Benign Diseases of the Vulva and Vagina

According to the work conducted in Israel by Prof. Michael Dan in 2003, out of approximately 208 women who visited gynecological clinics with symptoms like discharge, itching, pain, or tingling, only 35% were diagnosed with yeast infections. This finding indicates that the majority of itching in the vulva and vagina is caused by other factors, including skin diseases, allergen sensitivity, other infectious diseases, estrogen deficiency, and more. For a comprehensive list of potential causes and further information, please refer to the patient information sheets provided in the provided link.

In approximately 50%-70% of cases, the presence of fungus can be confirmed by examining the vaginal surface under a microscope. If there is a suspicion of a fungal infection but the fungus cannot be directly sampled and observed under a microscope, a vaginal culture should be obtained and sent to the laboratory. It typically takes around 48 hours to receive an initial response from the culture. Although there are kits available for diagnosing fungal infections based on molecular methods, their effectiveness has not been demonstrated to be superior to traditional culture methods.

The majority of vaginal infections (80-90% of cases) are caused by Candida albicans, a type of fungus. Other fungi within the same family, including Candida glabrata, Candida parapsilosis, and Candida tropicalis, can also cause vaginal infections. The specific type of fungus present determines the appropriate treatment approach.

In the majority of cases, the treatment for vaginal yeast infections is primarily aimed at relieving symptoms. Women who are "carriers" of the fungus but do not have any symptoms generally do not require treatment. Treating a partner is not necessary since vaginal yeast infections are not considered sexually transmitted diseases. The presence of these infections in individuals during childhood, adolescence, or in women who are not sexually active suggests that the primary source of infection is not through sexual relations. Treating a spouse or partner is ineffective in resolving the infection.

The most probable source of the fungus causing vaginal infections is the digestive system, with the fungus transitioning to the vagina through direct passage from the anal area. Vaginal infection can also occur through direct contact with other body parts where the fungus is present. Some women report a tendency to develop infections following antibiotic treatment, exposure to estrogen, a diet high in sugars, or after intercourse. However, it is important to note that more than half of women experiencing recurrent episodes of vaginal yeast infection are unable to identify a specific cause preceding the onset of the infection.

In certain cases, the composition of vaginal bacteria can undergo an unexplained change, resulting in the displacement of lactobacilli by non-acid-producing bacteria, such as anaerobic bacteria. These bacteria produce amines that are associated with an unpleasant odor. This shift in vaginal bacterial composition, accompanied by discharge and an unpleasant odor, is referred to as bacterial vaginosis. It is worth noting that this condition does not typically cause any accompanying pain.

Engaging in sexual activity can increase the risk of contracting sexually transmitted diseases such as HIV, gonorrhea, chlamydia, and herpes. Additionally, certain gynecological procedures like scraping, hysteroscopy, hysterectomy, and intrauterine device insertion carry an elevated risk of intrauterine infection. In pregnant women, the presence of bacterial vaginosis has been associated with higher rates of miscarriages and premature births.

The treatment targets the anaerobic bacterial population. The two antibiotic groups metronidazole (Flagyl) and clindamycin (Delcin) are similarly effective. The treatment can be systemic (oral) or local to the vagina.

As previously mentioned, the source of an unpleasant odor is not necessarily from the vagina alone. It can originate from secretions originating from the uterus or cervix, as well as from the groin area, particularly in overweight women where the folds of skin can contribute to the odor. In women with incontinence or urinary leakage, the use of excessive absorbent pads can also be a source of unpleasant odor. Therefore, a thorough examination of the vagina is necessary to determine the precise source of the discharge and address the issue appropriately.

These symptoms are commonly associated with estrogen deficiency, which can lead to vaginal atrophy characterized by the degeneration of the vaginal walls. The preferred treatment for this condition involves the application of estrogen directly into the vagina using a cream or vaginal pill. With this treatment, significant improvement can be observed within approximately a month. Initially, it is important to administer the estrogen daily, but as symptoms improve, the dosage can be reduced to a supportive treatment regimen of once to three times a week.

The treatment is very effective and within 4-6 weeks it is possible to achieve significant clinical improvement and considerable relief in complaints.

In Israel, it has been found that only 35% of women who complain of vaginal itching have a yeast infection. The most common cause of itching is different. A microscopic examination or vaginal culture is required to confirm the diagnosis. There are special kits available to identify the fungus for diagnostic purposes. Vaginal yeast infections can be caused by various types of Candida fungi, with Candida albicans being the most common (80-90% of cases). Other fungi from the Candida family, such as Candida glabrata, Candida parapsilosis, and Candida tropicalis, can also cause vaginal infections. The origin of the fungus is likely from the digestive system, with direct passage to the vagina through the anus. Risk factors for vaginal yeast infections include antibiotic use, exposure to estrogen, a high-sugar diet, and sexual intercourse. Treatment is aimed at alleviating symptoms, and antifungal medications, either topical or systemic, are commonly used. Not all women require treatment, as asymptomatic carriers do not need treatment. Treating the partner is not necessary, as vaginal yeast infections are not primarily transmitted through sexual activity. Treatment duration and effectiveness depend on the severity of the infection, with simple infections typically responding well to treatment and more complex or recurrent infections requiring longer-term or preventive treatment.

If vaginal fungus has been ruled out as the cause of itching, several other conditions should be considered in the differential diagnosis. These include allergic reactions or sensitivity to allergens or chemicals such as topical ointments, sanitary pads, or soaps. Discontinuing the use of any potential irritants can often resolve the itching. It is important to note that various skin diseases like psoriasis, lichen sclerosis, lichen simplex chronicus, eczema, and dry skin can also present with itching symptoms. Therefore, a thorough examination is necessary to determine the accurate diagnosis and appropriate treatment approach for itching in the vaginal area.

Genital herpes is an infectious disease caused by the herpes simplex virus (HSV) transmitted through sexual contact. Most cases are asymptomatic, but symptoms may include itching, tingling, and painful blisters that develop into ulcers. Recurrent outbreaks are milder. Risk factors include direct contact with the virus and HSV-2 prevalence is around 20% in the US. Diagnosis is based on symptoms and tests, and treatment involves antiviral medications to manage symptoms and reduce recurrence. During pregnancy, primary infection near delivery requires caution, and prophylactic treatment may be recommended. Other conditions can cause similar genital ulcers and should be considered in the diagnosis.

Lichen sclerosis is a chronic skin disease that causes degeneration of the upper skin layer and anatomical changes in the genital area. Itching of the vulva is the main complaint, along with skin cracks and pain during intercourse. Women with lichen sclerosis are at a 3%-4% risk of developing penile skin cancer. Steroid treatment is highly effective in relieving itching, but anatomical changes are often irreversible. Complications may include infections, and regular monitoring is recommended. Differential diagnosis involves considering other skin diseases with similar symptoms.

Bacterial vaginosis is a condition characterized by an imbalance in the vaginal bacteria, resulting in symptoms such as vaginal discharge and an unpleasant odor. The diagnosis of bacterial vaginosis can be made through clinical criteria, including examination findings such as discharge appearance, vaginal pH higher than 4.5, the presence of clue cells, and the "whiff test" using 10% KOH. Additionally, bacterial staining on a Gram surface can be used to assess the bacterial composition. Risk factors for bacterial vaginosis include certain behaviors and sexual practices. Complications of bacterial vaginosis include an increased risk of sexually transmitted infections and pregnancy complications. Treatment involves antibiotics targeting the anaerobic bacteria, with high effectiveness reported. However, recurrence rates are not uncommon, requiring additional supportive treatment. It is important to differentiate bacterial vaginosis from other causes of vaginal discharge and unpleasant odor through a comprehensive vaginal examination and testing.

Trichomonas is a single-celled parasite with flagella that is primarily transmitted through sexual intercourse. It is only found in humans and can cause vaginal discharge, unpleasant odor, and pain during intercourse in some infected women. About half of the infected women do not experience any symptoms. Diagnosis can be confirmed through microscopic examination or molecular biology techniques. Treatment involves antibiotic therapy for both partners, with high effectiveness and success rates reported. It is important to avoid alcohol during treatment and refrain from sexual intercourse until one week after completing the treatment.