Basics
Description
- Vaginitis is inflammation or irritation of the vagina causing typical symptoms of vaginal discharge, burning, and itching.
- May be due to infection such as trichomoniasis, candidiasis, or bacterial vaginosis (BV); see Appendix, Table 7.
- Noninfectious causes include foreign body or exposure to an irritant or allergen.
- Vulvovaginitis is irritation or inflammation of both the vulva and the vagina; most often due to Candida albicans
- In postpubertal females, BV is the most prevalent cause of vaginal discharge and typically causes a fishy odor.
- Physiologic leukorrhea (i.e., "physiologic discharge " ) is usually associated with pubertal onset and frequently precedes menarche. It is typically thin, white, and mucoid.
Epidemiology
- Vaginitis affects females of all ages.
- In prepubescent girls, 25 " 75% of vaginitis is nonspecific in etiology.
- Approximately 75% of women have had at least one episode of vulvovaginitis due to candida in their lifetime.
- The most common causes of postpubertal vaginitis are as follows:
- BV (22 " 50%)
- Vulvovaginal candidiasis (17 " 39%)
- Trichomonas vaginalis (4 " 35%)
Risk Factors
- For prepubertal females, poor hygiene is a common risk factor.
- For BV: vaginal douching, smoking, intrauterine device usage, non-white race, prior pregnancy, unprotected sexual intercourse, usage of spermicide, homosexual relationships
- For trichomoniasis: multiple sexual partners, other sexually transmitted infections, lack of condom usage, smoking
- For vulvovaginal candidiasis: use of systemic antibiotics, uncontrolled diabetes mellitus, diet high in refined sugars
- Irritant risk factors often include soaps, tampons, topical products and medications, extreme cleansing, clothing, and douching.
Pathophysiology
- In prepubescent female, with prepubertal hormones, the vagina has a neutral pH, atrophic mucosa, and a warm environment that easily allow for bacterial overgrowth.
- Physiologic leukorrhea
- Estrogen levels; the volume of discharge varies with the menstrual cycle and is especially heavy at the time of ovulation.
- Candida vulvovaginitis
- Use of antibiotics increases the occurrence of candidiasis by eliminating competitive organisms.
- BV
- Caused by shift in vaginal flora
- Normal Lactobacillus species decrease and overgrowth of bacteria, including Gardnerella vaginalis, Mycoplasma hominis, and anaerobes such as Prevotella and Mobiluncus species
Etiology
- All ages:
- Chemical, irritant, allergy
- Nonspecific vaginitis (may be associated with hygiene)
- Foreign body or material such as rolled up toilet paper
- Candidiasis associated with antibiotic use
- Trauma, mechanical irritation
- Sexual abuse
- More common in prepubertal females:
- Group A ²-hemolytic Streptococcus
- Haemophilus influenzae
- Shigella
- Pinworms or scabies
- Congenital abnormalities
- More common in postpubertal females:
- Physiologic leukorrhea (may cause discharge but not irritation)
- BV
- Trichomoniasis
- STIs such as gonorrhea and chlamydia
- Pubic lice
Diagnosis
History
- For many adolescent girls, vaginal symptoms may be uncomfortable to talk about. Important to meet alone with an adolescent.
- Symptoms alone cannot distinguish between the different causes of vaginitis but can assist the clinician.
- Describe the discharge including color (white, green-yellow, gray?), consistency (frothy? thick?), amount, odor, and duration of symptoms.
- Is there pain? Pain with intercourse? Burning?
- Bladder symptoms: Is there dysuria? Frequency? Urgency?
- Is there itching? Is it worse at night? Is it present in other family members?
- Exposure to any new possible irritants (e.g., new soap, spermicides, douching)
- Anything that makes symptoms better or worse?
- Prior history of similar symptoms? Prior treatment for past vaginitis?
- Sexual history including number of partners, use of barrier methods, history of STI
- Any medications, such as systemic antibiotics
- STI risk factors
- Any chronic diseases such as diabetes or other immunocompromised conditions
Physical Exam
- Vital signs, including height, weight, BMI, and temperature
- Inspect pubic hair for sexual maturity rating (tanner scores) and also evidence of infection or irritation.
- External genital or vaginal evidence of erythema, excoriation, and discharge. In younger children, this can be done in the "frog-leg " position.
- Discharge should be sampled.
- Examination of other evidence for irritation or inflammation such as warts, injury, and ulceration
- Consistency, color of discharge
- If patient is sexually active, speculum exam may need to be performed to evaluate the cervix. "Strawberry cervix " can be a sign of inflammation seen in trichomoniasis.
- Bimanual exam also should be considered if symptoms suggest risk for pelvic inflammatory disease.
Diagnostic Tests & Interpretation
Lab
In order to best evaluate etiology, a sample of discharge should be collected. The sample can be obtained by the clinician or by the patient typically using a cotton-tipped applicator.
- Odor/ " whiff " or "amine " test:
- Slide prepared with drop of 10% KOH
- The examiner should whiff the slide for presence of a fishy odor suggestive of BV, also seen in trichomoniasis, negative in candida.
- Wet mount of the vaginal discharge mixed with saline for microscopy
- This slide is examined for evidence of trichomonads, clue cells, and yeast.
- Clue cells are vaginal epithelial cells with adherent coccobacilli seen on wet mount and when >20% of epithelial cells suggestive of BV.
- Wet mount with 10% KO
- May demonstrate budding yeast ( "spaghetti with meatballs " appearance) suggestive of candida
- Nitrazine paper
- Measures pH of sample
- Vaginal pH >5 seen in BV, >5.4 seen in trichomoniasis, <4.9 candidiasis
- Urinalysis may be helpful if patient complains of dysuria.
- STI testing as warranted based on risk factors. Chlamydia PCR can be obtained by cervical or vaginal swab or urine; gonorrhea PCR or culture (cervical or vaginal swab)
- Consider a pregnancy test as indicated.
Differential Diagnosis
- Physiologic leukorrhea
- Candidiasis
- BV
- Trichomonas
- Other STIs including chlamydia, gonorrhea, herpes simplex virus infection, HPV
- Skin conditions including psoriasis
- Lichen sclerosis (hypotrophic dystrophy of the vulva)
- Congenital abnormalities, such as ectopic ureter
- Sexual abuse
- Mechanical irritation from lack of lubrication, trauma
- Pinworm infection
Treatment
Medication
- Medication management depends on the etiology.
- Vulvovaginal candidiasis
- Topical antifungals such as clotrimazole, butoconazole, miconazole, or terconazole are available over the counter.
- Oral fluconazole 6 mg/kg up to a maximum of 150 mg as a single dose can also be given.
- Longer treatments may be necessary for recurrent or severe infections.
- BV
- Antibiotics are treatment of choice.
- Oral metronidazole 500 mg twice daily for 7 days or intravaginal metronidazole gel for 5 days or clindamycin cream (7 days) or suppository (100 mg ovules for 3 days)
- Higher rates of recurrence are seen with single-dose therapy for BV.
- Relapse may require longer courses of treatment.
- Trichomonas
- Metronidazole 2 g orally in a single-dose
- Sexual partners should be treated simultaneously if possible to avoid reinfection.
- Chlamydia
- Azithromycin 1 g orally for 1 dose or doxycycline 100 mg orally twice daily for 7 days
- Gonorrhea
- Ceftriaxone 125 mg intramuscular for one dose
- PLUS azithromycin 1 g orally for 1 dose or doxycycline 100 mg orally twice daily for 7 days
- HSV
- For initial outbreak: acyclovir 400 mg orally 3 times daily for 7 " 10 days or 200 mg 5 times daily for 7 " 10 days; can use valacyclovir or famciclovir alternatively
- Suppressive therapy for recurrent infections can use acyclovir, valacyclovir, or famciclovir.
- Lichen sclerosus
- Mild pruritus consider mild emollient
- More severe symptoms consider topical steroids
- Group A ²-hemolytic Streptococcus and H. influenzae
- Amoxicillin 40 mg/kg/day to max 500 mg divided twice daily for 7 days
- Shigella
- Trimethoprim/sulfamethoxazole
- Pinworm infestations
- Mebendazole 100 mg orally, repeat dosage 2 weeks later
- Consider treatment of entire family
Additional Treatment
General Measures
- Good hygiene and avoidance/removal of irritants includes hand washing following toileting, encourage wiping from front to back, clean with a mild nonscented soaps or lotions, wear cotton underwear, and avoid bubble baths and douching.
- Warm bath/Sitz baths followed by air-drying
- Use of topical emollients, zinc creams, or topical low-potency steroids to assist with itching and/or inflammation
Complementary & Alternative Treatments
Probiotics may be helpful in preventing recurrence in BV and candida vulvovaginitis.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- If symptoms persist following over the counter or other treatment, patients need to be reevaluated by a clinician as may be another etiology.
- Patients with an STI such as trichomonas, gonorrhea, or chlamydia should make certain that all sexual partners receive treatment in order to prevent reinfection.
Alert
Patients taking metronidazole for trichomonas or BV should be told explicitly to avoid alcohol.
Patient Education
- In prepubescent females: Encourage good hygiene to prevent recurrence.
- In sexually active adolescents: Encourage regular condom usage. Consider discussion of contraceptive options.
Prognosis
With treatment, vaginitis typically resolves quickly with no complications.
Complications
- BV is associated with premature labor and preterm birth, premature rupture of membranes, and increased risk of acquiring STIs.
- Trichomonas
- Gonorrhea and chlamydial infections that are not treated can lead to pelvic inflammatory disease.
Additional Reading
- Freeto JP, Jay MS. "What 's really going on down there? " A practical approach to the adolescent who has gynecologic complaints. Pediatr Clin North Am. 2006;53(3):529 " 545. [View Abstract]
- Hainer BL, Gibson MV. Vaginitis. Am Fam Physician. 2011;83(7):807 " 815. [View Abstract]
- Jasper JM. Vulvovaginitis in the prepubertal child. Clin Ped Emerg Med. 2009;10:10 " 13.
- Sharma B, Preston J, Greenwood P. Management of vulvovaginitis and vaginal discharge in prepubertal girls. Rev Gynaecol Pract. 2004;4:111 " 120.
- Sobel JD. Vaginitis. N Engl J Med. 1997;337(26):1896 " 1903. [View Abstract]
- Syed T, Braverman P. Vaginitis in adolescents. Adolesc Med Clin. 2004;15(2):235 " 251. [View Abstract]
Codes
ICD09
- 616.10 Vaginitis and vulvovaginitis, unspecified
- 623.5 Leukorrhea, not specified as infective
- 112.1 Candidiasis of vulva and vagina
- 131.01 Trichomonal vulvovaginitis
ICD10
- N76.0 Acute vaginitis
- N89.8 Other specified noninflammatory disorders of vagina
- B37.3 Candidiasis of vulva and vagina
- A59.01 Trichomonal vulvovaginitis
SNOMED
- 30800001 Vaginitis (disorder)
- 271939006 Vaginal discharge (finding)
- 72934000 Candidiasis of vagina (disorder)
- 276877003 Trichomonal vaginitis
- 53277000 Vulvovaginitis (disorder)
FAQ
- Q: How do you diagnose BV?
- A: BV is a clinical diagnosis based on having 3 out of 4 Amsel Criteria:
- Thin, homogenous discharge
- Vaginal pH >4.5
- Positive "whiff " test
- >20% clue cells on wet mount or Gram stain
- Q: Should sex partners of patients with vaginitis be treated?
- A: Depends on the etiology of the vaginitis. For BV and candida, there are no treatment recommendations for sex partners. For patients with trichomonas, partners should be treated, and to reduce recurrence, partners should avoid sexual intercourse until both have been treated and are asymptomatic.
- Q: In prepubescent females, is a positive culture definitive for infection?
- A: One common issue in prepubertal females is how to distinguish between normal vaginal flora and potential pathogens. Growth of normal pathogens even in girls who are symptomatic are not diagnostic.