Generality
Vulvovaginitis is an inflammation that involves the vagina and the vulva, that is, the lower part of the female genital tract.
The symptoms of vulvovaginitis are usually burning, itching, erythema, edema and tenderness, often associated with vaginal discharge. Vaginal and vulvar irritation can worsen with sexual intercourse and the habit of excessive intimate hygiene.
The diagnosis of vulvovaginitis is formulated by physical examination and analysis of vaginal secretions. Treatment is directed to the triggering cause, control of symptoms and correction of hygiene habits.
Anatomy outline
The lower part of the female genital tract consists of:
- Vulva : region surrounding the access to the vagina; is formed by clitoris, large and small lips, hymen, external orifice of the urethra, Bartholin's glands and vaginal vestibule.
- Vagina : muscle-membranous duct, about eight to ten centimeters long, extending from the vulva (vestibule of the vagina) to the cervix (cervix). In other words, the vagina connects the lower portion of the uterus to the external genital organs.
Causes and risk factors
Vulvovaginitis consists of the simultaneous inflammation of the vagina ( vaginitis ) and vulva ( vulvitis ). This inflammatory process recognizes various causes, including infections, irritations, hormonal changes and traumas.
Normally, in women of reproductive age, lactobacilli are the predominant constituents of the vaginal microbial flora . Colonization by these bacteria is normally protective, as it keeps the vaginal pH at normal values (between 3.8 and 4.2) and prevents the excessive growth of pathogenic bacteria. Furthermore, high levels of estrogen maintain the thickness of the vaginal mucosa, reinforcing local defenses.
The non-infectious causes represent about 30% of the cases of vulvovaginitis.
Infectious causes
In many cases, vulvovaginitis is favored by an increase in local pH (due to menstrual blood, post-coital sperm, reduction of lactobacilli and concomitant diseases) and by the alteration of the microbial flora (secondary to poor personal hygiene, use of antibiotics or corticosteroids and unbalanced diets). These conditions predispose to the proliferation of pathogenic microorganisms and make the vulvar and vaginal mucosa more vulnerable to infectious attacks.
The agents responsible for vulvovaginitis can be fungi (such as, for example, Candida albicans ), bacteria (eg Gardnerella vaginalis, streptococci and staphylococci), protozoa (eg Trichomonas vaginalis ) and, more rarely, viruses such as Herpes simplex .
In girls between the ages of 2 and 6, inflammation usually results from infections from the microbial flora of the gastrointestinal tract; a factor that frequently favors this condition is poor perineal hygiene (eg incorrect habit of wiping from back to front after evacuation; do not wash hands after defecating; scratching in response to itching etc.).
In women of reproductive age, vulvovaginitis can result from the infection of pathogens responsible for sexually transmitted diseases (including Neisseria gonorrhoeae, Trichomonas vaginalis and Chlamydia trachomatis ).
Other predisposing conditions vaginal and vulvar infections include fistulas between the intestine and the genital tract, and radiation therapy or pelvic tumors, which damage the tissues, thus compromising the normal defenses of the host.
Irritative causes
Vulvovaginitis may result from hypersensitivity or irritative reactions of the vulvar and vaginal mucosa.
Excessive use of intimate cleansers and vaginal cleans greatly increases the risk of suffering from the disorder. In susceptible people, exposure to certain chemicals contained in bubble baths and soaps can even cause an allergic reaction.
The category of potential sensitizing agents also includes hygienic sprays or perfumes, softeners, dyes and additives in detergents. Occasionally, irritation may result from the use of vaginal lubricants or creams, latex condoms, spermicides, vaginal contraceptive rings, diaphragms or intrauterine devices.
In incontinent or bedridden patients, poor hygiene can cause chronic vulvar inflammation caused by chemical irritation from urine or faeces .
Vulvovaginitis can also be caused by physical causes, such as abrasions due to inadequate lubrication during sexual intercourse, prolonged mechanical stimuli or rubbing against too tight clothing, especially if made of a synthetic material.
Even prolonged contact with a foreign body - represented by a condom, internal absorbent, toilet paper residues or grains of sand - can cause non-specific vulvovaginitis with blood secretion.
Other causes
As mentioned, the imbalances in the vulvar and vaginal environment can also depend on immunodepression and systemic diseases, such as diabetes.
Other risk factors for vulvovaginitis include prolonged use of certain drugs, such as antibiotics and corticosteroids.
Hormonal changes can also favor the appearance of vulvovaginitis. After menopause, for example, a marked decrease in estrogen causes thinning of the vagina and an increased susceptibility to inflammation (atrophic vaginitis). Changes in hormonal status may also occur on other occasions, such as after childbirth or during breastfeeding. The reduction of estrogen can also be induced by some treatments, such as surgical removal of the ovaries, pelvic irradiation and chemotherapy.
In some cases, non-infectious vulvovaginitis can be favored by psychological factors (eg unsatisfactory sex life or depressive pictures).
Signs and Symptoms
The vulvovaginitis generally manifests itself with itching, tenderness and redness of the small and large lips and the vaginal orifice. These symptoms are often accompanied by secretions from the vulva and burning pain during sexual intercourse (dyspareunia).
Local irritation can also lead to burning or mild bleeding. Furthermore, dysuria (pain on urination) and vaginal dryness may occur. In some cases, the vulva may appear edematous and there may be excoriations, blisters, ulcerations and fissures.
Vaginal and vulvar secretions
The appearance and the amount of vulvovaginal losses differ depending on the cause of the inflammation.
- Normal vaginal secretion is milky white or mucoid, with no odor and no irritation; sometimes, it can lead to a dampening that wets the underwear.
- In the case of bacterial infections, usually, a white or greyish leucorrhoea appears, with an amino odor, similar to that of fish. The latter can become very intense when an alkalinisation of the losses occurs, after coitus and menstruation; they are also frequent itching and irritation.
- Candida vulvovaginitis typically causes a whitish vaginal discharge, of a cheesy appearance; these losses are accompanied by severe itching and pain during intercourse.
- Profuse, frothy and foul-smelling green-yellow leaks typically signal an infection with Trichomonas .
- The herpes virus infection does not alter the normal vaginal discharge, but is accompanied by the appearance of painful vesicles.
Possible complications
If not treated properly, infectious vulvovaginitis can become chronic. In addition, some infections (including chlamydia and trichomoniasis) can spread to the uterus, tubes and ovaries, increasing the risk of pelvic inflammatory disease and potentially compromising a woman's fertility.
Vulvovaginitis can also promote post-partum endometritis, chorioamnionitis, premature rupture of membranes and preterm birth.
Diagnosis
The diagnosis of vulvovaginitis is formulated on the basis of the symptoms and signs that emerged during the gynecological examination, during which the lower part of the female genital tract is examined.
Upon inspection, redness and edema can be seen, accompanied by excoriations and fissures. Less often, vulvovaginitis can be associated with the appearance of blisters, ulcerations or vesicles.
To define the cause of the inflammation, samples of vaginal secretions can be taken using tampons. Measurement of the pH and microscopic examination of this material gives a first indication of the aetiology that caused the disorder.
The finding of atypical vaginal discharge, the presence of white blood cells in the sample or a concomitant inflammation of the cervix must lead to assess the possible presence of a sexually transmitted disease and requires further investigation. If the results of examinations in the clinic are inconclusive, the secretion can be cultured.
The persistence of symptoms, accompanied by the presence of particular styles and habits of life (eg abuse of intimate cleansers, internal sanitary napkins or panty liners) must focus attention on the fact that it may be a form of vaginal hypersensitivity to irritative agents.
Differential diagnosis
- Cervical secretions caused by inflammation of the cervix may resemble those of the vulvovaginitis; abdominal pain, tenderness of the cervix or inflammation of the cervix suggest, instead, a pelvic inflammatory disease .
- An aqueous and / or blood secretion may be the result of a vulvar, vaginal or cervical cancer . These neoplasms can be differentiated from a vulvovaginitis by physical examination and Papanicolau test (PAP test).
- The itching and vaginal discharge can also derive from skin diseases (such as psoriasis and tinea versicolor), which can be revealed through anamnesis and skin findings.
- In girls, if Trichomonas vulvovaginitis is found, a differential diagnosis should be made with sexual abuse .
Treatment
The treatment is, first of all, addressed to the causes of vulvovaginitis.
- In the case of a vulvovaginitis of bacterial origin, the therapy involves the use of antibiotics, such as metronidazole, clindamycin and tinidazole, to be taken orally or applied topically for a few days.
- In the presence of fungal infections, however, the use of antifungal drugs is recommended, to be applied topically or taken orally.
- In case of allergic or irritative phenomena, it is necessary to avoid the application of excessively alkaline soaps or dyes and non-essential topical preparations (such as perfumes or intimate deodorants and depilatory creams) on the vulva, in addition to suspending the use of the sensitizing substance which caused the reaction. If the symptoms are moderate or intense, the doctor may prescribe a pharmacological treatment based on antiseptic and anti-inflammatory products, such as benzidamine. For itching, however, the application of topical corticosteroids on the vulva, but not in the vagina, may be indicated. Oral antihistamines also reduce the itching sensation and cause drowsiness, sometimes improving the patient's night rest.
In the case of vulvovaginitis, attention must be paid to the adoption of correct hygienic measures . In particular, it is important to clean oneself from the front to the back after each evacuation and urination, remember to wash your hands and avoid touching the perineum. Furthermore, it is advisable to abstain from sexual intercourse or to use a condom, until a cure is established.
The use of intimate cleansers must not be carried out excessively: this habit could alter the natural vaginal immune defenses and the saprophytic microbial flora.
If chronic inflammation is due to lodging or incontinence, it may be useful to maintain better vulvar hygiene, carefully drying the skin and mucous membranes after the toilet; changing underwear frequently and wearing loose cotton clothes reduces local humidity and the proliferation of pathogenic microorganisms.
The use of over-tight or non-breathable clothing, in addition to favoring a vulvovaginitis, can prolong healing time.
Prevention
In addition to scrupulously following the therapy of vulvovaginitis indicated by the gynecologist, it is advisable to associate some useful behaviors to prevent subsequent infections or irritations. The use of condoms can help limit the risk of incurring certain infectious processes that can be transmitted through sexual contact.
Another good rule is to choose undergarments that ensure proper transpiration and do not irritate the genital area. Therefore, the use of pure cotton linens should be preferred, preferably white; this natural tissue allows a correct tissue oxygenation and limits the stagnation of secretions. Furthermore, to prevent vulvovaginitis, it is advisable to avoid the continuous use of intimate deodorant wipes, panty liners, internal absorbents and acid pH soaps.
In the prophylaxis of reinfections it can be useful, finally, to correct any hormonal imbalances, insert yogurt or lactic ferments in daily nutrition and limit the intake of carbohydrates and sugars.
