Vaginitis

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Vaginitis Main Page
Patient Information
Overview
Classification Bacterial Vaginosis Candida vulvovaginitis Trichomonas infection Atrophic Vaginitis
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Dima Nimri, M.D. [3], Aravind Kuchkuntla, M.B.B.S[4]

Overview

Vulvovaginitis, a common condition for which women seek medical care, accounts for greater than 10% of visits made to providers of women's health care. It is characterized by symptoms that cause itching, irritation, burning, and abnormal vaginal discharge. The three most common causes of vaginal discharge in women within the reproductive age group are, in order: bacterial vaginosis, candida vulvovaginitis, and trichomoniasis. All patients with vulvovaginitis present with common symptoms like vaginal discharge, itching, and dysuria. A diagnosis of vulvovaginitis requires a complete history of the patient's symptoms, as well as her sexual history, both of which facilitate an accurate diagnosis. Physical examination of the external genitalia and speculum examination should focus on documenting the nature of the discharge present, the presence of any vulvar or labial lesions, foreign body, presence of cervical inflammation, cervical lesions, and any cervical motion or adnexal tenderness with a bimanual examination. It is essential to rule out pelvic inflammatory disease and cervical lesions as the cause of vaginal discharge. Estimation of vaginal pH and vaginal smear wet mount examination constitute the initial diagnostic test, which helps differentiate among common etiologies. Treatment of vulvovaginitis includes medical therapy targeted against the causative pathogen and a counseling on hygiene, voiding techniques, and sexual practices. The prognosis is good in most patients, though a minority of patients experience recurrence.

Differential Diagnosis

The differential diagnosis for patients presenting with vaginal discharge includes the following considerations:

Common Presentation	Disease	Symptoms						Examination Findings
		Discharge	Dysuria	Vaginal odor	Dyspareunia	Genital skin lesion	Genital pruritus
Vaginitis Conditions	Candida Vulvovaginitis	✔	✔	✔	✔	✔	✔✔	Vulvar edema, fissures, excoriations Thick, curdy vaginal discharge
	Bacterial Vaginosis	✔		✔	—	—	—	Fishy odor from the vagina Thin, white/gray homogeneous vaginal discharge Lack of significant vulvovaginal inflammation
	Trichomoniasis	✔	✔	✔	✔	—	✔	Strawberry cervix: petechial haemorrhages on the ectocervix, specific to trichomoniasis Frothy, mucopurulent, yellow-green or gray vaginal discharge
	Atrophic Vaginitis	✔	✔	✔	✔✔	✔	✔	Pale and dry vaginal mucosa Increased friability of the vaginal mucosa with patchy erythema and petechiae Sparsity of pubic hair, fusion of the labia minora, narrow and a shortened vagina
	Aerobic Vaginitis	✔	✔	✔	✔	—	✔	Vaginal mucosa is red and inflamed, severe ecchymotic bleeding points and ulcers can be seen in severe cases Erosions, hyperaemia, scattered bleeding points and ulcers can be demonstrated on the cervix
Cervicitis Conditions	Chlamydia	✔	✔		✔	—	✔	Cloudy, yellow mucoid discharge from the cervical os Friable appearance of cervix Cervical motion tenderness may be present
	Gonorrhea	✔	✔	✔	✔	—	—	Mucopurulent urethral, cervical or vaginal discharge Positive cervical motion tenderness Friable cervical mucosa Abdominal pain with negative rebound tenderness Lower abdominal pain (consistent with PID) Right upper quadrant pain (Fitz-Hugh-Curtis syndrome) Labial edema and Bartholin’s gland enlargement and tenderness (Bartholinitis)

Diagnosis and Treatment

The following table summarizes the diagnosis and management of common vaginitis conditions:

Disease	Investigation			Diagnostic Approach	Treatment
	pH	Saline Wet mount preparation	Gold Standard test
Candida Vulvovaginitis	Normal	Hyphae and pseudohyphae can be demonstrated	Culture	In patients with normal pH and positive microscopy, culture is not neccessary and treatment can be initiated In patients with normal pH and negative microscopy, culture for candida is done	Topical Azoles for uncomplicated infection Oral Fluconazole one dose of 150mg for complicated infection
Bacterial Vaginosis	>4.5	Clue cells are demonstrated	Gram Stain to determine the relative concentration of lactobacilli, G. vaginalis, Prevotella, Porphyromonas, peptostreptococci and Mobiluncus	Amsel’s criteria: Presence of three out of four criteria is required to make the diagnosis of BV Vaginal fluid pH >4.5 >20% of “clue” cells (cells with unclear borders, dotted with bacteria) Milky homogenous, adherent vaginal discharge Positive “whiff” test, which is an amine or “fishy” odor noted after the addition of 10% potassium hydroxide Correlation of the criteria and gram stain is performed to confirm diagnosis	Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
Trichomoniasis	>4.5	Motile Trichomonads Positive Whiff test	Nucleic acid amplification test(NAAT)	NAAT is highly sensitive for the diagnosis of Trichomonas vaginalis. Treatment is initiated after confirmation of the diagnosis	Metronidazole 2g or Tinidazole 2g in a single dose
Atrophic Vaginitis	Normal	Vaginal smear cytology shows increased parabasal cells	Leftward shift of the vaginal maturation index	Diagnosis requires the correlation of clinical presentation and vaginal cytology findings. Other causes causing atrophic changes in the vagina should be ruled out.	Lubricants and moisturizers for mild symptoms Topical or Oral estrogen therapy for moderate to severe symptoms
Aerobic Vaginitis	Increased >6	Numerous leukocytes are present	No gold standard confirmative test but excessive growth of aerobes on culture helps in diagnosis when the vaginal smear findings are indeterminate	Microscopic diagnosis is made by Lactobacillus grade( LBG) and the severity is scored based on number of leucocytes, proportion of toxic leucocytes and parabasl epitheliocytes, and background flora	Probiotics Kanamycin and Clindamycin vaginal suppositories