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 dyspareunia. Symptoms of vaginitis are one of the most common gynecologic complaints.
Pathophysiology of Vaginal Itching and Discharge
Physiologic vaginal discharge occurs daily in many 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 drugs that contain estrogen or that increase estrogen production (eg, some fertility drugs)
During the first 2 weeks of life (because maternal estrogens are transferred before birth)
However, irritation, burning, and pruritus are never normal.
Normally in women of reproductive age, 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.
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 mellitus
An intravaginal foreign body (eg, a forgotten tampon or vaginal pessary)
Etiology of Vaginal Itching and Discharge
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 nonspecific vulvovaginitis, usually due to infection with gastrointestinal tract flora. 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. If abuse is suspected, measures to ensure the child’s safety must be taken, and a report must be made to state authorities.
Women of reproductive age
Vaginitis is also a common cause in women of reproductive age. The most common types are
Trichomonal vaginitis (usually sexually transmitted)
Sometimes another infection (eg, gonorrhea, chlamydial infection) causes a discharge. These infections may also cause pelvic inflammatory disease.
Genital herpes sometimes causes vaginal itching, tingling, or burning, A first outbreak typically manifests with pain and ulceration.
Vaginitis may also result from foreign bodies (eg, a forgotten tampon).
Postmenopausal women
In postmenopausal women, genitourinary syndrome of menopause is a common cause.
Women who are incontinent or bedbound may develop chemical vulvitis.
Women of all ages
At any age, a fistula between the intestines and genital tract can predispose to vaginal or vulvar infection. This rare disorder is usually obstetric in origin (due to vaginal birth trauma or a complication of episiotomy infection), but fistulas sometimes result from inflammatory bowel disease, pelvic tumors, or 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.
Evaluation of Vaginal Itching and Discharge
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, diaphragms, and pessaries.
Review of systems should seek symptoms suggesting possible causes, including the following:
Fever or chills and abdominal or suprapubic pain: Pelvic inflammatory disease (PID) or cystitis
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)
Fistulas (eg, Crohn disease, genitourinary or gastrointestinal cancer, pelvic or rectal surgery, lacerations during delivery)
Sexually transmitted infections (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
The following findings are of particular concern:
Fever or pelvic pain
Bloody discharge in postmenopausal women
Fecal discharge (suggesting a fistula, even if not seen)
Trichomonal vaginitis in children (suggesting sexual abuse)
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 infection, should be considered, and cervical cultures should be done. Nonspecific vulvovaginitis is a diagnosis of exclusion.
In women of reproductive age, discharge due to vaginitis must be distinguished from normal discharge:
Normal 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 white discharge that may resemble cottage cheese.
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, lichen planus), 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 genitourinary syndrome of menopause, 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 with vaginal itching or discharge require the following in-office testing:
pH
Wet mount
Potassium hydroxide (KOH) preparation
Testing for gonorrhea and chlamydial infections is typically done unless a noninfectious cause (eg, allergy, foreign body) is obvious.
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 look for clue cells and 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 of Vaginal Itching and Discharge
Any specific cause of the itching or discharge is treated.
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 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. Prepubertal girls should be taught good vulvar hygiene (eg, wiping front to back after bowel movements and voiding).
Women should be advised not use vaginal douches.
Geriatrics Essentials
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 watery and thin or thick and yellowish. Dyspareunia is common, and vaginal tissue appears fragile and dry.
Other common causes of decreased estrogen in older women include oophorectomy, pelvic radiation, and certain chemotherapy drugs.
Low-dose vaginal estrogen is the preferred treatment for genitourinary syndrome of menopause.
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 may occur in postmenopausal women.
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 vaginal pruritus and itching 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.
