Vulvovaginitis is an inflammation involving the vagina and vulva, i.e. the lower part of the female genital tract. There are several causes that can lead to its onset

These include infections, irritative reactions, hormonal changes and other situations that contribute to altering the vaginal ecosystem, making it more vulnerable.

Symptoms of vulvovaginitis are usually burning, itching, erythema, oedema and soreness, often associated with vaginal discharge.

Vaginal and vulvar irritation may worsen with sexual intercourse and the habit of excessive intimate hygiene.

The diagnosis of vulvovaginitis is made through an objective examination and analysis of vaginal secretions.

Treatment is directed at the root cause, symptom control and correction of hygiene habits.

Causes and risk factors of vulvovaginitis

Vulvovaginitis consists of simultaneous inflammation of the vagina (vaginitis) and vulva (vulvitis).

This inflammatory process has a variety of causes, including infection, irritation, hormonal changes and trauma.

Normally, in women of reproductive age, lactobacilli are the predominant constituents of the vaginal microbial flora.

Colonisation by these bacteria is normally protective, as it maintains the vaginal pH at normal values (between 3.8 and 4.2) and prevents excessive growth of pathogenic bacteria.

In addition, high oestrogen levels maintain the thickness of the vaginal mucosa, strengthening local defences.

Non-infectious causes account for about 30% of vulvovaginitis cases.

Infectious causes of vulvovaginitis

In many cases, vulvovaginitis is favoured by an increase in local pH (due to menstrual blood, post-coital semen, reduced lactobacilli and concomitant diseases) and altered 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 mycetes (e.g. Candida albicans), bacteria (e.g. Gardnerella vaginalis, streptococci and staphylococci), protozoa (e.g. Trichomonas vaginalis) and, more rarely, viruses such as Herpes simplex.

In girls between the ages of 2 and 6 years, inflammation usually results from infection by the microbial flora of the gastrointestinal tract; a factor that frequently promotes this condition is poor perineal hygiene (e.g. incorrect habit of wiping from the back to the front after evacuation; not washing hands after defecating; scratching in response to itching, etc.).

In women of reproductive age, vulvovaginitis may result from infection with pathogens responsible for sexually transmitted diseases (including Neisseria gonorrhoeae, Trichomonas vaginalis and Chlamydia trachomatis).

Other predisposing conditions for vaginal and vulvar infections include fistulas between the intestine and the genital tract, and radiation therapy or pelvic tumours, which injure tissues and thus compromise normal host defences.

Irritative causes of vulvovaginitis

Vulvovaginitis may result from hypersensitivity or irritative reactions of the vulvar and vaginal mucosa.

Excessive use of intimate cleansers and vaginal douches greatly increases the risk of suffering from the disorder.

In susceptible persons, exposure to certain chemicals contained in bubble baths and soaps may even provoke an allergic reaction.

Also included in the category of potential sensitisers are hygiene sprays or perfumes, fabric softeners, dyes and additives in detergents.

Occasionally, irritation may result from the use of vaginal lubricants or creams, latex condoms, spermicides, contraceptive vaginal 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 stimulation, or rubbing from excessively tight clothing, especially if it is made of a synthetic material.

Prolonged contact with a foreign body – such as a condom, tampon, toilet paper remnants or grains of sand – can also cause nonspecific vulvovaginitis with blood secretion.

Other causes of Vulvovaginitis

As mentioned, imbalances in the vulvar and vaginal environment can also result from immunodepression and systemic diseases, such as diabetes.

Other risk factors for vulvovaginitis include the prolonged use of certain medications, such as antibiotics and corticosteroids.

Hormonal changes can also favour the occurrence of vulvovaginitis.

After the menopause, for instance, a marked decrease in oestrogen causes thinning of the vagina and increased susceptibility to inflammation (atrophic vaginitis).

Changes in hormonal balance can also occur at other times, such as after childbirth or during breastfeeding.

Reduction of oestrogen can also be induced by certain treatments, such as surgical removal of the ovaries, pelvic irradiation and chemotherapy.

In some cases, vulvovaginitis of a non-infectious nature may be favoured by psychological factors (e.g. unsatisfactory sex life or depressive pictures).

Signs and Symptoms

Vulvovaginitis generally manifests as itching, soreness and redness of the labia minora, labia majora and vaginal orifice.

These symptoms are often accompanied by discharge from the vulva and aching pain during sexual intercourse (dyspareunia).

Local irritation may also result in burning or slight bleeding.

In addition, dysuria (pain on urination) and vaginal dryness may occur.

In some cases, the vulva may appear oedematous and excoriations, blisters, ulcerations and fissures may occur.

Vaginal and vulvar discharge

The appearance and quantity of vulvovaginal discharge differs depending on the cause of the inflammation.

Normal vaginal discharge is milky white or mucoid in colour, odourless and non-irritating; sometimes, it may lead to wetting of the underwear.

In the case of bacterial infections, a white or greyish leucorrhoea usually appears, with an amine, fish-like odour.

The latter can become very intense when alkalinisation of the discharge occurs, after coitus and menstruation; itching and irritation are also common.

Candida vulvovaginitis typically causes a whitish, caseous-looking vaginal discharge; these losses are accompanied by severe itching and pain during coitus.

Profuse, foamy, foul-smelling, greenish-yellow discharge typically signals a Trichomonas infection.

Herpes virus infection does not alter normal vaginal discharge, but is accompanied by the appearance of painful blisters.

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 may also promote postpartum endometritis, chorioamnionitis, premature rupture of membranes and preterm delivery.

Diagnosis of vulvovaginitis

The diagnosis of vulvovaginitis is made on the basis of symptoms and signs during the gynaecological examination, during which the lower part of the female genital tract is examined.

On inspection, vulvar redness and oedema may be noted, accompanied by excoriations and fissures.

Less often, vulvovaginitis may be associated with the appearance of blisters, ulcerations or vesicles.

To determine the cause of the inflammation, samples of the vaginal secretions can be taken using swabs.

By measuring the pH and microscopic examination of this material, a first clue can be given as to the aetiology causing the disorder.

The finding of atypical vaginal discharge, the presence of white blood cells in the specimen or a concomitant inflammation of the cervix should lead to an assessment of the possible presence of a sexually transmitted disease and requires further investigations.

If the results of outpatient examinations are inconclusive, the secretion may be cultured.

The persistence of symptoms, accompanied by the presence of particular lifestyles and habits (e.g. abuse of intimate cleansers, tampons or panty liners) should direct attention to the fact that this may be a form of vaginal hypersensitivity to irritating agents.

Differential diagnosis

Cervical discharge caused by inflammation of the cervix may resemble vulvovaginitis; abdominal pain, pain on palpation of the cervix or inflammation of the cervix suggest pelvic inflammatory disease.

A watery and/or haematic discharge may be the consequence of vulvar, vaginal or cervical cancer.

These neoplasms can be differentiated from vulvovaginitis by objective examination and the Papanicolau test (PAP test)

Itching and vaginal discharge can also result from skin diseases (such as psoriasis and tinea versicolor), which can be revealed through history and skin findings.

In girls, if Trichomonas vulvovaginitis is found, a differential diagnosis should be made with sexual abuse.

Treatment Vulvovaginitis: What is the treatment?

Treatment is, first of all, directed at the causes of vulvovaginitis.

In the case of vulvovaginitis of bacterial origin, treatment involves antibiotics, such as metronidazole, clindamycin and tinidazole, to be taken orally or applied topically for a few days.

In the case of fungal infections, on the other hand, antifungal drugs are indicated, to be applied topically or taken orally.

In the case of allergic or irritative phenomena, the application of excessively alkaline or dye-rich soaps and non-essential topical preparations (such as perfumes or intimate deodorants and depilatory creams) on the vulva should be avoided, and the use of the sensitising substance that caused the reaction should be discontinued.

If the symptoms are moderate or intense, the doctor may prescribe a pharmacological treatment based on antiseptic and anti-inflammatory products, such as benzidine.

For itching, however, the application of topical corticosteroids on the vulva, but not in the vagina, may be indicated.

Oral antihistamines also reduce the itchy sensation and cause drowsiness, sometimes improving the patient’s sleep at night.

In the case of vulvovaginitis, attention must be paid to adopting proper hygienic measures.

In particular, it is important to clean oneself from front to back after each evacuation and urination, to remember to wash one’s hands, and to avoid touching the perineum.

In addition, it is advisable to abstain from sexual intercourse or to use a condom, until recovery is established.

The use of intimate cleansers should not be done excessively: this habit may alter the vagina’s natural immune defences and saprophytic microbial flora.

If chronic inflammation is due to bedwetting or incontinence, it may be helpful to maintain better vulvar hygiene by carefully drying the skin and mucous membranes after toileting; changing underwear frequently and wearing loose cotton clothing reduces local moisture and the proliferation of pathogenic microorganisms.

Wearing clothing that is too tight or non-breathable, in addition to promoting vulvovaginitis, can prolong healing time.

Vulvovaginitis: can it be prevented?

In addition to strictly following the therapy for vulvovaginitis indicated by the gynaecologist, it is advisable to associate certain useful behaviours to prevent subsequent infections or irritations.

The use of condoms can help limit the risk of certain infectious processes that can be transmitted sexually.

Another good rule is to choose undergarments that ensure proper breathability and do not irritate the genital area.

Therefore, one should prefer the use of pure cotton underwear, preferably white; this natural fabric allows proper tissue oxygenation and limits the stagnation of secretions.

To prevent vulvovaginitis, it is also advisable to avoid continuous use of deodorant intimate wipes, panty liners, tampons and acid pH soaps.

Finally, in the prophylaxis of re-infections it may be useful to correct any hormonal imbalances, to include yoghurt or milk enzymes in the daily diet, and to limit carbohydrate and sugar intake.

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