Vaginal or genital malodour in women

What is vaginal malodour?

Many women complain that they have a bad smell or malodour coming from the vagina, even after washing frequently. This can be very distressing, particularly if it is noticed and commented on by someone else.

The genital odour is due to the combination of vaginal secretions, eccrine and apocrine sweat and external sources (urine, faeces, topical applications).

What symptoms should lead to concern?

A bad smell could be due to genital infection or disease. Clues include:

• Excessive vaginal discharge
• Itching (pruritus vulvae)
• Pain and soreness.

What conditions cause vaginal malodour?

Sometimes the apparently bad vaginal smell is actually normal, as vaginal secretions in every adult woman have a rather musty odour. The smell can vary throughout the menstrual cycle. There is also a wide variation in what is considered acceptable.

Bad smell is however often associated with infectious or noninfectious causes of vaginitis or less often, vulval disease.

Malodorous vaginal infections include:

• Bacterial vaginosis (the most common reason for genital malodour, a fishy smell)
• Trichomoniasis (this is foul-smelling in only about 20% of infected women)
• Vulval ulceration of any cause, particularly if due to donovanosis or chancroid
• The vaginal discharge associated with pelvic inflammatory disease
• Forgotten foreign bodies such as tampons, diaphragms or sponges
• Fistulas or passageways linking the vagina with the rectum or bladder following childbirth, injury or surgery
• Hidradenitis suppurativa.

Although candidal vulvovaginitis (thrush) is very common, it causes a yeasty smell, which is not considered particularly unpleasant by most women.

Noninfectious causes of vaginal malodour include:

• Excessive perspiration ( hyperhidrosis leading to bromhidrosis) especially associated with obesity
• Chronic constipation and bloating or dietary factors leading to release of smelly rectal gases
• Urinary incontinence, releasing ammonia  
• Poor hygiene, often in women who are elderly or mentally unwell
• Vulval cancer, when it is due to necrosis (death of tissue)
• Discharge or necrosis of other genital cancers
• Trimethylaminuria (fish-odour syndrome)
• Olfactory hallucinations, e.g. associated with temporal lobe epilepsy
• Psychiatric conditions.

What tests should be done?

Women complaining of genital malodour should undergo careful external and internal examination after a careful history has been taken. Tests may include pH, vaginal and/or vulval swabs for microbiology and sometimes skin biopsy.

What is the treatment for vaginal malodour?

Treatment depends on the underlying cause. Antibiotics should be prescribed for confirmed infection.

General measures should include:

• Avoid wearing tight or occlusive underwear
• Change underwear frequently
• Bathe gently using a non-soap cleanser once or twice daily
• Attempt to lose weight, if relevant
• If incontinent of urine, copper acetate impregnated incontinence pads may help to reduce the smell.

The hazards of self-treatment

Excessive washing, antiseptics, deodorants and douching (rinsing out the vagina) may irritate the vagina and vulva, potentially resulting in increased irritation and discharge from vulvitis, chemically-induced vaginitis or secondary infection. Don't do it!