Vaginitis
What is Vaginitis?
• Vaginitis is the general term for disorders of the
vagina caused by infection, inflammation, or
changes in the normal vaginal flora.
Symptoms and initial Evaluation
• Symptoms include vaginal discharge, odor, pruritus,
and/or discomfort.
• The initial evaluation typically consists of a history,
physical examination, microscopy, and cervical tests
for sexually transmitted infections.
Etiology
• Vaginitis is often the result of infectious agents. The most common
infections:
• Bacterial vaginosis
• Candida vulvovaginitis
• Trichomoniasis,
• These account for over 90 percent of infections
• Cervicitis, typically from STI’s such as gonorrhea, chlamydia, and
mycoplasma, can also present as nonspecific vaginal symptoms.
Pathogenesis - The Vaginal ecosystem
• Vaginal epithelium of premenopausal women is rich in glycogen.
Glycogen from sloughed cells is used by vaginal lactobacilli and is
converted into lactic acid creating an acidic environment (pH 4.0 to
4.5).
• This acidity helps maintain the normal vaginal flora and inhibits growth
of pathogenic organisms.
• Disruption of this ecosystem can lead to conditions favorable for
development of vaginitis.
What can disrupt the vaginal ecosystem?
• Multiple factors can disrupt the vaginal ecosystem and cause an
unbalance of the vaginal flora, some of these factors include:
• sexually transmitted diseases
• Antibiotics
• Foreign body
• Abnormal estrogen levels
• Use of hygienic products such as douche
• Pregnancy
• Sexual activity
• and contraceptive choice.
Patient Presentation
Women with vaginitis typically present with one or more of the following
nonspecific vulvovaginal symptoms:
• Change in the volume, color, or odor of vaginal discharge
• Pruritus
• Burning
• Irritation
• Erythema
• Dyspareunia
• Spotting
• Dysuria
Normal Findings
• Normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours),
which is white or transparent, thin or thick, and mostly odorless
• Vaginal pH 4.0 to 4.5
• Negative Amine test
• Wet Mount: PMN:EC ratio <1; rods dominate; squames +++
• 10% potassium hydroxide microscopy: Negative
• Differential diagnosis: Physiologic leukorrhea
Vulvovaginal
candidiasis
• Symptoms: Pruritus, soreness, dyspareunia
• Signs: Vulvar erythema, discharge may be
white and clumpy (cottage cheese
appearance) and may or may not adhere to
vagina.
• Vaginal pH 4.0 to 4.5
• Negative Amine test
• Wet mount: PMN:EC ratio <1; rods
dominate; squames +++; pseudohyphae
(present in about 40% of patients); budding
yeast for nonalbicans Candida.
Vulvovaginal
candidiasis (Cont.)
• 10% KOH microscopy: Pseudohyphae (in
about 70% of patients)
• Other tests: If microscopy nondiagnostic:
Culture or DNA hybridization probe.
• Differential diagnosis: Contact irritant or
allergic vulvar dermatitis, chemical
irritation, focal vulvitis (vulvodynia)
• Treatment: single-dose oral fluconazole
(150 mg).
Bacterial vaginosis
• Symptoms: Malodorous (Fishy smell)
discharge, no dyspareunia
• Signs: Off-white/gray thin discharge that
coats the vagina
• Vaginal pH >4.5
• Positive Amine test (in 70 to 80% of
patients)
• Wet mount: PMN:EC <1; loss of rods;
increased coccobacilli; clue cells comprise
at least 20% of epithelial cells (present in
>90% of patients)
Bacterial vaginosis (Cont.)
• KOH microscopy: Negative
• Other Tests: Quantitative Gram stain (eg, Nugent criteria, Hay/Ison
criteria), DNA hybridization probe (eg, Affirm VPIII), Culture of no
value.
• Differential diagnosis: Elevated pH in trichomoniasis, atrophic
vaginitis, and desquamative inflammatory vaginitis
• Treatment: Oral Metronidazole 500 mg twice daily for seven days, or
Vaginal 0.75% Metronidazole inserted as 5 gm of gel once daily for
five days. The choice of oral versus vaginal therapy should depend
upon patient preference.
Trichomoniasis
• Symptoms: Malodorous discharge, burning,
postcoital bleeding, dyspareunia, dysuria.
• Signs: Thin green-yellow discharge,
vulvovaginal erythema
• Vaginal pH: 5.0 to 6.0
• Amine test: positive sometimes.
• Wet mount: PMN ++++; mixed flora; motile
trichomonads (present in about 60% of
patients)
Trichomoniasis (Cont.)
• 10% KOH microscopy: Negative
• Other tests: If microscopy is nondiagnostic: Culture, Rapid antigen
test Nucleic acid amplification test, or DNA Hybridization probe.
• Differential diagnosis: Purulent vaginitis, desquamative inflammatory
vaginitis, atrophic vaginitis, erosive lichen planus
• Treatment: single 2 g oral dose of either tinidazole or metronidazole
for both patient and partner.
References
• https://www.uptodate.com/contents/approach-to-women-with-symptoms-of-
vaginitis?search=vaginitis&source=search_result&selectedTitle=1~150&usage_ty
pe=default&display_rank=1
• https://www.uptodate.com/contents/trichomoniasis?topicRef=5477&source=see
_link#H13
• https://www.uptodate.com/contents/approach-to-women-with-symptoms-of-
vaginitis?search=vaginitis&source=search_result&selectedTitle=1~150&usage_ty
pe=default&display_rank=1
• https://www.uptodate.com/contents/bacterial-vaginosis-
treatment?topicRef=5451&source=see_link
• https://www.uptodate.com/contents/candida-vulvovaginitis-
treatment?topicRef=5452&source=see_link
• https://www.uptodate.com/contents/image?imageKey=PC%2F68759&topicKey=
OBGYN%2F5477&search=vaginitis&rank=1~150&source=see_link
Thank you!
