Vaginitis

Aka: Vaginitis, Vaginal Discharge

1. Epidemiology
   1. Chronic vaginal symptoms in 105 women surveyed
      1. Women often self-treat chronic vaginal symptoms
         1. Over-the-counter yeast Vaginitis medication: 73%
         2. Alternative Medicine yeast Vaginitis treatment: 42%
      2. Self-diagnosis often incorrect and may be harmful (symptoms alone cannot distinguish cause)
         1. Correct diagnosis of yeast Vaginitis: 11-28%
         2. Secondary irritant Vaginitis: 15%
   2. References
      1. Ferris (1996) J Fam Pract 42:595-600 [PubMed]
      2. Nyrirjesy (1997) Obstet Gynecol 90:50-3 [PubMed]
2. Physiology: Normal vaginal secretions
   1. Variably dependent on multiple factors
      1. Age
      2. Timing of Menstrual Cycle
      3. Sexual arousal
      4. Contraceptive use
      5. Douching (counsel patients not to do this)
   2. Derivation
      1. Cervical Mucus
      2. Vaginal wall transudate
      3. Exfoliated vaginal cells
3. Causes
   1. Common
      1. Normal discharge (30%)
      2. Candida Vulvovaginitis (20-25%)
      3. Bacterial Vaginosis (23-50%)
      4. Trichomonas Vaginitis (5-15%)
      5. Mixed infection or Sexually Transmitted Disease (20%)
         1. See Cervicitis
   2. Uncommon
      1. Mycoplasma genitalium
      2. Ureaplasma urealyticum
4. Causes: Other
   1. Atrophic Vaginitis (post-menopausal women)
   2. Infectious Cervicitis
      1. Neisseria gonorrhoeae
      2. Chlamydia trachomatis
      3. Herpes Simplex Virus
   3. Vaginitis or Vulvitis
      1. Scabies
      2. Neurodermatitis
      3. Vaginal or vulvar Trauma
      4. Lichen Planus
      5. Vulvar Vestibulitis
      6. Herpes Vulvitis (presents with severe pain, often before vesicular lesions appear)
      7. Malignancy
      8. Irritant Contact Vaginitis
         1. Soaps
         2. Tampons or sanitary napkins
         3. Condoms
         4. Spermicidal gel
         5. Diaphragm
         6. Dyes
   4. Physiologic discharge
      1. Ovulation
      2. Pregnancy
5. History: Rule out Sexually Transmitted Disease (Gonorrhea, Chlamydia, HSV)
   1. Multiple sexual partners
   2. Intrauterine Device or no Contraception
   3. History of Sexually Transmitted Disease
6. Symptoms
   1. Vaginal itching or burning: Candida Vulvovaginitis
      1. Absence of itching makes Vulvovaginal Candidiasis unlikely
   2. Perceived odor (especially fishy): Bacterial Vaginosis
      1. Absence of odor makes Bacterial Vaginosis unlikely, and Candida Vulvovaginitis more likely
   3. Inflammatory signs and symptoms: Candida Vulvovaginitis
   4. Malodorous or unusual Vaginal Discharge
   5. External Dysuria (pain with urine passing over vulva)
      1. Severe pain in HSV Vaginitis
   6. Dyspareunia
7. Signs
   1. See Vaginal pH
   2. Character of vaginal secretions
      1. Normal: clear or white, non-clumping, odorless
      2. Dry cottage cheese-like discharge
         1. Candida Vulvovaginitis
      3. Frothy discharge (rarely present)
         1. Trichomonas Vaginitis
      4. Fishy Odor
         1. Bacterial Vaginosis
         2. Trichomonas Vaginitis
   3. Vagina and Cervix appearance
      1. Vulvar redness, edema and adherent white clumps
         1. Candida Vulvovaginitis
      2. Strawberry Cervix with punctate Hemorrhage
         1. Trichomonas Vaginitis
      3. Pale, dry, thin vaginal and vulvar skin
         1. Atrophic Vaginitis
8. Labs: Microscopy
   1. Patient collected samples
      1. Patient collected samples appear to be as accurate as those collected by clinicians
      2. Instruct patients to insert swab at least one inch into vagina
      3. Strauss (2005) Infect Dis Obstet Gynecol 13(1): 31-5 [PubMed]
   2. Normal
      1. Few Polymorphonuclear Leukocytes (PMNs)
      2. Vaginal epithelial cells
   3. KOH Preparation: Pseudo-hyphae or budding yeast
      1. Candida Vulvovaginitis
   4. Saline preparation (Wet Prep)
      1. Pear-shaped motile organisms: Trichomonas Vaginitis
      2. Clue Cells: Bacterial Vaginosis
      3. Numerous Leukocytes
         1. Trichomonas Vaginitis
         2. Gonorrhea
         3. Chlamydia
      4. Desquamative Vaginitis (local irritant induced)
         1. Many White Blood Cells
         2. Parabasilar cells
9. Labs: Newer advanced screening
   1. DNA probe for Trichomonas
      1. Preferred over microscopy in symptomatic or high risk women
   2. Multiple DNA Probe Test (e.g. BD Affirm VPIII Microbial Identification Test)
      1. High Sensitivity for Bacterial Vaginosis, Trichomoniasis, and Vulvovaginal Candidiasis
      2. Some false positives with Trichomoniasis
      3. Requires 45 minutes to run
   3. Sialidase Activity
      1. Specific for gardnerella vaginalis
10. Management
    1. Treat specific infectious cause
       1. Bacterial Vaginosis
       2. Candida Vulvovaginitis
       3. Trichomonas Vaginitis
       4. Herpes Vaginitis
    2. Consider Non-infectious causes with specific management protocols
       1. Atrophic Vaginitis
       2. Vaginal Dryness
       3. Irritant Contact Vaginitis (eliminate causes)
    3. Consider differential diagnosis
       1. Urethritis in Women
    4. Consider empiric treatment
       1. Not recommended due to poor correlation with symptoms
          1. Schaaf (1990) Arch Intern Med 150:1929-33 [PubMed]
       2. Anti-yeast medication (See Candida Vulvovaginitis)
       3. Metronidazole
       4. Clindamycin cream per vagina for 7 nights
    5. Consider increasing vaginal acidity (lower Vaginal pH)
       1. May increase Lactobacillus survival
       2. Aci-Jel Vaginal jelly per vagina for 21 days at bedtime
       3. Vinegar douche (not recommended)
          1. White Vinegar (2-4 tablespoons) in 1 quart water
11. References
    1. Anderson (2004) JAMA 291:1368-79 [PubMed]
    2. Hainer (2011) Am Fam Physician 83(7): 807-15 [PubMed]
    3. Paladine (2018) Am Fam Physician 97(5): 321-9 [PubMed]
    4. Reed (1993) Am Fam Physician 47(8):1805-16 [PubMed]