eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Vaginitis: Treatment & Medication
Updated: Nov 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
May impair barrier contraceptives
Documented hypersensitivity
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.
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
None reported
Documented hypersensitivity
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.
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
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
Documented hypersensitivity
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.
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
May impair barrier contraceptives
Documented hypersensitivity
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.
Adult
3-d therapy
2% cream: Insert 1 applicatorful (5 g, or 100 mg of butoconazole nitrate) intravaginally
Pediatric
No recommended dosage for children
None reported
Documented hypersensitivity
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.
Adult
1-d therapy
6.5% ointment: Insert 1 applicatorful (5 g) intravaginally once prior to bedtime
Pediatric
No dosage recommendation for children
None reported
Documented hypersensitivity
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.
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
Aminoglycosides increase nephrotoxic potential; probenecid increases effects by decreasing clearance
Documented hypersensitivity
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.
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
May increase toxicity of theophylline and digoxin when used concurrently; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; hepatic impairment
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.
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
None reported
Documented hypersensitivity; regional enteritis; ulcerative colitis; antibiotic-associated colitis; may develop vaginal yeast infection
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.
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
May potentiate the anticoagulant effects of warfarin, resulting in prolongation of PT
Documented hypersensitivity
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.
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
Carbamazepine: elevated levels reported in postmarketing experience when administered concomitantly with cefixime
Warfarin and anticoagulants: increased prothrombin time reported with and cefixime concomitant administration
Documented hypersensitivity
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.
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
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
Documented hypersensitivity; severe hepatic dysfunction
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.
Adult
1 g PO once
Pediatric
For treatment of Chlamydia: 20 mg/kg PO single dose (maximum 1 g)
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)
Documented hypersensitivity; hepatic impairment
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.
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
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
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)
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
More on Vaginitis |
| Overview: Vaginitis |
| Differential Diagnoses & Workup: Vaginitis |
 Treatment & Medication: Vaginitis |
| Follow-up: Vaginitis |
| References |
| Further Reading |
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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
