Vulvovaginitis: Symptoms, Types, Causes and Treatment

Vulvovaginitis is a common condition that affects millions of women and girls around the world. Characterized by inflammation of the vulva and vagina, it can disrupt daily life, impact intimacy, and cause significant discomfort. While often treatable, its varied symptoms and multiple potential causes can make diagnosis and management challenging. Understanding the nuances of vulvovaginitis—including its symptoms, types, causes, and treatment options—empowers individuals to seek timely and effective care.

Symptoms of Vulvovaginitis

Vulvovaginitis may present with a wide array of symptoms, which can range from mildly bothersome to significantly distressing. Recognizing these signs early is crucial for appropriate diagnosis and treatment, and can help prevent recurrence or complications. Let’s explore the hallmark symptoms and how they may differ depending on the underlying cause.

Symptom	Description	Prevalence/Notes	Source(s)
Discharge	Abnormal vaginal discharge (color, odor, consistency)	Most common; varies by etiology	3 4 5 8
Itching	Vulvar and/or vaginal pruritus	Common, may be intense	1 3 5
Burning	Sensation of burning, especially during urination	Often accompanies other symptoms	1 3 8
Redness	Erythema of vulva/vagina	May be localized or diffuse	1 3
Odor	Unpleasant or "fishy" smell	More common in bacterial vaginosis	4 5 8
Pain	Includes vulvar pain, dysuria, or dyspareunia	May be provoked or persistent	3 5 9

Table 1: Key Symptoms

Common Presentations

Vulvovaginitis symptoms often overlap, but certain features may point toward specific causes. For example:

• Discharge is present in most cases, but its characteristics differ:
  • Thick, white, "cottage cheese" discharge: Suggests candidiasis 1 5
  • Thin, gray/white, malodorous discharge: Suggests bacterial vaginosis 5 8
  • Frothy, yellow-green discharge: Suggests trichomoniasis 5 8
• Itching and burning are particularly prominent in candidiasis and allergic/irritant reactions 1 3 5.
• Painful urination (dysuria) or pain during intercourse (dyspareunia) may be present with any form but are commonly associated with candidiasis or atrophic vaginitis 3 5 8.
• Redness and swelling often accompany infectious causes but can also occur with dermatitis or other irritants 1 3.

Sensory and Skin Changes

• The nature of sensory symptoms (localized or generalized, intermittent or chronic) can guide diagnosis 2.
• Mucocutaneous changes such as lesions, erosions, or excoriations may be seen, especially with chronic irritation or infection 2 3.

Pediatric Considerations

• In prepubertal girls, vulvovaginitis often presents with discharge, irritation, pain, or redness, commonly due to poor hygiene, foreign bodies, or threadworm infestation 9.

Types of Vulvovaginitis

Vulvovaginitis is not a single disease, but rather a syndrome with multiple subtypes—each with its own distinct characteristics and management approaches. Understanding the different types is essential for accurate diagnosis and effective therapy.

Type	Main Features	Frequency/Significance	Source(s)
Bacterial Vaginosis	Malodorous, thin discharge; pH > 4.5	Most common infectious type	4 5 6 8
Vulvovaginal Candidiasis	Thick, white discharge; itching, redness	Second most common; may be recurrent	1 4 5 8 10
Trichomoniasis	Frothy, yellow-green discharge, odor	Sexually transmitted; 3rd most common	4 5 6 8 11
Mixed Infections	Overlapping symptoms of >1 infection	Increasingly recognized	4 7 8
Non-infectious	Atrophic, irritant, allergic, inflammatory	5–10% of cases	2 5 8

Table 2: Main Types of Vulvovaginitis

Infectious Vulvovaginitis

Bacterial Vaginosis (BV):

• Caused by an imbalance in vaginal flora, with overgrowth of anaerobic bacteria such as Gardnerella vaginalis, Mycoplasma hominis, and others 4 5 8.
• Accounts for 40–50% of identified cases 8.

Vulvovaginal Candidiasis (VVC):

• Most often due to Candida albicans, but non-albicans species like C. glabrata are increasingly reported 1 10.
• Second most common infectious cause, affecting up to 75% of women at least once 1 11.

Trichomoniasis:

• Sexually transmitted infection caused by Trichomonas vaginalis 5 8 11.
• Responsible for up to 20% of cases 8.

Mixed Infections:

• Coinfection with more than one organism is common and may complicate diagnosis and treatment 4 7.

Non-Infectious Vulvovaginitis

• Atrophic: Due to estrogen deficiency, often in postmenopausal women 5 8.
• Irritant/Allergic: Caused by exposure to products like soaps, detergents, or pads 2 3 8.
• Inflammatory: Less common; may be associated with autoimmune or dermatological conditions 2 8.
• Foreign Body: Especially in children; can trigger inflammation and discharge 3 9.

Causes of Vulvovaginitis

Vulvovaginitis can be caused by a spectrum of infectious and non-infectious agents, as well as underlying host and behavioral factors. Identifying the root cause is crucial for targeted treatment and prevention of recurrences.

Cause/Trigger	Description/Examples	Risk Factors/Notes	Source(s)
Infectious Agents	Bacteria, fungi (Candida), protozoa (Trichomonas)	Sexual activity, antibiotics, immunosuppression	1 3 4 5 6 8 10
Hormonal Changes	Estrogen deficiency (menopause, postpartum)	Atrophic vaginitis	5 8
Hygiene/Irritants	Soaps, douches, tight clothing, poor hygiene	Children, frequent washing, foreign bodies	3 9
Medical Conditions	Diabetes, immunosuppression, allergies	Recurrent or severe cases	1 10
Contraceptive Use	IUCDs associated with higher BV risk	Especially in younger women	6

Table 3: Vulvovaginitis Causes and Risk Factors

Infectious Causes

• Bacterial overgrowth (BV): Disruption of normal lactobacillus-dominated flora allows anaerobes to proliferate 4 5 8.
• Candida species: C. albicans is the main cause, but non-albicans species are increasingly common, especially in women with diabetes, immunosuppression, or recurrent infections 1 10.
• Trichomonas vaginalis: A protozoan parasite, transmitted sexually 5 8 11.

Non-Infectious Causes

• Hormonal changes: Low estrogen levels thin the vaginal lining and alter pH, predisposing to atrophic vaginitis 5 8.
• Chemical irritants and allergens: Use of scented products, douches, or even certain laundry detergents can trigger inflammation 2 3.
• Poor hygiene: Particularly in children, leading to irritation, infection, or threadworm infestation 9.
• Foreign bodies: Tissue paper, small objects, or retained tampons can cause persistent symptoms 3 9.

Host and Behavioral Factors

• Antibiotic use: Disrupts normal vaginal flora, increasing susceptibility to candidiasis 1.
• High estrogen states: Pregnancy and oral contraceptives can predispose to candidiasis 1 6.
• Sexual practices: Multiple partners or polygamy are risk factors for both BV and VVC 6.
• Immunosuppression/Chronic illness: Diabetes and immunodeficiency increase risk and recurrence, especially for VVC 1 10.

Treatment of Vulvovaginitis

Managing vulvovaginitis involves addressing the underlying cause, relieving symptoms, and preventing recurrence. Treatment regimens vary by type and may include medications, lifestyle changes, and, in some cases, partner management.

Approach	Intervention Examples	Indications/Notes	Source(s)
Antimicrobials	Metronidazole, clindamycin (BV, trichomoniasis)	Oral or topical routes; partner treatment for trichomoniasis	5 8 11
Antifungals	Topical/oral azoles, fluconazole (VVC)	Topical preferred in pregnancy; longer regimens for recurrent cases	1 5 8 11
Hormonal Therapy	Topical estrogen	Atrophic vaginitis	5 8
Probiotics	Lactobacillus supplements	Adjunct for recurrent BV/VVC	1 13
Lifestyle	Hygiene, avoiding irritants, safe sex	All types	3 9
Alternative	Boric acid, tea tree, herbal remedies	Evidence limited, caution advised	1 12

Table 4: Treatment Options for Vulvovaginitis

Infectious Vulvovaginitis

Bacterial Vaginosis:

• First-line: Oral metronidazole 500 mg twice daily for 7 days; alternatives include intravaginal metronidazole or clindamycin 5 8 11.
• Recurrent cases: May require longer or repeated courses 11.
• Partner treatment: Not routinely recommended.

Vulvovaginal Candidiasis:

• Uncomplicated cases: Topical azoles (e.g., clotrimazole) or single-dose oral fluconazole; both are equally effective 1 5 11.
• Pregnancy: Only topical azoles recommended 1 5.
• Non-albicans species: May require alternative or longer regimens (e.g., boric acid suppositories, higher-dose fluconazole) 1 10.
• Recurrent VVC: Suppressive therapy, such as weekly fluconazole for up to 6 months 1 11.

Trichomoniasis:

• Treatment: Single 2-gram oral dose of metronidazole, or 500 mg twice daily for 7 days 5 8 11.
• Partner treatment: Essential to prevent reinfection 8 11.

Non-Infectious Vulvovaginitis

• Atrophic: Topical estrogen therapy is effective in restoring vaginal mucosa 5 8.
• Irritant/Allergic: Removal of offending agents, improved hygiene, and, if needed, topical steroids 3 5 8.
• Foreign body: Removal is curative 3 9.

Adjuncts and Prevention

• Probiotics: Emerging evidence suggests that lactobacillus supplements can help restore healthy vaginal flora and reduce recurrence rates, especially for BV and VVC 1 13.
• Alternative therapies: Substances like boric acid and some herbal remedies show promise but require caution due to potential side effects and lack of robust clinical data 1 12.
• Lifestyle: Good hygiene, wearing breathable underwear, avoiding douching, and practicing safe sex all help reduce risk 3 9.

Special Populations

• Children: Emphasis on hygiene, treating threadworms, and avoiding unnecessary antibiotics 9.
• Pregnancy: Topical agents are preferred for infection; some treatments are contraindicated 1 5.

Conclusion

Vulvovaginitis is a multifaceted condition that can affect women and girls of all ages. Timely recognition and targeted treatment are vital for symptom relief, prevention of recurrence, and overall quality of life.

Key Takeaways:

• Symptoms include discharge, itching, burning, redness, odor, and pain, with variations depending on the underlying cause.
• Types range from bacterial vaginosis and candidiasis to trichomoniasis, mixed infections, and non-infectious forms such as atrophic or irritant vulvovaginitis.
• Causes are diverse—spanning infectious agents, hormonal changes, hygiene practices, medical conditions, and behavioral factors.
• Treatment must be tailored to the specific type and may involve antibiotics, antifungals, hormonal therapy, probiotics, and lifestyle changes; recurrent or resistant cases may require specialized regimens.

Staying informed, seeking prompt medical advice, and following prevention strategies can significantly reduce the burden of vulvovaginitis and enhance well-being.