Background
Definition: Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora or epidermis.
Main types: 1) Infectious vaginitis (caused by Trichomonas, BV, and Candida), and 2) Atrophic Vaginitis (caused by estrogen deficiency), and 3) Allergic or irritant contact forms of vaginitis.
Diagnosis
Presentation: Signs and symptoms are similar irrespective of the underlying etiology and include discharge (change in volume, color, and odor of vaginal discharge), spotting, pruritus, burning, dysuria, dyspareunia, Erythema.
DDx: Bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis are the top three causes of vaginitis and cause more than 90% of infection-related vaginitis in premenopausal women.
Diagnostic studies
-Microscopy. Patient collected specimen just as good.
–Nuswap is send out test for all common organisms that cause vaginitis.
-Pelvic exam
| Diagnosis | Treatment | Tx partners? | Pathogenesis | Distinguishing feature | |
| Bacterial Vaginosis (BV) | 3 of 4 Amsel criteria | Metronizadole 500mg PO BID x 7d. OR Metronizadol gel (Metrogel) 0.75% one full applicator (5g) intravaginally once daily for 5 days. OR Clindamycin cream 2% one full applicator (5g) Intravaginally once daily at bedtime for 7 days. |
NO It’s not an STI |
BV infection involves replacement of normal hydrogen peroxide-producing lactobacillus-predominant vaginal flora with anaerobic bacteria. Most common of these anaerobic bacteria is Gardnerella Vaginalis. | -Clue cells -Minimal itching or irritation. -Not an STD |
| Trichomoniasis | NAAT (preferred) or Wet Prep |
1st choice tx: Metronizadole 2g PO x 1 or Tinidazole 2g PO x 1; Alt: Metronidazole 500mg BID x 7d. **Reinfection rates are high (20% at 3 months). Consider rescreening. |
YES: Sex partners should be treated simultaneously. | Is an STD. Not normal part of flora. | -STD -Motile |
| Vulvovaginal Candidiasis | KOH prep Gram stain Culture if 1) complicated disease or 2) Pt has normal PH but negative microscopy. See more here. |
Fluconazole 150 mg PO x 1. Maybe given in two sequential doses given three days apart for complicated infection. PO is preferred over topical antimycotic agents. |
NO (It’s not an STI) | Candida is a normal vaginal flora. When the normal flora of the vagina is disturbed, it overgrows and penetrates the superficial epithelial cells causing vulvovaginitis. As such, candidal vulvovaginitis is not considered an STI. | -Normal pH -Pseudohyphae & budding yeast in KOH -Not an STD |
*Bacterial vaginosis happens just like C. diff happens. In C. diff, an antibiotic or some agent alters the GI biome leading to overgrowth of C. diff, and anaerobic bacteria. Metronizadole is the first line treatment.
In BV, some agent alters the biome of the vagina leading to overgrowth of anaerobic bacteria. You also use Metronizadole to treat it. In a sense, C. diff could be called “bacterial colonosis”.
In PID, chlamydia or gonorrhea infection alter the biome of the upper genital tract leading to an opportunistic growth of anaerobic organisms. Metronizadole is often added to the PID regimen.
From AAFP (AFP. 2011 Apr 1;83(7):807-815.)
Clindamycin and metronidazole (Flagyl, Metrogel) are equally effective for eradicating symptoms of bacterial vaginosis. All methods of estrogen delivery relieve the symptoms of atrophic vaginitis.
Nitroimidazole drugs (e.g., metronidazole) given orally in a single dose or over a longer period result in parasitologic cure of trichomoniasis in 90 percent of cases.
Oral and vaginal antifungals are equally effective for the treatment of uncomplicated vulvovaginal candidiasis.
**Trich is the only one of the three that is an STD.
Any nitroimidazole drug (e.g., metronidazole) given orally as a single dose or over a longer period resolves 90 percent of trichomoniasis cases.
Related post: Pelvic Inflammatory Disease (PID)
Laboratory Testing for Infectious Causes of Vaginitis (abridged from AAFP)
| TEST | BACTERIAL VAGINOSIS | TRICHOMONIASIS | VULVOVAGINAL CANDIDIASIS |
|---|---|---|---|
|
Point-of-care tests |
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|
Amsel criteria |
Sensitivity, 69%; specificity, 93% |
NA |
NA |
|
pH |
pH > 5: sensitivity, 77%; specificity, 35% |
pH > 5.4: sensitivity, 92%; specificity, 51% |
pH < 4.9: sensitivity, 71%; specificity, 90% |
|
Whiff test (the amine odor produced by mixing 10% potassium hydroxide solution with a sample of vaginal discharge) |
Positive test: sensitivity, 67%; specificity, 93% |
Positive test: sensitivity, 67%; specificity, 65% |
Negative test |
|
Microscopy (with 10% potassium hydroxide solution, saline) |
Clue cells, bacilli with corkscrew motility, scant or absent lactobacilli |
Motile protozoa with flagella; more leukocytes than epithelial cells |
Budding filaments, mycelia with 10% potassium hydroxide solution |
|
Sensitivity, 53 to 90%; specificity, 40 to 100% |
Sensitivity, 50 to 70% (may be increased by vaginal lavage to 74%); specificity, 100% |
Sensitivity, 61%; specificity, 77% |
|
|
Polymerase chain reaction: based on DNA amplification |
Effective at identifying bacteria responsible for bacterial vaginosis |
Sensitivity, 80%; specificity, 97% |
Polymerase chain reaction more sensitive than culture in detecting Candida; not yet commercially available as a diagnostic test |
|
Reference laboratory testing |
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Culture |
Predictive value of a positive Gardnerella vaginalis culture is less than 50%; generally not recommended, but may have value in recalcitrant cases |
InPouch Culture System (Biomed, White City, Ore.) |
Positive culture alone does not necessarily indicate that the yeast identified are responsible for vaginal symptoms |
|
Combined wet-mount preparation and culture kit; can be kept at room temperature for up to 18 hours; samples taken during menses were not adversely affected |
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Sensitivity, 81 to 100% |
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Resource
BARRY L. HAINER, MD, and MARIA V. GIBSON, MD, PhD, “Vaginitis: Diagnosis and Treatment” Am Fam Physician. 2011 Apr 1;83(7):807-815.
http://www.aafp.org/afp/2011/0401/p807.html