Genital Malodour in Women: An Unmet Therapeutic Challenge
Genital Malodour in Women: An Unmet Therapeutic Challenge
Unpleasant odour originating in or localised to the genital area is a not an uncommon symptom that brings a woman to her practitioner's office. In reality, women are frequently too embarrassed to discuss this symptom and only a fraction with this distressing complaint seek treatment. Not all malodour is persistent and when seeking medical help, frequently, the complaint of malodour only emerges well into a discussion of her other complaints of discharge, irritation, etc. Women reporting long-standing genital malodour are usually mortified, especially if another individual(s) has mentioned the odour to the patient. This may be a sexual partner, family member or most horrifically an associate or co-worker. When the complaint eventually emerges, the clinician faces anything but an easy task in tracking down causation. The practitioner cannot expect much assistance from medical textbooks or other gynaecological literature. Traditionally, textbooks use an approach based upon specific diagnostic entities and rarely focus on symptoms. Accordingly, little information is available in the diagnostic and therapeutic approach to genital malodour.
If the patient is found to have usually easily diagnosed trichomoniasis or bacterial vaginosis (BV), entities also presenting with abnormal vaginal discharge, then an explanation is rapidly at hand and treatment with antimicrobials directed at the abnormal vaginal pathogens and microbiome, including the overgrowth of anaerobic bacteria is available. Prompt relief from the malodour can be expected, although recurrence of symptoms is frequent in BV. But what to do when no evidence of trichomoniasis or BV emerges? A greater conundrum is women complaining of malodour that cannot be reproduced or confirmed at the time of examination, especially if routine vaginal sample studies are uniformly negative. The clinician searches one's 'experience or data memory' ensuring that a forgotten tampon is not the cause. It is reasonable to ensure that personal hygiene is not responsible for the odour, but this explanation is obvious and rarely the cause. A validated diagnostic approach is regrettably not available. Is obtaining a vaginal swab and testing for odour sufficient to question the validity of the complaint? When one finds objective abnormalities on physical examination, for example, abnormal pH, abnormal Gram stain indicating that the healthy normal vaginal flora is lost, then some direction in the diagnostic algorithm is provided. In this context, even in the absence of supporting data, it is reasonable to attempt a trial of therapy with anti-anaerobic agents at least once, as a microbial cause may still be responsible. Should the malodour improve and then recur after several weeks, treating the patients for recurrent BV may be worthwhile. Many post-menopausal women not receiving hormone replacement therapy with consequent vaginal atrophy will complain of a 'smelly, watery' discharge. Confirmation of diagnosis (visible vaginal thinning, elevated pH, increased parabasal cells seen on saline microscopy) justifies a trial of topical vaginal oestradiol, and when corrected, in 4–6 weeks the attributed malodour should resolve. In obese women, skin bacteria accumulating between skin folds may contribute to odour; however, the majority of women with this complaint spend hours scrubbing the genital area by the time they present.
Nevertheless, after excluding the few known causes of malodour, including cervical cancer with necrosis or pyometra, an explanation may not be at hand, at which time the clinician begins to doubt the credibility of the complaint. In fact, psychiatric causes are described; however, such diagnosis is based upon validated positive criteria and is not exclusively a diagnosis of exclusion. All in all, clinicians flounder in management, adding to the frustration of the patient and further undermining her confidence in the medical profession. What is needed is both research into the pathogenesis of malodour, including the link between vaginal flora and odour, and therapeutic protocols created by clinicians sharing their valuable experience in managing this challenging problem. Suggestions are welcome.
Abstract and Introduction
Introduction
Unpleasant odour originating in or localised to the genital area is a not an uncommon symptom that brings a woman to her practitioner's office. In reality, women are frequently too embarrassed to discuss this symptom and only a fraction with this distressing complaint seek treatment. Not all malodour is persistent and when seeking medical help, frequently, the complaint of malodour only emerges well into a discussion of her other complaints of discharge, irritation, etc. Women reporting long-standing genital malodour are usually mortified, especially if another individual(s) has mentioned the odour to the patient. This may be a sexual partner, family member or most horrifically an associate or co-worker. When the complaint eventually emerges, the clinician faces anything but an easy task in tracking down causation. The practitioner cannot expect much assistance from medical textbooks or other gynaecological literature. Traditionally, textbooks use an approach based upon specific diagnostic entities and rarely focus on symptoms. Accordingly, little information is available in the diagnostic and therapeutic approach to genital malodour.
If the patient is found to have usually easily diagnosed trichomoniasis or bacterial vaginosis (BV), entities also presenting with abnormal vaginal discharge, then an explanation is rapidly at hand and treatment with antimicrobials directed at the abnormal vaginal pathogens and microbiome, including the overgrowth of anaerobic bacteria is available. Prompt relief from the malodour can be expected, although recurrence of symptoms is frequent in BV. But what to do when no evidence of trichomoniasis or BV emerges? A greater conundrum is women complaining of malodour that cannot be reproduced or confirmed at the time of examination, especially if routine vaginal sample studies are uniformly negative. The clinician searches one's 'experience or data memory' ensuring that a forgotten tampon is not the cause. It is reasonable to ensure that personal hygiene is not responsible for the odour, but this explanation is obvious and rarely the cause. A validated diagnostic approach is regrettably not available. Is obtaining a vaginal swab and testing for odour sufficient to question the validity of the complaint? When one finds objective abnormalities on physical examination, for example, abnormal pH, abnormal Gram stain indicating that the healthy normal vaginal flora is lost, then some direction in the diagnostic algorithm is provided. In this context, even in the absence of supporting data, it is reasonable to attempt a trial of therapy with anti-anaerobic agents at least once, as a microbial cause may still be responsible. Should the malodour improve and then recur after several weeks, treating the patients for recurrent BV may be worthwhile. Many post-menopausal women not receiving hormone replacement therapy with consequent vaginal atrophy will complain of a 'smelly, watery' discharge. Confirmation of diagnosis (visible vaginal thinning, elevated pH, increased parabasal cells seen on saline microscopy) justifies a trial of topical vaginal oestradiol, and when corrected, in 4–6 weeks the attributed malodour should resolve. In obese women, skin bacteria accumulating between skin folds may contribute to odour; however, the majority of women with this complaint spend hours scrubbing the genital area by the time they present.
Nevertheless, after excluding the few known causes of malodour, including cervical cancer with necrosis or pyometra, an explanation may not be at hand, at which time the clinician begins to doubt the credibility of the complaint. In fact, psychiatric causes are described; however, such diagnosis is based upon validated positive criteria and is not exclusively a diagnosis of exclusion. All in all, clinicians flounder in management, adding to the frustration of the patient and further undermining her confidence in the medical profession. What is needed is both research into the pathogenesis of malodour, including the link between vaginal flora and odour, and therapeutic protocols created by clinicians sharing their valuable experience in managing this challenging problem. Suggestions are welcome.