From the Guidelines
Vulvobaginitis should be treated based on the underlying cause, with Candida vulvovaginitis responding well to fluconazole 150mg as a single oral dose or topical antifungals like clotrimazole 1% cream applied to the vulva and vagina for 7 days, as recommended by the 2021 Centers for Disease Control and Prevention guidelines 1.
Diagnosis and Treatment
The diagnosis of vulvovaginitis can be challenging due to the limitations of current diagnostic methods, including microscopy and clinical suspicion, which have poor sensitivity, and yeast cultures, which can lead to a delay in diagnosis and treatment 1. However, molecular testing, such as polymerase chain reaction (PCR), has been shown to have high clinical accuracy for the diagnosis of vulvovaginal candidiasis, with a sensitivity of 90.9% and specificity of 94.1% 1.
Treatment Options
The treatment of vulvovaginitis depends on the underlying cause, with the following options available:
- For Candida vulvovaginitis:
- For bacterial vaginosis:
- Metronidazole 500mg orally twice daily for 7 days or metronidazole gel 0.75% intravaginally once daily for 5 days
- For trichomoniasis:
- Metronidazole 2g as a single oral dose or 500mg twice daily for 7 days
Prevention and Maintenance
To prevent recurrent vulvovaginitis, it is essential to maintain good hygiene without overwashing, avoid irritants such as soaps and douches, and wear cotton underwear 1. Additionally, patients should complete the full course of prescribed medications even if symptoms improve quickly to prevent recurrence and antibiotic resistance.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Definition and Causes of Vulvovaginitis
- Vulvovaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning 2
- The most common causes of vulvovaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis, accounting for 40% to 50%, 20% to 25%, and 15% to 20% of cases, respectively 2
- Noninfectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis, are less common and account for 5% to 10% of vaginitis cases 2
Diagnosis of Vulvovaginitis
- Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing 2
- Bacterial vaginosis is traditionally diagnosed with Amsel criteria, although Gram stain is the diagnostic standard 2
- Newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity have similar sensitivity and specificity to Gram stain 2
- The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available 2
Treatment of Vulvovaginitis
- Bacterial vaginosis is treated with oral metronidazole, intravaginal metronidazole, or intravaginal clindamycin 2, 3
- The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available 2
- Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy 2, 4
- Trichomoniasis is treated with oral metronidazole or tinidazole, and patients' sex partners should be treated as well 2, 4
Recurrent and Resistant Cases
- Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year 4
- Treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months 4
- Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis 4
- Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences 4, 3