Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 18-16: Vaginitis + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Vaginal irritation Pruritus Abnormal or malodorous discharge +++ General Considerations ++ Inflammation and infection of the vagina are common Vaginitis results from a variety of pathogens, allergic reactions to vaginal contraceptives or other products, vaginal atrophy, or the friction of coitus The normal vaginal pH is 4.5 or less, and Lactobacillus is the predominant organism Normal secretions can be confused with vaginitis +++ Candida albicans ++ Pregnancy, diabetes, and use of broad-spectrum antibiotics or corticosteroids predispose to Candida vaginitis Heat, moisture, and occlusive clothing also contribute to its risk +++ Trichomonas vaginalis ++ This protozoal flagellate infects the vagina, Skene ducts, and lower urinary tract in women and the lower genitourinary tract in men It is sexually transmitted +++ Bacterial vaginosis ++ This condition is a polymicrobial overgrowth of Gardnerella vaginalis and other anaerobes and is not sexually transmitted +++ Condylomata acuminata (genital warts) ++ Caused by various types of the human papillomavirus Sexually transmitted Pregnancy and immunosuppression favor growth + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Careful history regarding Onset of the last menstrual period Recent sexual activity Use of contraceptives, tampons, or douches Recent changes in medications or use of antibiotics Vaginal burning, pain, pruritus Profuse or malodorous discharge Physical examination: careful inspection of the vulva and speculum examination of the vagina and cervix +++ Candida albicans ++ Pruritus Vulvovaginal erythema White curd-like discharge that is not malodorous +++ Trichomonas vaginalis ++ Pruritus and a malodorous frothy, yellow-green discharge Diffuse vaginal erythema and red macular lesions on the cervix in severe cases ("strawberry cervix") +++ Bacterial vaginosis ++ Copious grayish, frothy, malodorous discharge No obvious vulvitis or vaginitis +++ Condylomata acuminata ++ Warty growths on the vulva, perianal area, vaginal walls, or cervix There may be fissures at the fourchette Vaginal lesions may show diffuse hypertrophy or a cobblestone appearance +++ Differential Diagnosis ++ Normal vaginal discharge Gonococcal infection Chlamydial infection Atrophic vaginitis Friction from intercourse Reaction to douches, tampons, condoms, soap + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ A vaginal, cervical, or urine sample can be obtained for detection of gonococcus and Chlamydia, if clinically indicated The vaginal pH is frequently > 4.5 in infections due to trichomonads (pH of 5.0–5.5) and bacterial vaginosis Examine a specimen of vaginal discharge microscopically: In a drop of 0.9% saline solution (wet mount), search for motile organisms with flagella (trichomonads) and for epithelial cells covered with bacteria to such an extent that cell borders are obscured (clue cells) In a drop of 10% potassium hydroxide, search for the filaments and spores of Candida and an amine-like "fishy" odor of Trichomonas Cultures of vaginal discharge on Nickerson medium may be used if Candida is suspected but not demonstrated; otherwise, vaginal cultures are not generally useful in diagnosis Nucleic acid amplification tests are highly sensitive and specific to identify T vaginalis Other commercially available rapid diagnostic tests (eg, Affirm VP III and OSOM Trichomonas Rapid Test) have high sensitivity + Treatment Download Section PDF Listen +++ +++ Medications +++ Candida albicans ++ Women with uncomplicated vulvovaginal candidiasis will usually respond to a 1- to 3-day regimen of a topical azole or to a one-time dose of oral fluconazole One-day (single-dose) regimens include Miconazole (1200-mg vaginal suppository) Tioconazole ointment (6.5%, 5 g vaginally) Butoconazole sustained-release (2% cream, 5 g vaginally) Fluconazole (150-mg oral tablet) Three-day regimens include Butoconazole (2% cream, 5 g) once daily Clotrimazole (2% cream, 5 g) once daily Terconazole (0.8% cream, 5 g, or 80-mg suppository) once daily Miconazole (200-mg vaginal suppository) once daily Women with complicated vulvovaginal candidiasis should receive 7–14 days of a topical regimen or two doses of oral fluconazole 3 days apart. Complicated infections include Four or more episodes in 1 year Severe symptoms and signs Nonalbicans species Uncontrolled diabetes HIV infection Corticosteroid treatment Pregnancy Seven-day regimens include Clotrimazole (1% cream) once daily Miconazole (2% cream, 5 g, or 100-mg vaginal suppository) once daily Terconazole (0.4% cream, 5 g) once daily Fourteen-day regimen include Nystatin (100,000-unit vaginal tablet once daily) Women with recurrent vulvovaginal candidiasis may require maintenance therapy (for up to 6 months) with Clotrimazole (500-mg vaginal suppository) once weekly or clotrimazole (200 mg cream) twice weekly Fluconazole (100, 150, or 200 mg orally) once weekly Women with recurrent nonalbicans infections may require 600 mg of boric acid in a gelatin capsule intravaginally once daily for 2 weeks; this therapy is ~70% effective +++ Trichomonas vaginalis ++ Treatment of both partners is recommended with Metronidazole or tinidazole, 2 g orally, single dose For treatment failure with metronidazole in the absence of reexposure, retreat with metronidazole, 500 mg twice daily for 7 days, or tinidazole, 2 g orally as a single dose If this is not effective, metronidazole and tinidazole susceptibility testing can be arranged with the Centers for Disease Control and Prevention Women infected with T vaginalis are at increased risk for concurrent infection with other STDs +++ Bacterial vaginosis ++ Effective regimens most often used include Metronidazole, 500 mg twice daily orally for 7 days Clindamycin vaginal cream (2%, 5 g), once daily for 7 days Metronidazole gel (0.75%, 5 g), twice daily for 5 days Alternative regimens include Clindamycin, 300 mg twice daily orally for 7 days Clindamycin ovules, 100 g intravaginally at bedtime for 3 days Tinidazole, 2 g orally once daily for 3 days Tinidazole, 1 g orally once daily for 7 days +++ Condylomata acuminata ++ For vulvar warts Podophyllum resin 10–25% in tincture of benzoin (do not use during pregnancy or on bleeding lesions). Wash off after 2–4 hours 80–90% trichloroacetic or bichloroacetic acid. Apply carefully to avoid the surrounding skin Freezing with liquid nitrogen Patient-applied regimens Useful when the entire lesion is accessible to the patient Include podofilox 0.5% solution or gel, imiquimod 5% cream, or sinecatechins 15% ointment Vaginal warts may be treated with cryotherapy with liquid nitrogen or trichloroacetic acid Interferon is not recommended for routine use +++ Therapeutic Procedures ++ Routine examination of sex partners of women with genital warts is not necessary. However, partners may wish to be examined for detection and treatment of genital warts and other sexually transmitted diseases Vulvar warts: freezing with cryoprobe and electrocautery Vaginal warts: extensive warts may require treatment with CO2 laser, electrocautery, or excision under anesthesia + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Examination for pelvic infection + Reference Download Section PDF Listen +++ + +Giovanini AF et al. Bacterial vaginosis and desquamative inflammatory vaginitis. N Engl J Med. 2019 Mar 14;380(11):1088–9. [PubMed: 30865815]