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BASICS

  • Vaginitis: Presence of vaginal inflammation.
  • Vaginosis: Absence of inflammation despite abnormal vaginal flora.
  • Most common causes:
  • Bacterial vaginosis (BV)
  • Vulvovaginal candidiasis (VVC)
  • Trichomoniasis
  • Noninfectious causes (<10%): atrophic, irritant, allergic vaginitis.

EPIDEMIOLOGY

  • Vaginal symptoms frequent in women; ~10 million visits/year in the US.
  • BV: most common cause of vaginal discharge in reproductive-aged women.
  • VVC: second most common cause.
  • Estimated 7.4 million BV cases/year in US.
  • BV prevalence: 15% in pregnancy; 20-40% in STI clinic populations; higher in African American (51%) and Mexican American (32%) women.
  • 29-40% of women report ≥1 episode of VVC; uncommon in prepubescent and postmenopausal women.
  • Trichomoniasis: 3-5 million cases/year in US; disproportionately affects African American women.

ETIOLOGY AND PATHOPHYSIOLOGY

  • BV: disruption of normal vaginal flora; lactobacilli replaced by facultative anaerobes (Gardnerella vaginalis, Prevotella, Mycoplasma hominis, etc.).
  • pH rises (>4.5), discharge becomes malodorous, thin, homogenous.
  • Not directly sexually transmitted but associated with sexual activity.
  • VVC: Candida species (mostly C. albicans, some C. glabrata) overgrowth on vaginal mucosa; symptoms when overgrowth overwhelms normal flora.
  • Trichomoniasis: infection with Trichomonas vaginalis, sexually transmitted, affecting vaginal and urethral epithelium.
  • Desquamative inflammatory vaginitis (DIV): chronic purulent vaginitis with uncertain pathogenesis; different flora than BV.
  • Other: atrophic and irritant/allergic vaginitis due to estrogen deficiency or irritants.

RISK FACTORS

  • BV: sexual activity, smoking, vaginal douching, low socioeconomic status, STIs, IUD use; male circumcision lowers risk.
  • VVC: diabetes, antibiotics, immunosuppression, high estrogen states (contraceptives, pregnancy).
  • Trichomoniasis: inconsistent barrier use, multiple partners, low socioeconomic status, drug use, smoking, STIs, incarceration.
  • Other: decreased estrogen, use of douches, creams, tight clothing, sex toys.

GENERAL PREVENTION

  • Vulvar hygiene with warm water, unscented cleanser.
  • Avoid douching.
  • Wear cotton underwear.
  • Partner treatment generally not recommended except in recurrent trichomoniasis.

COMMONLY ASSOCIATED CONDITIONS

  • STIs: gonorrhea, chlamydia, HSV, HIV.
  • Vaginal intraepithelial neoplasia and cancers may mimic vaginitis.

DIAGNOSIS

History

  • Distinguish vulvar vs vaginal symptoms.
  • Symptoms: itching, burning, irritation, dyspareunia, abnormal discharge (color, odor, consistency).
  • Sexual history, menstrual cycle relation, recurrence.
  • BV: thin, homogenous malodorous discharge.
  • VVC: thick white discharge, itching, burning, dyspareunia.
  • Trichomoniasis: often minimal symptoms; may have frothy yellow-green discharge, foul odor, postcoital bleeding.
  • DIV: purulent discharge with burning and pain.

Physical Exam

  • Examine vulva and perianal skin.
  • BV: thin watery discharge, vaginal pH >4.5, positive "whiff" test.
  • VVC: vulvar/vaginal erythema, swelling, thick discharge without odor.
  • Trichomoniasis: yellow/green frothy discharge, "strawberry cervix" (punctate hemorrhages).
  • DIV: purulent discharge, vaginal inflammation.

DIFFERENTIAL DIAGNOSIS

  • Physiologic discharge, leukorrhea of pregnancy
  • STIs
  • Foreign body
  • Contact dermatitis
  • Cervicitis
  • Urinary tract infection
  • Atrophic vaginitis
  • Dermatoses (lichen sclerosus, lichen planus, psoriasis)
  • Genitourinary syndrome of menopause

DIAGNOSTIC TESTS & INTERPRETATION

  • BV:
  • Vaginal pH >4.5
  • Homogenous thin discharge coating vaginal walls
  • Positive amine/“whiff” test

  • 20% clue cells on microscopy

  • VVC:
  • Visualization of blastospores or pseudohyphae on saline/KOH microscopy
  • Positive culture in symptomatic patients
  • Trichomoniasis:
  • Motile trichomonads on saline microscopy
  • Nucleic acid amplification tests (NAAT) for higher sensitivity
  • DIV:
  • Increased leukocytes on wet mount
  • pH >4.5

  • Wet mount preferred diagnostic test

  • New molecular tests (oligonucleotide probes, NAATs) may improve comfort but not clearly improve outcomes.

TREATMENT

General Measures

  • Avoid douching, tight clothing.
  • Use condoms regularly to reduce BV recurrence.
  • Pregnant asymptomatic women generally do not require BV treatment.
  • Avoid tampon use during intravaginal treatments.

Medication

First Line

  • BV:
  • Metronidazole 500 mg PO BID ×7 days or 0.75% gel vaginally daily ×5 days
  • Clindamycin 2% cream vaginally daily ×5-7 days
  • Avoid alcohol during and 24 hrs post oral metronidazole
  • VVC:
  • Uncomplicated: single 150 mg oral fluconazole dose
  • Topical azoles (butoconazole, clotrimazole, miconazole, terconazole, nystatin) ×3-7 days
  • Recurrent: fluconazole 150 mg three times in first week then weekly ×6 months
  • Avoid oral azoles in pregnancy
  • Trichomoniasis:
  • Metronidazole 500 mg PO BID ×7 days
  • Treat partner; abstain from sex until asymptomatic
  • Retesting at 3 months acceptable but not required
  • DIV:
  • Clindamycin 2% cream intravaginally nightly ×1-3 weeks
  • May require maintenance therapy

Second Line

  • BV:
  • Secnidazole 2 g PO once
  • Tinidazole or clindamycin orally 2-5 days
  • VVC:
  • Longer or alternative therapy for non-albicans species (topical/oral azoles or boric acid vaginal suppository 600 mg daily ×7-14 days)
  • Trichomoniasis:

  • One-time 2 g oral tinidazole or metronidazole

  • DIV:

  • Topical glucocorticoids (hydrocortisone or clobetasol intravaginally)

ONGOING CARE

  • Delay sexual activity until symptoms resolve.
  • Condoms may help prevent BV recurrence.
  • Consider suppressive therapy for recurrent BV (monthly treatment).

PATIENT EDUCATION

  • Proper vulvar hygiene (warm water, unscented cleanser).
  • Avoid douching and irritants.
  • Use cotton underwear.

PROGNOSIS

  • VVC cures in 80-90% of uncomplicated cases.
  • Recurrent VVC may relapse in 30-50% after stopping maintenance.
  • BV associated with increased risk of HIV, STIs, preterm birth, chorioamnionitis, postpartum infections, and PID.
  • VVC can occur after BV treatment.

COMPLICATIONS

  • BV: increased risk of HIV and other STIs, adverse pregnancy outcomes.
  • VVC: recurrent infections, treatment failures.

REFERENCES

  1. Paavonen J, Brunham RC. Bacterial vaginosis and desquamative inflammatory vaginitis. N Engl J Med. 2018;379:2246-2254.
  2. American College of Obstetricians and Gynecologists. Vaginitis in nonpregnant patients: ACOG Practice Bulletin No. 215. Obstet Gynecol. 2020;135(1):e1-e17.
  3. Balkus JE, Srinivasan S, Anzala O, et al. Impact of periodic presumptive treatment for bacterial vaginosis on the vaginal microbiome. J Infect Dis. 2017;215(5):723-731.

CLINICAL PEARLS

  • Most women experience symptom relief with appropriate therapy.
  • Vaginal pH measurement is underutilized but valuable in diagnosis.
  • Partner treatment generally not recommended except in recurrent trichomoniasis.
  • Avoid alcohol during metronidazole treatment.