eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Vaginitis
Updated: Nov 3, 2009
Introduction
Background
The composition of vaginal flora changes with age, stress, hormonal influence, general health status, and sexual activity. Vaginitis 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.
Pathophysiology
Aerobic and anaerobic bacteria can be cultured from the vagina of prepubertal girls, pubertal adolescents, and adult women. 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.
Frequency
United States
Vaginitis is common in adult women and uncommon in prepubertal girls. Vaginitis is one of the most common reasons for gynecologic consultation consisting of approximately 3 million office visits annually. Bacterial vaginosis accounts for 40-50% of vaginitis cases; candidiasis, 20-25%; and trichomoniasis, 15-20%.
Mortality/Morbidity
The presence of abnormal discharge, vulvovaginal discomfort, or both is required for the diagnosis of vaginitis. 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. Untreated bacterial vaginosis may result in complications after gynecologic surgery. Adverse pregnancy outcomes including preterm labor, premature rupture of membranes, preterm birth, and postpartum endometritis have been associated with bacterial vaginosis during pregnancy.
Age
The age of the patient affects the anatomy and physiology of the vagina.
- Prepubertal children have a more alkaline vaginal pH than pubertal and postpubertal adolescents and women. The vaginal mucosa is columnar epithelium, vaginal mucous glands are absent, normal vaginal flora is similar to that of postmenopausal women (eg, gram-positive cocci and anaerobic gram-negatives are more common), and labia are thin with a thin hymen.
- Pubertal and postpubertal adolescents and women have a more acidic vaginal pH, stratified squamous vaginal mucosa, vaginal mucous glands, normal vaginal flora of 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.
Clinical
History
Adults and children must be questioned regarding specific aspects of the symptoms of vaginitis. Vaginal bleeding in prepubertal females is always abnormal and merits full investigation. Essential information to obtain during the history is the onset of symptoms, previous occurrence, associated abdominal pain, trauma, and urinary or bowel symptoms.
- The most common etiologies in adults resulting in symptoms of vaginitis include Candida albicans, Trichomonas vaginalis, and bacterial vaginosis. Elicit symptoms with attention to these possible causes.
- Candidiasis is a fungal infection common in women of childbearing age that results in pruritus, with a thick, white vaginal discharge. Patients often have a history of recurrent yeast infections or recent antibiotic treatment. Symptoms of candidiasis often begin just before menses. Precipitating factors include immunosuppression, diabetes mellitus, pregnancy, and hormone replacement therapy. Candidiasis is usually not contracted from a sexual partner. Seventy-five percent of all women have one episode of candidiasis in their lifetime. Recurrent episodes may indicate underlying immunodeficiency or diabetes.
- Trichomoniasis is associated with risk factors for other sexually transmitted diseases (STDs); elicit a history of multiple sexual partners. The discharge is usually copious and frothy, resulting in local pain and irritation. Pruritus might be present. Symptoms often peak just after menses. Trichomonas vaginalis is the most common nonviral STD in the world. Infection during pregnancy has been associated with preterm deliveries and low birth weight infants.
- Bacterial vaginosis is asymptomatic in up to 50% of women. If a discharge is present, it is typically a homogeneous grayish white or yellowish white. Bacterial vaginosis is common in pregnant women and is associated with preterm birth. Treating pregnant women that have a history of preterm birth with symptomatic bacterial vaginosis early in pregnancy has been shown to decrease the incidence of preterm birth.
- In women with chronic vaginitis, atrophic vaginitis and hypoestrogenism must be considered. Elicit an accurate menstrual history.
- Vulvovaginitis has multiple nonvenereal causes in prepubertal children; however, if a vaginal discharge suggests an STD, question all children (and/or their caretakers) regarding possible sexual abuse. Symptoms of vulvovaginitis in prepubertal girls generally include localized pain, dysuria, pruritus, erythema, and discharge.
- Bacteria that can cause vulvovaginitis include streptococcal species (including group A streptococci), Escherichia coli, and Shigella sonnei. Symptoms (eg, pharyngitis, diarrhea) may result from infections in areas of the body other than the vagina. A Shigella infection may result in a bloody vaginal discharge without symptoms of diarrhea. A patient with group A streptococcal infection may present with itching or painful defecation. Purulent discharge may develop insidiously.
- Viral infections may cause symptoms of vulvovaginitis. Elicit a history of recent viral infections, including varicella. Herpes simplex viruses (HSVs), particularly HSV-1 transmitted via autoinoculation from the oral mucosa, might be present; elicit a history of recurrent oral herpes or digital herpes in the caretaker of a child in diapers.
- Consider helminthic infections (eg, Enterobius vermicularis infections) resulting in pruritus of the genital area. Ask about contact with pinworm-infected children, itching (particularly at night), and vaginal pain.
- Ask questions to exclude the possibility of a foreign body in the vagina, chemical irritation (eg, recent bubble baths, washing hair with shampoo while bathing, douching, feminine hygiene sprays), latex, semen, mechanical irritation, and poor hygiene. Foreign bodies in the vagina result in a persistent, foul-smelling, serosanguineous discharge. Contact dermatitis from unusual exposures may occur; ask about this possibility and about bathing patterns.
- Obtain a history of recent trauma to the vaginal area and a history of urination and defecation patterns and problems to exclude possible anatomic abnormalities (eg, rectovaginal fistula).
- Lichen sclerosis et atrophicus may be seen in prepubertal children and in postmenopausal women. Symptoms of chronic fissures, pain, or pruritus are often present. Rectal fissures may lead to chronic constipation in children.
- If candidal vulvovaginitis is considered (rare in healthy prepubertal girls), the history should include recent antibiotic use, possible diabetes mellitus, immunosuppression, and underlying skin disease. Ask about a family history of mucocutaneous candidiasis.
- Trichomoniasis is rare in prepubertal children. Sexual abuse should be suspected if symptoms are present. Symptoms include a copious frothy discharge, local pain, irritation, and, occasionally, pruritus.
Physical
The physical examination of pubertal and adult women should include a complete pelvic examination. The Tanner stage of development should be noted. The examination for prepubertal girls should be performed as described in Pediatrics, Child Sexual Abuse.
- Infectious causes of vaginitis may have the following specific physical findings:
- Candidiasis may present with a well-demarcated erythema of the vulva with satellite lesions surrounding the redness. The vulva, vagina, and surrounding areas may be edematous and erythematous, possibly accompanied by excoriations and fissures. A clumpy adherent discharge may be seen.
- Physical findings for trichomoniasis include a copious frothy discharge (white to greenish-yellow) and a raised punctate erythema of the cervix and upper portion of the vagina (strawberry cervix).
- Physical findings in bacterial vaginosis include a homogeneous grayish white to yellowish white vaginal discharge. Typically, no underlying erythema exists. Bacterial vaginosis can be diagnosed if 3 of the 4 Amsel criteria are present: increased vaginal pH (>4.5), grayish white homogenous discharge, an amine smell with or without potassium hydroxide, and clue cells.
- Physical findings associated with cervicitis from STDs include excessive vaginal discharge, erythema, and edema of the cervix. Fever, cervical motion or abdominal or adnexal tenderness may indicate upper genital tract infection such as cervicitis or pelvic inflammatory disease.
- Cervical ectopy or eversion may cause discharge with no apparent infectious etiology. Physical findings associated with atrophy, dysplasia, and vulvar vestibulitis syndrome include localized atrophy or infection in skin and mucous membranes. Half of all cases of women with mucopurulent discharge have an unknown etiology.
- Vaginal foreign bodies in adults include forgotten tampons; in children, pieces of toilet tissue typically are found. Findings of foul odor and irritation with a purulent discharge are common.
- A patient with pinworms may present with few physical findings. Occasionally, there may be erythema and excoriations around the perianal area. In severe cases, eggs and/or dead female nematodes may be seen on examination of the anal area.
- Perianal streptococcal dermatitis usually results in a beefy red perineal area that is edematous and tender. Fissures, drainage, and hemorrhagic spotting may be present.
Causes
- Causes of vulvovaginitis vary depending on the following:
- Age
- Sexual activity (or abuse)
- Hormonal status
- Hygiene
- Immunologic status
- Anatomy of the genital area
- Underlying skin diseases
- 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 Medscape's Women's Sexual Health Resource Center.
Differential Diagnoses
| Foreign Bodies, Rectum | Salmonella Infection |
| Pediatrics, Child Sexual Abuse | Sexual Assault |
| Pinworms | Urinary Tract Infection, Female |
| Pregnancy, Postpartum Infections | Vulvovaginitis |
Workup
Laboratory Studies
- The workup for patients with vaginitis depends on the risk factors for infection and the age of the patient.
- Test for Candida albicans via a potassium hydroxide (KOH) preparation.
- As many as 30% of symptomatic candidiasis cases have false-negative KOH results.
- One drop of vaginal discharge is mixed with 1 drop of 10% KOH solution and covered with a coverslip.
- Branching hyphae and buds of Candida are visible.
- Gram stain or culture on Nickerson media and Sabouraud agar may enhance diagnosis.
- Papanicolaou tests (Pap smears) may have frequent false-positive results for yeast.
- Motile trichomonads may be revealed by wet preparation (1 gtt of isotonic sodium chloride solution with 1 gtt of discharge).
- With trichomoniasis, more than 10 white blood cells (WBCs) per high power field (HPF) are seen on wet preparation. Diagnostic accuracy may be improved by culture on Diamond medium or Trichosel broth.
- InPouch TV is 90-95% specific and 100% sensitive for culturing Trichomonas vaginalis. Compared with culture, the sensitivity of the wet prep is only 60%.
- Trichomonas Rapid Test (an ELISA strip test) has 80% sensitivity.
- Affirm DNA hybridization is 80% sensitive for Trichomonas, and 94% sensitive for bacterial vaginosis.
- Pap smears may reveal trichomonads but have a high false-positive rate.
- Bacterial vaginosis is associated with an intense amine odor with the KOH preparation (the whiff test). The "Whiff" test is not very sensitive or specific for diagnosis.
- On wet preparation, clue cells are seen with a paucity of WBCs.
- On Gram stain, clue cells are identified as epithelial cells covered by small gram-negative rods.
- The Affirm DNA hybridization method is 94% sensitive for bacterial vaginosis.
- Culture is not generally indicated or recommended.
- Gonorrhea usually causes a cervicitis, not a vaginitis, and may be asymptomatic. Symptomatic Neisseria gonorrhoeae usually results in a purulent discharge.
- Obtain cultures of the vagina (prepubertal), cervix (pubertal, adult), oral pharynx, and rectum if gonococcal vulvovaginitis is suspected.
- Obtain cultures using a cotton-tipped swab and Thayer-Martin media on chocolate agar, incubated in a carbon dioxide–rich environment (see Pediatrics, Child Sexual Abuse).
- DNA amplification assays of genital tract specimens are both sensitive and specific. First-void urine specimens for nucleic acid amplification tests (NAATs) have also been shown to be sensitive and specific in females. They are less invasive than swabs, and with confirmation such as repeat testing using a different form of NAAT, urine NAAT may be used for the evaluation of chlamydia and gonorrhea in cases of suspected sexual abuse.
- Test for chlamydial vulvovaginitis via culture in prepubertal girls and in patients who show signs of abuse or sexual assault.
- Obtain rectal chlamydia swabs (see Pediatrics, Child Sexual Abuse).
- Nucleic acid amplification testing can be performed as a screen using cervical swabs of pubertal and adult women. Use of this form of testing in prepubertal children may be done for initial screening, but confirmation testing should be assured due to medical legal concerns.1
- The use of nucleic acid amplification tests has been implemented by many office and emergency settings. Tests such as polymerase chain reaction (PCR) can be performed using swabs of the cervix or vagina or by collecting a urine sample. These tests are generally used to test for common sexually transmitted diseases such as chlamydia and gonorrhea, but utilization for the diagnosis of bacterial vaginosis has been studied and shown to be potentially more sensitive and specific than Gram stain and clinical diagnosis.2,1
Treatment
Prehospital Care
- Treatment of vaginitis may include sitz baths and instruction regarding proper toilet and hygiene techniques. Many women assume vaginal symptoms are the result of an STD, which is often not the case. A patient's idea of vaginal normalcy may be inaccurate and result in increased or unnecessary treatment seeking.
- Intravaginal imidazoles, as described below, can be purchased over the counter and have proven efficacy for vaginal candidiasis. Patients may purchase and utilize these medications without a doctor's advice or prescription and the choice of treatment can be based on personal preference since they appear to be equally effective. Vaginal anti-itch creams provide only symptomatic relief. Homeopathic treatments for vaginitis (boric acid, tea tree oil, live acidophilus, garlic) have not been well studied but may have some efficacy.3,4,5
- If the patient shows no improvement, despite symptomatic or over-the-counter treatment, refer her for further workup of possible STDs and other infectious causes of vulvovaginitis.
Emergency Department Care
Usually, no active treatment is necessary in the ED. However, prepubertal girls with vulvovaginitis caused by a foreign body in the vagina may require sedation for removal of the foreign body.
Consultations
Refer patients with resistant infections or persistent symptoms of vulvovaginitis to a gynecologist.
Medication
Drugs used for infectious causes of vaginitis may be applied topically or require oral or parenteral administration.
Antifungal agents
Imidazole derivatives that exert a fungicidal effect by altering the permeability of the fungal cell membrane. Mechanism of action also may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to the fungal cell.
Intravaginal and topical therapy with a variety of antifungals (eg, clotrimazole, miconazole, terconazole, tioconazole) is highly effective. Many of these preparations are now available over-the-counter. Various 1-, 3-, and 7-day regimens can be used. Cure rates of 90% are reported with longer courses.
Miconazole (Monistat-Derm, Monistat Vaginal Cream, Vusion)
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
3-d therapy
200 mg vaginal supp: Insert 1 qhs for 3 d
7-d therapy
2% cream: Insert 1 applicatorful (5 g) intravaginally qhs for 7 d
100 mg vaginal supp: Insert 1 qhs for 7 d
Monistat Dual Pak: 1200 mg vaginal insert once plus 2% cream for external use
Pediatric
Administer as in adults for topical application only
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)
Broad-spectrum antifungal agents that inhibit yeast growth by altering cell membrane permeability, causing fungal cell death.
The recommended duration of intravaginal therapy is generally 3-7 d.
Dosing
Adult
7-d therapy
1% cream: Insert 1 applicatorful intravaginally qhs for 7-14 d
100 mg tab: Insert 1 tab intravaginally qhs for 7 d
Pediatric
Administer as in adults for topical treatment; pediatric dosage not defined
Interactions
None reported
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if irritation or sensitization occurs; chronic or recurrent candidiasis may be a symptom of unrecognized diabetes mellitus or a damaged immune system (including HIV infection); persistently resistant infection actually may be due to reinfection (evaluate sources of reinfection); if patient does not respond, repeat microbiological studies to confirm diagnosis and to exclude other pathogens before reinstituting antifungal therapy; do not use creams in mouth or eyes
Fluconazole (Diflucan)
PO antifungal agent. While ease of use should be considered, direct cost may be a limiting factor. PO antifungals should not be recommended in pregnancy. Current recommendations are for a 7-d course of antifungal topical therapy. Synthetic, broad-spectrum, bis-triazole antifungal agent; highly selective inhibitor of fungal CYP450 and sterol C-14 alpha-demethylation.
The recommended duration of intravaginal therapy is 3-7 d.
Dosing
Adult
1-d therapy
150 mg PO once
Pediatric
3-6 mg/kg/d PO for 14-28 d, depending on severity of infection; dosage has not been defined for vaginitis, but for oropharyngeal infection, 6 mg/kg/ on first day, followed by 3 mg/kg once daily for a minimum of 3 wk and for at least 2 wk following resolution of symptoms has been recommended
Interactions
Concomitant use with hydrochlorothiazides may increase concentrations, perhaps due to reduced renal clearance; chronic rifampin administration may decrease half-life; increases phenytoin concentrations when administered concurrently; increases half-life of theophylline; may increase concentrations of tolbutamide, glyburide, and glipizide; significant increases in cyclosporine concentrations have occurred following use
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor patients who develop rashes during treatment and discontinue if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure, including fatalities, especially when a serious underlying medical condition exists (eg, AIDS, malignancy) and in patients taking multiple concomitant medications; weigh convenience and efficacy of single-dose regimen against difficulties resulting from higher incidence of adverse reactions; not recommended in breastfeeding mothers
Terconazole (Terazol 3, Terazol 7)
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
3-d therapy
0.8% cream (Terazol 3): Insert 1 applicatorful (5 g) intravaginally qhs for 3 d
80-mg vaginal supp (Terazol 3): Insert 1 qhs for 3 d
7-d therapy
0.4% cream (Terazol 7): Insert 1 applicatorful (5 g) intravaginally for 7 d
Pediatric
Administer as in adults for topical use; pediatric dosage not defined
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
Butoconazole nitrate (Gynazole-1)
Broad-spectrum antifungal agent that inhibit yeast growth by altering cell membrane permeability, which causes fungal cell death. Effective only for vaginitis caused by candidal organisms.
Dosing
Adult
3-d therapy
2% cream: Insert 1 applicatorful (5 g, or 100 mg of butoconazole nitrate) intravaginally
Pediatric
No recommended dosage for children
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
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes
Tioconazole (Vagistat-1)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells.
Dosing
Adult
1-d therapy
6.5% ointment: Insert 1 applicatorful (5 g) intravaginally once prior to bedtime
Pediatric
No dosage recommendation for children
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
If sensitivity or chemical irritation occurs, discontinue use; use only externally; avoid contact with eyes
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. The use of antibiotic combinations usually is recommended for the treatment of serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections, prevents emergence of bacterial subpopulations that may be resistant to one of the antibiotic components, and provides additive or synergistic effects. Antibiotic monotherapy is recommended, however, once organisms and sensitivities are known.
Ceftriaxone (Rocephin)
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to 1 or more of the penicillin-binding proteins.
Dosing
Adult
125 mg IM as single dose in uncomplicated gonococcal infections; 250 mg IM as a single dose is recommended for upper genital tract infection with gonorrhea
Pediatric
Infants and children <45 kg (100 lb) with gonorrhea: 125 mg IM as single dose; with presumptive treatment for Chlamydia trachomatis using erythromycin or azithromycin
Interactions
Aminoglycosides increase nephrotoxic potential; probenecid increases effects by decreasing clearance
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin
Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Indicated in treatment of infections caused by susceptible strains, including Staphylococcus aureus. Alternative for treatment of chlamydia in pregnancy.
Dosing
Adult
500 mg erythromycin stearate/base (or 800 mg ethylsuccinate) PO q6h 1h ac for 7 d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6h; age, weight, and severity of infection determine proper dosage; when bid dosing is desired, half-total daily dose may be taken q12h; for more severe infections, dose may be doubled
Interactions
May increase toxicity of theophylline and digoxin when used concurrently; may potentiate anticoagulant effects of warfarin
Contraindications
Documented hypersensitivity; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Discontinue use if malaise, nausea, vomiting, abdominal colic, and/or fever occur
Clindamycin (Cleocin, Clinda-Derm, C/T/S)
Inhibits bacterial protein synthesis by its action at the bacterial ribosome. Binds preferentially to the 50S ribosomal subunit and affects the process of peptide chain initiation.
Intravaginal use is not recommended for pregnant women because it has been associated with an increased risk of preterm delivery. Treatment of bacterial vaginosis with oral clindamycin during the second and third trimesters of pregnancy has been shown to reduce the occurrence of preterm birth.
Dosing
Adult
2% vaginal cream: 5 g qhs for 3- 7 d
Alternatively, 300 mg PO bid for 7 d
Clindamycin ovules: 1 vaginal suppository per day for 3 d for bacterial vaginosis
Pediatric
For serious infections: 8-16 mg/kg/d divided into 3 or 4 doses
Interactions
None reported
Contraindications
Documented hypersensitivity; regional enteritis; ulcerative colitis; antibiotic-associated colitis; may develop vaginal yeast infection
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid contact with eyes; vaginal cream contains ingredients that cause burning and irritation of the eye; in the event of accidental contact with the eye, rinse eye with copious amounts of cool tap water; may result in overgrowth of nonsusceptible organisms, particularly yeasts, in the vagina; discontinue use with severe diarrhea
Metronidazole (MetroGel, Flagyl, MetroGel-Vaginal, Noritate Cream)
Active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells; the intermediate metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death. Indicated for treatment of bacterial vaginosis (formerly referred to as Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, or anaerobic vaginosis). Highly effective in treating trichomoniasis with one dose. Topical metronidazole is not effective therapy for trichomoniasis.
Treatment of bacterial vaginosis with oral metronidazole during the second and third trimester of pregnancy does not reduce the occurrence of preterm delivery.
The numbers of T vaginalis cases with metronidazole resistance are increasing.
Dosing
Adult
For trichomoniasis, 2 g PO once (or 1 g bid for 1 d)
Alternatively, 5 g intravaginally qd for 7 d of 0.75% vaginal gel
250 mg PO tid for 7 d if pregnant (but contraindicated during the first trimester); the one-day treatment reaches too high a concentration for the fetus in the second and third trimester
T vaginalis: 2 g PO once
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Interactions
May potentiate the anticoagulant effects of warfarin, resulting in prolongation of PT
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Known or previously unrecognized vaginal candidiasis may present more prominent symptoms during metronidazole vaginal-gel therapy; more than 6% of patients have developed symptomatic vaginal candidiasis during or immediately after therapy
Cefixime (Suprax)
An oral third-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. It is used to treat gonorrhea, tonsillitis, and pharyngitis.
Dosing
Adult
400 mg PO single dose for uncomplicated gonorrhea (200 mg/5 mL); 400 mg PO bid for 7 d for disseminated gonococcal urethritis
Pediatric
8 mg/kg (maximum 400 mg) PO in a single dose
>45 kg (100 lb) and >8 years: Administer as in adults
Interactions
Carbamazepine: elevated levels reported in postmarketing experience when administered concomitantly with cefixime
Warfarin and anticoagulants: increased prothrombin time reported with and cefixime concomitant administration
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Severe hypersensitivity reactions have been reported including anaphylactic reactions with shock and fatalities, skin rashes, urticaria, drug fever, angioedema, erythema multiforme, Stevens-Johnson syndrome, and serum sickness-like reactions; other side effects affecting various systems have been reported
Doxycycline (Doryx, Monodox, Vibramycin)
Inhibits protein synthesis and thus bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria.
Dosing
Adult
100 mg PO bid for 7 d for chlamydia
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO as single dose or divided bid; not to exceed 200 mg/d
Interactions
Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease tetracycline bioavailability; can increase hypoprothrombinemic effects of anticoagulants (monitor prothrombin activity in patients taking both medications concurrently); coadministration with PO contraceptives can decrease pharmacologic effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Prolonged exposure to sunlight or tanning equipment can cause a photosensitivity reaction; use lower-than-usual doses in patients with renal impairment; if therapy is prolonged, consider drug serum level determinations; use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; never administer outdated tetracyclines (the degradation products of tetracyclines are highly nephrotoxic and can cause a Fanconilike syndrome)
Azithromycin (Zithromax)
Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. Indicated for chlamydial infections of the genital tract.
Dosing
Adult
1 g PO once
Pediatric
For treatment of Chlamydia: 20 mg/kg PO single dose (maximum 1 g)
Interactions
May increase theophylline and digoxin concentrations and toxicity when used concurrently; may potentiate anticoagulant effects of warfarin; antacids containing aluminum and magnesium reduce peak serum levels but not absorption; concurrent use of cyclosporine may result in elevated cyclosporine concentrations with increased risk of toxicity (nephrotoxicity, neurotoxicity)
Contraindications
Documented hypersensitivity; hepatic impairment
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Local IV site reactions have been reported with the IV administration of azithromycin; bacterial or fungal overgrowth of nonsusceptible organisms may result from prolonged use of antibiotics, possibly leading to a secondary infection; take appropriate measures if superinfection occurs; can cause increases in hepatic enzymes and cholestatic jaundice (caution in patients with impaired hepatic function); not recommended for pneumonia in hospitalized patients or in patients who are elderly or debilitated; caution in patients with prolonged QT intervals
Estrogen
Indicated for atrophic vaginitis resulting from diminished levels of circulating estrogens. A relative lack of estrogen also predisposes the vagina and vulva to infection.
Conjugated estrogens (Premarin)
Indicated for atrophic vaginitis and atrophic urethritis associated with menopause.
Dosing
Adult
0.3-1.25 mg/d or more PO, depending on tissue response of patient
Insert half to 1 applicatorful (2-4 g) topical preparation intravaginally qhs
Cyclical administration consisting of 3 wk of daily estrogen and 1 wk off is recommended
Pediatric
Disease state not seen in children
Interactions
May reduce the hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; an increase in the pharmacologic and toxicologic effects of corticosteroids may occur via inactivation of hepatic P450 enzyme; loss of seizure control has been suggested when administered concurrently with hydantoins
Contraindications
Documented hypersensitivity; known or suspected pregnancy; breast cancer; undiagnosed abnormal genital bleeding; active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis, or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)
Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, (eg, abnormal or excessive uterine bleeding, mastodynia); estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia
Follow-up
Further Inpatient Care
- Parenteral treatment of infectious causes for vaginitis is rarely indicated. Complicated cases of certain infections (eg, gonorrhea, chlamydia) may require parenteral treatment.
Further Outpatient Care
- Recommend techniques of proper genital hygiene.
- Refer for sexual abuse evaluation all children in whom vaginitis was caused by an STD (see Pediatrics, Child Sexual Abuse).
- Treat sexual partners of patients with identified STDs.
Complications
- Infectious complications (eg, pelvic inflammatory disease, systemic disease resulting from the spread of gonorrhea) may occur.
Prognosis
- The prognosis for vaginitis is generally very good.
Patient Education
- Discuss further preventive efforts, including proper hygiene and toilet techniques, when appropriate. Remind patients that douching can spread a vaginal or cervical infection into the uterus increasing the likelihood of pelvic inflammatory diseases. Studies have also indicated that douching can be associated with endometritis.
- Educate patients regarding use of topical creams for treatment of vaginitis (eg, candidal vaginitis, bacterial vaginosis) as necessary.
- For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center, Women's Health Center, and Parasites and Worms Center. Also, see eMedicine's patient education articles Vaginal Infections, Candidiasis (Yeast Infection), Understanding Vaginal Yeast Infection Medications, Female Sexual Problems, and Trichomoniasis.
Miscellaneous
Medicolegal Pitfalls
- In cases of suspected sexual assault or child sexual abuse, proper documentation may assist with possible subsequent legal action.
- Prior to treatment with any of the drugs that should not be used during pregnancy, determine possibility of pregnancy, test for pregnancy as appropriate, and maintain proper documentation.
References
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Keywords
vaginitis, vaginitis symptoms, bacterial vaginitis, vaginitis treatment, candida vaginitis, causes of vaginitis, vulvovaginitis, bacterial vaginosis, yeast infection, vaginal discharge, candidiasis, Candida albicans, trichomoniasis, Trichomonas vaginalis
Contributor Information and Disclosures
Author
Ann S Botash, MD, Director, Child Abuse Referral and Evaluation Program, Professor and Vice Chair for Educational Affairs, Department of Pediatrics, State University of New York Upstate Medical University
Ann S Botash, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Helfer Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.
Medical Editor
David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Managing Editor
Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment
CME Editor
John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.