Vaginal Itching Or Burning
Vaginal itching or burning is an irritative symptom of the vulvovaginal area commonly caused by infections (such as candidiasis, bacterial vaginosis, or trichomoniasis), irritant or allergic contact dermatitis, atrophic vaginitis, or dermatologic conditions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Vulvovaginal candidiasis | White, curdy ("cottage cheese") discharge + itch, no odour; predisposed by antibiotics/DM/pregnancy [2] | 「分泌物係咪白色一撻撻好似豆腐渣咁？有冇臭味？」 |
| Bacterial vaginosis (BV) | Thin grey homogeneous discharge, fishy odour (especially after sex); not truly an STI [5] | 「分泌物係咪灰白色，有魚腥味，特別係房事之後？」 | |
| Contact / irritant dermatitis | Temporal link to new product; well-demarcated erythema at contact site [6] | 「最近有冇轉咗新嘅沐浴露或者護墊？」 | |
| Serious Not To Miss | Chlamydia cervicitis / PID | Young, sexually active, mucopurulent discharge, cervical motion tenderness → tubal infertility risk [4] | 「有冇肚痛？有冇新伴侶？」PE: cervical excitation tenderness |
| Vulvar / cervical malignancy | Persistent, non-healing ulcer / lump; post-coital bleeding; older age | 「有冇下面長咗嘢或者傷口唔埋口？有冇房事後出血？」 | |
| Genital herpes (primary) | Painful grouped vesicles/ulcers, tender inguinal LN, systemic symptoms (fever, myalgia); HSV-2 recurs 90% in 12 months [7] | 「有冇生水泡或者好痛嘅爛損？有冇發燒？」 | |
| Pitfalls | Trichomonas vaginalis | Yellow-green frothy discharge, fishy odour, "strawberry cervix" on exam [3] | 「分泌物係咪黃綠色、有泡、有臭味？」 |
| Lichen sclerosus | White atrophic plaques, figure-of-8 pattern around vulva/anus; chronic itch; risk of SCC | 「下面皮膚有冇變白變薄？」 | |
| Foreign body (e.g. retained tampon / condom) | Foul-smelling discharge, recent tampon/condom use [1] | 「有冇可能有嘢留咗喺入面？例如衛生棉條？」 | |
| Masquerades | Diabetes mellitus | Recurrent candida as presenting complaint; check glucose [2] | 「有冇口渴、多飲多尿、體重減輕？」 |
| Drug side effect | Antibiotics, OCP, immunosuppressants precipitating candida | 「最近有冇食新嘅藥？」 | |
| Atrophic vaginitis (menopause) | Postmenopausal; thin/red/dry vaginal mucosa; dyspareunia; burning [1] | 「月經停咗幾耐？有冇潮熱？」 | |
| Trying to Tell Me Something? | Fear of STI / partner infidelity | Patient anxious about partner's behaviour; embarrassed | 「你擔唔擔心係性病？」 |
| Sexual / relationship distress | Dyspareunia → avoidance of intimacy → relationship strain [1] | 「呢個問題有冇影響你同伴侶嘅關係？」 | |
| Body-image / menopausal distress | Feeling "old" or "losing femininity" | 「你覺得身體嘅變化點影響你嘅感受？」 |
Vaginal Itching or Burning — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係X醫生。今日有咩可以幫到你呀？」(Hello, I'm Dr X. How can I help you today?) | Friendly opening scores interpersonal marks immediately. |
| 0:30–1:00 | Chief complaint in patient's own words | 「可唔可以講多啲俾我聽，邊度痕？幾時開始？」(Can you tell me more — where is it itchy? When did it start?) | Establishes CC accurately for the Case Report Form. |
| 1:00–2:30 | Symptom analysis + red flags | 「有冇分泌物呀？咩顏色同味道？」/「有冇痛？小便有冇赤痛？」/「有冇出血？有冇發燒？」 | Covers HPI details and red flags — high weighting in CRF completeness. |
| 2:30–3:30 | Sexual, menstrual, obstetric Hx | 「我想問啲比較私人嘅問題，因為對診斷好重要，可以嗎？」(I need to ask some personal questions because they're important for diagnosis, is that OK?) /「最後一次月經幾時？」/「有冇性伴侶？有冇用安全套？」 | Permission-seeking + sexual history = essential for DDx (STI vs non-STI) and scores interpersonal marks. |
| 3:30–4:30 | PMH, drugs, allergies, social Hx | 「有冇糖尿病或者長期病？最近有冇食抗生素？」/「有冇用新嘅清潔產品或者護墊？」 | Uncovers masquerades (DM, antibiotics → candida) and contact irritants. |
| 4:30–5:15 | ICE + hidden agenda | 「你自己覺得可能係咩事呀？」(Ideas) /「你最擔心嘅係咩？」(Concerns) /「你今日嚟想我點幫你？」(Expectations) /「仲有冇其他嘢想講俾我聽？」 | ICE is directly examined in Q3. Hidden agenda may be: fear of STI, relationship worry, sexual dysfunction, cancer fear. |
| 5:15–5:50 | Summarise, check understanding | 「等我總結一下：你呢幾日下面痕同有少少分泌物，你擔心係……我理解得啱唔啱？」 | Summarising + checking = high interpersonal marks. |
| 5:50–6:00 | Safety-net and close | 「如果痕得更加嚴重，或者發燒、肚痛，要即刻返嚟睇。」/「多謝你今日嚟，仲有冇嘢想問？」 | Safety-net shows clinical competence; polite close completes the station. |
Uncovering the hidden agenda: The patient may not present "I'm worried I have an STI" upfront. Ask 「你覺得點解會咁呀？」and 「你最擔心嘅係咩嘢？」. Common hidden agendas: fear of STI from partner's infidelity, concern about cancer, embarrassment about sexual practices, relationship distress, or menopausal body-image concern [1].
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset / Duration | When did the itch/burn start? Acute or chronic? | 「幾時開始痕㗎？突然定慢慢嚟？」 | Acute → infection / irritant; Chronic/recurrent → candida, lichen sclerosus, dermatosis | Recurrent candida if >4×/yr |
| Discharge character | Any discharge? Colour, smell, amount? | 「有冇分泌物？咩顏色？有冇臭味？」 | White curdy → Candida; yellow-green frothy fishy → Trichomonas; thin grey fishy → BV [2][3] | Candida, TV, BV, cervicitis |
| Dysuria | Pain on urination? | 「小便有冇赤痛？」 | Internal dysuria → UTI; external dysuria (urine on inflamed vulva) → vulvovaginitis | UTI, herpes, candida |
| Dyspareunia | Pain during intercourse? | 「有冇行房痛？」 | Superficial → vulvar cause; deep → PID | Atrophic vaginitis, PID, vulvar dermatosis |
| Bleeding | Abnormal vaginal bleeding? | 「有冇唔正常出血？例如房事後出血？」 | Post-coital bleeding → cervical pathology | Cervical cancer, cervicitis, cervical ectropion |
| Ulcer / lump | Any sores, blisters, or lumps? | 「下面有冇生瘡、水泡或者粒粒？」 | Vesicles → herpes; warts → HPV; ulcer → syphilis | Genital herpes, condylomata, syphilis |
| Fever / pelvic pain | Any fever or lower abdominal pain? | 「有冇發燒？有冇肚痛？」 | Red flag for PID, tubo-ovarian abscess | PID — ascending chlamydia causes tubal infertility [4] |
| LMP | When was your last period? Could you be pregnant? | 「最後一次月經幾時？有冇可能懷孕？」 | Pregnancy changes Mx (e.g. avoid oral fluconazole); candida more common in pregnancy [2] | Pregnancy-related candida |
| Menopause symptoms | Hot flushes, night sweats, vaginal dryness? | 「有冇潮熱、夜晚出汗、下面乾？」 | Atrophic vaginitis: thin, red, dry vaginal mucosa; dyspareunia [1] | Atrophic vaginitis |
| Sexual Hx | New partner? Number of partners? Condom use? | 「最近有冇新嘅性伴侶？有冇用安全套？」 | STI risk assessment; STIs travel in packs → consider multiple pathogens [5] | Chlamydia, gonorrhoea, TV, herpes |
| Partner symptoms | Does your partner have any symptoms? | 「你嘅伴侶有冇唔舒服？」 | Partner with discharge/ulcer → STI | Chlamydia, gonorrhoea |
| Antibiotics / steroids | Recent antibiotics, steroids, or immunosuppressants? | 「最近有冇食抗生素或者類固醇？」 | Classic: cheesy discharge after finishing broad-spectrum antibiotics → Candida [2] | Candida |
| DM / immune status | Do you have diabetes or any condition affecting immunity? | 「有冇糖尿病？有冇食緊影響免疫力嘅藥？」 | DM / immunosuppression → predisposing factors for Candida [2] | Recurrent candida, DM complications |
| Irritants / hygiene | New soap, detergent, panty liner, douching? | 「有冇用新嘅沐浴露、洗衣液、護墊？有冇用洗液沖洗？」 | Contact irritant / allergic dermatitis [6] | Irritant contact dermatitis |
| Skin Hx | Eczema, psoriasis, lichen sclerosus elsewhere? | 「身體其他地方有冇濕疹、牛皮癬或者白色皮膚變薄？」 | Vulvar dermatoses often coexist with general skin disease | Lichen sclerosus, psoriasis |
| Functional impact | How does it affect your daily life / relationship? | 「呢個問題對你日常生活同伴侶關係有冇影響？」 | Scores bio-psycho-social marks; assesses psychological burden | Psychosocial problem for CRF |
Case Report Form Answer Builder
High-yield points to capture:
- CC: Vaginal itching/burning × [duration], ± discharge (character, colour, odour, amount)
- HPI: Onset, progression, aggravating/relieving factors, associated symptoms (discharge, dysuria, dyspareunia, bleeding, fever, pelvic pain), menstrual status (LMP, menopausal?), sexual history (new partner, condom use, partner symptoms), precipitants (antibiotics, new products), PMH (DM, immunosuppression), drug/allergy history, impact on daily life/sexual function
| Likely RFC Examples | How to Phrase |
|---|---|
| Symptom relief | "Vulvar pruritus causing significant discomfort and sleep disturbance" |
| Fear of STI | "Concern about possible sexually transmitted infection" |
| Relationship worry | "Worried partner may have been unfaithful" |
| Dyspareunia | "Painful intercourse affecting sexual relationship" |
| Best single answer format | Choose the MOST IMPORTANT reason the patient came TODAY. Often: "To find out the cause of vaginal itching and get treatment" or "Concern about possible STI" |
| Component | Likely Content | Exact Wording for CRF |
|---|---|---|
| Ideas | "Patient thinks it might be a yeast infection / STI / cancer" | "Pt believes the itching may be caused by a fungal infection after recent antibiotic use" |
| Concerns | "Worried about STI from partner / worried about cancer / embarrassed" | "Pt is worried the symptoms might indicate an STI and is concerned about her relationship" |
| Expectations | "Wants a test / wants treatment / wants reassurance" | "Pt expects to be tested for infections and receive treatment to relieve itching" |
Vulvovaginal candidiasis — most common cause of vaginal itch in primary care [2]
Minimum supporting evidence: pruritus + white curdy (cottage-cheese) non-odorous discharge ± recent antibiotic use / DM / pregnancy. Physical exam: vulvar erythema, oedema, thick white adherent discharge on speculum.
| DDx | One Key Discriminator |
|---|---|
| Bacterial vaginosis | Thin grey homogeneous discharge with fishy odour (especially post-coital); itch less prominent; positive whiff test |
| Trichomonas vaginalis | Yellow-green frothy malodorous discharge; strawberry cervix on speculum; it IS an STI |
| Atrophic vaginitis | Postmenopausal; vaginal dryness, burning, dyspareunia; thin/red/shiny vaginal mucosa [1] |
| Domain | Problem |
|---|---|
| Biological | Vulvovaginal candidiasis causing pruritus, discharge, and dysuria; need to screen for underlying DM if recurrent |
| Psychological | Anxiety/embarrassment about possible STI; fear of partner infidelity; impact on self-esteem/body image |
| Social/Functional | Dyspareunia leading to sexual avoidance and relationship strain; sleep disturbance from nocturnal itch affecting work performance |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Vulvovaginal candidiasis (most likely) | Thick white curdy ("cottage cheese") discharge adherent to vaginal walls with vulvar erythema and oedema | Speculum (cusco) examination of vagina + vulvar inspection | Pathognomonic appearance; no odour distinguishes from BV/TV [2] |
| Bacterial vaginosis | Thin, greyish-white homogeneous discharge coating vaginal walls; positive whiff test (fishy odour with 10% KOH) | Speculum exam; apply KOH to discharge on slide | Amsel criteria: whiff test + clue cells + pH >4.5 + characteristic discharge |
| Trichomonas vaginalis | "Strawberry cervix" (punctate haemorrhages on cervix) | Speculum exam of cervix | Highly specific for TV though sensitivity only ~2% clinically; frothy yellow-green discharge supports [3] |
| Atrophic vaginitis | Thin, pale/red, shiny, smooth vaginal mucosa with loss of rugae | Speculum exam | Reflects oestrogen deficiency; mucosa may bleed on contact [1] |
| Contact dermatitis | Well-demarcated vulvar erythema ± vesicles/fissures at site of irritant contact | Visual inspection of vulva | Distribution matches contact area; history of new product exposure [6] |
| Chlamydia/PID | Cervical motion (excitation) tenderness | Bimanual pelvic examination | Cervical motion tenderness is a key clinical criterion for PID [4] |
| Genital herpes | Grouped vesicles/shallow ulcers on erythematous base + tender inguinal lymphadenopathy | Visual inspection of vulva; palpate inguinal nodes | Painful vesicles/ulcers with systemic symptoms in primary episode [7] |
Top Traps That Lose Marks
- Forgetting to ask sexual history — cannot differentiate STI from non-STI causes; loses major marks in both consultation and CRF.
- Labelling BV as an STI — BV and candidiasis are NOT STDs [5]. TV IS an STD.
- Not asking about antibiotics / DM — the classic Candida precipitant in exam questions is a patient who recently finished a course of broad-spectrum antibiotics [2].
- Missing atrophic vaginitis in a peri/postmenopausal woman — always ask about menopausal symptoms and LMP.
- Not asking about foreign body — classic exam "pitfall" (retained tampon/condom → foul discharge) [1].
- Confusing internal vs external dysuria — external dysuria (urine stinging inflamed vulva) suggests vulvovaginitis, not UTI.
- Not screening for PID red flags — fever + pelvic pain + new sexual contact = urgent referral needed.
- Not asking ICE — Q3 is directly examined; forgetting it loses guaranteed marks.
Must-Not-Miss Red Flags → Urgent Referral:
- Fever + bilateral lower abdominal/pelvic pain + cervical motion tenderness → PID → same-day Gynae referral
- Non-healing vulvar ulcer / lump → vulvar malignancy → urgent Gynae referral
- Painful vesicles + systemic symptoms → primary genital herpes → STD clinic referral
- Post-coital bleeding → investigate for cervical pathology
Shortest Safe Management / Safety-Net Line:
- 「如果食完藥之後症狀冇改善，或者出現發燒、肚痛、出血，要即刻返嚟覆診或者去急症室。」
- (If symptoms don't improve after treatment, or you develop fever, abdominal pain, or bleeding, come back immediately or go to A&E.)
High Yield Summary
What to ASK: Discharge character (colour/odour/consistency), sexual history (with permission), LMP/menopausal status, recent antibiotics/DM, new products/irritants, partner symptoms, red flags (fever, pelvic pain, ulcers, bleeding), ICE, functional impact.
What to WRITE: CC with discharge description and duration → HPI covering the above → RFC as one clear sentence → ICE verbatim → Most likely dx: vulvovaginal candidiasis (curdy discharge, vulvar erythema) → DDx: BV, TV, atrophic vaginitis → BPS: biological (candida ± DM screen), psychological (anxiety/STI fear/embarrassment), social (relationship/sexual dysfunction/work impact) → Physical sign: thick white curdy discharge on speculum with vulvar erythema.
What NOT to MISS: (1) Sexual history, (2) Antibiotic/DM trigger for candida, (3) PID red flags, (4) Atrophic vaginitis in postmenopausal, (5) BV and candidiasis are NOT STIs, (6) Foreign body as a pitfall.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: MBBS4 t Sexual problems in GP160925.pdf (p.37 — Atrophic vaginitis; p.10-14 — Clinical example 2: foreign body, hidden agenda) [2] Lecture slides: Block C - Vaginal discharge_ obstetric and gynaecological infections.pdf (p.11 — Candida predisposing factors and diagnosis) [3] Lecture slides: GC 119. Vaginal discharge obstetric and gynaecological infections.pdf (vaginal discharge DDx) [4] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1052 — Chlamydia trachomatis: cervicitis, PID, tubal infertility) [5] Senior notes: Ryan Ho Urogenital.pdf (p.242 — Approach to STDs; BV and candidiasis are NOT STDs; STIs travel in packs) [6] Senior notes: Ryan Ho Rheumatology.pdf (p.118 — Irritant contact dermatitis) [7] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.1797 — Genital herpes: HSV-2 recurrence rate 90%)
Vaginal Dryness Or Atrophy
Vaginal dryness or atrophy is a condition characterized by thinning, drying, and inflammation of the vaginal walls due to decreased estrogen levels, most commonly occurring during menopause.
Visual Loss (acute / Subacute)
Acute or subacute visual loss is a rapid decline in vision occurring over seconds to days (acute) or days to weeks (subacute), resulting from ocular, retinal, optic nerve, or central nervous system pathology requiring urgent evaluation.