Vulvovaginitis is a primary non–infectious or infectious (specific or non-specific) inflammatory lesion of the mucous membrane of the external genitalia and vagina. Symptoms of vulvovaginitis of any etiology are represented by hyperemia, swelling, burning and itching of the vulva. The nature of the discharge from the genital tract depends on the cause / causative agent of vulvovaginitis. The disease is diagnosed on the basis of gynecological examination, results of smear examination by bacterioscopy, microbiological seeding, PCR. Treatment of vulvovaginitis consists of etiotropic therapy, local procedures (baths, douches, the introduction of candles), restoration of the vaginal microflora.
Vulvovaginitis is a group of inflammatory diseases of the lower genital tract (vulva and vagina) of various etiologies. The greatest incidence of vulvovaginitis is diagnosed among girls under 10 years of age and postmenopausal women, which is associated with the peculiarities of female age physiology. Despite the success of pharmacotherapy, the prevalence of inflammatory diseases (vulvitis, vaginitis, vulvovaginitis) remains at a consistently high level. In the structure of gynecological pathology, vulvovaginitis accounts for up to 60-80% of all referrals.
The torpidity of the course, the tendency to relapse and chronization, the mixed etiology of the disease, the involvement of the urinary tract and the overlying parts of the genital tract determine the relevance of the problem of vulvovaginitis for modern gynecology. The pathology, which seems harmless at first glance, can have very serious long-term consequences for women’s reproductive health in the form of ectopic pregnancy, miscarriage, tubal infertility, etc.
Based on the clinical and etiological principle, two groups of vulvovaginitis are distinguished: primary non-infectious and primary infectious. Primary non-infectious vulvovaginitis may have traumatic, allergic, parasitic, dishormonal, dysmetabolic origin. Taking into account the etiology , infectious vulvovaginitis is divided into:
- nonspecific (coccobacillar)
- specific (candidiasis, ureaplasma, mycoplasma, chlamydia, trichomonas, gonorrhea, tuberculosis, diphtheria, cytomegalovirus, herpes virus, etc.).
Taking into account the age criterion, vulvovaginitis is distinguished in girls, women of childbearing age and postmenopausal women. According to the duration of the course, vulvovaginitis can be acute (up to 1 month), subacute (up to 3 months) and chronic (over 3 months); by the nature of the course, persistent and recurrent.
The leading role in the development of inflammatory vulvovaginal pathology belongs to the infectious factor. In girls under 10 years of age, representatives of nonspecific bacterial microflora predominate among the pathogens: E. coli (60%), Staphylococcus aureus (21%), Diplococcus (11%), enterococcus (7%), chlamydia (13%) and anaerobes (7%). In women of childbearing age, vulvovaginitis is more often caused by pathogens of genital candidiasis (30-45%) and non-specific bacterial infection. Unprotected sexual contacts cause the development of vulvovaginitis in chlamydia, gonorrhea, mycoplasmosis, ureaplasmosis, trichomoniasis, genital herpes and other STIs. The defeat of the vagina and vulva is observed in genital tuberculosis and diphtheria. In recent years, there has been an increase in the etiological role of associations of microorganisms in the development of vulvovaginitis.
The cause of primary non-infectious forms of the disease can be foreign bodies of the vagina, masturbation, worm infestations (enterobiosis). Recurrent vulvovaginitis is noted in people suffering from endocrine-metabolic disorders (diabetes mellitus, obesity), diseases of the urinary tract, intestinal dysbiosis, allergic diseases, frequent viral infections. Atrophic vaginitis prevails in the postmenstrual period.
In childhood, hormonal rest (absence of hormonal activity of the ovaries), anatomical features (proximity of the anus to the genitals, thin and loose mucous membrane), alkaline reaction of vaginal secretions, errors in hygiene contribute to the high prevalence of vulvovaginitis. The maximum peak of morbidity occurs at the age of 3-7 years. In postmenopausal women, changes in the vaginal microflora and a decrease in local protective mechanisms occur against the background of age-related estrogen deficiency.
Regardless of age, factors predisposing to the development of vulvovaginitis can be considered improper intimate hygiene; at the same time, it should be remembered that too frequent washing and douching with the use of antiseptics and cleaning agents is also dangerous, as is neglect of hygienic procedures. Uncontrolled treatment with antibiotics, taking glucocorticoids, cytostatics, COCs, and radiation therapy can provoke a violation of the vulvovaginal ecosystem with the subsequent addition of an infectious and inflammatory process. Pregnancy, genital prolapse, vulva injuries and scratching, eczema of the skin of the perineum and anus, chronic stress, prolonged uterine bleeding can contribute to the occurrence of vulvovaginitis.
In the body of a healthy woman, there are natural local protective mechanisms that prevent the reproduction of pathogens and their introduction into the underlying tissues, limiting and preventing the development of the inflammatory process. Such mechanisms include intact mucosa, normal, balanced vaginal microflora, pH 4-4.5. With a decrease in the protective properties of the vaginal ecosystem, vulvovaginitis develops, which opens the possibility for the upward spread of infection to the internal genitals.
Despite the variety of etiological factors of vulvovaginitis, their clinical manifestations are generally identical. Acute vulvovaginitis occurs with pronounced signs of local inflammation. Patients are concerned about pain, burning and itching, which increase with urination, walking, sexual intercourse. When examining the external genitals, swelling of the labia, hyperemia of the vulva is determined, often redness, scratching and maceration of the skin of the perineum and thighs. Severe forms of vulvovaginitis can be accompanied by the formation of erosions in the area of the external genitals. Children with itching can develop neurotic reactions, sleep disorders. General infectious symptoms (fever, enlargement of regional lymph nodes) are rare. Whites with acute vulvovaginitis can be scanty or abundant in volume, watery, curd, serous-purulent, purulent, bloody in nature. Often the discharge has an unpleasant specific smell.
With the chronization of vulvovaginitis, the main symptoms are pathological discharge from the genital tract and constant itching in the vulva. Exacerbations occur against the background of hypothermia, errors in nutrition (abuse of sweets, spices, extractive substances), intercurrent diseases. In young girls, this form of the disease is fraught with the formation of synechiae of the labia minora, which can create an obstacle to urination. Prolonged vulvovaginal inflammation contributes to the formation of scarring in the vagina, complicating further sexual life.
With the upward spread of infection, VZOMT (endometritis, salpingitis, oophoritis) often develop. Vulvovaginitis of various etiologies is particularly dangerous for pregnant women: they can cause spontaneous termination of pregnancy, chorioamnionitis, postpartum endometritis, infections of newborns.
To identify and clarify the etiological form of vulvovaginitis, complex instrumental and laboratory diagnostics are performed. Generally accepted measures include the appointment of a gynecologist, examination on a chair with sampling of smears. According to the indications, colposcopy (vaginoscopy for girls) and cervicoscopy are performed. Signs of inflammation are swelling and hyperemia of the mucous membrane and pathological vaginal discharge. In some cases, the introduction of a gynecological mirror can be dramatically painful for the patient.
The etiological diagnosis is established by laboratory means using smear microscopy and bacteriological examination of material from the genital tract. The inflammatory nature of the pathology is indicated by an increased number of leukocytes, the presence of bacteria. In order to identify specific flora, a PCR analysis of the scraping for major urogenital infections is performed. The method of fluorescent antibodies (MFA) is considered a highly specific study. A study of the general urinalysis is mandatory, and girls also have scraping for enterobiosis.
Differential diagnosis is carried out between specific and non-specific vulvovaginitis. To exclude inflammatory pathology of the uterus and appendages, ultrasound of the pelvic organs is performed. In order to clarify the etiology of recurrent vulvovaginitis, it may be necessary to consult narrow specialists: venereologist, allergist, endocrinologist, urologist, phthisiologist, etc.
Treatment of vulvovaginitis is strictly mandatory, regardless of the etiology and form of the disease, the severity of complaints, the age of the patient. It includes the use of etiotropic drugs, local treatment of the genitals with disinfectants and antiseptic solutions, elimination of provoking factors and concomitant diseases, restoration of normal vaginal microflora.
Etiotropic therapy of vulvovaginitis involves the use of drugs that act directly on the pathogen. To do this, local (in the form of vaginal tablets, candles, creams) and systemic antibiotics are used, which are prescribed taking into account the selected flora and sensitivity. Given the high prevalence of vulvovaginitis of polymicrobial etiology, it is very important to use polycomponent drugs with local antibacterial, antimycotic and antiprotozoal effects. Candidiasis vulvovaginitis requires the reception and local use of antifungal drugs (fluconazole, clotrimazole, natamycin, etc.). At the end of the course of antimicrobial therapy, the microflora is restored by intravaginal administration of probiotics and their oral administration.
To alleviate the symptoms of vulvovaginitis, sedentary baths and douching with herbal decoctions, antiseptic solutions, and the use of vaginal candles are recommended. Treatment of background diseases requires a decrease in allergic mood, correction of the level of glycemia in diabetes mellitus, rehabilitation of infectious foci, the appointment of HRT for atrophic vulvovagignitis, deworming in enterobiosis, etc. If a specific vulvovaginitis is detected, treatment of the sexual partner is required. Sexual rest is necessary until the end of treatment.
It is important to adjust the nature of nutrition, normalize weight, change hygiene habits. In certain cases, the elimination of provoking factors leads to a stable cure of vulvovaginitis without subsequent relapses. In order to control the cure after the course of therapy, a control bacterioscopic and microbiological examination of the discharge from the genital tract is performed.