Vaginitis

Snapshot

• A 26-year-old woman presents to her primary care physician due to a foul smelling vaginal discharge. She reports that this is the first time this occurred. She describes the discharge as off-white with a “fish-like” odor. She denies any pain during sexual intercourse, post-coital bleeding, burning, or pruritus. She has a new sexual partner where she consistently uses condoms. She reports to recently practicing vaginal douching. On physical exam, the vulva appears normal. Speculum examination demonstrates an off-white to gray vaginal discharge and a normal cervix. Vaginal pH is 5.5. An amine test is positive. Saline microscopy demonstrates clue cells within the vaginal epithelium. (Bacterial vaginosis)

Introduction

• Clinical definition
  • vaginal disorder secondary to
    • infection
    • inflammation
    • changes in normal vaginal flora
• Epidemiology
  • risk factors
    • bacterial vaginosis
      • multiple sexual partners
      • antibiotic use
      • intrauterine contraceptive device
    • trichomoniasis
      • multiple sexual partners
      • history of sexually transmitted infections
    • vulvovaginal candidiasis
      • immunosuppression (e.g., transplant patients and HIV infection)
      • uncontrolled diabetes
      • antibiotic use 
• Etiology
  • the most common infections include
    • bacterial vaginosis
    • Candida vulvovaginitis
    • trichomoniasis
• Pathobiology
  • normal biology
    • in premenopausal women, the vaginal nonkeratinized stratified squamous epithelium contains a large amount of glycogen
      • lactobacilli use this glycogen from sloughed cells to produce lactic acid creating an acidic vaginal environment (pH 4-4.5) that prevents the growth of pathogenic organisms
        • acidic enviroment normally maintains normal vaginal flora
  • pathogenesis
    • disruption of this acidic environment results in vaginitis
      • disruptive causes include
        • menstruation
        • sexual activity
        • pregnancy
        • foreign bodies
        • sexually transmitted disease
        • hygienic products
        • antibiotics
        • hypoestrogenic states (e.g., menopause)
• Prognosis
  • bacterial vaginosis
    • infection may recur in 30% of women
  • trichomoniasis
    •  infection may recur in 5-31% of cases
  • vulvovaginal candidiasis
    • infection may recur in ~ 50% of initially infected women

Presentation

Vaginitis
Vaginitis	Etiology	Clinical Presentation
Bacterial vaginosis	Gardnerella vaginalis	Symptomsmalodorous (“fishy” odor) vaginal dischargenonpainfulPhysical examoff-white or gray and thin vaginal dischargenormal vulva
Vulvovaginal candidiasis	Candida albicans	Symptomspruritus and sorenessdyspareuniaPhysical examthick, white, odorless, and curd-like vaginal dischargevulvar erythema and edema
Trichomoniasis	Trichomonas vaginalis	Symptomsmalodorous greenish dischargeburningdyspareunia and dysuriapostcoital bleedingPhysical exammalodorous discharge”strawberry” cervixvulvovaginal erythemaImportant notesexually transmitted; therefore, the partner must also be treated

Studies

• Management approach
  • a definitive diagnosis can be obtained by examining the vaginal discharge for
    • pH
    • fishy amine odor
    • microscopy
• Speculum exam
  • indication
    • to evaluate for underlying causes of vaginitis
      • foreign body (e.g., retained tampon) leading to vaginitis
• Vaginal pH
  • normal findings
    • pH of 4-4.5
  • bacterial vaginosis
    • pH of > 4.5
  • vulvovaginal candidiasis
    • pH of 4-4.5
  • trichomoniasis
    • pH of 5-6
• Saline microscopy (wet mount)
  • bacterial vaginosis
    • clue cells found in epithelial cells  
  • vulvovaginal candidiasis
    • pseudohyphae
  • trichomoniasis
    • motile trichomonads 
• Potassium hydroxide (KOH) wet mount
  • vulvovaginal candidiasis
    • pseudohyphae
• Amine test (“whiff” test)
• positive in ~70-80% of patients with bacterial vaginosis

Differential

• Atrophic vaginitis
  • distinguishing factors
    • typically seen in menopausal women
    • on physical exam there is
      • thinning of the vaginal epithelium
      • loss of rugae
• cervicovaginal friability

Treatment

• Medical
  • metronidazole
    • indications
      • first-line agent for both pregnant and nonpregnant women with bacterial vaginosis
        • clindamycin is an alternative
      • first-line agent pregnant and nonpregnant women with trichomoniasis
        • tinidazole is another option
        • sexual partner must be treated and sex must be avoided until treatment is complete and the patients are asymptomatic
  • -azole 
    • indication
      • first-line treatment option for women with vulvovaginal candidiasis
        • topical -azoles are preferred in pregnancy
    • medications include
      • fluconazole
      • clotrimazole
• miconazole

Complications

• Bacterial vaginosis
  • miscarriage and spontaneous abortion
  • maternal infection
  • postpartum endometritis
  • neonatal complications include
    • low birth weight
    • prematurity
• Trichomoniasis
  • premature rupture of membranes
  • preterm premature rupture of membranes
• Vulvovaginal candidiasis
  • premature rupture of membranes
  • preterm labor
  • cerebral candidiasis in the neonate
  • neonatal death