Snapshot A 25-year-old woman presents to her primary care physician due to malodorous vaginal discharge. She says the discharge has a greenish hue and her symptom is accompanied by postcoital bleeding and a burning sensation in her vaginal area. She describes practicing unprotected sex with her new partner. On speculum examination, there is a "strawberry cervix." Vaginal pH is 5.5. Saline microscopy demonstrates motile trichomonads. She is started on metronidazole and she is told that her partner must be started on the same medication. summary Clinical definition login to view 6 more bullets Epidemiology Risk factors login to view 10 more bullets Etiology The most common infections include login to view 3 more bullets Pathobiology login to view 15 more bullets Presentation VaginitisVaginitisEtiologyClinical PresentationBacterial vaginosisGardnerella vaginalisSymptomsmalodorous ("fishy" odor)vaginal dischargenonpainfulPhysical examoff-white or gray and thin vaginal dischargenormal vulvaVulvovaginal candidiasisCandida albicansSymptomspruritus and sorenessdyspareuniaPhysical examthick, white, odorless, and curd-like vaginal dischargevulvar erythema and edemaTrichomoniasisTrichomonas vaginalisSymptomsmalodorousgreenishdischargeburningdyspareunia and dysuriapostcoital bleedingPhysical exammalodorous discharge"strawberry" cervixvulvovaginal erythemaImportant notesexually transmitted; therefore, the partner must also be treatedStudiesManagement approacha definitive diagnosis can be obtained by examining the vaginal discharge forpHfishy amine odormicroscopySpeculum examindicationto evaluate for underlying causes of vaginitisforeign body (e.g., retained tampon) leading to vaginitisVaginal pHnormal findingspH of 4-4.5bacterial vaginosispH of > 4.5vulvovaginal candidiasispH of 4-4.5trichomoniasispH of 5-6Saline microscopy (wet mount)bacterial vaginosisclue cells found in epithelial cellsvulvovaginal candidiasispseudohyphaetrichomoniasismotile trichomonadsPotassium hydroxide (KOH) wet mountvulvovaginal candidiasispseudohyphaeAmine test ("whiff" test)positive in ~70-80% of patients with bacterial vaginosisDifferentialPhysiologic leukorrhea (normal vaginal discharge)odorless, white or yellowish dischargeno other symptoms or exam abnormalitiesAtrophic vaginitisdistinguishing factorstypically seen in menopausal womenon physical exam there isthinning of the vaginal epitheliumloss of rugaecervicovaginal friabilityVaginal foreign bodydistinguishing factorsmost common cause of foul-smelling discharge and spotting or vaginal bleeding in childrenTreatmentMedicalmetronidazoleindicationsfirst-line agent for both pregnant and nonpregnant women withbacterial vaginosisclindamycin is an alternativepartners do not require treatment as this is not a sexually transmitted infectionfirst-line agent pregnant and nonpregnant women withtrichomoniasistinidazole is another optionsexual partner must be treated and sex must be avoided until treatment is complete and the patients are asymptomaticside -effectsdisulfiram-like reaction-azoleindicationfirst-line treatment option for women with vulvovaginal candidiasistopical -azoles are preferred in pregnancymedications includefluconazoleclotrimazolemiconazoleComplicationsBacterial vaginosismiscarriage and spontaneous abortionmaternal infectionpostpartum endometritisneonatal complications includelow birth weightprematurityTrichomoniasisprematuritypremature rupture of membranespreterm premature rupture of membranesVulvovaginal candidiasispremature rupture of membranespreterm laborcerebral candidiasis in the neonateneonatal deathCluecells (vaginal epithelial cells covered withGardnerella) have stippled appearance alongouter margin (arrow in A ). VaginitisVaginitisEtiologyClinical PresentationBacterial vaginosisGardnerella vaginalisSymptomsmalodorous ("fishy" odor)vaginal dischargenonpainfulPhysical examoff-white or gray and thin vaginal dischargenormal vulvaVulvovaginal candidiasisCandida albicansSymptomspruritus and sorenessdyspareuniaPhysical examthick, white, odorless, and curd-like vaginal dischargevulvar erythema and edemaTrichomoniasisTrichomonas vaginalisSymptomsmalodorousgreenishdischargeburningdyspareunia and dysuriapostcoital bleedingPhysical exammalodorous discharge"strawberry" cervixvulvovaginal erythemaImportant notesexually transmitted; therefore, the partner must also be treated Prognosis Bacterial vaginosis login to view 1 more bullet Trichomoniasis login to view 1 more bullet Vulvovaginal candidiasis login to view 1 more bullet