Inflammation and infection of the vagina are common gynecologic complaints, resulting from a variety of pathogens, allergic reactions to vaginal contraceptives or other products, vaginal atrophy, or friction during coitus. The normal vaginal pH is 4.5 or less, and Lactobacillus is the predominant organism. Normal secretions during the middle of the cycle, or during pregnancy, can be confused with vaginitis.
When the patient complains of vaginal irritation, pain, pruritus or unusual or malodorous discharge, a history should be taken, noting the onset, location, duration, and characterization of symptoms including triggers and alleviating factors. Additional history should include the LMP; recent sexual activity; use of contraceptives, tampons, or douches; and recent changes in medications or use of antibiotics. The physical examination should include careful inspection of the vulva and speculum examination of the vagina and cervix. A vaginal, cervical, or urine sample can be obtained for detection of gonococcus and chlamydia, if clinically indicated. Evaluation for yeast, bacterial vaginosis, and trichomonas should be performed. The vaginal pH should be tested; it is frequently greater than 4.5 in infections due to trichomonads and bacterial vaginosis. A bimanual examination to look for evidence of pelvic infection, namely cervical motion, uterine, or adnexal tenderness, should follow. Point-of-care testing is available for all three main organisms that cause vaginitis and can be used if microscopy is not available or for confirmatory testing of microscopy.
A. Vulvovaginal Candidiasis
Pregnancy, diabetes mellitus, and use of broad-spectrum antibiotics or corticosteroids predispose patients to Candida infections. Heat, moisture, and occlusive clothing also contribute to the risk. Pruritus, vulvovaginal erythema, and a white curd-like discharge that is not malodorous are found (Figure 18–2). Microscopic examination with 10% potassium hydroxide reveals hyphae and spores (eFigure 18–16). A swab for cultures or for PCR testing may be performed if Candida is suspected but not demonstrated.
Potassium hydroxide (KOH) preparation showing branched hyphae and budding yeast of Candida albicans. (Reproduced, with permission, from DeCherney AH, Nathan L, Laufer N, Roman S. Current Diagnosis & Treatment: Obstetrics & Gynecology, 12th edition. McGraw-Hill, 2019.)
Cervical candidiasis. (Public Health Image Library, CDC.)
B. Trichomonas vaginalis Vaginitis
This sexually transmitted protozoal flagellate infects the vagina, Skene ducts, and lower urinary tract in women and the lower genitourinary tract in men. Pruritus and a malodorous frothy, yellow-green discharge occur, along with diffuse vaginal erythema and red macular lesions on the cervix in severe cases (“strawberry cervix,” Figure 18–3). Motile organisms with flagella ...