
• Vaginal pH greater than 4.5 2
• Positive "whiff test" (fishy odor when 10% KOH is added to discharge) 2
• Presence of "clue cells" on microscopic examination 2

Trichomoniasis

• Diffuse, malodorous, yellow-green discharge 1
• Vulvar irritation 1
• Frothy discharge in some cases 3
• Vaginal inflammatory changes 3
• Vaginal pH greater than 5.4 2

Diagnosis

• Clinical diagnosis is based on symptoms and physical examination findings 1
• Microscopic examination of vaginal secretions:
  • For candidiasis: 10-20% potassium hydroxide (KOH) preparation showing yeast forms or pseudohyphae 1
  • For bacterial vaginosis: Clue cells on wet mount 2
  • For trichomoniasis: Motile trichomonads on saline wet mount 1, 3
• Vaginal pH testing (normal: ≤4.5; elevated in bacterial vaginosis and trichomoniasis) 1, 2
• Culture may be necessary for recurrent or complicated cases to identify specific pathogens 3

Treatment Options

For Vulvovaginal Candidiasis:

Uncomplicated VVC:

• Topical azoles (available over-the-counter):
  • Butoconazole 2% cream for 3 days 1
  • Clotrimazole 1% cream for 7-14 days or 100mg vaginal tablets for 7 days 1
  • Miconazole 2% cream for 7 days or 200mg vaginal suppository for 3 days 1
  • Tioconazole 6.5% ointment as single application 1
• Oral option: Fluconazole 150mg as a single dose 1, 4

Complicated VVC (recurrent, severe, or non-albicans):

• Longer initial therapy (7-14 days of topical therapy or fluconazole 150mg repeated after 3 days) 1
• Maintenance regimens for recurrent cases (defined as ≥4 episodes per year):
  • Clotrimazole 500mg vaginal suppositories once weekly 1
  • Fluconazole 100-150mg once weekly 1
  • Itraconazole 400mg once monthly or 100mg daily 1
  • Continue maintenance therapy for 6 months 1

For Bacterial Vaginosis:

• Oral metronidazole 500mg twice daily for 7 days 3, 5
• Topical clindamycin or metronidazole are alternatives 2

For Trichomoniasis:

• Oral metronidazole 2g as a single dose 1, 5
• Treatment of sexual partners is essential to prevent reinfection 1
• Avoid sexual intercourse until both partners are cured 1

Special Considerations

• Pregnant women with VVC should only use 7-day topical azole therapies 1
• HIV-infected women should receive the same treatment as non-HIV-infected women 1
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC experiencing the same symptoms 1
• Patients should return for follow-up only if symptoms persist or recur within 2 months 1
• Treatment of sexual partners is generally not recommended for VVC but may be considered for women with recurrent infection 1

Common Pitfalls and Caveats

• Unnecessary or inappropriate use of OTC preparations can delay proper diagnosis and treatment of other causes of vulvovaginitis 1
• Non-albicans Candida species (found in 10-20% of recurrent VVC cases) may not respond well to conventional treatments 1
• Patients taking oral azoles should be aware of potential drug interactions with medications like astemizole, cisapride, and certain anticoagulants 1
• Rare hepatotoxicity can occur with long-term ketoconazole use (1 in 10,000-15,000 persons) 1
• Despite appropriate treatment, 30-40% of women with recurrent VVC will experience recurrence after maintenance therapy is discontinued 1