Vaginitis

OVERVIEW: What every practitioner needs to know

Symptoms suggestive of vaginitis (vaginal discharge, vaginal itching or burning, change in vaginal odor) are a common reason adolescent and young adult women seek care; while less common, vaginitis also occurs among prepubertal girls. A careful history combined with an external genital examination and microscopic examination of vaginal fluid will usually establish the diagnosis; however, in some cases a complete pelvic examination and more extensive laboratory testing will be necessary.

Are you sure your patient has vaginitis? What are the typical findings for this disease?

Key symptoms and signs of the disease:

• New onset vaginal discharge or increase in normal amount; vaginal/vulvar itching/burning (external/internal)

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• Vaginal odor or change from normal odor

• Dyspareunia with moderate or severe vulvar/vaginal inflammation

• Dysuria (urine flowing over inflamed vulva)

• Labial ulcers are characteristic of genital herpes, but severe vulvovaginal candidiasis (VVC) may present with extensive vulvar erythema, edema, excoriation, and fissures.

• Punctate hemorrhages on the cervix (“strawberry cervix”) occur in 2%-5% of cases of trichomoniasis

• A thick, curdy discharge, especially if associated with itching, is highly predicitive of VVC. A “bubbly/frothy” greenish-yellow discharge suggests trichomoniasis. A thin, homogeneous grayish white discharge suggests bacterial vaginosis (BV).

What other disease/condition shares some of these symptoms?

Diseases/conditions that can mimic vaginitis:

• Cervicitis (due to infection with N. gonorrhoeae, C. trachomatis, or herpes) can produce discharge; if concomitant endometritis (pelvic inflammatory disease), purulent discharge from the cervical os may mimic vaginal discharge

• Retained tampon or foreign body (e.g., condom) – discharge is usually more purulent, foul-smelling, and may be bloody

• Physiologic leukorrhea (increase in normal vaginal secretions due to rising estrogen levels in the peripubertal period); normal increase in secretions in the periovulatory period

• Estrogen effect of birth control pills (including increased risk for VVC in some adolescent females); hormonal contraceptive vaginal ring may cause sense of “vaginal wetness”

• Stress

• Chemical irritants (ask about douching, use of deodorants), contact dermatitis/allergies (material in underpants, chemicals in some sanitary pads, soaps or bubblebaths, etc; latex allergy (if partner using latex condoms) or sensitivity to spermicides (nonoxynol-9), either as condom lubricated with spermicide or as stand-alone product

• Poor hygiene

• Trauma

• Enterobius vermicularis (pinworms) – perinanal and vaginal itching

• Vulvodynia/vestibulitis

• (Unusual but should be considered in treatment-resistant cases): psoriasis, seborrheic dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosus

What caused this disease to develop at this time?

• Puberty (physiologic leukorrhea) or mid-cycle increase in clear secretions (estrogen effect)

• Exogenous estrogen (oral contraceptives, vaginal ring)

• Infection (vaginal, cervical, upper genital tract [uterus/adnexa]) – inquire about location of any associated pain, burning or itching (external/at introitus, intravaginal, lower abdominal/pelvic pain)

• Sexual activity (new onset or change in activity, including new partner within 30-60 days). BV is associated with sexual activity, including non-penetrative digito-genital contact and oral sex; however, it is not considered a sexually transmitted infection. Women who are not sexually active can get BV. Having a female sex partner increases the risk for BV.

• Stress

• Retained foreign body

• Pregnancy (ask about missed period or change in periods)

• Antibiotic use, steroids (increased risk for VVC)

• Chemical/allergic – inquire about deodorant sprays, douching, type of menstrual pad/tampon used (scented), new soap; type of underpants (cotton or polyester)

• Diabetes – inquire about other symptoms of diabetes; is patient obese (type 2 diabetes)

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

• Mid-vaginal pH is an important diagnostic criterion. Normal pH is <4.5. pH >=5.0 likely indicates infection. Avoid obtaining pH from near or at the cervical os. Candidiasis usually not associated with pH >=4.5

• Whiff test – fishy or amine-like odor released when vaginal fluid mixed with KOH suggests BV or trichomoniasis

• Vaginal wet prep (must examine promptly to maximize likelihood of detecting trichomonads). Look for clue cells, white blood cells, trichomonads, presence or absence of lactobacilli. If 3 of the 4 following criteria are present, BV is highly likely: increased numbers of clue cells; thin, white homogenous vaginal discharge; mid-vaginal pH >= 5.0; positive whiff test. Commercial test kits for in-office detection of BV are available and have acceptable performance.

• Presence of trichomonads (motile or stationary) diagnostic for trichomoniasis. However, wet prep is only 50 to 65% sensitive, even when performed under ideal conditions by an experienced microscopist. Culture is more sensitive than wet prep but less sensitive than DNA-based (not yet FDA approved) and FDA approved point of care tests (unamplified RNA, rapid antigen). Any woman diagnosed with trichomoniasis should be tested for C. trachomatis and N. gonorrhoeae infection. One suggested protocol for diagnosis of trichomoniasis in a population where the prevalence of infection is significant is to perform a wet prep first; if negative, perform a rapid antigen test. Culture has comparable sensitivity to rapid antigen tests, but results are available in days rather than minutes. KOH prep – presence of hyphae or buds suggests candidiasis. Hyphae and/or buds may also be seen on vaginal wet prep.

• Large numbers of white blood cells not typically seen with VVC or bacterial vaginosis. Their presence suggests trichomoniasis or cervicitis/upper genital tract infection.

• Women with cervicitis (mucopurulent discharge from cervical os and/or easily induced bleeding at the cervical os) should be tested for C. trachomatis and N. gonorrhoeae and, if clinically indicated, for herpes and T. vaginalis

Would imaging studies be helpful? If so, which ones?

• Imaging studies are not indicated

If you are able to confirm that the patient has vaginitis, what treatment should be initiated?

Women being treated for bacterial vaginosis should avoid intercourse or use condoms during treatment (Table I). Women with trichomoniasis should avoid intercourse during treatment and until their sex partner(s) have been treated and are symptom-free (Table I).