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Persistent vaginitis is a challenging problem. Women with untreated chronic vaginitis suffer not only because of their symptoms but also due to their fear that they may be harbouring a sexually transmitted infection. Furthermore, once the common infective causes have been eliminated, it can be very difficult make a confident diagnosis, because the available tests are often not diagnostic.
What Is Persistent Vaginitis?
Vaginitis is inflammation of the vaginal epithelium evidenced by erythema, discharge or other changes such as erosions. Infection is the most common cause, but there are less common, non-infective aetiologies. It may occur in isolation or be associated with a dermatosis of the mucosal surface of the labia minora, vulva or perianal skin. Persistent vaginitis is when this symptomatic inflammation either recurs after, or is resistant to, initial treatment.
Most general practice presentations of vaginitis are acute: that is, sudden in onset and of short duration. Most cases are due to acute candidiasis or bacterial vaginosis, diagnosable by vaginal swab, microscopy, culture and pH level, and are promptly treatable with a short course of antifungals or antibiotics. In practice, these patients are often treated empirically. We will not deal in this chapter with the sexually transmitted or tropical infective causes for vaginitis, as the former are covered well in other texts and the latter are usually not a feature of Western medical practice.
Persistent vaginitis is less common and, for the clinician, often perplexing. For the patient, it can be the cause of enormous misery, anxiety, sexual guilt and even relationship breakdown. Historically, it has three patterns: recurring attacks, chronic unremitting symptoms, and symptoms that are chronic but exacerbate at certain times of the menstrual cycle. The main differentiating feature between acute and chronic disease is the duration of symptoms and rapid recurrence after treatment. A previous systematic review has demonstrated that, taken individually, symptoms, signs and tests are poor predictors of the cause of vaginitis.
Does the Complaint of Persistent Vaginitis Indicate Pathology?
A patient presenting with persistent, symptomatic vaginitis is very likely to have a defined aetiology. Evidence-based medicine in the field of vaginal disease is lacking. There have been no large well-conducted trials, and the publications cited here are observational case series, reviews and expert opinion pieces by experienced clinicians.
Our own differential diagnosis of persistent vaginitis is not long (Table 6.1). The list is based on our published observations and is listed in the order of the prevalence we think may occur in general practice.
| Common | Uncommon | Rare | Very rare |
|---|---|---|---|
| Chronic vulvovaginal candidiasis | Desquamative inflammatory vaginitis | Mucosal lichen planus | Crohn’s disease |
| Bacterial vaginosis | Intra-vaginal foreign body (e.g. retained tampon) | Oestrogen-hypersensitivity vaginitis | Immunobullous disease |
| Contact dermatitis (allergic or contact) | Chronic fixed drug eruption | Graft-versus-host disease | |
| Type 1 hypersensitivity reaction |
Some of the less common conditions that may be unfamiliar to general clinicians include the following:
Recurrent and chronic vaginal candidiasis (see Chapter 3). The definition of recurrent vulvovaginal candidiasis is four attacks per year; however, there are also patients whose presentation of candidiasis is more indicative of a chronic, continuous process. This is usually obvious on history.
Recurrent bacterial vaginosis. Although this is usually a single event, in some patients it may recur frequently.
Type 1 hypersensitivity responses. This can result in itch, burning and swelling, and even anaphylaxis can occur as a result of exposure to latex condoms and seminal fluid.
Intra-vaginal foreign body such as a retained tampon. This normally presents with a heavy discharge and/or recurrent infection.
Chronic fixed drug eruption (see Chapter 5).
Desquamative inflammatory vaginitis (see Chapter 5). This is an uncommon, non-infective, painful vaginitis of unknown aetiology characterised by shiny, erythematous patches and/or petechiae.
Lichen planus (see Chapter 5). This is a rare skin disease that often involves the oral as well as the vaginal mucosa with very painful erosions, which eventually lead to scarring.
Oestrogen-hypersensitivity vulvovaginitis (see Chapter 3). This is a rare cyclical vaginitis with a presentation very similar to recurrent candidiasis but not causally associated with Candida.
Crohn’s disease (see Chapter 5). This is a rare manifestation of vaginitis.
Graft-versus-host disease (see Chapter 5). This can present with a picture indistinguishable from vaginal lichen planus.
Immunobullous diseases (see Chapter 5), particularly mucosal pemphigoid. This can present with vaginitis, but is very rare.
In most patients, chronic persistent vaginitis is not a sign of systemic illness, or indeed infection. It should be noted that, of all of these conditions, only recurrent candidiasis and bacterial vaginosis are causally related to specific micro-organisms. With the exceptions of lichen planus, immunobullous disease and Crohn’s disease, which have defined histopathology, none are diagnosable by biopsy.
As these diseases are very different in aetiology, an accurate diagnosis is therefore essential for rational management.
History Taking
A detailed and specific history is essential to making a diagnosis.
The symptoms should be defined as follows:
Itch, soreness or burning
Discharge or swelling
Superficial dyspareunia or skin splitting
Sudden or insidious onset
Duration
Whether continuous or recurrent
Whether there is a relationship to the menstrual cycle
Historical triggers can be critical to the diagnosis, especially for contact dermatitis, type 1 hypersensitivity reactions, desquamative inflammatory vaginitis and fixed drug eruptions. Vaginal surgery may trigger candidiasis and desquamative inflammatory vaginitis, as can antibiotic use. Events that exacerbate symptoms are also useful, for example the tendency of candidiasis to exacerbate in the pre-menstrual phase of the menstrual cycle.
Ask specifically about the following:
Medications including over-the-counter medications and whether the vaginitis occurred before they were commenced
Condoms
Relationship to contact with semen
Topically applied substances, lubricants, pessaries and devices such as intrauterine devices
Presence of oral lesions that might indicate lichen planus
Previous results of swabs
Previous response to treatment
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