eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Vaginitis

Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, New Jersey

Updated: Dec 8, 2008

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 (BV) (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.

For a related CME activity, see Screening Pregnant Women for Bacterial Vaginosis Not Recommended.

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 (BV) is the most common vaginal infection in women of childbearing age.²⁰
• In the United States, as many as 16% of pregnant women have BV.²⁰
• An estimated 7.4 million new cases of BV occur each year.²⁰
• An estimated 5 million cases of trichomoniasis occur each year in the United States.¹⁹
• 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.²⁰

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 BV include endometritis, pelvic inflammatory disease (PID), and vaginal wound infections after gynecologic surgeries. In pregnancy, Trichomonas infection and BV are associated with increased risk of premature rupture of the membranes, preterm labor, low birth weight, and preterm delivery.

Race

Vaginitis affects all races. The highest incidence of bacterial vaginosis is in African Americans (23%) and lowest in Asians (6%). The incidence is 9% in whites and 16% in Hispanics.¹⁹

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: BV discharges are frothy and white to grey. The discharge appears adherent to the vaginal mucosa. As many as 50% of women with BV are asymptomatic.
• For diagnosis of BV, 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

BV, vaginal candidiasis, and T vaginalis infection are thought to cause approximately 90% of all vaginal infections.

• BV is the most common cause of vaginitis, accounting for 50% of vaginitis cases. As previously mentioned, BV 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.

Differential Diagnoses

Other Problems to Be Considered

Atrophic vaginitis
Cervical polyp
Contact dermatitis
Entamoeba histolytica
Excessive desquamation of normal vaginal epithelium
Foreign objects
Large cervical ectropion
Lichen sclerosis
Lichen simplex chronicus
Vaginal adenosis
Vaginal cancer
Vaginal intraepithelial neoplasia
Vaginal ulcers
Vaginal emphysematosa (multiple gas-filled cysts on the vaginal and cervical mucosa)

Workup

Laboratory Studies

• Saline wet mount: Vaginal discharge is placed on a slide with 1-2 drops of 0.9% isotonic sodium chloride solution and examined under high power (x 400).
  • Bacterial vaginosis: Saline wet mount is 60% sensitive and 98% specific. Clue cells are vaginal epithelial cells covered with many vaginal rods and cocci bacteria, creating a stippled or granular appearance. A decreased number of lactobacilli is observed, and WBCs are absent.
  • Vaginal candidiasis: Hyphae and budding yeast forms are noted.
  • T vaginalis infection: Saline wet mount is 80-90% sensitive in symptomatic women. T vaginalis is an oval- or fusiform-shaped protozoan that is 15 mm long (size of a leukocyte), with erratic, twitching motility. A large number of WBCs and epithelial cells are observed.
• Potassium hydroxide preparation: Vaginal discharge is placed on a slide with 10% KOH solution. Known as the whiff test, a positive finding is the release of a fishy odor after addition of 10% KOH to discharge. The odor is due to the release of amines such as putrescine, cadaverine, histamine, and trimethylamine.
  • Bacterial vaginosis: Whiff test is one of the most specific tests for BV and the least sensitive.
  • Vaginal candidiasis: Negative whiff test is 65%-85% sensitive for candidal infection.
  • Trichomonas vaginitis: Whiff test may be positive.
• pH: Vaginal pH can be determined with litmus paper. A pH greater than 4.5 often is found in patients with Trichomonas infection or BV (84-97% sensitive, 57-78% specific). Recent intercourse, douching, cervical mucus, and blood can lead to false-positive results.
  • Bacterial vaginosis: pH is 5.0-6.0.
  • Vaginal candidiasis: pH is less than 4.5.
  • T vaginalis infection: pH is 5.0-7.0.
• Cultures
  • Cultures have little utility for diagnosing BV. Gram stain is 89-97% sensitive and 79-85% specific for detecting BV.
  • Cultures with Nickerson or Sabouraud mediums should be performed in refractory or recurrent cases of vaginal candidiasis.
  • Culture using Diamond medium is the criterion standard for detection of trichomonads and should be used when infection is suspected but cannot be confirmed by other means.
• Other second-line tests
  • Staining methods (Giemsa, Papanicolaou, Schiff): Sensitivity is 55% and specificity is 97% for detecting BV. Papanicolaou test is not accurate in the diagnosis of Trichomonas infections due to high false-positive and false-negative rates.
  • Latex agglutination test: This test employs polyclonal antibodies reactive against multiple species of Candida.
  • Gas-liquid chromatography: This can be used to detect the succinate-to-lactate ratio in vaginal fluid to assist in diagnosis of BV. Succinate and lactate are metabolites produced by anaerobic gram-negative rods and lactobacilli, respectively.
  • Oligonucleotide probes: These detect high (>10⁷/mL) concentrations of Gardnerella vaginalis. This test also can detect Candida.
  • Antigen-detecting immunoassays, the OSOM Trichomonas Rapid Test, DNA probes, and polymerase chain reaction (PCR): These are useful for detecting trichomonads.

Procedures

All women presenting with abnormal vaginal discharge should have a careful pelvic examination. Have patients take condition-specific tests, ie, colposcopy and cervical biopsies, for suspected cervical cancer.

Histologic Findings

T vaginalis infection can be confused with koilocytotic atypia, caused by the human papilloma virus, and may mimic findings of mild dysplasia. BV may produce inflammation and atypical squamous cells of undetermined significance (ASCUS) on Papanicolaou tests. Also, BV may be linked with cervical intraepithelial neoplasia (CIN).

Treatment

Medical Care

T vaginalis infection

• Recommended regimens for T vaginalis infection
  • Metronidazole 2 g orally in a single dose
    
    OR
  • Tinidazole 2 g orally in a single dose
• An alternative regimen - Metronidazole 500 mg orally twice a day for 7 days
• Because trichomonads often infect the urethra and the Skene and Bartholin glands, metronidazole gel is considerably less efficacious than an oral preparation; therefore, use of the gel is not recommended.
• Sex partners of patients with T vaginalis should be treated and avoid intercourse till both are treated and are asymptomatic.
• Pregnant women with trichomoniasis may be treated with 2 g of metronidazole in a single dose.
• Lactating women should withhold breastfeeding during treatment and for 12-24 hours after the last dose of metronidazole. For women taking tinidazole, breastfeeding should be interrupted during treatment and for 3 days after the last dose.
• Metronidazole (Flagyl) is the treatment of choice both for patients who are immunocompetent and for those who are immunocompromised.
• Topical treatment with nonoxynol-9 and povidone-iodine douches has been shown to be effective in treating T vaginalis infection in women unable to use metronidazole. Further studies are needed to confirm this preliminary finding.
• A vaccine of killed "aberrant lactobacilli" is available in Europe. This vaccine has not been evaluated in well-controlled, double-blind prospective trials.

Bacterial vaginosis         

• Recommended regimens for bacterial vaginosis
  • Metronidazole 500 mg orally twice a day for 7 days
    
    OR
  • Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally, once a day for 5 days
    
    OR
  • Clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days
• Alternative regimen
  • Clindamycin 300 mg orally twice a day for 7 days
    
    OR
  • Clindamycin ovules 100 mg intravaginally once at bed time for 3 days.
• Patients should be advised to avoid alcohol consumption during and 24 hrs after treatment with metronidazole.
• Clindamycin cream is oil based and might weaken latex condoms and diaphragms for 5 days after use. 
• Clindamycin should not be used in the second half of pregnancy.
• Routine follow-up visits are unnecessary.
• Routine treatment of sex partners is not recommended.
• Regimens for pregnant women with bacterial vaginosis
  • Metronidazole 500 mg orally twice a day for 7 days
    
    OR
  • Metronidazole 250 mg orally 3 times a day for 7 day
    
    OR
  • Clindamycin 300 mg orally twice a day for 7 day
• Pregnant women should have a follow up visit 1 month after completion of treatment.
• Treatment regimens in patients with HIV are the same as in patients without HIV, but bacterial vaginosis appears to be more persistent in women who are HIV positive.

Vaginal candidiasis

• Classification of vulvovaginosis candidiasis (VVC)
  • Uncomplicated VVC - Sporadic or infrequent VVC and mild-to-moderate VVC and likely to be Candida albicans candidiasis and nonimmunocompromised women  
  • Complicated VVC - Recurrent VVC or severe VVC or non - albicans or immunocompromised women
• Recommended regimens - Intravaginal agents
  • Butoconazole 2% cream 5g intravaginally for 3 days 
    
    OR
  • Butaconazole 2% cream 5g (butaconazole 1 sustained release) single intravaginal application
    
    OR
  • Clotrimazole 1% cream 5 g intravaginally for 7-14 days
    
    OR
  • Clotrimazole 100 mg vaginal tablet for 7 days
    
    OR
  • Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
    
    OR
  • Miconazole 2% cream 5 g intravaginally for 7 days
    
    OR
  • Miconazole 100 mg vaginal suppository, 1 suppository for 7 days
    
    OR
  • Miconazole 200 mg vaginal suppository, 1 suppository for 3 days
    
    OR
  • Miconazole 1200 mg vaginal suppository, 1 suppository for 1 day
    
    OR
  • Nystatin 100,000 unit vaginal tablet, 1 tablet for 14 days
    
     OR
  • Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
• Recommended regimens - Oral agents
  • Fluconazole, 150 mg oral tablet in single dose
• The cream and suppositories are oil based and might weaken latex condoms. 
• Patients are instructed to return only if symptoms persists or recur within 2 months of onset of initial symptoms.
• Routine treatment of sex partners is not indicated.
• Complicated VVC
  • Recurrent VVC is 4 or more episodes of symptomatic VVC in 1 year.
  • Recommended regimen: 7-10 days of topical therapy or 100 or 150 mg oral dose of fluconazole every third day for a total of 3 doses (day 1, 4, and 7).
  • Maintenance regimen: Oral fluconazole 100 or 150 mg weekly for 6 months is first line of treatment.
  • Topical azole therapies applied for 7 days are recommended in pregnant patients. 

Consultations

For resistant infections, consider an infectious disease consultation. Notification of the Centers for Disease Control and Prevention (CDC) may be warranted.

Diet

Acidophilus supplements in the diet may help prevent vaginitis, especially if patients are taking antibiotics.

Activity

Instruct patients to abstain from sexual activity and from douching until a diagnosis has been made. Patients also should abstain from unprotected sexual activity (sexual activity without proper male condom use) until the infection has been treated.

Medication

The goals of pharmacotherapy are to reduce morbidity, prevent complications, and eradicate the infection.

Antiprotozoal agents

Metronidazole is the antimicrobial agent of choice to treat T vaginalis infections and bacterial vaginosis.

Metronidazole (Flagyl)

Causes chemical reduction reaction within anaerobic bacteria and sensitive protozoa. Readily absorbed and permeates all tissues, including cerebral spinal fluid, breast milk, and alveolar bone. Metabolized and excreted in liver and kidneys. Treatment of partners increases cure rates.

Dosing

Adult

2 g PO as single dose (to treat trichomoniasis) or 500 mg PO bid for 7 d
Recurrence: 2 g PO qd for 3-5 d

Pediatric

15 mg/kg/d PO divided tid for 7 d; not to exceed adult dose

Interactions

Possible increased toxicity with concurrent administration of cimetidine; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol; may cause psychosis with disulfiram; possible decreased effects with phenytoin and phenobarbital

Contraindications

Documented hypersensitivity; long-term blood dyscrasias

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; may cause nausea, headaches, dry mouth or metallic taste in mouth, and reddish or dark-colored urine; rarely, vomiting, diarrhea, insomnia, weakness, dizziness, stomatitis, rash, urethral burning, vertigo, and paresthesias may occur; if pregnant, delaying use is recommended until after first trimester (however, no increased risk of congenital abnormalities, stillbirths, or low birth weight infants has been reported); try to avoid in breastfeeding women; the current STD guidelines published by the CDC recommend deferring use of metronidazole past the first trimester

Antifungals

Imidazole derivatives that exert a fungicidal effect by altering permeability of the fungal cell membrane. The mechanism of action also may involve alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to fungal cell.

Miconazole (Monistat 3, Monistat 7 suppository or cream, Monistat Dual Pak)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death. Metabolism occurs in the liver. Products available OTC are indicated. Recurrent infections usually are treated with intravaginal regimens for 10-14 d, followed by maintenance oral treatment for 6 mo. Dual Pak is not for use in children.

Dosing

Adult

200-mg vaginal supp: Insert 1 qhs for 3 d
100-mg vaginal supp: Insert 1 qhs for 7 d
2% cream: Insert 1 applicator full (5 g) intravaginally qhs for 7 d
Monistat Dual Pak: 1200 mg vaginal insert once plus 2% cream for external use

Pediatric

Administer as in adults

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; adverse effects include vaginal burning, irritation, and dyspareunia

Clotrimazole (Gyne-Lotrimin, Mycelex 7, Mycelex G)

Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.

Dosing

Adult

100-mg tab: Insert 1 tab intravaginally qhs for 7 d or 2 tabs intravaginally for 3 d
500-mg tab: Insert 1 tab intravaginally once
1% cream: Insert 1 applicator full intravaginally qhs for 7-14 d

Pediatric

Children: Not established
Adolescents: Administer as in adults

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for treatment of systemic fungal infections; avoid contact with the eyes; if irritation or sensitivity develops, discontinue use and institute appropriate therapy

Terconazole (Terazol 7, Terazol 3)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased, causing nutrients to leak out, which results in fungal cell death

Dosing

Adult

0.4% cream: Insert 1 applicator full (5 g) intravaginally for 7 d
0.8% cream: Insert 1 applicator full (5 g) intravaginally qhs for 3 d
80-mg vaginal supp: Insert 1 qhs for 3 d

Pediatric

Not established

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes; high doses may cause fever or flulike symptoms

Tioconazole (Vagistat 1)

Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.

Dosing

Adult

6.5% ointment: Insert 1 applicator full (5 g) intravaginally once

Pediatric

Not established

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid contact with eyes; if irritation or sensitivity develops, discontinue use

Butoconazole (Femstat 3, Mycelex 3)

Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.

Dosing

Adult

2% cream: Insert 1 applicator full (5 g) intravaginally qhs for 3 d

Pediatric

Not established

Interactions

May impair barrier contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Avoid contact with eyes; if irritation or sensitivity develops, discontinue use

Nystatin (Mycostatin)

Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak.

Dosing

Adult

100,000-U tab: Insert 1 tab intravaginally qd for 14 d

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat systemic mycoses

Fluconazole (Diflucan)

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha demethylation.

Dosing

Adult

150-mg tab PO as single dose

Pediatric

5 mg/kg PO as single dose; not to exceed 150 mg/d

Interactions

Levels may increase with hydrochlorothiazides; fluconazole levels may decrease with chronic coadministration of rifampin; may increase concentrations of theophylline, phenytoin, tolbutamide, cyclosporine, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration

Contraindications

Documented hypersensitivity; liver failure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor closely if rashes develop and discontinue drug if lesions progress; possible clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions (eg, AIDS, malignancy) and while taking multiple concomitant medications; not recommended for breastfeeding women; convenience and efficacy of the single-dose regimen should be weighed against the difficulties resulting from a higher incidence of adverse reactions reported with oral fluconazole versus intravaginal agents; causes nausea, vomiting, rashes, abdominal pain, headaches, and hepatic impairment

Ketoconazole (Nizoral)

Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, which results in fungal cell death. Usually used for maintenance therapy for recurrent vulvovaginal candidiasis

Dosing

Adult

100 mg (half of 200-mg tab) PO qd for up to 6 mo

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Interactions

Isoniazid may decrease bioavailability of ketoconazole; coadministration decreases effects of either rifampin or ketoconazole; may increase effect of anticoagulants; may increase toxicity of corticosteroids and cyclosporine (cyclosporine dosage can be adjusted); may decrease theophylline levels

Contraindications

Documented hypersensitivity; fungal meningitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatotoxicity may occur; may reversibly decrease corticosteroid serum levels (adverse effects avoided with dose of 200-400 mg/d); administer antacid, anticholinergics, or H2-blockers at least 2 h after taking ketoconazole; may cause nausea, vomiting, rash, abdominal pain, headache, and elevation of serum transaminases; may lead to gynecomastia and decreased libido by inhibiting synthesis of adrenal steroids and androgens; starting maintenance ketoconazole therapy not recommended until culture confirms cause of vaginitis

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Clindamycin (Cleocin, Clinda-Derm, C/T/S)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys. For recurrent infections, administer a trial of alternative regimens. Used as an alternative treatment to metronidazole in pregnancy.

Dosing

Adult

Insert 1 applicator full (5 g) intravaginally qhs for 7d
Alternatively, administer 300-mg tab PO bid for 7d

Pediatric

10-20 mg/kg/d PO divided tid for 7d; not to exceed adult dose

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis (Clostridium difficile is causal organism and usually will resolve with vancomycin treatment); may cause nausea or rashes; occasionally, impaired liver function and neutropenia

Hormones

Indicated for atrophic vaginitis resulting from diminished levels of circulating estrogens. A relative lack of estrogen also predisposes the vagina and vulva to infection.

Estrogen (Premarin, Estrace)

Reserved for women experiencing vaginal changes secondary to a deficiency of estrogen.

Dosing

Adult

Premarin: 0.625 mg topically or PO qd
Estrace 0.01% vaginal cream: 2-4 g intravaginally qd for 1-2 wk, then half the dose for 1-2 wk, then 1 g up to 3 times/wk as maintenance
Premarin vaginal cream: 2-4 g qd for 3 wk (with 1 wk off in between) for 3-6 mo
Dienestrol 0.01% cream: Insert 1-2 applicators full for 1-2 wk, then decrease dosage

Pediatric

Not established

Interactions

May reduce hypoprothrombinemic effects of anticoagulants; levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and pregnancy; increase in fluid retention caused by estrogen intake may reduce seizure control

Contraindications

Documented hypersensitivity; thrombophlebitis; undiagnosed vaginal bleeding; pregnancy

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease

Anti-infectives, topical

Boric acid can be used in the treatment of refractory, recurrent vaginal candidiasis.

Boric acid (Boroformol, Borofax)

Soothing to chafed skin, abrasions, burns, and other skin irritations. For recurrent infection, maintain treatment at qod initially, then decrease to 2 times per wk.

Dosing

Adult

600 mg in a gelatin size 0 capsule intravaginally qd until culture results are negative (10-14 d)

Pediatric

Not recommended

Interactions

Increases riboflavin excretion

Contraindications

Documented hypersensitivity; inflamed skin; pregnancy

Precautions

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Excessive amount can lead to severe chemical vaginitis

Follow-up

Further Inpatient Care

• Inpatient care usually is not indicated for vaginal infections, unless serious pelvic infections arise or evidence of systemic infection in an immunocompromised host is present.

Further Outpatient Care

• Follow-up care is not indicated if patients are asymptomatic. However, in women who are pregnant or those with recurrent infections, a follow-up evaluation should be performed 1 month after completion of treatment.
• Consider treatment of partners in case of trichomoniasis;
• If chronic or recurrent infections occur, consider treatment of partners in case of bacterial vaginosis.
• Yeast culture, glucose intolerance test, and HIV test should be offered in case of recurrent or resistant vaginal candidiasis.

Inpatient & Outpatient Medications

• All regimens are administered on an outpatient basis (see Medication).

Deterrence/Prevention

• Although not extensively studied, safe sexual practices may play a role in decreasing BV and T vaginalis infections. Good hygiene also may play a role in preventing candidal infections. No studies show any benefit to douching as a treatment or prevention for vaginitis; douching may actually exacerbate symptoms. Tampon use does not seem to be associated with vaginitis.

Complications

• BV has been associated with PID, endometritis, and vaginal cuff cellulitis when invasive procedures have been performed. Such procedures include endometrial biopsies, cesarean section, uterine curettage, and IUD placement.
• During pregnancy, BV and trichomoniasis are associated with an increased risk of premature rupture of membranes, preterm labor, low birth weight, and preterm delivery.

Prognosis

• The prognosis is very good because the majority of those infected will be cured.

Patient Education

• Safe sex and STD counseling may help decrease the rates of reinfection.
• For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center and Women's Health Center. Also, see eMedicine's patient education articles Vaginal Infections, Candidiasis (Yeast Infection), Understanding Vaginal Yeast Infection Medications, and Female Sexual Problems.

Miscellaneous

Special Concerns

• Patients who are immunocompromised, such as those with HIV, should be treated with the same regimens.
• Pregnancy should not delay treatment.

References

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Keywords

vaginitis, vaginal infection, Trichomonas vaginalis, vaginal candidiasis, Candida infection, bacterial vaginosis, BV, pelvic inflammatory disease, PID, yeast infection, vaginal pH

Contributor Information and Disclosures

Author

Hetal B Gor, MD, FACOG, Consulting Staff, Private Practice, Bergen County, New Jersey
Hetal B Gor, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Bruce A Meyer, MD, MBA, Vice President for Medical Affairs, Associate Dean for Health System Affairs and Director of the Faculty Practice Plan, Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical School
Bruce A Meyer, MD, MBA is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Physician Executives, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Medical Group Management Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Antonio V Sison, MD, Medical Director, Ob/Gyn Group, Robert Wood Johnson University Hospital at Hamilton
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Phuong H Nguyen, MD and Susanne Ching, MD to the development and writing of this article.

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