Clinical Management of Patients Presenting with symptoms of Vulvovaginitis Urgent message: As the cause of approximately 10 million office visits in the United States annually, vulvovaginitis remains a common but important complaint seen in the urgent care setting. Jansen Tiongson, MD, Samuel Keim, MD, and Peter Rosen, MD lthough numerous eti- ologies account for vul- vovaginitis, the vast ma- jority of cases are due to bacterial vaginosis (BV), trichomoniasis, and vulvo- vaginal candidiasis (VVC). BV causes 40% to 50% of all cases, while candidiasis and trichomoniasis account for 20% to 25% and 15%-20%, respectively. 1 Other notable causes, such as atrophic/con- tact vaginitis and sexually transmitted diseases, are be- yond the scope of this re- view. This article presents a review of practical concepts of evaluation and manage- ment along with supportive data from current literature about the three main causes. A Pathophysiology The moist vaginal environment promotes the growth of various organisms. However, a balance between different w w w. j u c m . c o m organisms ordinarily prevents the growth of pathogens. Lactobacillus, the predom- inant bacteria found in the vagina, produces glycogen that is broken down to form lactic and acetic acids, thus favoring the growth of nor- mal flora over pathogens by maintaining a pH of 4-5. Normal flora produce nor- mal vaginal secretions that range from being watery thin to a whitish thick dis- charge. The disruption of the normal balance in the mi- croflora of the vagina leads to the symptomology as- cribed to vulvovaginitis. Women often present with varying signs and symptoms, including vaginal dis- charge, malodor, irritation, and itch. Often, urgent care physicians can narrow down the differential diagnosis (Table 1) based on the descriptions provided by pa- tients. Systemic illnesses, antibiotic use, diet, immuno- suppression, and sexual practices can disrupt the normal © Brian Evans Introduction JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | J u n e 2 0 0 7 11