II. Epidemiology
- Chronic vaginal symptoms in 105 women surveyed
- Women often self-treat chronic vaginal symptoms
- Over-the-counter Yeast Vaginitis medication: 73%
- Alternative MedicineYeast Vaginitis treatment: 42%
- Self-diagnosis often incorrect and may be harmful (symptoms alone cannot distinguish cause)
- Correct diagnosis of Yeast Vaginitis: 11-28%
- Secondary irritant Vaginitis: 15%
- Women often self-treat chronic vaginal symptoms
- References
III. Physiology: Normal vaginal secretions
- Variably dependent on multiple factors
- Age
- Timing of Menstrual Cycle
- Sexual arousal
- Contraceptive use
- Douching (counsel patients not to do this)
- Derivation
- Cervical Mucus
- Vaginal wall transudate
- Exfoliated vaginal cells
IV. Causes
- Common
- Normal discharge (30%)
- Candida Vulvovaginitis (20-25%)
- Bacterial Vaginosis (23-50%)
- Trichomonas Vaginitis (5-15%)
- Mixed infection or Sexually Transmitted Disease (20%)
- See Cervicitis
- Uncommon
V. Causes: Other
- Atrophic Vaginitis (post-menopausal women)
- Infectious Cervicitis
- Vaginitis or Vulvitis
- Scabies
- Neurodermatitis
- Vaginal or Vulvar Trauma
- Lichen Planus
- Vulvar Vestibulitis
- Herpes Vulvitis (presents with severe pain, often before vesicular lesions appear)
- Malignancy
- Irritant Contact Vaginitis
- Physiologic discharge
- Ovulation
- Pregnancy
VI. History: Rule out Sexually Transmitted Disease (Gonorrhea, Chlamydia, HSV)
- Multiple sexual partners
- Intrauterine Device or no Contraception
- History of Sexually Transmitted Disease
VII. Symptoms
- Vaginal itching or burning: Candida Vulvovaginitis
- Absence of itching makes Vulvovaginal Candidiasis unlikely
- Perceived odor (especially fishy): Bacterial Vaginosis
- Absence of odor makes Bacterial Vaginosis unlikely, and Candida Vulvovaginitis more likely
- Inflammatory signs and symptoms: Candida Vulvovaginitis
- Malodorous or unusual Vaginal Discharge
- External Dysuria (pain with urine passing over vulva)
- Severe pain in HSV Vaginitis
- Dyspareunia
VIII. Signs
- See Vaginal pH
- Character of vaginal secretions
- Normal: clear or white, non-clumping, odorless
- Dry cottage cheese-like discharge
- Frothy discharge (rarely present)
- Trichomonas Vaginitis
- Fishy Odor
- Bacterial Vaginosis
- Trichomonas Vaginitis
- Vagina and Cervix appearance
- Vulvar redness, edema and adherent white clumps
- Strawberry Cervix with punctate Hemorrhage
- Trichomonas Vaginitis
- Pale, dry, thin vaginal and vulvar skin
IX. Labs
X. Management
- Treat specific infectious cause
- Bacterial Vaginosis
- Candida Vulvovaginitis
- Trichomonas Vaginitis
- Herpes Vaginitis
- Consider Non-infectious causes with specific management protocols
- Atrophic Vaginitis
- Vaginal Dryness
- Irritant Contact Vaginitis (eliminate causes)
- Consider differential diagnosis
- Consider empiric treatment
- Not recommended due to poor correlation with symptoms
- Anti-yeast medication (See Candida Vulvovaginitis)
- Metronidazole
- Clindamycin cream per vagina for 7 nights
- Consider increasing vaginal acidity (lower Vaginal pH)
- May increase Lactobacillus survival
- Aci-Jel Vaginal jelly per vagina for 21 days at bedtime
- Vinegar douche is NOT recommended
- White Vinegar (2-4 tablespoons) in 1 quart water