Merck Manuals on COVID-19 View Professional Resources 

MERCK MANUAL
Professional Version
The trusted provider of medical information since 1899

Vaginal Itching and Discharge

By David H. Barad , MD, MS, Center for Human Reproduction

Last full review/revision Mar 2020| Content last modified Mar 2020

Vaginal itching (pruritus), discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa
(vaginitis), often with inflammation of the vulva (vulvovaginitis). Symptoms may also include irritation, burning,
erythema, and sometimes dysuria and dyspareunia. Symptoms of vaginitis are one of the most common gynecologic
complaints.

Pathophysiology
Some vaginal discharge is normal, particularly when estrogen levels are high. Estrogen levels are high in the following
situations:
A few days before ovulation

During the first 2 weeks of life (because maternal estrogens are transferred before birth)

During the few months before menarche and during pregnancy (when estrogen production increases)

With use of drugs that contain estrogen or that increase estrogen production (eg, some fertility drugs)

However, irritation, burning, and pruritus are never normal.

Normally in women of reproductive age, Lactobacillus species is the predominant constituent of normal vaginal flora.
Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of
pathogenic bacteria. Also, high estrogen levels maintain vaginal thickness, bolstering local defenses.
Factors that predispose to overgrowth of bacterial vaginal pathogens include
Use of antibiotics (which may decrease lactobacilli)

Alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli

Poor hygiene

Frequent douching

Pregnancy

Diabetes mellitus

An intravaginal foreign body (eg, a forgotten tampon or vaginal pessary)

Etiology
The most common causes of vaginal itching and discharge vary by patient age (see table Some Causes of Vaginal
Pruritus and Discharge).

Children
In children, a common cause is vaginitis, usually due to infection with gastrointestinal (GI) tract flora (nonspecific
vulvovaginitis). A common contributing factor in girls aged 2 to 6 years is poor perineal hygiene (eg, wiping from back to
front after bowel movements, not washing their hands after bowel movements).
Chemicals in bubble baths or soaps may cause inflammation and pruritus of the vulva, which often recur.
Foreign bodies may cause nonspecific vaginitis, often with a scant bloody discharge.
Less commonly, a vaginal discharge in children results from sexual abuse.

Women of reproductive age

Vaginitis is also a common cause in women of reproductive age; it is usually infectious. The most common types are
Bacterial vaginosis

Candidal vaginitis

Trichomonal vaginitis (usually sexually transmitted)

Sometimes another infection (eg, gonorrhea, chlamydial infection) causes a discharge. These infections often also
cause pelvic inflammatory disease.
Genital herpes sometimes causes vaginal itching but typically manifests with pain and ulceration.
Vaginitis may also result from foreign bodies (eg, a forgotten tampon). Inflammatory noninfectious vaginitis is
uncommon.

Postmenopausal women
In postmenopausal women, atrophic vaginitis is a common cause.
Other causes of discharge include vaginal cancer, cervical cancer, and endometrial cancer and, in women who are
incontinent or bedbound, chemical vulvitis.

Women of all ages

At any age, conditions that predispose to vaginal or vulvar infection include
Fistulas between the intestine and genital tract (which allow intestinal flora to seed the genital tract)

Pelvic radiation or tumors (which break down tissue and thus compromise normal host defenses)

Fistulas are usually obstetric in origin (due to vaginal birth trauma or a complication of episiotomy infection) but are
sometimes due to inflammatory bowel disease or pelvic tumors or occur as a complication of pelvic surgery (eg,
hysterectomy, anal surgery).
Noninfectious vulvitis accounts for up to 30% of vulvovaginitis cases. It may result from hypersensitivity or irritant
reactions to various agents, including hygiene sprays or perfumes, menstrual pads, laundry soaps, bleaches, fabric
softeners, and sometimes spermicides, vaginal creams or lubricants, latex condoms, vaginal contraceptive rings, and
diaphragms.
Some Causes of Vaginal Pruritus and Discharge
Cause Suggestive Findings Diagnostic Approach*
Children
Pruritus, vulvovaginal erythema, vaginal odor,
Poor perineal hygiene Diagnosis of exclusion
sometimes dysuria, no discharge
Clinical evaluation (may require a
Foreign bodies (often toilet Vaginal discharge, usually with a foul odor and
topical anesthetic or procedural
paper) vaginal spotting
sedation)
Pruritus and vaginal discharge with vulvar
erythema and swelling, often with dysuria Microscopic examination of vaginal
Infections (eg, candidal, Worsening of pruritus at night (suggesting secretions for yeast and hyphae and
pinworm, streptococcal, pinworm infection) culture to confirm
staphylococcal) Significant erythema and vulvar edema with Examination of vulva and anus for
discharge (suggesting streptococcal or pinworms
staphylococcal infection)
Clinical evaluation
Vulvovaginal soreness, bloody or malodorous
Cultures or PCR for sexually
vaginal discharge
transmitted diseases
Sexual abuse† Often, vague and nonspecific medical complaints
Measures to ensure the child’s
(eg, fatigue, abdominal pain) or behavior changes
safety and a report to state
(eg, temper tantrums)
authorities if abuse is suspected
Women of reproductive age
Criteria for diagnosis (3 of 4):
Gray discharge

Malodorous (fishy), thin, gray vaginal discharge Vaginal secretion pH > 4.5
Bacterial vaginosis with pruritus and irritation Fishy odor to discharge
Erythema and edema uncommon
Clue cells seen during
microscopic examination

Clinical evaluation plus

Vulvar and vaginal irritation, edema, pruritus
Vaginal pH < 4.5
Discharge that resembles cottage cheese and
adheres to the vaginal wall Yeast or hyphae identified on
Candidal infection Sometimes worsening of symptoms after a wet mount or KOH
intercourse and before menses preparation
Sometimes recent antibiotic use or history of
Sometimes culture
diabetes

Yellow-green, frothy vaginal discharge, often with

a fishy odor
Often soreness, erythema, and edema of the Motile, pear-shaped flagellated
vulva and vagina organisms seen during microscopic
Trichomonal infection Sometimes dysuria and dyspareunia examination
Sometimes punctate, red “strawberry” spots on Rapid diagnostic assay for
the vaginal walls or cervix Trichomonas, if available
Mild cervical motion tenderness often detected
during bimanual examination
Extremely malodorous, often profuse vaginal
Foreign bodies (often a discharge, often with vaginal erythema, dysuria,
Clinical evaluation
forgotten tampon) and sometimes dyspareunia
Object visible during examination

* If discharge is present, microscopic examination of a saline wet mount and KOH preparation and cultures or PCR
for sexually transmitted organisms are done (unless a noninfectious cause such as allergy or a foreign body is
obvious).
† If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child
Health and Human Development (NICHD) Protocol can be used.
‡ Such inflammatory conditions are an uncommon cause of vaginitis.
KOH = potassium hydroxide; PCR = polymerase chain reaction.
 Cause Suggestive Findings Diagnostic Approach*
Abdominal or pelvic pain
Pelvic inflammatory Mucopurulent discharge Cultures or PCR for sexually
disease Fever transmitted diseases
Cervical motion and/or adnexal tenderness
Postmenopausal women
Clinical evaluation plus
Vaginal pH > 6
No fishy odor to discharge
Atrophic (inflammatory) Dyspareunia, scant discharge, thin and dry Increased number of
vaginitis vaginal tissue neutrophils, parabasal cells,
and cocci and decreased
number of bacilli seen during
microscopic examination

Gradual onset of pain, a watery or bloody vaginal

discharge (which precedes bleeding), abnormal
vaginal bleeding (eg, postmenopausal bleeding,
Vaginal cancer, cervical Pelvic ultrasonography or
premenopausal recurrent metrorrhagia)
cancer, or endometrial sometimes MRI or CT
Often no other symptoms until the cancer is
cancer Biopsy
advanced
Sometimes weight loss
Rarely, a palpable pelvic mass
Chemical vulvitis due to Diffuse redness
irritation from urine or Risk factors (eg, incontinence, restriction to bed Clinical evaluation
feces rest)
All ages
Vulvovaginal erythema, edema, pruritus (often
intense), vaginal discharge
History of recent use of hygiene sprays or Clinical evaluation
Hypersensitivity reactions
perfume, bath water additives, topical treatment Trial of avoidance
for candidal infections, fabric softeners, bleaches,
or laundry soaps
Diagnosis of exclusion based on
Purulent vaginal discharge, dyspareunia, dysuria, history and risk factors
Inflammatory (eg, pelvic irritation Vaginal pH > 6
radiation, oophorectomy, Sometimes pruritus, erythema, burning pain, mild Negative whiff test
chemotherapy)‡ bleeding Granulocytes and parabasal cells
Thin, dry vaginal tissue seen during microscopic
examination
Enteric fistulas Direct visualization or palpation of
(complication of delivery, the fistula in the lower part of the
Malodorous vaginal discharge with passage of
pelvic tumors, pelvic vagina
feces from vagina
surgery, or inflammatory CT with contrast
bowel disease) Endoscopy
Skin disorders (eg,
Characteristic genital and extragenital skin Clinical evaluation
psoriasis, lichen sclerosus,
findings Biopsy
tinea versicolor)
* If discharge is present, microscopic examination of a saline wet mount and KOH preparation and cultures or PCR
for sexually transmitted organisms are done (unless a noninfectious cause such as allergy or a foreign body is
obvious).
† If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child
Health and Human Development (NICHD) Protocol can be used.
‡ Such inflammatory conditions are an uncommon cause of vaginitis.
KOH = potassium hydroxide; PCR = polymerase chain reaction.

Evaluation
History
History of present illness includes nature of symptoms (eg, pruritus, burning, pain, discharge), duration, and intensity.
If vaginal discharge is present, patients should be asked about the color and odor of the discharge and any
exacerbating and remitting factors (particularly those related to menses and intercourse). They should also be asked
about use of hygiene sprays or perfumes, spermicides, vaginal creams or lubricants, latex condoms, vaginal
contraceptive rings, and diaphragms.
Review of systems should seek symptoms suggesting possible causes, including the following:
Fever or chills and abdominal or suprapubic pain: Pelvic inflammatory disease (PID) or cystitis

Polyuria and polydipsia: New-onset diabetes

Past medical history should note risk factors for the following:
Candidal infection (eg, recent antibiotic use, diabetes, HIV infection, other immunosuppressive disorders)

Fistulas (eg, Crohn disease, genitourinary or gastrointestinal cancer, pelvic or rectal surgery, lacerations during
delivery)

Sexually transmitted diseases (eg, unprotected intercourse, multiple partners)

If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health
and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced
event and improves the quality of information obtained.

Physical examination
Physical examination focuses on the pelvic examination.
The external genitals are examined for erythema, excoriations, and swelling. A water-lubricated speculum is used to
check the vaginal walls for erythema, discharge, and fistulas. The cervix is inspected for inflammation (eg,
trichomoniasis) and discharge. Vaginal pH is measured, and samples of secretions are obtained for testing. A bimanual
examination is done to identify cervical motion tenderness and adnexal or uterine tenderness (indicating PID).

Red flags
The following findings are of particular concern:
Trichomonal vaginitis in children (suggesting sexual abuse)

Fecal discharge (suggesting a fistula, even if not seen)

Fever or pelvic pain

Bloody discharge in postmenopausal women

Interpretation of findings
Often, the history and physical examination help suggest a diagnosis (see table Some Causes of Vaginal Pruritus and
Discharge), although there can be much overlap.
In children, a vaginal discharge suggests a foreign body in the vagina. If no foreign body is present and children have
trichomonal vaginitis, sexual abuse is likely. If they have unexplained vaginal discharge, cervicitis, which may be due to
a sexually transmitted disease, should be considered. Nonspecific vulvovaginitis is a diagnosis of exclusion.
In women of reproductive age, discharge due to vaginitis must be distinguished from normal discharge:
Normal vaginal discharge is commonly milky white or mucoid, odorless, and nonirritating; it can result in vaginal
wetness that dampens underwear.

Bacterial vaginosis produces a thin, gray discharge with a fishy odor.

A trichomonal infection produces a frothy, yellow-green vaginal discharge and causes vulvovaginal soreness.

Candidal vaginitis produces a white discharge that resembles cottage cheese, often increasing the week before
menses; symptoms worsen after sexual intercourse.

Contact irritant or allergic reactions cause significant irritation and inflammation with comparatively minimal discharge.
Discharge due to cervicitis (eg, due to PID) can resemble that of vaginitis. Abdominal pain, cervical motion tenderness,
or cervical inflammation suggests PID.
In women of all ages, vaginal pruritus and discharge may result from skin disorders (eg, psoriasis, lichen sclerosus,
tinea versicolor), which can usually be differentiated by history and skin findings.
Discharge that is watery, bloody, or both may result from vulvar cancer, vaginal cancer, or cervical cancer; cancers can
be differentiated from vaginitis by examination and biopsy.
In atrophic vaginitis, discharge is scant and may be watery and thin or thick and yellowish. Dyspareunia is common, and
vaginal tissue appears thin and dry.

Testing
All patients require the following in-office testing:
pH

Wet mount

Potassium hydroxide (KOH) preparation

Testing for gonorrhea and chlamydial infections is typically done unless a noninfectious cause (eg, allergy, foreign
body) is obvious.
Vaginal secretions are tested using pH paper with 0.2 intervals from pH 4.0 to 6.0. Then, a cotton swab is used to place
secretions on 2 slides; secretions are diluted with 0.9% sodium chloride on one slide (saline wet mount) and with 10%
KOH on the other (KOH preparation).
The KOH preparation is sniffed (whiff test) for a fishy odor, which results from amines produced in trichomonal vaginitis
and bacterial vaginosis. The slide is examined using a microscope; KOH dissolves most cellular material except yeast
hyphae, making identification easier.
The saline wet mount is examined using a microscope as soon as possible to detect motile trichomonads, which can
become immotile and more difficult to recognize within minutes after slide preparation.
If clinical criteria and in-office test results are inconclusive, the discharge may be cultured for fungi and trichomonads.

Treatment
Any specific cause of the itching or discharge is treated.
The vulva should be kept as clean as possible. Soaps and unnecessary topical preparations (eg, feminine hygiene
sprays) should be avoided. If a soap is needed, a hypoallergenic soap should be used. Intermittent use of ice packs or
warm sitz baths (with or without baking soda) may reduce soreness and pruritus. Flushing the genital area with
lukewarm water may also provide relief. If chronic vulvar inflammation is due to being bedbound or incontinent, better
vulvar hygiene may help.
Women should be advised not use douches.
If symptoms are moderate or severe or do not respond to other measures, drugs may be needed. For pruritus, topical
corticosteroids (eg, 1% hydrocortisone twice a day as needed) can be applied to the vulva but not into the vagina. Oral
antihistamines lessen pruritus and cause drowsiness, helping patients sleep.
Prepubertal girls should be taught good perineal hygiene (eg, wiping front to back after bowel movements and voiding,
washing their hands, avoiding fingering the perineum).

Geriatrics Essentials
In postmenopausal women, a marked decrease in estrogen causes vaginal thinning (atrophic vaginitis), increasing
vulnerability to infection and inflammation. Other common causes of decreased estrogen in older women include
oophorectomy, pelvic radiation, and certain chemotherapy drugs.
In atrophic vaginitis, inflammation often results in an abnormal discharge, which is scant and may be watery and thin or
thick and yellowish. Dyspareunia is common, and vaginal tissue appears thin and dry.
Poor hygiene (eg, in patients who are incontinent or bedbound) can lead to chronic vulvar inflammation due to chemical
irritation by urine or feces.
Bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis are uncommon among postmenopausal women but
may occur in those with risk factors.
After menopause, risk of cancer increases, and a bloody or watery discharge is more likely to be due to cancer; thus,
any vaginal discharge in postmenopausal women should be promptly evaluated.

Key Points

Vaginal symptoms related to itching and/or discharge are often nonspecific.

Causes of vaginal pruritus and itching vary depending on the patient’s age.
 For most patients, measure vaginal pH and obtain a sample of secretions for microscopic examination
and testing; if needed, do culture for sexually transmitted organisms.

In postmenopausal women, promptly evaluate any vaginal discharge.

Drugs Mentioned In This Article

Drug Name Select Trade

hydrocortisone CORTEF, SOLU-CORTEF

© 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)