Persistent vaginitis

A 36 year old woman visits her general practitioner complaining of a six month history of vaginal soreness, itch, discharge, dyspareunia, and painful postcoital vulval swelling. Her symptoms are worse premenstrually and improve during menstruation. She reports that she has had recurrent “thrush” since her mid-20s, precipitated by courses of antibiotics, and has successfully self medicated with intravaginal miconazole. These episodes have gradually become more frequent, and recently her symptoms failed to resolve with over the counter antifungals. Although she had been known to have positive swabs for Candida albicans in the past, recent swabs and vaginal microscopy had been persistently negative. She is healthy and does not have diabetes, and her only medication is the oral contraceptive pill with 30 μg oestrogen. A trial of pill cessation did not improve her problem. She is very embarrassed about this problem and, when asked, she volunteers that she is worried that she may have somehow contracted genital herpes or cancer. Examination shows a confluent, oedematous vulvovaginitis extending to the labia majora, with associated fissuring; erythema of the perineum; and erythema of the vagina. In this article we explore the features of persistent vaginitis and suggest recommendations for managing the condition.