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Updated: Apr 16 2022

Vaginitis

5.0

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(17)

  • 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
      • vaginal disorder secondary to
        • infection
          • in very rare cases, it may be caused by Enterobius vermicularis
            • typically causes perianal itching
        • inflammation
        • changes in normal vaginal flora
  • Epidemiology
    • Risk factors
      • bacterial vaginosis
        • multiple sexual partners
        • antibiotic use
        • intrauterine contraceptive device
      • trichomoniasis
        • multiple sexual partners
        • history of sexually transmitted infections
      • vulvovaginal candidiasis
        • immunosuppression (e.g., transplant patients and HIV infection)
        • uncontrolled diabetes
  • Etiology
    • The most common infections include
      • bacterial vaginosis
      • Candida vulvovaginitis
      • trichomoniasis
    • Pathobiology
      • normal biology
        • in premenopausal women, the vaginal nonkeratinized stratified squamous epithelium contains a large amount of glycogen
          • lactobacilli use this glycogen from sloughed cells to produce lactic acid creating an acidic vaginal environment (pH 4-4.5) that prevents the growth of pathogenic organisms
            • acidic environment normally maintains normal vaginal flora
      • pathogenesis
        • disruption of this acidic environment results in vaginitis
          • disruptive causes include
            • menstruation
            • sexual activity
            • pregnancy
            • foreign bodies
            • sexually transmitted disease
            • hygienic products
            • antibiotics
            • hypoestrogenic states (e.g., menopause)
  • Presentation
    • Vaginitis
      VaginitisEtiologyClinical Presentation
      Bacterial vaginosis
      • Gardnerella vaginalis
      • Symptoms
        • malodorous ("fishy" odor)vaginal discharge
        • nonpainful
      • Physical exam
        • off-white or gray and thin vaginal discharge
        • normal vulva
      Vulvovaginal candidiasis

      • Candida albicans
      • Symptoms
        • pruritus and soreness
        • dyspareunia
      • Physical exam
        • thick, white, odorless, and curd-like vaginal discharge
        • vulvar erythema and edema
      Trichomoniasis
      • Trichomonas vaginalis
      • Symptoms
        • malodorousgreenishdischarge
        • burning
        • dyspareunia and dysuria
        • postcoital bleeding
      • Physical exam
        • malodorous discharge
        • "strawberry" cervix
        • vulvovaginal erythema
      • Important note
        • sexually transmitted; therefore, the partner must also be treated
      Studies
      • Management approach
        • a definitive diagnosis can be obtained by examining the vaginal discharge for
          • pH
          • fishy amine odor
          • microscopy
      • Speculum exam
        • indication
          • to evaluate for underlying causes of vaginitis
            • foreign body (e.g., retained tampon) leading to vaginitis
      • Vaginal pH
        • normal findings
          • pH of 4-4.5
        • bacterial vaginosis
          • pH of > 4.5
        • vulvovaginal candidiasis
          • pH of 4-4.5
        • trichomoniasis
          • pH of 5-6
      • Saline microscopy (wet mount)
        • bacterial vaginosis
          • clue cells found in epithelial cells
        • vulvovaginal candidiasis
          • pseudohyphae
        • trichomoniasis
          • motile trichomonads
      • Potassium hydroxide (KOH) wet mount
        • vulvovaginal candidiasis
          • pseudohyphae
      • Amine test ("whiff" test)
        • positive in ~70-80% of patients with bacterial vaginosis
      Differential
      • Physiologic leukorrhea (normal vaginal discharge)
        • odorless, white or yellowish discharge
        • no other symptoms or exam abnormalities
      • Atrophic vaginitis
        • distinguishing factors
          • typically seen in menopausal women
          • on physical exam there is
            • thinning of the vaginal epithelium
            • loss of rugae
            • cervicovaginal friability
      • Vaginal foreign body
        • distinguishing factors
          • most common cause of foul-smelling discharge and spotting or vaginal bleeding in children
      Treatment
      • Medical
        • metronidazole
          • indications
            • first-line agent for both pregnant and nonpregnant women withbacterial vaginosis
              • clindamycin is an alternative
              • partners do not require treatment as this is not a sexually transmitted infection
            • first-line agent pregnant and nonpregnant women withtrichomoniasis
              • tinidazole is another option
              • sexual partner must be treated and sex must be avoided until treatment is complete and the patients are asymptomatic
          • side -effects
            • disulfiram-like reaction
        • -azole
          • indication
            • first-line treatment option for women with vulvovaginal candidiasis
              • topical -azoles are preferred in pregnancy
          • medications include
            • fluconazole
            • clotrimazole
            • miconazole
      Complications
      • Bacterial vaginosis
        • miscarriage and spontaneous abortion
        • maternal infection
        • postpartum endometritis
        • neonatal complications include
          • low birth weight
          • prematurity
      • Trichomoniasis
        • prematurity
        • premature rupture of membranes
        • preterm premature rupture of membranes
      • Vulvovaginal candidiasis
        • premature rupture of membranes
        • preterm labor
        • cerebral candidiasis in the neonate
        • neonatal death
      Clue
      cells (vaginal epithelial cells covered with
      Gardnerella) have stippled appearance along
      outer margin (arrow in A ).
    • Vaginitis
      VaginitisEtiologyClinical Presentation
      Bacterial vaginosis
      • Gardnerella vaginalis
      • Symptoms
        • malodorous ("fishy" odor)vaginal discharge
        • nonpainful
      • Physical exam
        • off-white or gray and thin vaginal discharge
        • normal vulva
      Vulvovaginal candidiasis

      • Candida albicans
      • Symptoms
        • pruritus and soreness
        • dyspareunia
      • Physical exam
        • thick, white, odorless, and curd-like vaginal discharge
        • vulvar erythema and edema
      Trichomoniasis
      • Trichomonas vaginalis
      • Symptoms
        • malodorousgreenishdischarge
        • burning
        • dyspareunia and dysuria
        • postcoital bleeding
      • Physical exam
        • malodorous discharge
        • "strawberry" cervix
        • vulvovaginal erythema
      • Important note
        • sexually transmitted; therefore, the partner must also be treated
  • Prognosis
    • Bacterial vaginosis
      • infection may recur in 30% of women
    • Trichomoniasis
      • infection may recur in 5-31% of cases
    • Vulvovaginal candidiasis
      • infection may recur in ~ 50% of initially infected women
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