Vaginal itching (pruritus) and / or discharge are the result of an infectious or non-infectious inflammation of the vaginal mucosa (vaginitis), which is often accompanied by inflammation of the vulva (vulvovaginitis). Irritation, burning, redness and sometimes dysuria and dyspareunia may show up as well. The symptoms of vaginitis among the most common gynecological problems. Pathophysiology Especially with high estrogen levels, as occurs several days before ovulation, a vaginal discharge is normal. Increased estrogen levels also come in the first 2 weeks of life (because estrogen has been transmitted from mother to child before birth), in the months before menarche and during pregnancy (when estrogen production increases) and when taking estrogen-containing or estrogen production-enhancing drugs (eg. as some fertility enhancing drugs) before. However, irritation, burning and itching are never normal. Lactobacillus sp. is the predominant germ type of the normal vaginal flora in women of childbearing age. The colonization with this bacterium maintains the pH of the vagina in the normal range (pH 3.8-4.2) and thus prevents overgrowth of pathogenic bacteria. In addition, ensure high estrogen concentrations for a sufficiently thick vaginal mucosa, causing local immunity is strengthened. Factors that contribute to overgrowth by pathogenic bacteria, are taking antibiotics (reduce the lactobacilli) alkaline vaginal pH, caused by menstrual blood, sperm or too few lactobacilli Poor hygiene Frequent vaginal douches gestational diabetes mellitus Etiology The most common causes vary with age the patient (see table: causes of vaginal itching and discharge). A children vaginitis is usually the flora of the gastrointestinal tract caused (nonspecific vaginitis). One factor that often contributes in girls aged 2-6 years to be poor perineal hygiene (z. B. Clean from back to front and waiver of hand washing after defecation). And chemical additives in bubble baths or soaps can cause recurrent inflammation and itching. Foreign objects can nonspecific vaginitis, often with scant bloody discharge, hervorrufen.Frauen of childbearing age, the vaginitis is most infectious. Most commonly Bacterial vaginosis Candida vaginitis trichomonas vaginitis (mostly transmitted sexually) Sometimes another infection (eg. B., gonorrhea, chlamydia infection) causes discharge. These infections often cause inflammation in the pelvic genital herpes sometimes causes vaginal itching, but usually it manifests itself with pain and ulceration (mucocutaneous HSV infection). Vaginitis may also by foreign bodies (eg. As a forgotten tampon) arise. A non-inflammatory infectious vaginitis rarely vor.Frauen after menopause In postmenopausal women (vaginal itching and discharge: Geriatric aspects) Is atrophic vaginitis a common cause. Other causes of vaginal discharge are vaginal, cervical and endometrial cancer and, in women who are incontinent bedridden or chemical Vulvitis.Frauen of all ages in every age group can enter conditions that increase susceptibility to infections of the vagina or vulva, z. B. fistula between intestines and genital tract (which allow the passage of intestinal flora in the genital tract) and pelvic radiation or tumors (which lead to tissue death and thereby impair the immune functions of the body). Fistulas are due mostly to obstetric conditions (by vaginal birth trauma or complication of an infected episiotomy), can sometimes result of an inflammatory bowel disease or pelvic tumors or pelvic surgery (z. B. hysterectomy, Analchirurgie) be. A non-infectious vulvitis is responsible for up to 30% of vaginitis cases. They may be due to hypersensitivity or irritant reaction to hygiene sprays or perfumes, sanitary napkins, detergents, optical brighteners, fabric softeners and occasionally arise on spermicides, vaginal lubricants or creams, latex condoms, vaginal Ringkontrazeptiva and diaphragms. Causes of vaginal itching and discharge cause suspicious findings Diagnostic procedure * Children Poor perineal hygiene pruritus, vulvovaginal redness, vaginal foetor, sometimes dysuria, no discharge diagnosis of exclusion Chemical irritation (eg. As soaps, bubble baths) Vulvovaginal redness and pain, often recurring and accompanied itching and dysuria Clinical sub investigation foreign bodies (often toilet paper) Vaginal discharge, usually with Clinical foul odor and vaginal spotting investigation (may require local anesthetic or sedation) infections (eg. B. Candida, pinworm, streptococci, staphylococci) pruritus and vaginal discharge with redness and swelling of the vulva, often with dysuria Stronger itching at night (indication of pinworm infection) Significant redness and Vulvaödem (with discharge indication of streptococcal or staphylococcal infection) Microscopic examination of the vaginal secretion Vulvovaginal on yeasts and hyphae and culture to confirm invest examination of the vulva and anus on pinworm sexual abuse pain, bloody or foul-smelling vaginal discharge often vague and non-specific health complaints (eg. as fatigue, abdominal pain) or behavioral changes (eg. as tantrums ) Clinical examination cultures or PCR Create take measures in case of suspected abuse, to ensure the safety of the child to sexually transmitted diseases, and competent authorities inform women of childbearing age Bacterial vaginosis evil smelling (fishy), thinner, gray vaginal discharge with itching and irritation Rare erythema and edema diagnostic criteria ( 3 of 4): Gray discharge vaginal pH> 4.5 after fish smelling discharge key cells (engl. clue cells) detected by a microscopic examination of Candida infection irritation of the vulva and vagina, edema, pruritus cottage cheese-like discharge, of the vaginal walls adhere occasionally worsening symptoms after intercourse and before the menstrual period Occasionally previous antibiotic ingestion or diabetes in the history Physical examination and vaginal pH <4.5 yeast or hyphae, which were detected in a wet mount or by culture Kaliumhydroxidpräparation Occasionally trichomonas infection yellow-green, frothy vaginal discharge, often with a fishy smell often S Pain-erythema and edema of the vulva and vagina Occasionally, dysuria and dyspareunia dotted Occasionally, red "strawberry marks" on the walls of the vagina or cervix often weak cervical motion pain during bimanual examination Moving, pear-shaped organisms with flagella by microscopic examination demonstrated rapid test for Trichomonas (if available) foreign body (often forgotten tampon) Strong malodorous, often excessive vaginal discharge, often with vaginal redness, dysuria and occasional dyspareunia object visible during examination Clinical examination inflammation in the pelvic area Abdominal or pelvic pain fever Cervical motion and / or tenderness adnexal cultures or PCR on STDs create postmenopausal women Atrophic (inflammatory) vaginitis dyspareunia, scanty discharge, thin appearing and dry vaginal mucosa Clinical examination and vaginal pH> 6 Not for fish smelling discharge Increased granulocytes, parabasal cells and cocci and bacilli decreased by microscopic examination proved Malignant tumors of the vagina, cervix or de s endometrium Gradual beginning of pain, a watery or bloody vaginal discharge (which precedes bleeding), abnormal vaginal bleeding (eg. B. postmenopausal bleeding, premenopausal recurrent metrorrhagia) no other symptoms until the tumor has progressed often already. Sometimes weight loss rarely palpable pelvic sonography of the pelvis biopsy Chemical Vulvitis by irritation from urine or feces Diffuse redness risk factors (eg. As incontinence, restricted to bed rest) Clinical Investigation All ages hypersensitivity reactions vulvovaginal erythema, edema, pruritus (often strong), discharge recent use of hygiene sprays or perfumes, bath water additives, topical treatment of Candida infections, fabric softeners, bleach or washing powder Try to avoid clinical examination inflammation (eg. B. radiation of the pelvis, oophorectomy, chemotherapy) Purulent vaginal discharge, dyspareunia, dysuria and irritation. Occasionally, itching, redness, burning pain, minor bleeding thin appearing, dry vaginal diagnosis of exclusion based on history and risk factors Vaginal pH> 6 Negative odor sample granulocytes and parabasal cells by microscopic examination demonstrated intestinal fistulas (birth complication, pelvic tumors, surgery in the pelvic area or inflammatory bowel disease) Ill-smelling vaginal discharge with excretion of feces from the vagina direct visible or palpable fistula in the lower part of the vagina skin diseases (eg., psoriasis lichen sclerosus, tinea versicolor) Characteristic genital and extragen itale skin findings Clinical examination * At discharge, a microscopic examination of a NaCl-native preparation and a KOH preparation is done, and there are cultures or PCR created for sexually transmitted organisms (unless it is obviously a non-infectious cause, such as allergy or foreign body). These infections are a rare cause of vaginitis. KOH = potassium hydroxide. Clarification history The history of the current disease involves the nature of complaints (eg. As itching, burning, pain, discharge), duration and intensity. When vaginal discharge, patients should be asked about the color and odor of the effluent as well as initiating and recurrent factors (especially in relation to menstruation and sexual intercourse). They should also provide information about the use of hygiene sprays or perfumes, spermicides, vaginal creams or lubricants, latex condoms, vaginal Ringkontrazeptiva or diaphragms. Clues to the possible causes are to be found on the review of organ systems; it includes fever or chills, abdominal or suprapubic pain (pelvic inflammatory disease [PID] or cystitis) and polyuria and polydipsia (new onset diabetes). The history should risk factors for Candida infection (z. B. last antibiotics, diabetes, HIV infection or other immunosuppressive diseases), fistulas (z. B. Crohn’s disease, urogenital or gastrointestinal tumors, pelvic or rectal surgery, injury during birth) and sexually transmitted diseases (eg. as unprotected sex, multiple partners) berücksichtigen.Körperliche investigation in the clinical studies is the investigation of the basin at the center. The outer genital area is examined for redness, swelling and abrasions. Using a wetted with water speculum vaginal wall is examined for redness, discharge, and fistulas. The cervix is ??an inflammation (z. B. trichomoniasis) and discharge controls. The vaginal pH is measured and taken secretion samples. Using the bimanual examination, a cervical movement pain and tenderness adnexal or uterine (reference to pelvic inflammatory disease [PID]) can be detected werden.Warnzeichen The following findings are of particular importance: trichomonas vaginitis (reference to sexual abuse) Fecal in children outflow (reference to a fistula, even if they do not see is) fever or pelvic pain Bloody discharge in women after menopause interpretation of the findings Most enter the medical history and physical examination clues to the diagnosis (see table: causes of vaginal pruritus and discharge), although they may overlap. In children with vaginal discharge you have to think of a vaginal foreign body. Is not a foreign body present and the children have a trichomonas vaginitis, a sexual abuse is likely. If they have an unexplained discharge, should cervicitis, may be the result of a sexually transmitted disease, should be considered. Nonspecific vaginitis is a diagnosis of exclusion. In women of childbearing age vaginal discharge as a result of vaginitis must be distinguished from normal vaginal discharge. The normal vaginal discharge is usually milky white or clear, odorless and non-irritating; it can cause moisture in the vagina, which is strong enough to wet the underwear. Bacterial vaginosis produces a low-viscosity, gray discharge that smells like fish. A frothy, yellow-green discharge and vulvovaginal pain arising from a trichomonas infection. A Candida vaginitis produces a white cottage cheese-like discharge which often increases during the week before the menstrual period; the symptoms worsen after sexual intercourse. Contacting objects irritating or allergic reactions cause significant irritation and inflammation at a comparatively low discharge. Outflow through cervicitis (eg., By pelvic inflammatory disease [PID]) may be similar to a vaginitis. Abdominal pain, cervical pain on motion or cervical inflammation point to a pelvic inflammatory disease (PID). In women of all ages vaginal pruritus and vaginal discharge can express a skin disorder (e., Psoriasis, lichen sclerosis, tinea versicolor), which can be differentiated by the history and skin findings mostly. An effluent is aqueous, blood, or both, may occur in a vulvar, vaginal or cervical cancer; Malignancies can be differentiated from a vaginitis by inspection and cytology (Pap smear). In atrophic vaginitis, the outflow is sparse, dyspareunia is common, and the vaginal mucosa appears thin and trocken.Tests All patients following tests are carried out in practice: pH wet mount Kaliumhydroxidpräparation A test for gonorrhea and chlamydia infection is usually carried out, unless it is a non-infectious cause (z. B. allergy, foreign body) to indicate clearly. The pH value of vaginal secretion is measured with indicator paper, which allows the determination at 0.2 intervals between 4.0 and 6.0, the secretion samples are applied to 2 slides using a cotton swab. Subsequently, the first sample with 0.9% NaCl solution (NaCl-native preparation) and the second with 10% potassium hydroxide solution (potassium hydroxide-native preparation) is diluted. The potassium hydroxide-native preparation is assayed for amines using Odor Test, which cause a distinct fish odor and are produced at trichomoniasis vaginitis and bacterial vaginosis. The slide is examined under the microscope; the potassium hydroxide dissolves all cells except hyphae and thus facilitates their identification. The NaCl wet smear is examined under the microscope without delay of moving trichomoniasis, since they are immobile in minutes on the slide and thus may be difficult to see. If the clinical criteria and the tests in the clinic fail not unique, you can create a mushroom and Trichomonadenkultur from the effluent. Each treatment specific cause needs to be treated. The vulva should be kept as clean as possible. Soaps and unnecessary, locally applied preparations (eg. As hygiene sprays) should be avoided. If a soap is needed, a hypoallergenic soap should be used. The intermittent application of ice packs or warm sitz baths (with or without the addition of baking soda) can relieve skin irritation and pruritus. In chronic vulvitis due to being bedridden or incontinence better Vulvahygiene can be helpful. When symptoms are moderate to severe, or do not respond to other measures, drugs may be required. In pruritus a Kortikosteroidpräparat (z. B. 1% hydrocortisone, 2 times / day as needed) can not apply to the vulva, the vaginal mucosa. Oral antihistamines improve itching and make you tired, so that the patient can sleep better. Girls before puberty should be the foundations of a good perineal hygiene teach (z. B. to clean themselves after defecating and urinating from front to back, to wash your hands, avoid touching the dam). Geriatric aspects After menopause, leading the strong decrease estrogen cause the vaginal mucosa is thinner (athropische vaginitis); characterized the susceptibility to infections and inflammations (atrophic vaginitis) increases. Other common causes of estrogen loss in elderly women are oophorectomy, pelvic radiation and certain chemotherapeutic agents. In atrophic vaginitis, inflammation often leads to an abnormal vaginal discharge, which may be watery and thin or thick and yellowish. Dyspareunia is common, and the vaginal mucosa appears thin and dry. Poor hygiene (z. B. in incontinent or bedridden patients) can lead to chronic inflammation of the vulva due to chemical irritation caused by urine or feces. Bacterial vaginosis, candida vaginitis and trichomonas vaginitis rarely occur in postmenopause, but then most likely in women with risk factors. After menopause, the risk of cancer is increased, and rather caused a bloody or watery discharge cancer; so any discharge should be promptly evaluated in postmenopausal women. Summary Vaginal complaints are often non-specific. The cause depends on the age of the patient. In most patients the vaginal pH are determined, and the secretions examined under the microscope; if necessary, a culture for sexually transmitted organisms is created. In postmenopausal women of any vaginal discharge should be investigated immediately.