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    Recurrent vulvovaginitis: Tips for treating a common condition



    Vaginal itching, discharge, and odor are among the most common complaints in gynecologic and primary care offices.1 Women often call their practitioners after self-treating at home. Self-diagnosis has been shown to be correct less than one-third of the time, leading to millions of dollars wasted on treating the wrong entity.2 Diagnosis by phone has also been shown to be only marginally better than chance. The symptoms of an infectious vaginitis are often confused and/or complicated by irritation, allergy, or other systemic diseases. Contact dermatitis and atrophy are similar in prevalence to candidiasis among patients referred for chronic vaginitis.3

    Recognition and tailoring treatment to the correct disease process is paramount when managing patients with recurrent vulvovaginal symptoms. This involves seeing a patient, making a correct diagnosis, and treating any other conditions that may affect the success of the treatment chosen.

    The natural defense of the vagina relies on protective organisms, intact epithelial cells, and often estrogen. Lactobacillus is the cornerstone of this protection, lowering the vaginal pH to create an environment unsuited to the growth of bacteria.4 It also inhibits bacterial adherence to epithelial cells and competes with them for nutrients. The vaginal equilibrium is affected by semen, arousal, tampons, menstrual blood, douching, antibiotics, and other contact irritants (Table 1).

     

     

    Damage to the epithelial cells in the vagina due to trauma, bacterial overgrowth, or loss of estrogen can lead to difficulty in eliminating unwanted bacteria and increased sensitivity to the many irritants that come in contact with vulvovaginal tissue.5 Contact dermatitis can compound an otherwise “simple” infection and predispose women to recurrence due to a breakdown of their natural defenses.

    Many cases of acute vaginitis can be easily treated when correctly diagnosed, however, some women will have persistent or recurrent disease. This article focuses on the more common causes of recurrent infectious vaginitis: Candidiasis and bacterial vaginosis (BV) and the methods used for their treatment and prevention.

     

    Merida Miller, MD
    Dr. Miller is Associate Professor of Obstetrics and Gynecology, University of Iowa, Iowa City.

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    • Dr. Neil S. Gladstone
      I appreciated Dr. Miller's discussion of a common and vexing problems for both patients and clinicians. For 45 years, I have seen more unhappy patients with BV than any other condition including malignancies. At least with cancer, there is hope of a cure. With BV it never goes away. The two most important tools for the clinician in diagnosis BV are pH paper and a microscope. After the history, which is predictable, and after my vaginal exam. I do a pH on the discharge taken from the upper aspects of the vagina. The pH helps to direct what comes next. If the pH is in the acidic range the differential diagnosis is either Candida (yeast) or leucorrhea. If the patient presents with a history suggestive of yeast and she has a "Typical" cottage cheese discharge, and we are not dealing with multiple recurrences, I elect to treat with either topical or oral agents. For problem cases I will use a NAAT testing procedure. If the pH is in the alkaline range, I do a wet smear. If there is no evidence of Trichomands and with presence of Clue Cells, I make the diagnosis of BV. My treatment is two fold: I take the time needed to explain to the patient what are the triggers for BV, that the bacteria that cause the BV symptoms are residents of the vagina and can not be totally eliminated, and the change in pH temporarily eliminates the beneficial action of Lactobacillus. In this environment it is the anaerobes that were listed in the article that predominate. I encourage all patients to use condoms at all times and to use tampons to get rid of menstrual blood as quickly as possible. Instead of continually prescribing Metronidazole or Clindamycin orally, I use Boric acid vaginal suppositories 600 mg for at least one week. Patients do not like the topical antibiotics as the perception these measures do not work. They are unhappy because the oral antibiotics do not work because the "infection" keeps reoccurring, I never reference BV as a STI,but I also talk about keeping the environment of the vagina healthy by keeping out the offending substances and restoring the pH. The suppositories help with Candida as well. One part of therapy most clinicians especially non OBGYNS fail to do is to use a steroid and antifungal topical combination for the skin of the vulva. This maneuver provides relief for the irritated itchy skin. Each patient gets a written information about BV and I always offer to discuss the diagnosis with reluctant partners. This approach is not the panacea for BV , but I think it is more successful than the manner most people treat BV.This is anecdotal information, but I think it would merit someone with the time and patients to do a RCT. Also, I am very liberal in ordering STI panels including the use of NAAT panels. Neil S Gladstone, MD, FACOG,CCD

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