Vaginitis

Key Features

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

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

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 ...