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Vaginitis
Aka: Vaginitis, Vaginal Discharge, Vulvovaginitis
- See Also
- Vulvovaginitis in Children
- 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%
- References
- Ferris (1996) J Fam Pract 42:595-600 [PubMed]
- Nyrirjesy (1997) Obstet Gynecol 90:50-3 [PubMed]
- 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
- 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
- Mycoplasma genitalium
- Ureaplasma urealyticum
- Causes: Other
- Atrophic Vaginitis (post-menopausal women)
- Infectious Cervicitis
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Herpes Simplex Virus
- 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
- Soaps
- Tampons or sanitary napkins
- Condoms
- Spermicidal gel
- Diaphragm
- Dyes
- Physiologic discharge
- Ovulation
- Pregnancy
- History: Rule out Sexually Transmitted Disease (Gonorrhea, Chlamydia, HSV)
- Multiple sexual partners
- Intrauterine Device or no Contraception
- History of Sexually Transmitted Disease
- 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
- Signs
- See Vaginal pH
- Character of vaginal secretions
- Normal: clear or white, non-clumping, odorless
- Dry cottage cheese-like discharge
- Candida Vulvovaginitis
- Frothy discharge (rarely present)
- Trichomonas Vaginitis
- Fishy Odor
- Bacterial Vaginosis
- Trichomonas Vaginitis
- Vagina and Cervix appearance
- Vulvar redness, edema and adherent white clumps
- Candida Vulvovaginitis
- Strawberry Cervix with punctate Hemorrhage
- Trichomonas Vaginitis
- Pale, dry, thin vaginal and vulvar skin
- Atrophic Vaginitis
- Labs: Microscopy
- Patient collected samples
- Patient collected samples appear to be as accurate as those collected by clinicians
- Instruct patients to insert swab at least one inch into vagina
- Strauss (2005) Infect Dis Obstet Gynecol 13(1): 31-5 [PubMed]
- Normal
- Few Polymorphonuclear Leukocytes (PMNs)
- Vaginal epithelial cells
- KOH Preparation: Pseudo-hyphae or budding yeast
- Candida Vulvovaginitis
- Saline preparation (Wet Prep)
- Pear-shaped motile organisms: Trichomonas Vaginitis
- Clue Cells: Bacterial Vaginosis
- Numerous Leukocytes
- Trichomonas Vaginitis
- Gonorrhea
- Chlamydia
- Desquamative Vaginitis (local irritant induced)
- Many White Blood Cells
- Parabasilar cells
- Labs: Newer advanced screening
- DNA probe for Trichomonas
- Preferred over microscopy in symptomatic or high risk women
- Multiple DNA Probe Test (e.g. BD Affirm VPIII Microbial Identification Test)
- High Sensitivity for Bacterial Vaginosis, Trichomoniasis, and Vulvovaginal Candidiasis
- Some False Positives with Trichomoniasis
- Requires 45 minutes to run
- Sialidase Activity
- Specific for gardnerella vaginalis
- 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
- Urethritis in Women
- Consider empiric treatment
- Not recommended due to poor correlation with symptoms
- Schaaf (1990) Arch Intern Med 150:1929-33 [PubMed]
- 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 (not recommended)
- White Vinegar (2-4 tablespoons) in 1 quart water
- References
- Anderson (2004) JAMA 291:1368-79 [PubMed]
- Hainer (2011) Am Fam Physician 83(7): 807-15 [PubMed]
- Paladine (2018) Am Fam Physician 97(5): 321-9 [PubMed]
- Reed (1993) Am Fam Physician 47(8):1805-16 [PubMed]