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 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 ).