1 of 27

Vulvovaginal Disease|

Vulvovaginitis

​

​

​

2 of 27

BACKGROUND

VULVOVAGINITIS

  • Inflammation of the vulva and/or vagina
  • Can be infectious or non-infectious etiology
  • Commonly presents with vulvar/vaginal pain, irritation, erythema, and vaginal discharge.

2

3 of 27

DIFFERENTIAL DIAGNOSIS

INFECTIOUS CAUSES

  • Bacterial Vaginosis
  • Vulvovaginal Candidiasis
  • Trichomoniasis
  • Cervicitis: Chlamydia or Gonorrhea
  • Post-operative

NON-INFECTIOUS CAUSES

  • Normal Vaginal Discharge
  • Genitourinary Syndrome of Menopause
  • Foreign Body
  • Antibiotic use
  • Pregnancy
  • Sexual activity
  • Dermatoses
  • Systemic Medical Condition
  • Contraceptive Use
  • Desquamative Inflammatory Vaginitis

3

4 of 27

HISTORY

HPI

  • Characteristics of discharge
    • Quantity, colour, odour, consistency.
  • Associated symptoms
    • Pelvic pain, bleeding
    • Vulvar/vaginal pain
    • Lesions/dermatoses

​

  • Systemic symptoms
    • Fevers, chills
  • Duration of symptoms
  • Provoking/inciting factors
    • Sexual activity, antibiotic use, menses
  • Any previous episodes

What do you want to know on history?

4

5 of 27

HISTORY

  • MEDICAL HISTORY
    • Diabetes, other systemic diseases
  • SURGICAL HISTORY
  • OBGYN HISTORY
    • Obstetrical history
    • Previous STIs
    • Contraceptive use
    • Menstrual history and menopausal status
  • MEDICATIONS
    • Antibiotic use
  • ALLERGIES
  • FAMILY HISTORY
  • SOCIAL HISTORY
    • Sexual History
    • Smoking, EtOH
    • Drug use

What do you want to know on history?

5

6 of 27

PHYSICAL EXAM

What should you look for on exam?

6

    • Discharge
    • Erythema
    • Dermatoses

EXTERNAL VULVAR EXAM

    • Discharge characteristics and location
    • Look at vagina and cervix for erythema, edema
    • Discrete lesions

SPECULUM EXAM

    • Tenderness
    • Masses

BIMANUAL EXAM

    • Consider additional exam for other features of systemic disease or dernatosis depending on clinical context

PERIPHERY

    • Vitals
    • Well or unwell?

GENERAL

7 of 27

INVESTIGATIONS

  • VAGINAL SAMPLES
    • pH (normal 3.8 to 4.5)
    • KOH Whiff test
    • Wet mount microscopy
    • Vaginal swab for culture
      • BV, Trichomonas, yeast
    • Cervical swab or first catch urine for NAAT
      • If suspects STI/Chlamydia and Gonorrhea
  • LABS
    • Usually not needed

What investigations should you order?

7

8 of 27

Interpretation

​

​

9 of 27

CASE

9

  • 35 Year-old woman
  • Gravidity: 2
  • Para: 2
  • Presents with vaginal discharge
  • Vitals
    • HR 74
    • 119/77
    • Temp 36.8 degrees
  • HPI
    • Copious thin discharge, clear, present for the past few weeks
    • No pain, bleeding, associated symptoms.
    • No systemic symptoms
    • Multiple previous episodes, but has not seen medical professional for diagnosis
    • Provoked by sexual activity
  • Medical history: healthy, no surgeries
  • OBGYN history
    • 2 previous SVDs, uncomplicated
    • No previous STIs
    • Partner has vasectomy for contraception
    • Normal menses, 28 day cycle
  • Medications: none
  • Allergies: none
  • Family history: none
  • Social history: no new sexual partners

10 of 27

CASE

10

  • 35 Year-old woman
  • Gravidity: 2
  • Para: 2
  • Presents with vaginal discharge
  • Vitals
    • HR 74
    • 119/77
    • Temp 36.8 degrees
  • Exam
    • Systemically well
    • External vulvar exam normal
      • Copious clear/white discharge present
      • No erythema of vaginal mucosa nor cervix noted
    • Bimanual
      • Non-tender, no masses
  • Investigations
    • Vaginal sample
      • pH: 4.8
      • Wet mount microscopy: clue cells noted
      • Positive Whiff test

11 of 27

Most likely diagnosis?

BACTERIAL VAGINOSIS!

12 of 27

BACTERIAL VAGINOSIS (BV)

Bacterial Vaginosis (BV), is the most common cause of vaginitis, vaginal discharge and odour in premenopausal women.

​

Cause: reduction in normal vaginal lactobacillus, resulting in overgrowth of normal vaginal flora, including Gardnerella sp., Mobiluncus sp., Bacteroides sp., Prevotella, and Mycoplasma sp.

​

Risk Factors: Race (Black), smoker, vaginal douching, and sexual activity.

12

13 of 27

BACTERIAL VAGINOSIS (BV)

Treatment:

  • Only treat if patient is symptomatic!
  • Regimen:
    • Metronidazole 500 mg 2 times/day for 7 days
    • Metronidazole gel 0.75% 1 full applicator intravaginally once daily for 5 days
    • Clindamycin cream 2% 1 full applicator intravaginally at bedtime for 7 days
  • Pregnancy
    • Only oral treatment should be used
  • Recurrent BV
    • Often need longer courses, 10-14 days

​

Prevention:

  • Condom use!
  • More data needed to support prevention via probiotics and intravaginal vitamin C

​

New England Journal Medicine 2025 – Male-Partner Treatment to Prevent Recurrence of Bacterial Vaginosis

​

“The addition of combined oral and topical antimicrobial therapy for male partners to treatment of women for bacterial vaginosis resulted in a lower rate of recurrence of bacterial vaginosis within 12 weeks than standard care”

13

14 of 27

VULVOVAGINAL CANDIDIASIS (VVC)

Up to 75% of women have Vulvovaginal Candidiasis (VVC) at least once in their lifetime.

​

Cause: most commonly Candida Albicans; other Non-Albicans rare, include Candida Glabrata, Candida Parapsilosis, and Candida Tropicalis.

​

Risk Factors: sexual activity, recent antibiotic use, pregnancy, immunosuppression (i.e. HIV, Diabetes)

14

15 of 27

VULVOVAGINAL CANDIDIASIS (VVC)

Diagnosis:

  • Usually clinical diagnosis:
    • Thick, white discharge like cottage cheese, with associated pruritus, burning, pain, and vulvar/vaginal erythema/edema
    • pH normal, and pseudohyphae on microscopy (usually not done)
  • If complicated infection is suspected, culture should be done to confirm diagnosis and rule out non-albicans species

​

Complicated Infection:

  • >4 in 1 year
  • Severe symptoms
  • Non-albicans species
  • Immunocompromised

15

16 of 27

VULVOVAGINAL CANDIDIASIS (VVC)

Treatment:

  • Again, only treat if symptomatic!
  • Many over the counter topical/intravaginal antifungals available
  • Oral fluconazole 150 mg once also OTC
  • Pregnancy
    • Only topical treatments recommended
  • Recurrent
    • Can involve induction, followed by weekly antifungal maintenance therapy for at least 6 months
  • Non-albicans
    • Different therapies recommended, including boric acid inserts, amphotericin B or nystatin suppositories

16

17 of 27

TRICHOMONIASIS

Non-reportable sexually transmitted infection; most common non-viral STI

​

Cause: Trichomonas vaginalis, an anaerobic protozoan parasite that is flagellated.

​

Risk factors: Other STIs, multiple sexual partners, previous STI, partner with STI.

​

17

18 of 27

TRICHOMONIASIS

Symptoms/signs:

  • Up to 90% asymptomatic;
  • Large volume green/yellow frothy vaginal discharge, malodorous.
  • Seen with vaginal erythema, hemorrhagic spots on genital mucosa and cervix (strawberry cervix)

​

Diagnosis:

  • Laboratory diagnosis
    • Vaginal culture, or NAAT
  • Wet mount: motile parasite seen

18

19 of 27

TRICHOMONIASIS

Treatment:

  • Metronidazole 2 g oral once; or 500 mg 2 times per day for 7 days
  • Alternative: tinidazole 2 g oral once
    • Recommended if resistant disease
  • Partner must receive treatment; do not need partner testing pretreatment
    • Abstinence recommended until treatment complete and symptoms resolve

19

20 of 27

SEXUALLY TRANSMITTED CERVICITIS

Neisseria Gonorrhoeae

  • Gram negative coccobacillus

​

Chlamydia trachomatis

  • Obligate intracellular pathogen
  • Most common reportable STI

​

Diagnosis

  • Cervical swab with NAAT
  • First catch urine NAAT

​

Treatment

  • Ceftriaxone 500 mg IM once and azithromycin 1 g PO once
  • Reportable; require partner treatment

​

Sequelae

  • Infertility, ectopic pregnancy, chronic pelvic pain

20

21 of 27

MCQ!

QUESTION 1

​

You are seeing a 23 year old G0 female for chief complaint of vaginal discharge. She denies pelvic pain and associated symptoms. She is otherwise healthy, takes an oral contraceptive pill, is sexually active and has no history of STI.

​

On exam, her external genitalia appears normal. You notice clear thin vaginal discharge present.

pH 4.1. Normal epithelial cells on microscopy. Negative Whiff test.

You collect swabs and they are pending.

​

What is the most likely diagnosis?

​

  1. Bacterial vaginosis
  2. Vulvovaginal candidiasis
  3. Trichomoniasis
  4. Normal vaginal discharge

21

D. Normal Vaginal Discharge

22 of 27

MCQ!

QUESTION 2

​

Same case, except this time you notice yellow/green, malodorous vaginal discharge present.

pH 5.0. Motile pathogen noted on microscopy. Positive Whiff test.

You collect swabs and they are pending.

​

What is the most likely diagnosis?

​

  • Bacterial vaginosis
  • Vulvovaginal candidiasis
  • Trichomoniasis
  • Normal vaginal discharge

22

C. Trichomoniasis

23 of 27

MCQ!

QUESTION 3

​

What is the recommended treatment for the previous case? Select all that apply.

​

  • Fluconazole 150 mg PO once
  • Metronidazole 2 g PO once
  • Metronidazole 500 mg PO BID x 7 days
  • Ceftriaxone 500 mg IM once and azithromycin 1 g PO once

23

B. Metronidazole 2 g PO once

&

C. Metronidazole 500 mg PO BID x 7 days

​

Either regime is acceptable per CDC! Also note, she is pregnant and oral fluconazole is contraindicated for treatment of Vulvovaginitis Candidiasis.

24 of 27

MCQ!

QUESTION 4

​

You are seeing a 56 year old postmenopausal women for complaints of dyspareunia. She is diabetic, and takes hormone replacement therapy. She has had multiple previous episodes of vulvovaginal candidiasis in the past year. She takes probiotics daily to try to prevent VVC.

​

On physical exam, you notice thick white vaginal discharge and vulvar erythema and edema. pH is 4.3. Pseudohyphae are noted on microscopy.

Which of the following is the strongest risk factor for VVC?

​

  • Postmenopausal
  • Diabetes
  • Multiple previous episodes of VVC
  • Probiotic use

24

B. Diabetes

25 of 27

MCQ!

QUESTION 5

​

Should you perform a vaginal swab for culture for diagnosis for the previous patient? Select all that apply

​

  • No- clinical diagnosis
  • Not if the diagnosis previously established on culture
  • Yes- suspect complicated infection
  • Yes- need speciation to guide treatment

25

C. Yes- suspect complicated infection

&

D. Yes- need speciation to guide treatment

​

Because she is immunocompromised (diabetic) and had multiple previous episodes, she might have a complicated infection. A repeat culture should be performed even if one was done previously, for speciation to guide treatment.

26 of 27

RESOURCES & REFERENCES

​

​

​

26

27 of 27

AUTHOR(S)

Dr Alanna Dunn

27