Vaginal itching (pruritus), discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa (vaginitis), often with inflammation of the vulva (vulvovaginitis). Symptoms may also include irritation, burning, erythema, and sometimes dysuria and dyspareunia. Symptoms of vaginitis are one of the most common gynecologic complaints.
Pathophysiology
Some vaginal discharge is normal, particularly when estrogen levels are high. Estrogen levels are high in the following situations:
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A few days before ovulation
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During the first 2 weeks of life (because maternal estrogens are transferred before birth)
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During the few months before menarche and during pregnancy (when estrogen production increases)
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With use of drugs that contain estrogen or that increase estrogen production (eg, some fertility drugs)
However, irritation, burning, and pruritus are never normal.
Normally in women of reproductive age, Lactobacillus species is the predominant constituent of normal vaginal flora. Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of pathogenic bacteria. Also, high estrogen levels maintain vaginal thickness, bolstering local defenses.
Factors that predispose to overgrowth of bacterial vaginal pathogens include
Etiology
The most common causes of vaginal itching and discharge vary by patient age (see table Some Causes of Vaginal Pruritus and Discharge).
Children
In children, a common cause is vaginitis, usually due to infection with gastrointestinal (GI) tract flora (nonspecific vulvovaginitis). A common contributing factor in girls aged 2 to 6 years is poor perineal hygiene (eg, wiping from back to front after bowel movements, not washing their hands after bowel movements).
Chemicals in bubble baths or soaps may cause inflammation and pruritus of the vulva, which often recur.
Foreign bodies may cause nonspecific vaginitis, often with a scant bloody discharge.
Less commonly, a vaginal discharge in children results from sexual abuse.
Women of reproductive age
Vaginitis is also a common cause in women of reproductive age; it is usually infectious. The most common types are
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Trichomonal vaginitis (usually sexually transmitted)
Sometimes another infection (eg, gonorrhea, chlamydial infection) causes a discharge. These infections often also cause pelvic inflammatory disease.
Genital herpes sometimes causes vaginal itching but typically manifests with pain and ulceration.
Vaginitis may also result from foreign bodies (eg, a forgotten tampon). Inflammatory noninfectious vaginitis is uncommon.
Postmenopausal women
In postmenopausal women, atrophic vaginitis is a common cause.
Other causes of discharge include vaginal cancer, cervical cancer, and endometrial cancer and, in women who are incontinent or bedbound, chemical vulvitis.
Women of all ages
At any age, conditions that predispose to vaginal or vulvar infection include
Fistulas are usually obstetric in origin (due to vaginal birth trauma or a complication of episiotomy infection) but are sometimes due to inflammatory bowel disease or pelvic tumors or occur as a complication of pelvic surgery (eg, hysterectomy, anal surgery).
Noninfectious vulvitis accounts for up to 30% 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.
Some Causes of Vaginal Pruritus and Discharge
Cause |
Suggestive Findings |
Diagnostic Approach* |
Children |
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Poor perineal hygiene |
Pruritus, vulvovaginal erythema, vaginal odor, sometimes dysuria, no discharge |
Diagnosis of exclusion |
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Foreign bodies (often toilet paper) |
Vaginal discharge, usually with a foul odor and vaginal spotting |
Clinical evaluation (may require a topical anesthetic or procedural sedation) |
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Infections (eg, candidal, pinworm, streptococcal, staphylococcal) |
Pruritus and vaginal discharge with vulvar erythema and swelling, often with dysuria Worsening of pruritus at night (suggesting pinworm infection) Significant erythema and vulvar edema with discharge (suggesting streptococcal or staphylococcal infection) |
Microscopic examination of vaginal secretions for yeast and hyphae and culture to confirm Examination of vulva and anus for pinworms |
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Vulvovaginal soreness, bloody or malodorous vaginal discharge Often, vague and nonspecific medical complaints (eg, fatigue, abdominal pain) or behavior changes (eg, temper tantrums) |
Clinical evaluation Cultures or PCR for sexually transmitted diseases Measures to ensure the child’s safety and a report to state authorities if abuse is suspected |
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Women of reproductive age |
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Malodorous (fishy), thin, gray vaginal discharge with pruritus and irritation Erythema and edema uncommon |
Criteria for diagnosis (3 of 4): |
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Vulvar and vaginal irritation, edema, pruritus Discharge that resembles cottage cheese and adheres to the vaginal wall Sometimes worsening of symptoms after intercourse and before menses Sometimes recent antibiotic use or history of diabetes |
Clinical evaluation plus |
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Yellow-green, frothy vaginal discharge, often with a fishy odor Often soreness, erythema, and edema of the vulva and vagina Sometimes dysuria and dyspareunia Sometimes punctate, red “strawberry” spots on the vaginal walls or cervix Mild cervical motion tenderness often detected during bimanual examination |
Motile, pear-shaped flagellated organisms seen during microscopic examination Rapid diagnostic assay for Trichomonas, if available |
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Foreign bodies (often a forgotten tampon) |
Extremely malodorous, often profuse vaginal discharge, often with vaginal erythema, dysuria, and sometimes dyspareunia Object visible during examination |
Clinical evaluation |
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Abdominal or pelvic pain Mucopurulent discharge Fever Cervical motion and/or adnexal tenderness |
Cultures or PCR for sexually transmitted diseases |
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Postmenopausal women |
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Atrophic (inflammatory) vaginitis |
Dyspareunia, scant discharge, thin and dry vaginal tissue |
Clinical evaluation plus |
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Gradual onset of pain, a watery or bloody vaginal discharge (which precedes bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia) Often no other symptoms until the cancer is advanced Sometimes weight loss Rarely, a palpable pelvic mass |
Pelvic ultrasonography or sometimes MRI or CT Biopsy |
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Chemical vulvitis due to irritation from urine or feces |
Diffuse redness Risk factors (eg, incontinence, restriction to bed rest) |
Clinical evaluation |
All ages |
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Hypersensitivity reactions |
Vulvovaginal erythema, edema, pruritus (often intense), vaginal discharge History of recent use of hygiene sprays or perfume, bath water additives, topical treatment for candidal infections, fabric softeners, bleaches, or laundry soaps |
Clinical evaluation Trial of avoidance |
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Inflammatory (eg, pelvic radiation, oophorectomy, chemotherapy)‡ |
Purulent vaginal discharge, dyspareunia, dysuria, irritation Sometimes pruritus, erythema, burning pain, mild bleeding Thin, dry vaginal tissue |
Diagnosis of exclusion based on history and risk factors Vaginal pH > 6 Negative whiff test Granulocytes and parabasal cells seen during microscopic examination |
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Enteric fistulas (complication of delivery, 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 CT with contrast Endoscopy |
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Skin disorders (eg, psoriasis, lichen sclerosus, tinea versicolor) |
Characteristic genital and extragenital skin findings |
Clinical evaluation Biopsy |
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* If discharge is present, microscopic examination of a saline wet mount and KOH preparation and cultures or PCR for sexually transmitted organisms are done (unless a noninfectious cause such as allergy or a foreign body is obvious). |
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† If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. |
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‡ Such inflammatory conditions are an uncommon cause of vaginitis. |
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KOH = potassium hydroxide; PCR = polymerase chain reaction. |
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Evaluation
History
History of present illness includes nature of symptoms (eg, pruritus, burning, pain, discharge), duration, and intensity. 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 intercourse). They should also be asked about use of hygiene sprays or perfumes, spermicides, vaginal creams or lubricants, latex condoms, vaginal contraceptive rings, and diaphragms.
Review of systems should seek symptoms suggesting possible causes, including the following:
Past medical history should note risk factors for the following:
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Candidal infection (eg, recent antibiotic use, diabetes, HIV infection, other immunosuppressive disorders)
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Fistulas (eg, Crohn disease, genitourinary or gastrointestinal cancer, pelvic or rectal surgery, lacerations during delivery)
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Sexually transmitted diseases (eg, unprotected intercourse, multiple partners)
If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced event and improves the quality of information obtained.
Physical examination
Physical examination focuses on the pelvic examination.
The external genitals are examined for erythema, excoriations, and swelling. A water-lubricated speculum is used to check the vaginal walls for erythema, discharge, and fistulas. The cervix is inspected for inflammation (eg, trichomoniasis) and discharge. Vaginal pH is measured, and samples of secretions are obtained for testing. A bimanual examination is done to identify cervical motion tenderness and adnexal or uterine tenderness (indicating PID).
Red flags
Interpretation of findings
Often, the history and physical examination help suggest a diagnosis (see table Some Causes of Vaginal Pruritus and Discharge), although there can be much overlap.
In children, a vaginal discharge suggests a foreign body in the vagina. If no foreign body is present and children have trichomonal vaginitis, sexual abuse is likely. If they have unexplained vaginal discharge, cervicitis, which may be due to a sexually transmitted disease, should be considered. Nonspecific vulvovaginitis is a diagnosis of exclusion.
In women of reproductive age, discharge due to vaginitis must be distinguished from normal discharge:
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Normal vaginal discharge is commonly milky white or mucoid, odorless, and nonirritating; it can result in vaginal wetness that dampens underwear.
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Bacterial vaginosis produces a thin, gray discharge with a fishy odor.
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A trichomonal infection produces a frothy, yellow-green vaginal discharge and causes vulvovaginal soreness.
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Candidal vaginitis produces a white discharge that resembles cottage cheese, often increasing the week before menses; symptoms worsen after sexual intercourse.
Contact irritant or allergic reactions cause significant irritation and inflammation with comparatively minimal discharge.
Discharge due to cervicitis (eg, due to PID) can resemble that of vaginitis. Abdominal pain, cervical motion tenderness, or cervical inflammation suggests PID.
In women of all ages, vaginal pruritus and discharge may result from skin disorders (eg, psoriasis, lichen sclerosus, tinea versicolor), which can usually be differentiated by history and skin findings.
Discharge that is watery, bloody, or both may result from vulvar cancer, vaginal cancer, or cervical cancer; cancers can be differentiated from vaginitis by examination and biopsy.
In atrophic vaginitis, discharge is scant and may be watery and thin or thick and yellowish. Dyspareunia is common, and vaginal tissue appears thin and dry.
Testing
All patients require the following in-office testing:
Testing for gonorrhea and chlamydial infections is typically done unless a noninfectious cause (eg, allergy, foreign body) is obvious.
Vaginal secretions are tested using pH paper with 0.2 intervals from pH 4.0 to 6.0. Then, a cotton swab is used to place secretions on 2 slides; secretions are diluted with 0.9% sodium chloride on one slide (saline wet mount) and with 10% KOH on the other (KOH preparation).
The KOH preparation is sniffed (whiff test) for a fishy odor, which results from amines produced in trichomonal vaginitis and bacterial vaginosis. The slide is examined using a microscope; KOH dissolves most cellular material except yeast hyphae, making identification easier.
The saline wet mount is examined using a microscope as soon as possible to detect motile trichomonads, which can become immotile and more difficult to recognize within minutes after slide preparation.
If clinical criteria and in-office test results are inconclusive, the discharge may be cultured for fungi and trichomonads.
Treatment
Any specific cause of the itching or discharge is treated.
The vulva should be kept as clean as possible. Soaps and unnecessary topical preparations (eg, 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 (with or without baking soda) may reduce soreness and pruritus. Flushing the genital area with lukewarm water may also provide relief. If chronic vulvar inflammation is due to being bedbound or incontinent, better vulvar hygiene may help.
Women should be advised not use douches.
If symptoms are moderate or severe or do not respond to other measures, drugs may be needed. For pruritus, topical corticosteroids (eg, 1% hydrocortisone twice a day as needed) can be applied to the vulva but not into the vagina. Oral antihistamines lessen pruritus and cause drowsiness, helping patients sleep.
Prepubertal girls should be taught good perineal hygiene (eg, wiping front to back after bowel movements and voiding, washing their hands, avoiding fingering the perineum).
Geriatrics Essentials
In postmenopausal women, a marked decrease in estrogen causes vaginal thinning (atrophic vaginitis), increasing vulnerability to infection and inflammation. Other common causes of decreased estrogen in older women include oophorectomy, pelvic radiation, and certain chemotherapy drugs.
In atrophic vaginitis, inflammation often results in an abnormal discharge, which is scant and may be watery and thin or thick and yellowish. Dyspareunia is common, and vaginal tissue appears thin and dry.
Poor hygiene (eg, in patients who are incontinent or bedbound) can lead to chronic vulvar inflammation due to chemical irritation by urine or feces.
Bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis are uncommon among postmenopausal women but may occur in those with risk factors.
After menopause, risk of cancer increases, and a bloody or watery discharge is more likely to be due to cancer; thus, any vaginal discharge in postmenopausal women should be promptly evaluated.
Key Points
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Vaginal symptoms related to itching and/or discharge are often nonspecific.
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Causes of vaginal pruritus and itching vary depending on the patient’s age.
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For most patients, measure vaginal pH and obtain a sample of secretions for microscopic examination and testing; if needed, do culture for sexually transmitted organisms.
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In postmenopausal women, promptly evaluate any vaginal discharge.
