Essentials of Diagnosis
- Vaginal irritation, pruritus, pain, or unusual discharge.
Inflammation and infection of the vagina are common gynecologic problems, resulting from a variety of pathogens, allergic reactions to vaginal contraceptives or other products, or the friction of coitus. The normal vaginal pH is 4.5 or less, and lactobacillus is the predominant organism. At the time of the midcycle estrogen surge, clear, elastic, mucoid secretions from the cervical os are often profuse. In the luteal phase and during pregnancy, vaginal secretions are thicker, white, and sometimes adherent to the vaginal walls. These normal secretions can be confused with vaginitis by concerned women.
When the patient complains of vaginal irritation, pain, or unusual discharge, a careful history should be taken, noting the onset of the last menstrual period; recent sexual activity; use of contraceptives, tampons, or douches; and the presence of vaginal burning, pain, pruritus, or unusually profuse or malodorous discharge. The physical examination should include careful inspection of the vulva and speculum examination of the vagina and cervix. The cervix is cultured for gonococcus or chlamydia if applicable. A specimen of vaginal discharge is examined under the microscope in a drop of 0.9% saline solution to look for trichomonads or clue cells and in a drop of 10% potassium hydroxide to search for candida. 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 should follow.
A. Vulvovaginal Candidiasis
Pregnancy, diabetes, and use of broad-spectrum antibiotics or corticosteroids predispose 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. Microscopic examination with 10% potassium hydroxide reveals filaments and spores. Cultures with Nickerson’s medium may be used if candida is suspected but not demonstrated.
B. Trichomonas vaginalis Vaginitis
This protozoal flagellate infects the vagina, Skene’s ducts, and lower urinary tract in women and the lower genitourinary tract in men. It is transmitted through coitus. Pruritus and a malodorous frothy, yellow-green discharge occur, along with diffuse vaginal erythema and red macular lesions on the cervix in severe cases. Motile organisms with flagella are seen by microscopic examination of a wet mount with saline solution.
C. Bacterial Vaginosis
This condition is considered to be a polymicrobial disease which is not sexually transmitted. An overgrowth of gardnerella and other anaerobes is often associated with increased malodorous discharge without obvious vulvitis or vaginitis. The discharge is grayish and sometimes frothy, with a pH of 5.0-5.5. An amine-like (“fishy”) odor is present if a drop of discharge is alkalinized with 10% potassium hydroxide. On wet mount in saline, epithelial cells are covered with bacteria to such an extent that cell borders are obscured (clue cells). Vaginal cultures are generally not useful in diagnosis.
D. Condylomata Acuminata (Genital Warts)
Warty growths on the vulva, perianal area, vaginal walls, or cervix are caused by various types of the human papillomavirus. They are sexually transmitted. Pregnancy and immunosuppression favor growth. Vulvar lesions may be obviously wart-like or may be diagnosed only after application of 4% acetic acid (vinegar) and colposcopy, when they appear whitish, with prominent papillae. Fissures may be present at the fourchette. Vaginal lesions may show diffuse hypertrophy or a cobblestone appearance. Cervical lesions may be visible only by colposcopy after pretreatment with 4% acetic acid. These lesions may be related to dysplasia and cervical cancer. Vulvar cancer is also currently considered to be associated with the human papillomavirus.
A. Vulvovaginal Candidiasis
A variety of regimens are available to treat vulvovaginal candidiasis. Women with uncomplicated vulvovaginal candidiasis will usually respond to a 1- to 3-day regimen of a topical azole. Women with complicated infection (including four or more episodes in 1 year, severe signs and symptoms, non-albicans species, uncontrolled diabetes, HIV infection, corticosteroid treatment, or pregnancy) should receive 7-14 days of a topical regimen or two doses of fluconazole 3 days apart. (Pregnant women should use only topical azoles.)
1. Three-day regimens
Butoconazole (2% cream, 5 g), clotrimazole (two 100-mg vaginal tablets), terconazole (0.8% cream, 5 g, or 80-mg suppository), or miconazole (200-mg vaginal suppository) once daily.
2. Seven-day regimens
Clotrimazole (1% cream or 100-mg vaginal tablet), miconazole (2% cream, 5 g, or 100-mg vaginal suppository), or terconazole (0.4% cream, 5 g) once daily.
3. Single-dose regimens
Clotrimazole (500-mg tablet) or tioconazole ointment (6.5%, 5 g). Fluconazole, 150 mg orally in a single dose, is also effective.
4. Fourteen-day regimens
Nystatin (100,000-unit vaginal tablet once daily).
5. Recurrent vulvovaginitis (maintenance therapy)
Ketoconazole (100 mg orally) once daily for up to 6 months, clotrimazole (500-mg vaginal suppository) once weekly, fluconazole (100-150 mg) once weekly, or itraconazole (400 mg) once monthly or 100 mg once daily.
B. Trichomonas vaginalis Vaginitis
Treatment of both partners simultaneously is recommended; metronidazole, 2 g as a single dose or 500 mg twice a day for 7 days, is usually employed. In the case of treatment failure in the absence of reexposure, the patient should be re-treated with metronidazole, 500 mg twice a day for 7 days. If treatment failure occurs again, give metronidazole, 2 g once daily for 3-5 days. If this is not effective in eradicating the organisms, metronidazole susceptibility testing can be arranged with the CDC at 770-488-4115.
C. Bacterial Vaginosis
The recommended regimens are metronidazole, 500 mg twice daily for 7 days, clindamycin vaginal cream (2%, 5 g), once daily for 7 days, or metronidazole gel (0.75%, 5 g), twice daily for 5 days. Alternative regimens include metronidazole, 2 g orally as a single dose, clindamycin, 300 mg orally twice daily for 7 days, or clindamycin ovules, 100 g intravaginally at bedtime for 3 days.
D. Condylomata Acuminata
Recommended treatments for vulvar warts include podophyllum resin 10-25% in tincture of benzoin (do not use during pregnancy or on bleeding lesions) or 80-90% trichloroacetic or bichloroacetic acid, carefully applied to avoid the surrounding skin. The pain of bi- or trichloroacetic acid application can be lessened by a sodium bicarbonate paste applied immediately after treatment. Podophyllum resin must be washed off after 2-4 hours. Freezing with liquid nitrogen or a cryoprobe and electrocautery are also effective. Patient-applied regimens include podofilox 0.5% solution or gel and imiquimod 5% cream. Vaginal warts may be treated with cryotherapy with liquid nitrogen, trichloroacetic acid, or podophyllum resin. Extensive warts may require treatment with CO2 laser under local or general anesthesia. Interferon is not recommended for routine use because it is very expensive, associated with systemic side effects, and no more effective than other therapies. Routine examination of sex partners is not necessary for the management of genital warts since the risk of reinfection is probably minimal and curative therapy to prevent transmission is not available. However, partners may wish to be examined for detection and treatment of genital warts and other STDs.
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Egan ME: Diagnosis of vaginitis. Am Fam Physician 2000;62:1095.
Sexually transmitted disease treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51(RR-6):1.
Revision date: July 6, 2011
Last revised: by Andrew G. Epstein, M.D.