Practice Practice Pointer

Persistent vaginitis

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7314 (Published 29 November 2011) Cite this as: BMJ 2011;343:d7314
  1. Gayle Fischer, associate professor of dermatology 1,
  2. Jennifer Bradford, conjoint senior lecturer in gynaecology 2
  1. 1University of Sydney, Sydney Medical School, PO Box 4028, Royal North Shore Hospital, LPO, St Leonard’s, New South Wales, Australia
  2. 2University of Western Sydney, Campbelltown, Australia
  1. Correspondence to: G Fischer gayle.fischer{at}sydney.edu.au

Persistent vaginitis can be a challenging problem in general practice. We review the steps to accurate diagnosis and effective treatment.

A 36 year old woman visits her general practitioner complaining of a six month history of vaginal soreness, itch, discharge, dyspareunia, and painful postcoital vulval swelling. Her symptoms are worse premenstrually and improve during menstruation. She reports that she has had recurrent “thrush” since her mid-20s, precipitated by courses of antibiotics, and has successfully self medicated with intravaginal miconazole. These episodes have gradually become more frequent, and recently her symptoms failed to resolve with over the counter antifungals. Although she had been known to have positive swabs for Candida albicans in the past, recent swabs and vaginal microscopy had been persistently negative. She is healthy and does not have diabetes, and her only medication is the oral contraceptive pill with 30 µg oestrogen. A trial of pill cessation did not improve her problem. She is very embarrassed about this problem and, when asked, she volunteers that she is worried that she may have somehow contracted genital herpes or cancer. Examination shows a confluent, oedematous vulvovaginitis extending to the labia majora, with associated fissuring; erythema of the perineum; and erythema of the vagina.

In this article we explore the features of persistent vaginitis and suggest recommendations for managing the condition.

Methods

We assessed previous publications on persistent vaginitis, including several from our group. We conducted a literature search using Medline and PubMed databases up to August 2011. We found few systematic reviews and randomised controlled trials and cohort studies on persistent vaginitis; however, we also selected several well conducted and convincingly reported case series and narrative reviews by respected authors. Our suggestions in this article are based on these publications and on our own clinical experience in a large dermatogynaecology practice.

What is persistent vaginitis?

Vaginitis is inflammation of the vaginal epithelium evidenced by erythema, discharge, or other changes, such as erosions (loss of epithelium). Infection is the most common cause, but there are less common, non-infective causes (box). Vaginitis may occur in isolation or be associated with a dermatosis of the mucosal surface of the labia minora, the vulva, and/or perianal skin. Persistent vaginitis occurs when this symptomatic inflammation either recurs after, or is resistant to, initial treatment. Many of the causes of persistent vaginitis are rare and may not be familiar to the general practitioner (box).

Differential diagnosis of chronic vulvovaginitis

Common
  • Recurrent vulvovaginal candidiasis: defined as four attacks a year1; however, some patients’ candidiasis is more indicative of a chronic continuous process2 3)

  • Recurrent bacterial vaginosis

  • Contact dermatitis (allergic and irritant contact): caused by intravaginal pessaries and creams (usually obvious on history4)

Uncommon
  • Desquamative inflammatory vaginitis: an uncommon, non-infective, painful vaginitis of unknown cause characterised by shiny erythematous patches and/or petechiae3 5

  • Intravaginal foreign body (eg, retained tampon): a cause of persistent vaginitis with a heavy discharge

  • Chronic fixed drug eruption: an erosive vulvovaginitis most often associated with non-steroidal anti-inflammatory drugs and statins

  • Type 1 hypersensitivity reactions: itch, burning, swelling, and even anaphylaxis can result from exposure to latex condoms and seminal fluid6

Rare
  • Mucosal lichen planus: a skin disease that often involves the oral as well as the vaginal mucosa with very painful erosions that may eventually lead to scarring7 8

  • Oestrogen hypersensitivity vulvovaginitis: a cyclical vulvitis with a presentation closely similar to that of recurrent candidiasis but not causally associated with candida9

Very rare
  • Crohn’s disease: a cause of vulvovaginitis10

  • Immunobullous disease: erosive vaginal involvement without generalised skin disease may occur, particularly in cicatricial pemphigoid11 12

  • Graft versus host disease: a vulvovaginitis indistinguishable from lichen planus13

Most presentations of vaginitis in general practice are acute—that is, of sudden onset and short duration. Most vaginitis is the result of acute candidiasis or bacterial vaginosis, diagnosable by vaginal swab, microscopy, culture, and pH level and treatable with a prompt short course of antifungal or antibiotic medication.1 14 In practice these patients are often treated empirically. In this article we will not cover the sexually transmitted causes of vaginitis as they are not a cause of persistent symptoms.

Persistent vaginitis is less common than acute vaginitis and is often perplexing for the clinician. For the patient, it can be the cause of enormous misery, anxiety, sexual guilt, and even relationship breakdown. There are three patterns: recurring attacks, chronic unremitting symptoms, or symptoms that are chronic but worsen at certain times of the menstrual cycle. The main differentiating feature between acute and chronic disease is duration of symptoms and rapid recurrence after treatment. A systematic review has shown that, taken individually, symptoms, signs, and tests are poor predictors of the cause of vaginitis.15

Does the complaint of persistent vaginitis indicate disease?

A patient presenting with persistent, symptomatic vaginitis is highly likely to have a defined cause.16 The exception is the patient who presents with culture negative heavy, non-offensive discharge in the absence of other symptoms and signs. This is a normal variant.

The differential diagnosis of persistent vulvovaginitis is not long (box). The list is based on our published observations17 and shows relative prevalence in our own tertiary practice, although no published studies record prevalence in general practice.

In most patients, chronic persistent vulvovaginitis is not a sign of systemic illness or infection. Of all of the conditions listed in the box above, only recurrent candidiasis and bacterial vaginosis are causally related to specific micro-organisms. With the exceptions of lichen planus, immunobullous disease, and Crohn’s disease (which have defined histopathology), none are diagnosable by biopsy and a previous study has shown that biopsy is not reliable for lichen planus.8

The causes of these conditions differ greatly, and an accurate diagnosis is therefore essential for rational management.

History

A detailed and specific history is essential for making a diagnosis (table) Historical triggers can be critical for a correct diagnosis, especially for contact dermatitis,4 type 1 hypersensitivity reactions,6 and fixed drug eruptions.18 Vaginal surgery may trigger desquamative inflammatory vaginitis,17 and both candidiasis and desquamative inflammatory vaginitis can be exacerbated by antibiotic use and contraceptive pills with high oestrogen content.1 17 Events that exacerbate symptoms are also useful to know about—for example, the tendency of candidiasis to worsen in the premenstrual phase of the menstrual cycle.1

History taking in persistent vaginitis

View this table:

Examination

Several diagnoses may also affect the external genital skin (for example, candidiasis (fig 1), fixed drug eruption (fig 2), lichen planus (fig 3)), Crohn’s disease (fig4), or precipitate reactive external dermatosis (fig 5). Any vaginitis may trigger genital psoriasis as a result of the Koebner phenomenon in predisposed individuals.16

Figure1

Fig 1 Vulvovaginal candidiasis with non-erosive vaginitis, discharge (black arrow) and extension to the vulval and perineal skin with accentuation in the sulcus between the labia major and minora (white arrow)

Figure2

Fig 2 Chronic fixed drug eruption showing complete loss of vaginal epithelium (black arrow), erosions (red arrow), and extension onto the vulva. The white arrow indicates the peeling vaginal epithelium, and the yellow arrow points a build-up of desquamated epithelium at tips of labia majora

Figure3

Fig 3 Left: Erosions in lichen planus. Right: End stage lichen planus with severe scarring (black arrow) and vaginal erosion (white arrow)

Figure4

Fig 4 Crohn’s disease of the vulva showing intense oedema of the labia minora and erosion of the introital epithelium and sulcus between the labia minora and majora. The vagina is obscured by labial oedema

Figure5

Fig 5 Acute contact dermatitis from topical antifungal medication showing extension to the vulva with intense oedema, erythema, and erosion

Examination of female genital skin is very difficult because of the great variation in texture and colour and because the clinical signs of dermatosis may be far more subtle in this area than on other parts of the skin.

External examination

  • First inspect the labia minora and majora for erythema, oedema, and scale, and note whether erythema is accentuated in the sulcus between them, which may indicate candidiasis. Loss of the labia minora and introital fusion may be associated with lichen planus. This is also seen in lichen sclerosus, but the latter does not involve the vagina.

  • Look for fissures on the introitus, perineum, or perianal skin; these are common in candidiasis.16

  • Inspect the mucosal surface of the introitus: look for confluent erythema or the petechial lesions typical of desquamative inflammatory vulvovaginitis.17

  • Look for erosions that might indicate a fixed drug eruption, erosive lichen planus, or immunobullous disease.5 7 11 12 18 19 It is rare to see intact blisters as they rapidly erode in this location; nonetheless, they should be sought.

  • Perform a general skin and, particularly, oral examination to look for other signs of lichen planus, such as a reticulate white eruption on the buccal mucosa.

Speculum examination (if possible)

  • Note if the inflammation is confluent or patchy: patchy inflammation (especially with petechiae) is typical of desquamative inflammatory vaginitis (fig 6) or lichen planus.

  • Note the type of discharge: recurrent candidiasis may not produce the “cheesy” discharge so typical of its acute counterpart. A green discharge may indicate desquamative inflammatory vaginitis. A heavy purulent discharge is seen in lichen planus.

  • Look carefully for erosions, ulcers, adhesions, or scarring, which indicate lichen planus or immunobullous disease.

  • Ensure there are no intravaginal foreign bodies such as a retained tampon.20

Figure6

Fig 6 Desquamative inflammatory vaginitis: characteristic petechial eruption (arrow)

Investigations and further management

Always do a vaginal swab for microscopy and culture to exclude candidiasis and bacterial vaginosis, especially if this has not been done recently. However, if the history and clinical examination are consistent with candidiasis (see case scenario), a negative swab result should not preclude a trial of antifungal medication. Although vaginal microscopy at the point of care may be useful, it is often non-specific and requires equipment, time, and a level of skill that is not available in general practice.1 We do not usually recommend biopsy in a general practice setting. There are no other reliable and valid tests for recurrent or chronic vaginitis, and sometimes the only option is a treatment trial.17

If candidiasis and bacterial vaginosis have been excluded, it is usually possible, after the history and examination, to make a short list of likely diagnoses.

Contact dermatitis and type 1 hypersensitivity are confirmed by resolution of the vaginitis after cessation of the offending substance. If the patient has erosive vaginitis and is taking a drug that has been implicated in vulval fixed drug eruption, the next step is to stop the drug(s). A rapid improvement will occur within two weeks.18 19 Rechallenge will confirm the diagnosis in one or two days.

A non-erosive vaginitis extending only to the labia minora, particularly if patchy or petechial, may indicate desquamative inflammatory vaginitis.5 17 This is a clinical diagnosis confirmed by exclusion of other causes and by an adequate response to treatment .5 A two to four week trial of intravaginal clindamycin 2% cream with 1% hydrocortisone used externally will give an adequate clinical response.17

If erosive vaginitis has not responded to stopping an offending drug or if the patient is not taking any drugs (including over the counter drugs such as paracetamol19) that are suspected of triggering the condition, then consider lichen planus or immunobullous disease and refer the patient to a specialist for biopsy, which may require immunofluorescent testing. Indeed, we recommend specialist referral for any perplexing vaginitis case: these women must receive timely and effective help to prevent even more distress.

At specialist  review a vulval biopsy from the edge of the erosion is indicated to rule out lichen planus. Note that this is specific but not sensitive.8 A negative biopsy result in the presence of a strong suspicion of lichen planus warrants a trial with a potent topical corticosteroid or a short course of oral prednisone at a dose of 0.25 mg/kg a day. A good response is usually seen within four to six weeks.21

Outcome

This patient’s recent negative results for swabs and vaginal microscopy might have been the result of her ongoing self medication with antifungal agents. Recurrent candidiasis was provisionally diagnosed, and she was prescribed a trial of oral fluconazole 50 mg a day.16 In any chronic vulvovaginitis, advice on environmental modification—for example, avoidance of soaps, irritating topical treatment (such as antifungal creams), sanitary towels, and panty liners—and use of loose, cotton underwear will aid treatment response. She gradually became asymptomatic over the next three months. This patient is at high risk of recurrence. A randomised placebo controlled trial has shown that relapse can be prevented by weekly treatment with fluconazole, and she was subsequently prescribed fluconazole 150 mg weekly for the next six months.22 She was warned about the potential risks of fluconazole in pregnancy and was advised to maintain effective contraception. She was given strong reassurance about the benign, non-transmissible nature of her condition.

Learning points

  • A drug history, including over the counter medications, is essential to check for a chronic fixed drug eruption. Ask about use of intravaginal pessaries and creams as allergic or irritant contact dermatitis is often a cause of persistent vaginitis

  • Always do a vaginal swab to check for common causes, Candida albicans, and bacterial vaginosis; however, a negative swab result does not rule out recurrent or chronic candidiasis. Confluent erythema or petechiae may indicate desquamative inflammatory vulvovaginitis (a non-infective, painful vaginitis of unknown cause)

  • Referral for specialist review and biopsy may be useful if an erosive vaginitis, unresponsive to cessation of possible allergens, is present or there is a lack of response to empiric treatment

  • No other reliable and valid diagnostic tests are available for many causes of chronic vaginitis, and treatment trials may sometimes be the only option—for example, if chronic candidiasis and desquamative inflammatory vaginitis are suspected

Notes

Cite this as: BMJ 2011;343:d7314

Footnotes

  • Contributors: Both authors contributed equally to the manuscript, and both are guarantors.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Patient consent not required (patient anonymised, dead, or hypothetical).

References