33 Vaginal Discharge and Itching
Vaginal discharge, which may be accompanied by vulvar itching or burning, is one of the most common problems seen in the physician’s office. These symptoms usually indicate bacterial vaginosis (a polymicrobial superficial infection characterized by an increase in aerobic bacteria, especially Gardnerella, and a decrease in lactobacilli), candidiasis (moniliasis) (Candida albicans), or trichomoniasis (Trichomonas infection). Other common causes of vaginal discharge are acute cervicitis, gonorrhea, and herpes genitalis. Sexual abuse and sexually transmitted diseases such as gonorrhea must always be considered in all prepubescent girls with vaginal discharge.
Vulvar itching (which often accompanies vaginal discharge) is common and can occur by itself. The most common vulvar dermatoses are dermatitis, psoriasis, and lichen sclerosus. Streptococcal vulvovaginitis is seen only in children, whereas chronic vulvovaginal candidiasis occurs only after puberty because it is estrogen dependent.
Many discussions of vaginitis emphasize a typical appearance of the discharge: cheesy, frothy, or mucoid. However, appearances may be misleading. In addition, 15% to 20% of patients in one series had two coexisting infections. Other studies of patients with vaginitis have shown that 35% had bacterial vaginosis, 25% had candidiasis, and 20% had trichomoniasis. The remaining 20% had less common types of vaginitis.
In contrast to cervicitis, vaginitis is an inflammatory change of the vaginal mucosa in the absence of a profuse discharge from the cervix. A vaginal discharge can be produced by cervicitis without a significant vaginal infection, as can be the case with gonorrhea. Chlamydia also causes mucopurulent cervicitis.
Prepubertal girls may experience a vaginal discharge in association with vulvovaginitis or exocervicitis. These young girls are particularly susceptible to vulvovaginitis because of the anterior location of the vagina; the proximity of the vagina to the anus; the lack of labial fat pads; a neutral to alkaline vaginal pH; a thin, atrophic vaginal wall; and, occasionally, poor hygiene.
Trichomonal vaginitis is rare in children and women older than 60 years but does occur in neonates of infected mothers. Conversely, candidal (monilial) vaginitis can occur at any age but is uncommon in prepubertal girls unless they have been receiving antibiotics. It is a common cause of vulvovaginitis in postpubescent girls and women. In prepubertal girls, vulvovaginitis is more common than vaginitis. Vulvovaginitis can be caused by bubble baths, other chemical irritants, tight nylon panties, mixed bacterial infections, and foreign bodies.
Bacterial vaginosis is uncommon in premenarchal girls. Gonorrheal infections in premenarchal children are rare but do occur. In such cases, sexual abuse must be suspected. Although a girl may be asymptomatic when a gonococcal infection is present, vulvovaginitis and exocervicitis are usually present.
After puberty, a vaginal discharge may be caused by physiologic factors, cervicitis, or vaginitis. Although trichomonal vaginitis and candidal vaginitis may occur in adolescents, the most common cause of vaginitis with discharge in adolescent girls is bacterial vaginosis. Candida infection is the second most common cause of specific leukorrhea in adolescents. There is a high and increasing incidence of chlamydial and gonococcal infections among postpubertal girls. Among young mothers, the growing prevalence of Chlamydia trachomatis may increase the incidence of this infection among neonates and some children. It is important to question the patient about genital or urinary tract infections (UTIs) in other family members (male or female) or sexual partners (male or female).
The physician must remember that physiologic leukorrhea may occur in menarchal girls. This is not usually profuse or associated with itching. Although these girls may be concerned about a vaginal discharge, they may not present with it as a chief complaint. Therefore, the physician should provide reassurance concerning this and other normal changes that may occur with menarche. The discharges that occur just before and after menarche are often thick, grayish white, and odorless and have a pH of less than 4.5. No signs of inflammation exist because these discharges represent a physiologic reaction to the initial phase of cyclic estrogen production.
In adult women of reproductive age, the common causes of vaginitis are bacterial vaginosis, Candida, and Trichomonas, in decreasing order of frequency. The three most common causes of cervicitis are C. trachomatis, Neisseria gonorrhoeae, and herpes simplex virus. In elderly postmenopausal women, senile atrophic vaginitis often causes a discharge, as do other specific forms of vaginitis.
The duration and type of symptoms do not consistently distinguish the common infectious causes of vaginitis. However, certain symptoms and findings strongly suggest the diagnosis. For instance, although an acute onset of vaginal discharge or vulvar irritation indicates that a yeast infection is the probable cause, these symptoms are often unreliable. Likewise, a curdlike discharge (resembling cottage cheese) strongly suggests yeast vaginitis; however, the gross appearance is less sensitive and specific in establishing the diagnosis than microscopic examination of the vaginal discharge. A curdlike appearance virtually eliminates the possibility of trichomonal vaginitis, which usually produces a profuse, frothy, white or grayish green, malodorous discharge. The discharge from trichomonal vaginitis is typically described as frothy, whereas the discharge from bacterial vaginosis is described as homogeneous.
Because itching and burning may occur with virtually all forms of vaginitis, these symptoms are not particularly helpful in differentiating the cause. Women who diagnose themselves as having a yeast infection have been shown to be only 11% to 34% accurate (bacterial vaginosis being the other most likely diagnosis). It is important to differentiate vulvar pain from vulvar itching. Itching is most prominent in candidal vaginitis and least prominent in bacterial vaginosis. Itching and burning are uncommon with gonococcal infections, but a significant percentage of patients with a gonococcal infection have a combined infection. They may have gonorrhea with their itching that is caused by Trichomonas or Candida.
Vulvar itching is commonly caused by eczema, dermatitis, and vulvovaginal candidiasis. In prepubertal girls, atopic and irritant dermatitis are the most common causes of vulvar itching. Irritants to vulval skin can be chemical (soaps, bath oils, bubble baths, douches, perfume, lubricants, antifungal creams, retained sweat, and vaginal secretions) or physical (sanitary pads, tight clothing, synthetic underwear, excessive cleansing, and shaving). Systemic causes of vulvar itching include diabetes, which predisposes to candidiasis, liver disease, polycythemia, psoriasis, seborrheic dermatitis, and medications, such as penicillin, ampicillin, and sulfa drugs.