Debra L. Fromer, MD
Drew A. Freilich, MD
BASICS
DESCRIPTION
• Vaginitis is infection or inflammation of only the vagina. Vulvovaginitis involves both the vagina and vulvar areas
• The spectrum of conditions that cause vulvovaginal symptoms such as itching, burning, irritation, and abnormal discharge (1)
• Can be infectious, noninfectious (chemical or irritants), or hormonal
• Bacterial vaginitis (BV) is the most common cause of vaginal discharge in women of childbearing age
EPIDEMIOLOGY
Incidence
7.4 million cases of BV annually in USA
Prevalence
• Among women with vulvovaginitis symptoms, prevalences are (1):
– BV: 22–50%
– Candidiasis: 17–39%
– Trichomoniasis: 4–35%
RISK FACTORS
• Depends on etiology
• Risk factors for BV include new sex partner, multiple partners, and douching (2)
• Risk factors for vulvovaginitis candidiasis (VVC) (3):
– Recent use of antibiotics
– Corticosteroids
– Diabetes mellitus
– Immunosuppression
– Pregnancy
• Risk for any STD is increased with:
– Number of partners
– Number of partners’ partners
– Unprotected sexual contact
Genetics
Evolving data supporting potential genetic predisposition
PATHOPHYSIOLOGY
• Depends on etiology
– BV: Normal vaginal Lactobacillus are replaced with anaerobic bacteria, Gardnerella vaginalis and Mycoplasma hominis (some of these are normal vaginal flora; their overgrowth leads to BV)
– VVC: Overgrowth of Candida
– Trichomonas and other STIs: Infection with organism
– Atrophic vaginitis: Lack of estrogen
ASSOCIATED CONDITIONS
STI/STD’s are often associated with other STI/STD’s
GENERAL PREVENTION
• Avoid local irritants such as perfumed soaps and shower gels, wipes, powders, and sprays
• Wash external skin with water alone or mild soap
• Avoid tight clothing
• For STIs, treat partners as applicable
• Avoid douching, a risk factor for BV
• For trichomoniasis and other STIs:
– Latex male condoms
– Abstain from sexual contact, or be in a long-term mutually monogamous relationship with an uninfected partner
DIAGNOSIS
HISTORY
• Potential predisposing factors:
– Prior vaginitis
– Antibiotic use
– Pregnancy
– Diabetes
– Sexual intercourse
– Method of contraception
– STI history
– Response to prior treatment
– Any current treatments that have been self-administered (OTC products)
• Symptoms of current condition:
– Duration
– Itching, burning
– Color, consistency, and odor of discharge
PHYSICAL EXAM
• Inspect the vulva, vagina, and cervix for:
– Erythema or skin lesions
– Degree of estrogenization
– Discharge
– Foreign body (eg, forgotten tampon)
– Friable cervix: Consider Chlamydia or gonorrhea
• Inspect the vulva, vagina, and cervix for:
– BV: White or gray, homogeneous, thin, coats the vaginal walls, can have fishy odor
– Candida: White, thick, curdy, not malodorous
– Trichomonas: Yellow or yellow-green, malodorous, can be profuse and frothy
– Cervicitis: Purulent, comes from cervix
– Extensive condyloma can cause discharge
• Palpate for tenderness:
– Vulvar tenderness without discharge suggests atrophic vaginitis, vulvodynia, or dermatologic condition
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis and culture if dysuria is present
• Evaluate discharge by wet mount and KOH:
– Put a drop of discharge on a glass slide
– Add a drop of saline to the discharge, add cover slip, and look under microscope for Trichomonas and clue cells (BV)
– Repeat with another slide, using a drop of 10% KOH instead of saline.
– “Whiff test”: Fishy smell (amine odor) immediately after KOH application suggests BV.
Wait 2 min for KOH to dissolve most of the cells. Yeast cells or hyphae remain undissolved.
• Clinical diagnosis of BV (Amsel criteria) requires the presence of ≥3 of the following:
– Homogeneous, thin, white discharge that smoothly coats the vaginal walls
– Vaginal pH > 4.5 (sample from midvagina)
– Positive amine test (aka whiff test) (fishy odor before or after addition of 10% KOH)
– Presence of clue cells on microscopic exam
• Diagnosis of candidiasis:
– Hyphae or yeast cells on KOH or wet mount
– If Candida suspected but not seen on KOH or wet mount, send discharge for yeast culture
• Diagnosis of trichomoniasis:
– See organisms on wet mount about 60% sensitive (1,2)
– FDA-approved point-of-care tests have sensitivity >83% and specificity >97% (2)
Affirm VP III (45 min for result)
OSOM Trichomonas Rapid Test (10 min)
– Culture is most accurate test for trichomonas (∼98%)
• Indications for Chlamydia/Gonorrhea testing (1):
– Purulent discharge
– Discharge has leukocytes (>10 WBC on microscopy) without trichomonads
– Friable cervix; symptoms of PID (pelvic pain, fever)
– Patient in high-risk group for STIs
– NAAT (nucleic acid amplification testing) should be used for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae with cervicitis
Imaging
Rarely indicated
Diagnostic Procedures/Surgery
• Vaginal sidewall pH can help with diagnosis:
– Premenopausal: normal pH 4–4.5
BV: pH >4.5
Trichomoniasis: pH 5–6
Candidiasis: pH 4–4.5
– Postmenopausal: normal pH >4.7
• Biopsy may be indicated for vulvar dermatologic disorders or to rule out cancer. Not needed in most cases
Pathologic Findings
Based on organism
DIFFERENTIAL DIAGNOSIS
• The most common vaginal infections that cause discharge are:
– Bacterial vaginosis (BV)
– Vulvovaginitis Candidiasis (VVC)
– Trichomoniasis
– Cervicitis due to Chlamydia or gonorrhea can present with discharge
– Group A Streptococcus (very rare)
• Noninfectious etiologies:
– Atrophic vaginitis
– Ectropion
May normalize vaginal discharge volume
Normalize physiologic presence of endocervical glandular tissue on the cervix.
More common with estrogen–progestin contraceptives and with pregnancy.
– Foreign body (ie, retained tampon)
– Allergies and irritants: Contraceptives, douches, perfumes, soaps, laundry detergents, panty liners, etc.
– Vulvar dermatologic conditions
– Vulvodynia
TREATMENT
GENERAL MEASURES
• See “General Prevention.”
• Attempt to identify specific cause based on history, lab testing to target treatment
• Correct underlying conditions if possible
MEDICATION
First Line
• Bacterial vaginosis (2,5):
– Metronidazole 500 mg PO BID for 7 days
– Metronidazole gel 0.75%; 1 applicator (5 g) per vagina every day for 5 days
– Clindamycin cream 2% 1 applicator (5 g) per vagina at bedtime for 7 days
• Uncomplicated VVC:
– Multiple topical azole regimens, or single PO dose 150 mg fluconazole
All have similar results
Fluconazole has many drug interactions.
• Complicated VVC (2): (<5% of women)
– Defined as severe disease (extensive erythema, edema, excoriation, fissures), recurrent disease, not Candida albicans, uncontrolled diabetes, debilitation, immunosuppression, or pregnancy, >4 per year
– Start with same drugs but give longer courses (7–14 days).
– If azoles fail, use 600 mg of boric acid in a gelatin capsule, per vagina daily for 2 wk
• Trichomonas (2):
– Metronidazole or tinidazole 2 g single dose PO (tinidazole is equivalent or superior) (2)
– Gel is much less effective than PO dose.
• Cervicitis: Azithromycin 1 g PO single dose OR Doxycycline 100 mg PO BID for 7 days
– Consider concurrent treatment for gonococcal infection if prevalence of gonorrhea is high in the patient population (Ceftriaxone 250 mg IM 1 dose)
• Atrophic vaginitis: Topical estrogen is effective; several forms can be used
Second Line
• BV (2):
– Clindamycin ovules 100 mg per vagina at bedtime for 3 days
– Clindamycin 300 mg PO BID. for 7 days
• VVC: No 2nd-line treatments described (2)
• Trichomoniasis: Metronidazole 500 PO BID for 7 days (2)
Pregnancy Considerations
• Bacterial vaginosis (1,2)
– BV in pregnancy is associated with preterm birth and postpartum endometriosis
– However only proven benefit of treating symptomatic BV in pregnancy is reduction in symptoms
– Trial results inconsistent for screening/treating asymptomatic high-risk patients
– USPSTF recommends not screening for BV in low or average risk for preterm birth
– BV treatment in pregnancy (2):
Metronidazole 500 mg PO BID for 7 days
Metronidazole 250 mg PO TID for 7 days
Clindamycin 300 mg BID for 7 days
Topical clindamycin should not be used in the 2nd half of pregnancy
• VVC: If pregnant, the only recommended treatment is topical azole for 7 days (2)
• Trichomoniasis in pregnancy is associated with adverse outcomes, but no strong evidence that treatment improves outcomes, therefore(1, 2):
– No need to screen
– Do treat women who have symptoms
– Metronidazole is pregnancy category B and OK for 2 g single PO dose
– Tinidazole is pregnancy category C
– With both drugs, stop breast-feeding.
SURGERY/OTHER PROCEDURES
N/A
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Partners should be notified and examined if chlamydia, gonorrhea, or trichomoniasis found
• For atrophic vaginitis, if estrogen cannot be used, moisturizers and lubricants may help
Complementary & Alternative Therapies
For Candida, no evidence for lactobacilli, yogurt, garlic, tea tree oil, a low-carbohydrate diet, or desensitization to Candida species antigen (1); but minimal evidence for atrophic vaginitis.
ONGOING CARE
PROGNOSIS
Depends on etiology
COMPLICATIONS
Inflammation from trichomonas, gonococcal urethritis, chlamydial urethritis, and nongonococcal, nonchlamydial urethritis might facilitate HIV transmission to her partner (3)
FOLLOW-UP
Patient Monitoring
• BV is not thought to be a STD (4):
– No follow-up needed if symptoms resolve (2)
– Partner notification not needed/partner treatment does not improve the outcome
• Candidiasis (2):
– No follow-up needed unless symptoms persist or recur within 2 mo
– No partner treatment, unless he has balanitis or if she has frequent recurrences
• Trichomoniasis (2):
– Treat partners and avoid sexual contact until both partners have completed treatment and are asymptomatic
– Consider follow-up screening as >17% relapse within 3 mo
Patient Resources
Medline Plus: Vaginitis http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000566.htm
REFERENCES
1. ACOG Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol.2006;107:1195–1206.
2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. Online at http://www.cdc.gov/std/treatment/2010/vaginal-discharge.htm (Accessed July 21, 2014)
3. Kagan R, Williams RS, Pan K, et al. A randomized, placebo- and active-controlled trial of bazedoxifene/conjugated estrogens for treatment of moderate to severe vulvar/vaginal atrophy in postmenopausal women. Menopause. 2010;17(2):281–289.
4. Sherrard J, Donders G, White D, et al. European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011. Int J STD AIDS. 2011;22:421–429.
ADDITIONAL READING
Muzny CA, Schwebke JR. The clinical spectrum of Trichomonas vaginalis infection and challenges to management. Sex Transm Infect. 2013;89(6):423–425.
See Also (Topic, Algorithm, Media)
• Sexually Transmitted Infections (STI) (Sexually Transmitted Diseases [STD]), General
• Vaginitis/Vulvovaginitis Image 
• Vaginal Discharge Algorithm 
• Vaginal Discharge, Urologic Considerations
• Vaginosis
CODES
ICD9
• 112.1 Candidiasis of vulva and vagina
• 131.01 Trichomonal vulvovaginitis
• 616.10 Vaginitis and vulvovaginitis, unspecified
ICD10
• A59.01 Trichomonal vulvovaginitis
• B37.3 Candidiasis of vulva and vagina
• N76.0 Acute vaginitis
CLINICAL/SURGICAL PEARLS
• Pelvic pain and fever are red flags for pelvic inflammatory disease.
• Avoid alcohol with metronidazole until 24 hr after last dose (72 hr for tinidazole) as it can cause nausea.
• Clindamycin cream may weaken latex condoms and diaphragms for 5 days after use.
• Consider delaying breast-feeding 12–24 hr after metronidazole and 72 hr for tinidazole.