Updated: 5/11/2020

Vaginitis

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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
  • Symptoms
    • malodorous ("fishy" odor) vaginal discharge
    • nonpainful
  • Physical exam
    • off-white or gray and thin vaginal discharge
    • normal vulva
Vulvovaginal candidiasis 

  • Candida albicans
  • Symptoms
    • pruritus and soreness
    • dyspareunia
  • Physical exam
    • thick, white, odorless, and curd-like vaginal discharge
    • vulvar erythema and edema
Trichomoniasis 
  • Trichomonas vaginalis
  • Symptoms
    • malodorous greenish discharge
    • burning
    • dyspareunia and dysuria
    • postcoital bleeding
  • Physical exam
    • malodorous discharge
    • "strawberry" cervix
    • vulvovaginal erythema
  • Important note
    • sexually 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
Clue
cells (vaginal epithelial cells covered with
Gardnerella) have stippled appearance along
outer margin (arrow in A ).
 

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(M1.RP.15.75) A 24-year-old woman presents complaining of a new onset vaginal odor. She reports that she is sexually active in a monogamous relationship with the same partner for two years. You perform a KOH prep, and notice an abnormal smell. On microscopy in your office, you observe the findings in figure A.

What is the most likely causative organism?
Tested Concept

QID: 106728
FIGURES:
1

Trichomonas vaginalis

15%

(18/122)

2

Candida albicans

5%

(6/122)

3

Escherichia coli

0%

(0/122)

4

Gardnerella vaginalis

77%

(94/122)

5

Neisseria gonorrhoeae

1%

(1/122)

M 2 E

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