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. Introduction Clinical definition vaginal disorder secondary to infection inflammation changes in normal vaginal flora Epidemiology risk factors bacterial vaginosis login to view 3 more bullets trichomoniasis login to view 2 more bullets vulvovaginal candidiasis login to view 3 more bullets 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 login to view 2 more bullets pathogenesis disruption of this acidic environment results in vaginitis login to view 9 more bullets 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 login to view 1 more bullet Vaginal pH normal findings login to view 1 more bullet bacterial vaginosis login to view 1 more bullet vulvovaginal candidiasis login to view 1 more bullet trichomoniasis login to view 1 more bullet Saline microscopy (wet mount) bacterial vaginosis login to view 1 more bullet vulvovaginal candidiasis login to view 1 more bullet trichomoniasis login to view 1 more bullet Potassium hydroxide (KOH) wet mount login to view 2 more bullets Amine test ("whiff" test) login to view 1 more bullet Differential Atrophic vaginitis distinguishing factors typically seen in menopausal womenon physical exam there is login to view 3 more bullets Treatment Medical metronidazole indications login to view 5 more bullets -azole indication login to view 2 more bullets medications include login to view 3 more bullets 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