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Vaginitis and Vaginosis
Heather O'Connor Greer, MD
Patricia Beauzile, MD
image BASICS
DESCRIPTION
  • “Vaginosis” and “Vaginitis” are broad terms indicating any disease process of the vagina caused by or leading to infection, inflammation, or changes in the normal vaginal flora.
  • The difference between vaginitis and vaginosis is the presence (vaginitis) or absence (vaginosis) of inflammation.
  • The most common symptoms of vaginitis/vaginosis are vaginal discharge, odor, itching, burning, or pain.
  • The most common causes of vaginitis are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis.
  • Other causes of vaginitis can be stratified by age and are generally associated with postmenopausal vaginal atrophy or foreign bodies in the pediatric population.
  • Lichen planus, lichen sclerosus, and psoriasis, may also cause vaginitis.
  • Diagnosis of vaginitis relies on thorough history, physical exam, and clinical assessment. Microscopy, cultures, DNA probes, and tissue biopsy can be helpful in confirming diagnosis.
  • BV is the most common cause of vaginal discharge in reproductive-aged women. It is caused by a disturbance in the normal vaginal flora. The normally dominant hydrogen-peroxide producing lactobacilli are overwhelmed by an overgrowth of gram-negative species causing an increase in the vaginal pH, discharge, and odor.
  • VVC is the second most common cause of vaginitis in reproductive-aged women. It is caused by invasion of the Candida organism into the superficial epithelial cells of the vagina causing mild to severe vaginal inflammation, pruritis, and discharge.
EPIDEMIOLOGY
  • Vaginal symptoms are typical and common in the general population and are one of the most frequent reasons women present to their medical care providers accounting for approximately 10 million office visits each year (1).
  • About 30% of women with complaint of vaginal discharge or irritation remain undiagnosed despite extensive testing.
  • In the United States, BV continues to be the leading cause of vaginal complaints.
  • The frequency of VVC is highest among women in their reproductive years (2).
  • Neither vaginal candidiasis nor BV is considered to be sexually transmitted diseases.
  • Vaginal trichomoniasis is a common sexually transmitted disease with 7.4 million cases diagnosed yearly in the United States (3).
ETIOLOGY AND PATHOPHYSIOLOGY
  • BV (4)
    • BV is caused by a change in the normal vaginal flora. Dominant lactobacilli responsible for maintaining the acidic vaginal pH are overcome by an increase of the gram-negative organisms.
    • Change in the vaginal environment leads to an increase in the pH and an overgrowth of vaginal anaerobes causing a malodorous discharge and frothy vaginal discharge.
    • BV is highly prevalent and associated with multiple adverse outcomes, including enhanced HIV transmission.
    • The organisms generally implicated in BV infections include:
      • Gardnerella vaginalis
      • Prevotella species
      • Porphyromonas species
      • Bacteroides species
      • Peptostreptococcus species
      • Mycoplasma hominis
      • Ureaplasma urealyticum
      • Mobiluncus species
      • Fusobacterium species
      • Atopobium vaginae
  • VVC
    • VVC is caused by Candida albicans (80-92%) and C. glabrata (<10%)
    • Candida organisms can be identified in the lower genital tract in healthy women, and it is thought to gain access via rectal and perianal colonization and migration.
    • Symptoms occur when candidal organisms overwhelm the normal vaginal flora and invade the superficial vaginal epithelial cells causing inflammation, pruritis, and thick vaginal discharge.
  • Trichomoniasis
    • Caused by an infection via Trichomonas vaginalis, a flagellate protozoan.The organism infects the squamous epithelium of the vagina, as well as the urethra, and paraurethral glands. This infection is primarily transmitted during sexual intercourse.
    • Other sources of vaginitis/vaginosis are usually mediated by disruption of the vaginal squamous epithelium. This disruption can lead to inflammation, pain, and discharge.
    • Other than the three most common causes of vaginitis/vaginosis, menses, sexual activity, contraception, pregnancy, foreign bodies, estrogen levels, STDs, and use of vaginal hygiene products, topical creams, or antibiotics can contribute to vaginal symptoms
RISK FACTORS
  • BV:
    • Sexual activity; while BV is not considered an STD, studies show increased rates of BV in women with multiple sex partners
    • Women who have sex with women
    • The presence of STDs such as HSV-2 (5)
  • VVC:
    • Diabetes
    • Use of broad-spectrum antibiotics.
    • Immunosuppresion
    • Higher estrogen levels have been associated with increased vaginal yeast infection, explaining why it is more commonly diagnosed in reproductiveaged women and in pregnancy.
  • Trichomoniasis:
    • Inconsistent use of barrier contraception
    • Multiple sex partners
    • African Americans
    • Limited education and low socioeconomic status
  • Other risk factors associated with vaginitis/vaginosis:
    • Decreased estrogen
    • Smoking
    • Use of vaginal douches and creams.
    • Tight fitting clothing
    • Poor hygienic practice
    • Changes in diet
GENERAL PREVENTION
  • Vulvar hygiene
  • Treatment of sexual partners generally is not recommended but may be considered in recurrent cases.
COMMONLY ASSOCIATED CONDITIONS
  • STDs such as gonorrhea, chlamydia, or HSV
  • Vaginal intraepithelial neoplasia and cancer can present with symptoms of vaginitis.
  • Desquamative inflammatory vaginitis presents with similar symptoms but most commonly occurs in postmenopausal women.
image DIAGNOSIS
PHYSICAL EXAM
  • BV
    • Thin watery, sometimes foamy discharge. Can appear beige- or tan-colored. An amine or “fishy” smell may be present on exam.
    • The vaginal epithelium should appear normal and noninflamed.
  • VVC
    • Erythema and swelling of the vulva and vaginal mucosa
    • Some patients may have vulvar excoriation and fissures.
    • If discharge is present, it is usually white, thick, and can have a cottage cheese appearance. Some women may have thin white dilute discharge. No odor is present.
  • Trichomoniasis
    • Significant erythema of the vulva and vaginal mucosa
    • Greenish discharge with an amine or fishy odor
    • Discharge can also appear purulent in some patients.
    • Occasionally punctate hemorrhages can be seen on the vaginal walls and on the cervix (“strawberry cervix”).
DIFFERENTIAL DIAGNOSIS
  • Physiologic discharge
  • Leukorrhea of pregnancy
  • STDs
  • Foreign body
  • Contact dermatitis
  • Cervicitis
  • Desquamative inflammatory vaginitis
  • Urinary tract infection (UTI)
  • Atrophic vaginitis
  • Dermatoses: lichen sclerosus, lichen planus, seborrheic dermatitis, psoriasis
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DIAGNOSTIC TESTS & INTERPRETATION
  • BV
    • Symptomatic patients complain of an abnormal vaginal discharge and a fishy odor.
    • Clinical diagnosis is established with Amsel criteria. A positive diagnosis can be made if 3 out of 4 of the following criteria are present (6)[B].
      • Gray, frothy, or foamy discharge
      • Vaginal pH >4.5
      • A positive amine or “Whiff” test with use of KOH solution added to discharge
      • >20% of the epithelial cells identified as “clue cells”
  • VVC
    • Visualization of blastospores or pseudohyphae on saline or 10% KOH microscopy
    • A positive culture in a symptomatic patient
  • Trichomoniasis
    • Visualization of motile trichomonads on saline microscopy (7)[B]
image TREATMENT
GENERAL MEASURES
  • Avoid douching and tight fitting clothing.
  • Regular use of condoms and spermicides may help to prevent BV.
MEDICATION
  • BV
    • Metronidazole 500 mg orally BID for 7 days, vaginally 0.75% gel 1 applicator daily for 5 days, or clindamycin given vaginally (1 applicator = 100 mg) for 5 days (8)[A]. Recurrent infection may require repeated treatment (e.g., 1 week monthly for 6 months).
  • VVC
    • Uncomplicated infections can be treated with a one time dose of fluconazole 150 mg tab. Topical/vaginal suppository antifungal regimens such as butoconazole, clotrimazole, miconazole, terconazole, or nystatin creams. Treatment can range from 3 to 7 days (7)[A].
    • Recurrent or complicated infections may require additional oral dosing of fluconazole 150 mg tab for extended treatment and/or prophylaxis (9)[A].
  • Trichomoniasis
    • A one time 2 g oral dose of either tinidazole or metronidazole. Alternatively, 500 mg dose of metronidazole twice daily for 7 days (10)[A].
    • The patient's partner should be treated as well and counseled to abstain from sex until both patients have completed treatment.
ISSUES FOR REFERRAL
Treating male partners does not reduce symptoms or prevent recurrence, but can be considered in patients with recurrent infection.
COMPLEMENTARY & ALTERNATIVE MEDICINE
A Cochrane analysis reviewed the use of probiotics for BV and found inconclusive evidence to recommend probiotics as primary treatment or as a preventive strategy (11)[A]. Further study was recommended.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Delay sexual relations until symptoms clear/discomfort resolves
  • Use of condoms may reduce recurrence of BV.
Patient Monitoring
  • No specific follow-up needed; if symptoms persist or recur within 2 months, repeat pelvic exam and culture.
  • Consider suppressive therapy for recurrent infection.
PATIENT EDUCATION
American College of Obstetricians and Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; 800-762-ACOG: www.acog.org
PROGNOSIS
VVC: 80-90% of uncomplicated cases cured with appropriate treatment; 30-50% of recurrent infections return after discontinuation of maintenance therapy; there is a relatively high spontaneous remission rate of untreated symptoms as well.
REFERENCES
1. Sobel JD. Vulvovaginitis in healthy women. Compr Ther. 1999;25(6-7):335-346.
2. Kent HL. Epidemiology of vaginitis. Am J Obstet Gynecol. 1991;165(4, Pt 2):1168-1176.
3. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36(1):6-10.
4. Hill GB. The microbiology of bacterial vaginosis. Am J Obstet Gynecol. 1993;169(2, Pt 2):450-454.
5. Esber A, Vicetti Miguel RD, Cherpes TL, et al. Risk of bacterial vaginosis among women with herpes simplex virus type 2 infection: a systematic review and meta-analysis. J Infect Dis. 2015;212(1):8-17.
6. Money D. The laboratory diagnosis of bacterial vaginosis. Can J Infect Dis Med Microbiol. 2005;16(2):77-79.
7. Sobel JD, Kapernick PS, Zervos M, et al. Treatment of complicated Candida vaginitis: comparison of single and sequential doses of fluconazole. Am J Obstet Gynecol. 2001;185(2):363-369.
8. Beigi RH, Austin MN, Meyn LA, et al. Antimicrobial resistance associated with the treatment of bacterial vaginosis. Am J Obstet Gynecol. 2004;191(4):1124-1129.
9. Sobel JD, Wiesenfeld HC, Martens M, et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med. 2004;351(9):876-883.
10. Gabriel G, Robertson E, Thin RN. Single dose treatment of trichomoniasis. J Int Med Res. 1982;10(2):129-130.
11. Senok AC, Verstraelen H, Temmerman M, et al. Probiotics for the treatment of bacterial vaginosis. Cochrane Database Syst Rev. 2009;(4):CD006289.
Additional Reading
&NA;
  • Donders G. Diagnosis and management of bacterial vaginosis and other types of abnormal vaginal bacterial flora: a review. Obstet Gynecol Surv. 2010;65(7):462-473.
  • Li J, McCormick J, Bocking A, et al. Importance of vaginal microbes in reproductive health. Reprod Sci. 2012;19(3):235-242.
  • Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(5):503-535.
  • Ray D, Goswami R, Banerjee U, et al. Prevalence of Candida glabrata and its response to boric acid vaginal suppositories in comparison with oral fluconazole in patients with diabetes and vulvovaginal candidiasis. Diabetes Care. 2007;30(2):312-317.
  • Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.
See Also
&NA;
Algorithm: Discharge, Vaginal
Codes
&NA;
ICD10
  • N76.0 Acute vaginitis
  • B37.3 Candidiasis of vulva and vagina
  • N95.2 Postmenopausal atrophic vaginitis
Clinical Pearls
&NA;
Clinical symptoms, signs, and microscopy have relatively poor performance compared with so-called gold standards such as culture and DNA probe assays, but these more sensitive assays can detect organisms that may not be causing symptoms.
  • Most women experience relief of symptoms with therapy chosen without such gold standard tests, even when the treatment does not correspond with the underlying infection.
  • Vaginal pH is underused as a diagnostic tool for evaluation of vaginitis.