Vaginitis (inflammation of the vagina) is the most common gynecologic condition encountered in the office. It is a diagnosis based on the presence of symptoms of abnormal discharge, vulvovaginal discomfort, or both. Cervicitis may also cause a discharge and sometimes occurs with vaginitis.
Discharge flows from the vagina daily as the body’s way of maintaining a normal healthy environment. Normal discharge is usually clear or milky with no malodor. A change in the amount, color, or smell; irritation; or itching or burning could be due to an imbalance of healthy bacteria in the vagina, leading to vaginitis.
The most common causes of vaginitis in symptomatic women are bacterial vaginosis (40-45%), vaginal candidiasis (20-25%), and trichomoniasis (15-20%); yet 7-72% of women with vaginitis may remain undiagnosed.
The workup for patients with vaginitis depends on the risk factors for infection and the age of the patient. Accurate diagnosis may be elusive, and care must be taken to distinguish vaginitis from other infectious and noninfectious causes of symptoms. All women presenting with abnormal vaginal discharge should have a careful pelvic examination. Condition-specific tests (ie, colposcopy and cervical biopsies) are indicated for suspected cervical cancer.
Studies that may be performed in cases of suspected vaginitis include saline wet mount, the so-called whiff test, pH testing, culture, nucleic acid amplification testing, and a number of other second-line tests (see Presentation, DDx, and Workup).
Treatment of vaginitis varies by cause and is directed at the relevant pathogen. Inpatient care usually is not indicated, unless serious pelvic infections arise or evidence of systemic infection in an immunocompromised host is present (see Treatment).
A complex and intricate balance of microorganisms maintains the normal vaginal flora. Important organisms include lactobacilli, corynebacteria, and yeast. Aerobic and anaerobic bacteria can be cultured from the vagina of prepubertal girls, pubertal adolescents, and adult women. A number of factors can change the composition of the vaginal flora, including the following:
Sexual activity (or abuse)
Underlying skin diseases
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 the vaginal environment include feminine hygiene products, contraceptives, vaginal medications, antibiotics, sexually transmitted diseases (STDs), sexual intercourse, and stress.
The overgrowth of normally present bacteria, infecting bacteria, or viruses can cause symptoms of vaginitis. Chemical irritation also can be a significant factor. Atrophic vaginitis is associated with hypoestrogenism, and symptoms include dyspareunia, dryness, pruritus, and abnormal bleeding. A state of decreased estrogen can result in an altered risk of infection.
Based on data from 11 countries, Kenyon and Colebunders found evidence that the risk of bacterial vaginosis is increased in women whose male sexual partner is concurrently having sexual relations with other partners. 
The age of the patient affects the anatomy and physiology of the vagina. Prepubertal children have a more alkaline vaginal pH than do pubertal and postpubertal adolescents and women. The vaginal mucosa is columnar epithelium, vaginal mucous glands are absent, the normal vaginal flora is similar to that of postmenopausal women (eg, gram-positive cocci and anaerobic gram-negatives are more common), and the labia are thin with a thin hymen.
Pubertal and postpubertal adolescents and women have a more acidic vaginal pH, a stratified squamous vaginal mucosa, vaginal mucous glands, a normal vaginal flora dominated by lactobacilli, thick labia, and hypertrophied hymens and vaginal walls. Loss of vaginal lactobacilli appears to be the primary factor in the changes leading to bacterial vaginosis. Recurrences of vaginitis are associated with a failure to establish a healthy vaginal microflora dominated by lactobacilli.
Approximately 90% of all cases of vaginitis are thought to be attributable to 3 causes: bacterial vaginosis, vaginal candidiasis (or vulvovaginal candidiasis [VVC]), and Trichomonas vaginalis infection (trichomoniasis).
Bacterial vaginosis is the most common cause of vaginitis, accounting for 50% of cases. As previously mentioned, bacterial vaginosis is caused by an overgrowth of organisms such as Gardnerella vaginalis (a gram-variable coccobacillus), Mobiluncus species, Mycoplasma hominis, and Peptostreptococcus species. Risk factors include pregnancy, intrauterine device (IUD) use, and frequent douching.
Candida species (including C albicans, C tropicalis, and C glabrata) are airborne fungi that are natural inhabitants of the vagina in as many as 50% of women. Vaginal candidiasis is the second most common cause of vaginitis. In 85-90% of cases, it is caused by C albicans, and in 5-10%, it is caused by C glabrata or C parapsilosis. 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, long-term antibiotic use, and pregnancy.
T vaginalis infection, the third most common cause of vaginitis, is caused by trichomonads. T vaginalis is an oval-shaped or fusiform-shaped flagellated protozoan that is 15 μm long (the size of a leukocyte). These organisms primarily infect vaginal epithelium; less commonly, they 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.
A study by Mercer et al suggested that symbionts, commensals, and concomitant infections impact the adaptive immune response to T vaginalis, finding that the presence of M hominis in vitro led to greater diversity in the inflammatory cytokine secretion response to T vaginalis. 
Noninfectious vaginitis is usually due to allergic reaction or irritation. Another common cause is atrophic vaginitis due to estrogen deficiency.
Common preventable causes of candidal vaginitis or bacterial vaginosis include damp or tight-fitting clothing, scented detergents and soaps, feminine sprays, and poor hygiene.
For related information, see the Women’s Sexual Health Resource Center.
Vaginitis is common in adult women and uncommon in prepubertal girls. Bacterial vaginosis accounts for 40-50% of vaginitis cases; vaginal candidiasis, 20-25%; and trichomoniasis, 15-20%.
In US women of childbearing age, bacterial vaginosis is the most common vaginal infection. An estimated 7.4 million new cases of bacterial vaginosis occur each year.  National data show that the prevalence is 29%. However, the rate varies in different subpopulations: it is 5-25% in college students and 12-61% in patients with STDs.  In the United States, as many as 16% of pregnant women have bacterial vaginosis.  A 50-60% prevalence is found in female prison inmates and commercial sex workers.
Eighty-five percent of those with bacterial vaginosis are asymptomatic. More than a billion dollars is estimated to be spent annually on both self-treatment and visits to a medical provider.
An estimated 3 million cases of trichomoniasis occur each year in the United States.  The worldwide prevalence of trichomoniasis is 174 million; these cases account for 10-25% of all vaginal infections. 
Age- and race-related demographics
All age groups are affected. The highest incidence is noted among young, sexually active women.
Vaginitis affects all races. The highest incidence of bacterial vaginosis is in blacks (23%), and the lowest is in Asians (6%). Prevalence increases with age among non-Hispanic black women. The incidence is 9% in whites and 16% in Hispanics. 
Overall, the prognosis is very good: most of those infected are cured. However, 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.
Although treatment of bacterial vaginosis has not been documented to prevent HIV, bacterial vaginosis and sexually transmitted infections, including trichomoniasis, are considered to be risk factors for HIV. Chronic vaginal infection can facilitate the transmission of various STDs, including HIV.
Complications of bacterial vaginosis include endometritis and pelvic inflammatory disease (PID). Untreated bacterial vaginosis may result in complications (eg, vaginal wound infections) after gynecologic surgical procedures.
In pregnancy, Trichomonas infection and bacterial vaginosis are associated with an increased risk of adverse pregnancy outcomes, including preterm labor, premature rupture of membranes, preterm delivery, low birth weight, and postpartum endometritis. 
Safe sex and STD counseling may help decrease the rates of reinfection. Discuss further preventive efforts, including proper hygiene and toilet techniques, when it is appropriate to do so. Remind patients that douching can spread a vaginal or cervical infection into the uterus, increasing the likelihood of PID; douching can also be associated with endometritis. Educate patients regarding use of topical creams for treatment of vaginitis (eg, candidal vaginitis, bacterial vaginosis) as necessary.
What would you like to print?