eMedicine Specialties > Obstetrics and Gynecology > General Gynecology
Vaginitis
Updated: Dec 17, 2009
Introduction
Background
Vaginitis (infection of the vagina) is the most common gynecologic condition encountered in the office. Vaginitis is defined as the spectrum of conditions that cause vulvovaginal symptoms such as itching, burning, irritation, and abnormal discharge.
The most common causes of vaginitis in symptomatic women are bacterial vaginosis (22-50%), vulvovaginal candidiasis (17-39%), and trichomoniasis (4-35%); yet, 7-72% of women with vaginitis may remain undiagnosed. Accurate diagnosis may be elusive and must be distinguished from other infectious and noninfectious causes.
Pathophysiology
A complex and intricate balance of microorganisms maintains the normal vaginal flora. Important organisms include lactobacilli, corynebacteria, and yeast. Hormones further influence this microenvironment. A state of decreased estrogen, as occurs in prepuberty and postmenopause and following oophorectomy, can result in an altered risk of infection.
The normal postmenarchal and premenopausal vaginal pH is 3.8-4.2. At this pH, growth of pathogenic organisms usually is inhibited. Disturbance of the normal vaginal pH can alter the vaginal flora, leading to overgrowth of pathogens. Factors that alter vaginal environment include feminine hygiene products, contraceptives, vaginal medications, antibiotics, sexually transmitted diseases (STDs), sexual intercourse, and stress.
Frequency
United States
Bacterial vaginosis is the most common vaginal infection in women of childbearing age.1 In the United States, as many as 16% of pregnant women have bacterial vaginosis.1 An estimated 7.4 million new cases of bacterial vaginosis occur each year.1 An estimated 5 million cases of trichomoniasis occur each year in the United States.2 More than a billion dollars is estimated to be spent annually on both self-treatment and visits to a medical provider.
International
The worldwide prevalence of trichomoniasis is 174 million and accounts for 10-25% of vaginal infections.1
Mortality/Morbidity
Recurrent vaginal infections can lead to chronic irritation, excoriation, and scarring. These, in turn, can lead to sexual dysfunction. Psychosocial and emotional stresses are not uncommon. In addition, chronic vaginal infection can facilitate the transmission of other STDs, including HIV. Complications of bacterial vaginosis include endometritis, pelvic inflammatory disease (PID), and vaginal wound infections after gynecologic surgeries. In pregnancy, Trichomonas infection and bacterial vaginosis are associated with increased risk of premature rupture of the membranes, preterm labor, low birth weight, and preterm delivery.3
Race
Vaginitis affects all races. The highest incidence of bacterial vaginosis is in blacks (23%) and lowest in Asians (6%). The incidence is 9% in whites and 16% in Hispanics.2
Age
All age groups are affected. The highest incidence is noted among young, sexually active women.
Clinical
History
Patients with vaginitis almost always present with a chief complaint of abnormal vaginal discharge. A carefully documented history is essential in the diagnosis of vaginitis.
- Ascertain the following attributes of the discharge:
- Quantity
- Duration
- Color
- Consistency
- Odor
- Obtain history of the following:
- Prior similar episodes
- Sexually transmitted infection
- Sexual activities
- Birth control method
- Last menstrual period
- Douching practice
- Antibiotic use
- General medical history
- Systemic symptoms such as lower abdominal pain, fever, chills, nausea, and vomiting
- Bacterial vaginosis: This is characterized by thin, homogenous, malodorous white-to-grey vaginal discharge and pruritus. Vaginal pain or vulvar irritation is uncommon.
- Vaginal candidiasis: Pruritus is the most common symptom of vaginal candidiasis. This is accompanied by thick, odorless, white vaginal discharge (with an appearance similar to cottage cheese) that can be minimal. Usually, associated vulvar candidiasis is present, commonly with vulvar burning, dyspareunia, and vulvar dysuria (burning sensation when urine comes into contact with vulva skin).
- T vaginalis infection: Many patients (20-50%) are asymptomatic. Symptoms include profuse vaginal discharge that can be white, gray, yellow, or green. The yellow and green colors are due to the presence of WBCs. Dysuria (20%), pruritus (25%), and postcoital bleeding due to cervicitis are other possible symptoms.
Physical
- Bacterial vaginosis: Bacterial vaginosis discharges are frothy and white to grey. The discharge appears adherent to the vaginal mucosa. As many as 50% of women with bacterial vaginosis are asymptomatic.
- For diagnosis of bacterial vaginosis, 3 out of the following 4 criteria must be present:
- Homogenous, white, adherent discharge
- Vaginal pH higher than 4.5
- Release of fishy odor from vaginal discharge with potassium hydroxide (KOH)
- Clue cells on wet mount
- Vaginal candidiasis
- Erythema and swelling of the labia and vulva with satellite lesions (discrete pustulopapular lesions)
- Vaginal erythema with adherent thick, cottage cheese like vaginal discharge (the cervix usually appears normal)
- T vaginalis infection
- The vulva may appear erythematous and edematous, with excoriation.
- Look for homogenous vaginal discharge that can be white, gray, yellow, or green.
- Small punctate cervical and vaginal hemorrhages with ulcerations may be observed.
- "Strawberry cervix" or "colpitis macularis" is very specific for Trichomonas infection, and 2-5% of patients will have this finding on examination.
- Diagnosis of Trichomonas infection based on clinical signs and symptoms is unreliable, so laboratory confirmation is mandatory.
Causes
Bacterial vaginosis, vaginal candidiasis, and T vaginalis infection are thought to cause approximately 90% of all vaginal infections.
- Bacterial vaginosis is the most common cause of vaginitis, accounting for 50% of vaginitis cases. As previously mentioned, bacterial vaginosis is caused by an overgrowth of organisms such as Gardnerella vaginalis (gram-variable coccobacillus), Mobiluncus species, Mycoplasma hominis, and Peptostreptococcus species. Risk factors include pregnancy, intrauterine device (IUD) use, and frequent douching.
- Candida species (C albicans, C tropicalis, and C glabrata) are airborne fungi that are natural inhabitants of the vagina in as many as 50% of women, and vaginal candidiasis is the second most common cause of vaginitis. Risk factors include oral contraceptive use, IUD use, young age at first intercourse, increased frequency of intercourse, receptive cunnilingus, diabetes, HIV or other immunocompromised states, chronic antibiotic use, and pregnancy.
- T vaginalis infection, the third most common cause of vaginitis, is caused by trichomonads. These organisms are flagellated protozoans. Trichomonads primarily infect vaginal epithelium, and they less commonly infect the endocervix, urethra, and Bartholin and Skene glands. Trichomonads are transmitted sexually and can be identified in as many as 80% of male partners of infected women. Risk factors include tobacco use, unprotected intercourse with multiple sexual partners, and the use of an IUD.
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References
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Further Reading
Keywords
vaginitis, vaginal infection, Trichomonas vaginalis, vaginal candidiasis, Candida infection, bacterial vaginosis, BV, pelvic inflammatory disease, PID, yeast infection, vaginal pH, treatment, diagnosis, symptoms
