AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Vaginitis (infection of the vagina) is the most common gynecologic condition encountered by physicians in the office. Vaginitis is defined as the spectrum of conditions that cause vulvovaginal symptoms such as itching, burning, irritation, and abnormal discharge.

The most common causes of vaginitis in symptomatic women are bacterial vaginosis (BV) (22-50%), vulvovaginal candidiasis (17-39%), and trichomoniasis (4-35%); yet, 7-72% of women with vaginitis may remain undiagnosed. Accurate diagnosis may be elusive and must be distinguished from other infectious and noninfectious causes.

Pathophysiology

A complex and intricate balance of microorganisms maintains the normal vaginal flora. Important organisms include lactobacilli, corynebacteria, and yeast. Hormones further influence this microenvironment. A state of decreased estrogen, as occurs in prepuberty and postmenopause and following oophorectomy, can result in an altered risk of infection.

The normal postmenarchal and premenopausal vaginal pH is 3.8-4.2. At this pH, growth of pathogenic organisms usually is inhibited. Disturbance of the normal vaginal pH can alter the vaginal flora, leading to overgrowth of pathogens. Factors that alter vaginal environment include feminine hygiene products, contraceptives, vaginal medications, antibiotics, sexually transmitted diseases (STDs), sexual intercourse, and stress.

Frequency

United States

The actual frequency of vaginitis is difficult to ascertain, due to numerous confounding factors, such as a high asymptomatic rate, inaccurate self-diagnosis and treatment, and population dependence. The reported rate at general gynecologic clinics is 5-15%. For STD clinics, reported rates range from 32% to as high as 64%.

International

International rates are uncertain but probably are similar to those in the United States.

Mortality/Morbidity

Recurrent vaginal infections can lead to chronic irritation, excoriation, and scarring. These, in turn, can lead to sexual dysfunction. Psychosocial and emotional stresses are not uncommon. In addition, chronic vaginal infection can facilitate the transmission of other STDs, including HIV. Complications of BV include endometritis, pelvic inflammatory disease (PID), and vaginal wound infections after gynecologic surgeries. In pregnancy, Trichomonas infection and BV are associated with increased risk of premature rupture of the membranes, preterm labor, low birth weight, and preterm delivery.

Race

Vaginitis affects all races.

• The highest incidence is in African Americans.
• The lowest incidence is in Asians.

Age

All age groups are affected. The highest incidence is noted among young, sexually active women.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients with vaginitis almost always present with a chief complaint of abnormal vaginal discharge. A carefully documented history is essential in the diagnosis of vaginitis.

• Ascertain the following attributes of the discharge:
• • Quantity
  • Duration
  • Color
  • Consistency
  • Odor
• Obtain history of the following:
• • Prior similar episodes
  • Sexually transmitted infection
  • Sexual activities
  • Birth control method
  • Last menstrual period
  • Douching practice
  • Antibiotic use
  • General medical history
  • Systemic symptoms such as lower abdominal pain, fever, chills, nausea, and vomiting
• Bacterial vaginosis: This is characterized by thin, homogenous, malodorous white-to-grey vaginal discharge and pruritus. Vaginal pain or vulvar irritation is uncommon.
• Vaginal candidiasis: Pruritus is the most common symptom of vaginal candidiasis. This is accompanied by thick, odorless, white vaginal discharge (with an appearance similar to cottage cheese) that can be minimal. Usually, associated vulvar candidiasis is present, commonly with vulvar burning, dyspareunia, and vulvar dysuria (burning sensation when urine comes into contact with vulva skin).
• T vaginalis infection: Many patients (20-50%) are asymptomatic. Symptoms include profuse vaginal discharge that can be white, gray, yellow, or green. The yellow and green colors are due to the presence of WBCs. Dysuria (20%), pruritus (25%), and postcoital bleeding due to cervicitis are other possible symptoms.

Physical

• Bacterial vaginosis: BV discharges are frothy and white to grey. The discharge appears adherent to the vaginal mucosa. As many as 50% of women with BV are asymptomatic.
• For diagnosis of BV, 3 out of the following 4 criteria must be present:
• • Homogenous, white, adherent discharge
  • Vaginal pH higher than 4.5
  • Release of fishy odor from vaginal discharge with potassium hydroxide (KOH)
  • Clue cells on wet mount
• Vaginal candidiasis
• • Erythema and swelling of the labia and vulva with satellite lesions (discrete pustulopapular lesions)
  • Vaginal erythema with adherent thick, cottage cheese–like vaginal discharge (the cervix usually appears normal)
• T vaginalis infection
• • The vulva may appear erythematous and edematous, with excoriation.
  • Look for homogenous vaginal discharge that can be white, gray, yellow, or green.
  • Small punctate cervical and vaginal hemorrhages with ulcerations may be observed.
  • "Strawberry cervix" or "colpitis macularis" is very specific for Trichomonas infection, and 2-5% of patients will have this finding on examination.
  • Diagnosis of Trichomonas infection based on clinical signs and symptoms is unreliable, so laboratory confirmation is mandatory.

Causes

BV, vaginal candidiasis, and T vaginalis infection are thought to cause approximately 90% of all vaginal infections.

• BV is the most common cause of vaginitis, accounting for 50% of vaginitis cases. As previously mentioned, BV is caused by an overgrowth of organisms such as Gardnerella vaginalis (gram-variable coccobacillus), Mobiluncus species, Mycoplasma hominis, and Peptostreptococcus species. Risk factors include pregnancy, intrauterine device (IUD) use, and frequent douching.
• Candida species (C albicans, C tropicalis, and C glabrata) are airborne fungi that are natural inhabitants of the vagina in as many as 50% of women, and vaginal candidiasis is the second most common cause of vaginitis. Risk factors include oral contraceptive use, IUD use, young age at first intercourse, increased frequency of intercourse, receptive cunnilingus, diabetes, HIV or other immunocompromised states, chronic antibiotic use, and pregnancy.
• T vaginalis infection, the third most common cause of vaginitis, is caused by trichomonads. These organisms are flagellated protozoans. Trichomonads primarily infect vaginal epithelium, and they less commonly infect the endocervix, urethra, and Bartholin and Skene glands. Trichomonads are transmitted sexually and can be identified in as many as 80% of male partners of infected women. Risk factors include tobacco use, unprotected intercourse with multiple sexual partners, and the use of an IUD.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Atrophic vaginitis
Cervical polyp
Contact dermatitis
Entamoeba histolytica
Excessive despumation of normal vaginal epithelium
Foreign objects
Large cervical ectropion
Lichen sclerosis
Lichen simplex chronicus
Vaginal adenosis
Vaginal cancer
Vaginal intraepithelial neoplasia
Vaginal ulcers
Vaginal emphysematosa (multiple gas-filled cysts on the vaginal and cervical mucosa)

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Saline wet mount: Vaginal discharge is placed on a slide with 1-2 drops of 0.9% isotonic sodium chloride solution and examined under high power (x 400).
• • Bacterial vaginosis: Saline wet mount is 60% sensitive and 98% specific. Clue cells are vaginal epithelial cells covered with many vaginal rods and cocci bacteria, creating a stippled or granular appearance. A decreased number of lactobacilli is observed, and WBCs are absent.
  • Vaginal candidiasis: Hyphae and budding yeast forms are noted.
  • T vaginalis infection: Saline wet mount is 80-90% sensitive in symptomatic women. T vaginalis is an oval- or fusiform-shaped protozoan that is 15 mm long (size of a leukocyte), with erratic, twitching motility. A large number of WBCs and epithelial cells are observed.
• Potassium hydroxide preparation: Vaginal discharge is placed on a slide with 10% KOH solution. Known as the whiff test, a positive finding is the release of a fishy odor after addition of 10% KOH to discharge. The odor is due to the release of amines such as putrescine, cadaverine, histamine, and trimethylamine.
• • Bacterial vaginosis: Whiff test is one of the most specific tests for BV and the least sensitive.
  • Vaginal candidiasis: Negative whiff test is 65%-85% sensitive for candidal infection.
  • Trichomonas vaginitis: Whiff test may be positive.
• pH: Vaginal pH can be determined with litmus paper. A pH greater than 4.5 often is found in patients with Trichomonas infection or BV (84-97% sensitive, 57-78% specific). Recent intercourse, douching, cervical mucus, and blood can lead to false-positive results.
• • Bacterial vaginosis: pH is 5.0-6.0.
  • Vaginal candidiasis: pH is less than 4.5.
  • T vaginalis infection: pH is 5.0-7.0.
• Cultures
• • Cultures have little utility for diagnosing BV. Gram stain is 89-97% sensitive and 79-85% specific for detecting BV.
  • Cultures with Nickerson or Sabouraud mediums should be performed in refractory or recurrent cases of vaginal candidiasis.
  • Culture using Diamond medium is the criterion standard for detection of trichomonads and should be used when infection is suspected but cannot be confirmed by other means.
• Other second-line tests
• • Staining methods (Giemsa, Papanicolaou, Schiff): Sensitivity is 55% and specificity is 97% for detecting BV. Papanicolaou test is not accurate in the diagnosis of Trichomonas infections due to high false-positive and false-negative rates.
  • Latex agglutination test: This test employs polyclonal antibodies reactive against multiple species of Candida.
  • Gas-liquid chromatography: This can be used to detect the succinate-to-lactate ratio in vaginal fluid to assist in diagnosis of BV. Succinate and lactate are metabolites produced by anaerobic gram-negative rods and lactobacilli, respectively.
  • Oligonucleotide probes: These detect high (>10⁷/mL) concentrations of Gardnerella vaginalis. This test also can detect Candida.
  • Antigen-detecting immunoassays, the OSOM Trichomonas Rapid Test, DNA probes, and polymerase chain reaction (PCR): These are useful for detecting trichomonads.

Procedures

• All women presenting with abnormal vaginal discharge should have a careful pelvic examination. Have patients take condition-specific tests, ie, colposcopy and cervical biopsies, for suspected cervical cancer.

Histologic Findings

T vaginalis infection can be confused with koilocytotic atypia, caused by the human papilloma virus, and may mimic findings of mild dysplasia. BV may produce inflammation and atypical squamous cells of undetermined significance (ASCUS) on Papanicolaou tests. Also, BV may be linked with cervical intraepithelial neoplasia (CIN).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• T vaginalis infection
• • Because trichomonads often infect the urethra and the Skene and Bartholin glands, systemic chemotherapy is recommended.
  • Metronidazole (Flagyl) is the treatment of choice both for patients who are immunocompetent and for those who are immunocompromised.
  • Topical treatment with nonoxynol-9 and povidone-iodine douches has been shown to be effective in treating T vaginalis infection in women unable to use metronidazole. Further studies are needed to confirm this preliminary finding.
  • A vaccine of killed "aberrant lactobacilli" is available in Europe. This vaccine has not been evaluated in well-controlled, double-blind prospective trials.
• Vaginal candidiasis
  • A variety of potent azole agents (oral and topical) are available. Azoles are fungistatic agents.
  • Boric acid can be used in resistant cases.
• Bacterial vaginosis: Metronidazole (Flagyl) and clindamycin are effective in the treatment of BV.

Consultations

For resistant infections, consider an infectious disease consultation. Notification of the Centers for Disease Control and Prevention (CDC) may be warranted.

Diet

Acidophilus supplements in the diet may help prevent vaginitis, especially if patients are taking antibiotics.

Activity

Instruct patients to abstain from sexual activity and from douching until a diagnosis has been made. Patients also should abstain from unprotected sexual activity (sexual activity without proper male condom use) until the infection has been treated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce morbidity, prevent complications, and eradicate the infection.

Drug Category: Antiprotozoal agents

Metronidazole is the antimicrobial agent of choice to treat T vaginalis infections and bacterial vaginosis.

Drug Category: Antifungals

Imidazole derivatives that exert a fungicidal effect by altering permeability of the fungal cell membrane. The mechanism of action also may involve alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to fungal cell.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Category: Hormones

Indicated for atrophic vaginitis resulting from diminished levels of circulating estrogens. A relative lack of estrogen also predisposes the vagina and vulva to infection.

Drug Category: Anti-infectives, topical

Boric acid can be used in the treatment of refractory, recurrent vaginal candidiasis.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care usually is not indicated, unless serious pelvic infections arise or evidence of systemic infection in an immunocompromised host is present.

Further Outpatient Care

• Follow-up care is not indicated if patients are asymptomatic. However, in women who are pregnant or those with recurrent infections, a follow-up evaluation should be performed 1 month after completion of treatment.
• Consider treatment of partners in case of trichomoniasis; if chronic or recurrent infections occur, consider treatment of partners in case of bacterial vaginosis. Yeast culture, glucose intolerance test, and HIV test should be offered in case of recurrent or resistant vaginal candidiasis.

In/Out Patient Meds

• All regimens are administered on an outpatient basis (see Medication).

Deterrence/Prevention

• Although not extensively studied, safe sexual practices may play a role in decreasing BV and T vaginalis infections. Good hygiene also may play a role in preventing candidal infections. No studies show any benefit to douching as a treatment or prevention for vaginitis; douching may actually exacerbate symptoms. Tampon use does not seem to be associated with vaginitis.

Complications

• BV has been associated with PID, endometritis, and vaginal cuff cellulitis when invasive procedures have been performed. Such procedures include endometrial biopsies, cesarean section, uterine curettage, and IUD placement.
• During pregnancy, BV and trichomoniasis are associated with an increased risk of premature rupture of membranes, preterm labor, low birth weight, and preterm delivery.

Prognosis

• The prognosis is very good because the majority of those infected will be cured.

Patient Education

• Safe sex and STD counseling may help decrease the rates of reinfection.
• For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center and Women's Health Center. Also, see eMedicine's patient education articles Vaginal Infections, Candidiasis (Yeast Infection), Understanding Vaginal Yeast Infection Medications, and Female Sexual Problems.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Special Concerns

• Patients who are immunocompromised, such as those with HIV, should be treated with the same regimens.
• Pregnancy should not delay treatment.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• ACOG. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. May 2006;107(5):1195-1206.
• American Academy of Family Practice. Vaginitis. ACOG Technical Bulletin. 2000;[Full Text].
• Association of Professors of Gynecology and Obstetrics. Diagnosis of vaginitis. In: APGO Educational Series in Women's Health Issues. 1996;1-9.
• CDC. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1):70-79. [Medline].
• Davis JD, Connor EE, Clark P, et al. Correlation between cervical cytologic results and Gram stain as diagnostic tests for bacterial vaginosis. Am J Obstet Gynecol. Sep 1997;177(3):532-5. [Medline].
• DeCherney AH, Pernoll ML, eds. Obstetric and Gynecologic Diagnosis and Treatment. 8th ed. Stamford, Conn:. Appleton & Lange;September 1996:689-712.
• Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. Sep 1 2000;62(5):1095-104. [Medline].
• Eschenbach DA, Hillier S, Critchlow C, et al. Diagnosis and clinical manifestations of bacterial vaginosis. Am J Obstet Gynecol. Apr 1988;158(4):819-28. [Medline].
• Force R. Management of Vulvovaginal Candidiasis: safe, effective and appropriate therapy -- A Pharmacology Perspective. Vulvovaginal Candidiasis: A contemporary approach to recognition and management. 1997:10-4.
• Gjerdingen D, Fontaine P, Bixby M, et al. The impact of regular vaginal pH screening on the diagnosis of bacterial vaginosis in pregnancy. J Fam Pract. Jan 2000;49(1):39-43. [Medline].
• Holmes KK, Sparling PF, Mardh P. Sexually Transmitted Diseases. 3rd ed. New York, NY:. McGraw Hill Text;1999:563-639.
• Katzung BG, ed. Basic and Clinical Pharmacology. 6th ed. New York, NY:. McGraw-Hill Professional Publishing;1995:723-9, 741-2, 799-803.
• Mishell DR, Stenchever MA, Droegemueller W. Comprehensive Gynecology. 3rd ed. St. Louis, Mo:. Mosby-Year Book;1997:625-635.
• Siberry GK, Iannone R. The Harriet Lane Handbook. 15th ed. St. Louis, Mo:. Mosby Year Book;2000:615-892.
• Sobel JD. Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol. Aug 1 1985;152(7 Pt 2):924-35. [Medline].
• Summers PR. Diagnosis of Vulvovaginal Candidiasis: considering conditions that mimic or mask. Vulvovaginal Candidiasis: A contemporary approach to recognition and management. 1997:6-9.
• Sweet RL. Importance of differential diagnosis in acute vaginitis. Am J Obstet Gynecol. Aug 1 1985;152(7 Pt 2):921-3. [Medline].

Article Last Updated: Aug 21, 2006