Vulvovaginal pruritus (itching) and/or vaginal discharge result from infectious or noninfectious inflammation of the skin or mucosa. Symptoms may also include irritation, burning, and dyspareunia. Vulvovaginal symptoms are one of the most common reasons patients seek gynecologic care.
The etiology, diagnosis, and treatment of vulvovaginal pruritus or discharge vary by reproductive phase or status: premenarche, reproductive age, pregnancy, or menopause. Vulvovaginal symptoms in nonpregnant reproductive-aged and postmenopausal women are discussed here. (See also Vulvovaginal Pruritus or Vaginal Discharge in Children.)
Pathophysiology of Vulvovaginal Pruritus or Vaginal Discharge
Physiologic vaginal discharge occurs daily in many reproductive-aged women, and volume may increase when estrogen levels are high. Estrogen levels are high in the following situations:
A few days before ovulation
During the few months before menarche and during pregnancy (when estrogen production increases)
With use of medications that contain estrogen or that increase estrogen production (eg, some fertility drugs)
However, persistent or recurrent pain, irritation, burning, and pruritus are not normal and require further evaluation.
Normally, in reproductive-aged women, species is the predominant constituent of normal vaginal flora. High levels of glycogen in the vaginal epithelial cells, secondary to the effects of estrogen, promote growth. Colonization by these bacteria keeps the pH within the normal vaginal range (3.5 to 4.5), thereby preventing overgrowth of pathogenic bacteria. Normal vaginal flora also consist of Gardnerella vaginalis, Escherichia coli, group B streptococci, genital Mycoplasma, and Candida albicans. In prepubertal and postmenopausal patients, lack of estrogen inhibits the normal growth of vaginal bacteria and results in low glycogen levels. Low glycogen levels lead to thin vaginal epithelium and vaginal pH > 4.5 and result in sparse numbers of species. Because of the different vaginal environment, bacterial vaginosis and candidiasis are less common in prepubertal and postmenopausal patients.
Factors that predispose to overgrowth of bacterial vaginal pathogens include
Use of antibiotics (which may decrease lactobacilli)
Alkaline vaginal pH due to menstrual blood or semen
Vaginal douching
Pregnancy
Diabetes
An intravaginal foreign body (eg, a forgotten tampon or vaginal pessary)
Vulvar pruritus may also be due to vulvar dermatitis caused by irritants or hypersensitivity. Patients may scratch and cause vulvar excoriations, or, if pruritus is chronic, they may develop a chronic skin condition of the vulva, called lichen simplex chronicus. Other vulvar dermatoses (eg, lichen planus and lichen sclerosus) are thought to result from immune-mediated processes.
Etiology of Vulvovaginal Pruritus or Vaginal Discharge
The most common causes of vulvovaginal pruritus and vaginal discharge vary by hormonal status (see table Some Causes of Vulvovaginal Pruritus and Vaginal Discharge).
Reproductive-aged women
Vaginitis is also a common cause of vaginal pruritus and discharge in women of reproductive age. The most common types are
Trichomonal vaginitis (usually sexually transmitted)
Sometimes another infection (eg, gonorrhea, chlamydia) causes a discharge. These infections may also cause pelvic inflammatory disease.
Vaginitis may also result from foreign bodies (eg, a forgotten tampon).
Genital herpes sometimes causes vaginal itching, tingling, or burning. A first outbreak typically manifests with painful vulvar ulcers and groin lymphadenopathy.
Postmenopausal women
In postmenopausal women, genitourinary syndrome of menopause (formerly referred to as atrophic vaginitis) is a common cause of vaginal discharge.
Women who are incontinent or bedbound may develop chemical vulvitis.
Women of all ages
Noninfectious vulvitis accounts for up to one third of vulvovaginitis cases. It may result from hypersensitivity or irritant reactions to various agents, including hygiene sprays or perfumes, menstrual pads, laundry soaps, bleaches, fabric softeners, and sometimes spermicides, vaginal creams or lubricants, latex condoms, vaginal contraceptive rings, and diaphragms.
Vulvovaginal pruritus and vaginal discharge may also result from skin disorders (eg, psoriasis, lichen sclerosus, lichen planus, lichen simplex chronicus).
Rarely, a fistula between the intestines and genital tract can develop and predispose to vaginal or vulvar infection. Fistulas are usually obstetric in origin (due to vaginal birth trauma or a complication of episiotomy infection), but they sometimes result from inflammatory bowel disease, pelvic tumors, or pelvic surgery (eg, hysterectomy, anal surgery).
Some Causes of Vulvovaginal Pruritus or Vaginal Discharge
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Women of reproductive age | ||
Malodorous (fishy), thin, yellow-green or gray, frothy vaginal discharge Sometimes with vulvovaginal irritation | Amsel criteria for diagnosis (3 of 4):
NAAT Sometimes detected on Papanicolaou (Pap) test† | |
White, thick, curd-like vaginal discharge that adheres to the vaginal wall Vulvar and vaginal irritation, edema, pruritus Sometimes worsening of symptoms after intercourse and before menses Sometimes recent antibiotic use Uncomplicated (all of the following): Sporadic, infrequent episodes; mild to moderate symptoms; pathogen is usually Candida albicans; immunocompetent patients Complicated (any of the following): Recurrent episodes (4 or more); severe symptoms; non-albicans Candida,;immunocompromised patient (eg, diabetes, HIV, immunosuppressant therapy) | Criteria for diagnosis:
Fungal culture, especially if non-albicans Candida suspected DNA probe test with PCR Sometimes detected on Pap test† | |
Yellow-green, frothy vaginal discharge, often with a fishy odor Often irritation, erythema, and edema of the vulva and vagina Sometimes dysuria or dyspareunia Sometimes punctate, red “strawberry” spots on the vaginal walls or cervix | NAAT (the preferred test) Vaginal pH and wet mount with motile, pear-shaped flagellated organisms seen on microscopy Rapid diagnostic test, immunochromatographic flow dipstick Culture Sometimes detected on Pap test† | |
Abdominal or pelvic pain Mucopurulent cervical discharge Sometimes fever Cervical motion, uterine, and adnexal tenderness | Gonorrhea and chlamydia tests White blood cell count Sometimes pelvic imaging | |
Foreign bodies (often a forgotten tampon) | Extremely malodorous, often profuse vaginal discharge, often with vaginal erythema, dysuria, and sometimes dyspareunia Object visible during examination | Pelvic examination |
Postmenopausal women | ||
Genitourinary syndrome of menopause | Scant white or pale yellow discharge, sometimes with blood Vaginal dryness and/or dyspareunia Sometimes vulvovaginal fissures or spotting with sexual activity Vulvovaginal atrophy with fragile, dry, sometimes mildly tender vulvovaginal tissue | Pelvic examination plus the following findings:
|
Chemical vulvitis due to irritation from urine or feces | Diffuse vulvar erythema Risk factors (eg, incontinence, restriction to bed rest) | Pelvic examination |
All ages | ||
Hypersensitivity reactions | Vulvovaginal erythema, edema, pruritus (sometimes intense), vaginal discharge History of recent exposure of vulvovaginal tissue to new product or medication (eg, hygiene sprays, lubricants, bath water additives, topical treatment for candidal infections, fabric softeners, bleaches, or laundry soaps) | Pelvic examination |
Inflammatory (eg, pelvic radiation, chemotherapy, chronic use of vaginitis medications) | Scant white or pale yellow vaginal discharge Sometimes dyspareunia Sometimes pruritus, erythema, burning pain, mild bleeding Sometimes vaginal stenosis (after pelvic radiation) | Diagnosis of exclusion based on history and risk factors plus the following findings:
|
Enteric fistulas (complication of obstructed labor, pelvic tumors, pelvic surgery, or inflammatory bowel disease) | Malodorous vaginal discharge with passage of feces from vagina | Direct visualization or palpation of the fistula in the lower part of the vagina |
Skin disorders (eg, psoriasis, lichen sclerosus, lichen planus, lichen simplex chronicus) | Characteristic genital and extragenital skin findings | Pelvic examination Sometimes biopsy |
* If discharge is present, microscopic examination of a saline wet mount and KOH preparation and usually tests for trichomoniasis, gonorrhea, and chlamydia are done (unless a noninfectious cause such as allergy or a foreign body is obvious). | ||
† Papanicolaou (Pap) test is not a reliable test for diagnosis of vaginitis; incidental report of vaginitis on a cervical cytology report should be confirmed based on symptoms and further evaluation. | ||
KOH = potassium hydroxide, NAAT = nucleic acid amplification test, PCR = polymerase chain reaction. | ||
Evaluation of Vulvovaginal Pruritus or Vaginal Discharge
History
History of present illness includes onset of symptoms (and whether there was any eliciting factor, eg, a new vaginal product), duration, severity, and nature of symptoms (eg, pruritus, burning, pain, discharge), and relation of symptoms to the menstrual cycle. If vaginal discharge is present, patients should be asked about the color and odor of the discharge and any exacerbating and remitting factors (particularly those related to menses and sexual activity). They should also be asked about use of hygiene sprays or perfumes, douches, vaginal creams or lubricants, latex condoms, spermicides, vaginal contraceptive rings, diaphragms, and pessaries.
Review of systems should seek symptoms suggesting possible causes, including the following:
Fever or chills and abdominal pain: Pelvic inflammatory disease
Polyuria and polydipsia: New-onset diabetes
Past medical history should note risk factors for the following:
Candidal infection (eg, recent antibiotic use, diabetes, HIV infection, other immunosuppressive disorders)
Sexually transmitted infections (eg, unprotected intercourse, multiple partners)
Fistulas (eg, Crohn disease, genitourinary or gastrointestinal cancer, pelvic or rectal surgery, lacerations during delivery)
Use of over-the-counter vulvovaginal medications or products
Vulvovaginal hygiene practices (eg, shaving, douching)
Physical examination
Physical examination focuses on the pelvic examination.
The groin, pubic mons, perineum, and perianal area are examined for injury, skin lesions (including excoriations, fissures, rash), pubic lice, and groin lymphadenopathy. The vulva is examined for lesions (eg, ulcers, erosions, macules, papules, plaques), erythema, edema, atrophy, changes in vulvar architecture (eg, resorption of labia minora), adhesions, or excoriations. The color of lesions are noted.
A water-lubricated speculum is used to check the vaginal walls for erythema, atrophy, lesions (eg, cysts, abrasions, adhesions), discharge, and evidence of a fistula. Normal physiologic vaginal discharge is usually white and creamy or clear and on examination is found in the vaginal fornix or adherent to vaginal wall. The cervix is inspected for inflammation, friability, lesions, and discharge. Vaginal pH is measured (normal range is 3.5 to 4.5), and samples of secretions are obtained for testing. A bimanual examination is done to identify cervical motion tenderness and adnexal or uterine tenderness (suggesting pelvic inflammatory disease).
If a systemic disease is suspected (eg, inflammatory bowel disease, diabetes), a general physical examination is also done.
Red flags
The following findings are of particular concern:
Fever or pelvic pain: Possible pelvic inflammatory disease
Bloody discharge in postmenopausal women: Requires evaluation for endometrial cancer
Fecal discharge: Suggests a fistula
Interpretation of findings
Often, the history and physical examination suggest a diagnosis (see table Some Causes of Vulvovaginal Pruritus and Vaginal Discharge), although there can be much overlap.
In reproductive-aged women, discharge due to vaginitis must be distinguished from physiologic discharge:
Physiologic vaginal discharge is commonly white or clear, odorless, and nonirritating.
Bacterial vaginosis produces a thin, gray discharge with a fishy odor.
A trichomonal infection produces a frothy, yellow-green vaginal discharge, often with a fishy odor, and causes vulvovaginal soreness.
Candidal vaginitis produces a thick, white, curd-like discharge with pruritus, often severe
Contact irritant or allergic reactions cause significant irritation and inflammation with comparatively minimal discharge.
Discharge due to cervicitis (eg, due to pelvic inflammatory disease) can resemble that of vaginitis. Abdominal or pelvic pain and cervical motion tenderness, uterine tenderness, and adnexal tenderness suggest pelvic inflammatory disease. If a pelvic infection with an abscess is suspected, ultrasound, CT, or MRI is done.
In women of all ages, vulvovaginal pruritus and vaginal discharge may result from skin disorders (eg, psoriasis, lichen sclerosus, lichen planus, lichen simplex chronicus), which can usually be differentiated by history and skin findings.
Discharge that is bloody may result from vulvar cancer, vaginal cancer, cervical cancer, or uterine cancer; cancers can be differentiated from vaginitis by examination, imaging, and biopsy.
In genitourinary syndrome of menopause, discharge is scant and is usually thin and white, or pale yellow, or may sometimes contain some blood. Dyspareunia is common, and vaginal tissue appears thin and dry.
Testing
All patients with vulvovaginal pruritus or vaginal discharge require the following in-office testing (1):
Vaginal pH
Wet mount
Potassium hydroxide (KOH) preparation (whiff test and microscopy)
Testing for gonorrhea, chlamydia, and trichomoniasis is typically done unless a noninfectious cause (eg, allergy, foreign body) is obvious.
A sample of vaginal discharge is tested with pH paper; normal vaginal pH is 3.5 to 4.5. Then, secretions are placed on 2 slides:
Potassium hydroxide (KOH) wet mount prepared with 10% potassium hydroxide
The saline wet mount is examined microscopically as soon as possible to detect trichomonads, which can become immotile and more difficult to recognize within minutes after slide preparation. The slide is also examined for clue cells and polymorphonuclear leukocytes.
The KOH wet mount is checked for a fishy odor (whiff test), which results from amines produced in trichomonal vaginitis or bacterial vaginosis. Potassium hydroxide is also used to test for Candida; KOH dissolves most cellular material except for yeast hyphae, making identification easier.
Commercial tests for bacterial vaginosis, candidiasis, and trichomoniasis are now available and can be used if pH paper, KOH, or microscopy is not available.
If clinical criteria and in-office test results are inconclusive, the discharge may be tested with nucleic acid amplification test (NAAT) for Trichomonas or cultured for fungi or trichomonads.
Papanicolaou (Pap) test is not a reliable test for diagnosis of vaginitis; incidental report of vaginitis on a cervical cytology report should be confirmed based on symptoms and further evaluation.
Self-diagnosis of common vaginitis is not recommended because of its limited accuracy and the nonspecific nature of vulvovaginal symptoms.
If cervicitis or pelvic inflammatory disease are suspected, a complete blood count and/or pelvic imaging with ultrasound, CT, or MRI is done.
Evaluation reference
1. Vaginitis in Nonpregnant Patients: ACOG Practice Bulletin, Number 215. Obstet Gynecol. 2020;135(1):e1-e17. doi:10.1097/AOG.0000000000003604
Treatment of Vulvovaginal Pruritus or Vaginal Discharge
The specific cause of the pruritus or discharge is treated, including bacterial vaginosis, vulvovaginal candidiasis, or trichomoniasis (1).
Women should be advised not to use vaginal douches. Use of vulvovaginal products (eg, soaps, feminine hygiene sprays) should be avoided. If a soap is needed, a hypoallergenic soap should be used. Intermittent use of ice packs or warm sitz baths may reduce soreness and pruritus. The vulvar and groin area should be fully dried after bathing.
If chronic vulvar inflammation is due to being bedbound or incontinent, vulvar care should be improved .
Treatment reference
1. Vaginitis in Nonpregnant Patients: ACOG Practice Bulletin, Number 215. Obstet Gynecol. 2020;135(1):e1-e17. doi:10.1097/AOG.0000000000003604
Geriatrics Essentials: Vulvovaginal Pruritus or Vaginal Discharge
In postmenopausal women, a marked decrease in estrogen causes the vaginal pH to become less acidic and causes vaginal thinning. Vaginal thinning is one symptom of genitourinary syndrome of menopause. In this syndrome, vaginal inflammation often results in an abnormal discharge, which is scant and may be thin and white or pale yellow. Dyspareunia is common, and vaginal tissue appears fragile and dry.
Other common causes of decreased estrogen in older (or other) women include oophorectomy, pelvic radiation, certain chemotherapy agents, and aromatase inhibitors.
Low-dose vaginal estrogen is the preferred treatment for genitourinary syndrome of menopause.
Bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis may occur in postmenopausal women.
Poor hygiene (eg, in patients who are incontinent or bedbound) can lead to chronic vulvar inflammation due to chemical irritation by urine or feces.
After menopause, risk of cancer increases, and a bloody discharge is more likely to be due to cancer; thus, any vaginal discharge in postmenopausal women should be promptly evaluated.
Key Points
Causes of vulvovaginal pruritus and vaginal discharge vary depending on the patient’s age.
For most patients, measure vaginal pH and obtain a sample of secretions for microscopic examination and testing; if needed, do testing for sexually transmitted infections.
In postmenopausal women, promptly evaluate any vaginal discharge.
