vaginitis

Etiology

• bacterial vaginosis
  • Gardnerella vaginalis
  • Mycoplasma hominis
  • Mobiluncus
  • other anaerobes
  • other gram-negative bacteria
  • NOT a sexually transmitted disease
• Candida vulvovaginosis: Candida albicans (85%)
• Trichomonas vaginalis - generally sexually transmitted
• atrophic vaginitis
• *lichen sclerosus*

* unclear whether lichen sclerosus is strictly vulvitis or involves vaginitis as well

Epidemiology

• bacterial vaginosis:
  • primarily sexually active women
  • most common lower genital tract infection in reproductive age women
• 75% of women will have at least one episode of vaginal candidiasis in their lifetime; 45% will have 2 or more episodes
• Trichomonas vaginitis: bimodal frequency: ages 15-25 & 45-65

Pathology

• Candida vulvovaginitis & trichomonas vaginitis are inflammatory conditions
• bacterial vaginosis is non-inflammatory

Clinical manifestations

• vaginal irritation, pruritus, pain, malodor or unusual vaginal discharge
• bacterial vaginosis
  • fishy odor of volatile amines, especially when mixed with KOH (whiff test)
  • thin, homogeneous, gray-white, adherent discharge
  • 50% of women are asymptomatic, no pain or irritation
  • symptomatic women may not have bacterial vaginosis
• Candida vulvovaginitis
  • thick, white, odorless discharge
  • intense itching or burning
  • vaginal & vulvar erythema
• Trichomonas vaginitis
  • vaginal odor
  • gray or yellow frothy discharge
  • vaginal erythema
  • erythematous 'strawberry' cervix (petechial hemorrhages)
  • urethral discharge
  • dysuria
  • dysparunia
  • vulvovaginal itching & irritation
  • 50% of women & most infected men are asymptomatic

* clinical findings insufficient for diagnosis; laboratory confirmation needed

Laboratory

• normal saline preparation of vaginal discharge
  • bacterial vaginosis
    • clue cells (squamous epithelial cells covered with bacteria that obsure edges)
    • pH of discharge > 4.5
  • Trichomonas vaginitis
    • mobile trichomonads
    • > 10 WBC per high-power field
    • pH of discharge > 5.0 (normal pH is < 4.5)
  • Candida vulvovaginitis
    • pH of discharge < 4.5 (normal pH is < 4.5)
• 10% KOH preparation of vaginal discharge
  • Candida vulvovaginitis
    • hyphae, pseudohyphae, yeast or budding spores
  • bacterial vaginosis: fishy odor from volatile amines
• culture
  • Sabouraud's agar or Nickerson's agar - Candida
  • modified Diamond liquid media - Trichomonas
  • do not order vaginal culture for diagnosis of vaginitis
• test for other sexually transmitted diseases if Trichomonas suspected
• PCR-based tests
  • test for Mobiluncus, Bacteroides fragilis & Gardnerella vaginalis (investigational)
  • vaginal PCR detects 3 most common causes of vaginitis
    • bacterial vaginosis markers, Candida species, & Trichomonas vaginalis
    • results within 12 hours
    • out performs clinicians' diagnoses based on signs, symptoms, & wet-mount microscopy
    • gold standard for trichomoniasis
• GenProbe (cervix, vagina, urine) for:
  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
• amines in vaginal fluid (probably not helpful)

* clinical findings insufficient for diagnosis; laboratory confirmation needed

Complications

• increased risk of adverse pregnancy outcomes
  • preterm labor
  • miscarriage
• increased risk of HIV infection
• increased risk of urinary tract infection
• increased risk of post-operative upper genital tract infection

Differential diagnosis

• atrophic vaginitis
• allergic vaginitis
• cervicitis
• vulvitis (lichen sclerosus)

Management

• Bacterial vaginosis
  • metronidazole
    • 500 mg PO BID for 7 days (95% cure rate)
    • 2 g single dose (84% cure rate)
    • metronidazole gel, 5 grams vaginally BID for 5 days
  • clindamycin
    • preferred agent if pregnant
    • 2% cream, 5 grams vaginally BID for 5 days
    • 300 mg PO BID for 7 days
  • only symptomatic women need be treated
  • treatment of male partners has NO effect on outcome
• Candida vulvovaginosis
  • miconazole
    • 200 mg suppository (Monistat 3) vaginally QHS for 3 nights or 100 mg suppository vaginally QHS for 7 nights
    • vaginal cream QHS for 7 nights
      • Monistat-Derm
      • clotrimazole (Gyne-Lotrimin)
  • buconazole (Femstat) 2% cream, 1 applicator full QHS for 3 nights
  • fluconazole
    • recurrent or persistent
    • 100 to 150 mg PO once
    • contraindicated during pregnancy
  • prophylaxis:
    • clotrimazole 500 mg tablet vaginally monthly
    • ketoconazole 100 mg PO QD for 6 months
  • pregnancy: clotrimazole 100 mg vaginally QHS for 7 days
  • only symptomatic women need be treated
    • 10-20% of healthy women have vaginal yeast
  • empiric treatment if clinical diagnosis
  • treatment of male partners has NO effect on outcome
• Trichomonas vaginitis
  • sexual partner will need treatment
  • metronidazole
    • 2 grams orally once
    • 500 mg BID for 5 days, 14 days for persistent cases
  • pregnancy
    • 1st trimester: clotrimazole (Gyne-Lotrimin) 100 mg suppository vaginally QHS for 7 nights
    • 2nd & 3rd trimester: metronidazole: 2 grams PO once
  • follow-up, test for cure
• inflammatory vulvovaginitis (lichen sclerosus)
  • high-potency topical glucocorticoid
• prophylaxis
  • intravaginal suppository (750-mg metronidazole plus 200-mg miconazole) used for 5 consecutive nights monthly
    • reduces incidence of bacterial vaginosis by 35%
    • no effect on incidence of candidiasis or trichomoniasis

More general terms

• vaginal disorder
• inflammation

More specific terms

• atrophic vaginitis
• vulvovaginitis

Additional terms

• cervicitis
• vagina