Abstract
Background: Vulvovaginal irritation is a common gynecologic complaint. A number of factors may lead to a trial of therapy without undertaking a physical exam or diagnostic testing. Case Report: A 45 year-old woman presented to our colposcopy clinic for evaluation of an abnormal Papanicolaou (Pap) test. She reported a one month history of vulvovaginal irritation, for which Premarin vaginal cream had been empirically prescribed. Examination of the external genitalia showed ulcers and erythema of the labia minora. Speculum exam was deferred because of the patient’s discomfort. Wet mount microscopy from a vaginal swab revealed evidence of Trichomonas vaginalis, bacterial vaginosis (BV), and yeast. A swab of the ulcers was sent for herpes simplex virus (HSV) polymerase chain reaction (PCR); this confirmed HSV-2. Treatment was initiated for each of these conditions, and the patient returned for colposcopy 21 days later. Conclusion: This case illustrates the importance of the physical exam when evaluating a complaint of vulvovaginal irritation. In many cases, the cause(s) of vulvovaginal irritation can be identified based on physical exam findings and in-office testing with wet mount microscopy, vaginal pH, and the amine “whiff” test. In some cases, additional testing may be required to establish or confirm a diagnosis. Accurate diagnosis is essential not only to initiate appropriate therapy, but also to prevent the transmission of sexually transmitted infections. In some cases, this may decrease the delay in diagnosing vulvar gynecologic malignancies.
Highlights
ConclusionThis case illustrates the importance of the physical exam when evaluating a complaint of vulvovaginal irritation
Vulvovaginal irritation—burning, itching, or pain, abnormal vaginal discharge, and odor are common gynecologic complaints that lead women to seek care from their primary care provider or gynecologist.[1,2,3,4] A number of factors, including the availability of over-thecounter antifungal medications,[5,6] and patient and provider time pressures and comfort with undertaking a pelvic exam, may lead to an empiric trial of therapy without undertaking a physical exam or Please cite this paper as: Christensen A, Haugsdal ML, Bowdler NC
This case illustrates the importance of the physical exam when evaluating a complaint of vulvovaginal irritation
Summary
The cause(s) of vulvovaginal irritation can be rapidly and accurately diagnosed using a combination of pelvic exam and in-office testing. Additional testing with a yeast culture, HSV PCR, or biopsy may be helpful. While there are barriers to the early evaluation of vulvovaginal irritation by a clinician, this will lead to cost savings related to the inappropriate use of over-the-counter products and help to avoid delays in the diagnosis of transmissible conditions or potentially serious conditions such as vulvar neoplasia
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