Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. The cause is usually a change in the normal balance of vaginal bacteria or an infection. Reduced estrogen levels after menopause and some skin disorders can also cause vaginitis.
The most common types of vaginitis are described below:
Candidal vaginitis is characterized by a thick, clumping, white discharge and vulvar discomfort. Intense vulvar erythema, pruritus, and /or burning are often present.
Predisposing factors may include
oral contraceptive,
antibiotic, or corticosteroid use;
pregnancy; and
diabetes.
Characteristics: White, thick, clumping discharge, vaginal pH <4.5, microscopic findings include: Hyphae andspores in KOH
Diagnosis: A microscopic slide prepare with 10% potassium hydroxide yielding characteristic branched chain hyphae and spores establishes the diagnosis.
Sexually transmitted diseases are not usually associated with isolated Candidal vaginitis.
Trichomonas vaginitis presents as a persistent, thin, copious discharge that is often frothy, green, or foul-smelling. The amount of vaginal and cervical erythema and inflammation varies considerably.
Characteristics: Green, thin, frothy, foul discharge, vaginal pH >4.5, and Flagellates in wet mount on microscope .
Diagnosis may be made by the presence of motile flagellates on normal saline wet-mount microscopy, but this is only 60% to 70% sensitive. New nucleic acid tests are emerging with ~95% specificity.
Multiple petechiae on the vaginal wall or cervix (strawberry spots/strawberry cervix) are pathognomonic but only occasionally seen.
Bacterial vaginosis is characterized by a malodorous, homogeneous discharge with an amine (fishy) odor that can be briefly accentuated by mixing with a drop of KOH solution.
Characteristics: Thin, white, “fishy” odor in KOH, with a vaginal pH >4.5. clue cells are seen on microscope examination.
Diagnosis: The presence of clue cells on normal saline wet mount establishes the diagnosis. Other associate vaginal or abdominal complaints are minimal and , if significant, suggest the presence of another disease process.
Although the above infectious causes are responsible for most cases of vaginitis, other possible etiologies including local chemical irritants or allergens, vaginal foreign bodies, and atrophic vaginitis should be considered in the differential diagnosis.
Management
For Candidal vaginitis, treat with topical antifungals (e.g, clotrimazole: 1% cream, 5 g for 7 to 14 days or two 100-mg vaginal tablets for 3 nights).
Oral fluconazole (150 mg as a single dose) is also effective, but has a higher risk of adverse effects.
For Trichomonas vaginitis, a single dose of metronidazole (2 g orally) is generally curative but is associated with a disulfiram-like reaction when taken with alcohol. Although metronidazole was previously considered contraindicated in pregnancy, the Centers for Disease Control an Prevention
(CDC) now recommends its use due to the association of Trichomonas infections with preterm rupture of membranes, low birth weight, an increase risk of prematurity.
For bacterial vaginosis, metronidazole (500 mg orally twice daily for 7 days) is recommended .
Treatment for asymptomatic infection or for male sexual partners is not generally recommended . The equivocal risk of metronidazole teratogenicity must be weighed against the likelihood of alleviating
symptoms and discomfort.
Points To Remember:
1. Diabetes mellitus or immunosuppression should be considered in refractory or recurrent cases of candidal vaginitis.
2. A history of balanitis in the sexual partner should be sought an treated if present.
3. Trichomonas should be considered a sexually transmitted infection. Therefore, it is generally recommended that concomitant culturing for Neisseria gonorrhoeae and Chlamydia be performed . Serologic testing for syphilis, HIV, an hepatitis B should also be considered for patient and partner.
The most common types of vaginitis are described below:
Candidal vaginitis is characterized by a thick, clumping, white discharge and vulvar discomfort. Intense vulvar erythema, pruritus, and /or burning are often present.
Predisposing factors may include
oral contraceptive,
antibiotic, or corticosteroid use;
pregnancy; and
diabetes.
Characteristics: White, thick, clumping discharge, vaginal pH <4.5, microscopic findings include: Hyphae andspores in KOH
Diagnosis: A microscopic slide prepare with 10% potassium hydroxide yielding characteristic branched chain hyphae and spores establishes the diagnosis.
Sexually transmitted diseases are not usually associated with isolated Candidal vaginitis.
Trichomonas vaginitis presents as a persistent, thin, copious discharge that is often frothy, green, or foul-smelling. The amount of vaginal and cervical erythema and inflammation varies considerably.
Characteristics: Green, thin, frothy, foul discharge, vaginal pH >4.5, and Flagellates in wet mount on microscope .
Diagnosis may be made by the presence of motile flagellates on normal saline wet-mount microscopy, but this is only 60% to 70% sensitive. New nucleic acid tests are emerging with ~95% specificity.
Multiple petechiae on the vaginal wall or cervix (strawberry spots/strawberry cervix) are pathognomonic but only occasionally seen.
Bacterial vaginosis is characterized by a malodorous, homogeneous discharge with an amine (fishy) odor that can be briefly accentuated by mixing with a drop of KOH solution.
Characteristics: Thin, white, “fishy” odor in KOH, with a vaginal pH >4.5. clue cells are seen on microscope examination.
Diagnosis: The presence of clue cells on normal saline wet mount establishes the diagnosis. Other associate vaginal or abdominal complaints are minimal and , if significant, suggest the presence of another disease process.
Although the above infectious causes are responsible for most cases of vaginitis, other possible etiologies including local chemical irritants or allergens, vaginal foreign bodies, and atrophic vaginitis should be considered in the differential diagnosis.
Management
For Candidal vaginitis, treat with topical antifungals (e.g, clotrimazole: 1% cream, 5 g for 7 to 14 days or two 100-mg vaginal tablets for 3 nights).
Oral fluconazole (150 mg as a single dose) is also effective, but has a higher risk of adverse effects.
For Trichomonas vaginitis, a single dose of metronidazole (2 g orally) is generally curative but is associated with a disulfiram-like reaction when taken with alcohol. Although metronidazole was previously considered contraindicated in pregnancy, the Centers for Disease Control an Prevention
(CDC) now recommends its use due to the association of Trichomonas infections with preterm rupture of membranes, low birth weight, an increase risk of prematurity.
For bacterial vaginosis, metronidazole (500 mg orally twice daily for 7 days) is recommended .
Treatment for asymptomatic infection or for male sexual partners is not generally recommended . The equivocal risk of metronidazole teratogenicity must be weighed against the likelihood of alleviating
symptoms and discomfort.
Points To Remember:
1. Diabetes mellitus or immunosuppression should be considered in refractory or recurrent cases of candidal vaginitis.
2. A history of balanitis in the sexual partner should be sought an treated if present.
3. Trichomonas should be considered a sexually transmitted infection. Therefore, it is generally recommended that concomitant culturing for Neisseria gonorrhoeae and Chlamydia be performed . Serologic testing for syphilis, HIV, an hepatitis B should also be considered for patient and partner.
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