Vaginitis Clinical Presentation

A carefully documented history is vital for establishing the diagnosis. ^[6] Adults and children must be questioned regarding specific aspects of the symptoms of vaginitis. Essential information to obtain during the history includes the onset of symptoms, previous occurrences, associated abdominal pain, trauma, and urinary or bowel symptoms.

Vaginal bleeding in prepubertal females is always abnormal and warrants a full investigation. In adults, as noted (see Etiology), the most common conditions resulting in symptoms of vaginitis include vaginal candidiasis, trichomoniasis, and bacterial vaginosis; accordingly, particular attention should be paid to symptoms suggesting these possible causes.

Patients with vaginitis almost always present with a chief complaint of abnormal vaginal discharge. Ascertain the following attributes of the discharge:

• Quantity

• Duration

• Color

• Consistency

• Odor

Obtain a history of the following:

• Previous similar episodes

• Sexually transmitted infection

• Sexual activities

• Birth control method

• Last menstrual period

• Douching practice

• Use of personal hygiene products

• Antibiotic use

• General medical history

• Systemic symptoms (eg, lower abdominal pain, fever, chills, nausea, and vomiting)

Bacterial vaginosis

Bacterial vaginosis is asymptomatic in up to 50% of women. If a discharge is present, it is typically thin, homogeneous, malodorous, and grayish white or yellowish white in color. Vaginal pain or vulvar irritation is uncommon. Pruritus may occur.

Bacterial vaginosis is common in pregnant women and is associated with preterm birth. In pregnant women with symptomatic bacterial vaginosis who have a history of preterm birth, administration of treatment early in pregnancy has been shown to decrease the incidence of preterm birth.

Vaginal candidiasis

Candidiasis is a fungal infection common in women of childbearing age. Pruritus is the most common symptom. This is accompanied by a thick, odorless, white vaginal discharge (with an appearance similar to that of cottage cheese), which can be minimal. Usually, associated vulvar candidiasis is present, commonly with vulvar burning, dyspareunia, and vulvar dysuria (a burning sensation arising when urine comes into contact with vulvar skin).

Patients often have a history of recurrent yeast infection 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. About 75% of all women have at least 1 episode of candidiasis in their lifetime. Recurrent episodes may indicate underlying immunodeficiency or diabetes.

Trichomoniasis

T vaginalis infection is the most common nonviral STD in the world. Many patients (20-50%) are asymptomatic. If discharge is present, it is usually copious and frothy and can be white, gray, yellow, or green (the yellow and green colors are due to the presence of white blood cells [WBCs]). Local pain and irritation are common. Dysuria (20%), pruritus (25%), and postcoital bleeding due to cervicitis are other possible symptoms. Symptoms often peak just after menses.

Trichomoniasis is associated with risk factors for other STDs; accordingly, a history of multiple sexual partners should be elicited. Infection during pregnancy has been associated with preterm deliveries and low-birth-weight infants.

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.

Other conditions

In women with chronic vaginitis, atrophic vaginitis and hypoestrogenism must be considered. Elicit an accurate menstrual history, along with statuses such perimenopause, postmenopause, postpartum, and lactation. Ask about medications such as depot leuprolide (Lupron) and antiestrogen medications used for breast cancer.

Vulvovaginitis has multiple nonvenereal causes in prepubertal children; however, if a vaginal discharge suggests an STD, question all children (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 and 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.

If candidal vulvovaginitis is considered (it is 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.

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, use of feminine hygiene sprays, colored or scented toilet papers, panty liners), 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.

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.

Bacterial vaginosis

Physical findings in bacterial vaginosis include a homogeneous, frothy vaginal discharge that is grayish-white to yellowish-white in color. The discharge appears adherent to the vaginal mucosa. Typically, no underlying erythema exists. As many as 50% of women with bacterial vaginosis are asymptomatic.

Bacterial vaginosis can be diagnosed if 3 of the following 4 Amsel criteria are present (see Workup):

• Homogeneous, white, adherent discharge

• Vaginal pH higher than 4.5

• Amine (fishy) smell from vaginal discharge when potassium hydroxide (KOH) is added (whiff test)

• Clue cells on wet mount

Vaginal candidiasis

Vaginal candidiasis may present with a well-demarcated erythema of the vulva with satellite lesions (discrete pustulopapular lesions) surrounding the redness. The vulva, vagina, and surrounding areas may be edematous and erythematous, possibly accompanied by excoriations and fissures. A thick, adherent, cottage cheese–like vaginal discharge may be seen. The cervix usually appears normal.

Trichomoniasis

In trichomoniasis, the vulva may appear erythematous and edematous, with excoriation. Look for a copious, frothy, homogeneous vaginal discharge that can be white, gray, yellow, or green. Small punctate cervical and vaginal hemorrhages with ulcerations may be observed. So-called strawberry cervix, or colpitis macularis, is highly specific for Trichomonas infection, and 2-5% of patients will have this finding on examination.

Because diagnosis of Trichomonas infection on the basis of clinical signs and symptoms is unreliable, laboratory confirmation is mandatory.

Other conditions

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 (eg, cervicitis or PID).

Cervical ectopy or eversion may cause discharge with no apparent infectious cause. Physical findings associated with atrophy, dysplasia, and vulvar vestibulitis syndrome include localized atrophy or infection in skin and mucous membranes. In about 50% of all cases of mucopurulent discharge in women, the etiology is unknown.

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 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.

Bacterial vaginosis has been associated with pelvic inflammatory disease (PID), endometritis, and vaginal cuff cellulitis when invasive procedures have been performed. Such procedures include endometrial biopsies, cesarean section, uterine curettage, and intrauterine device (IUD) placement.

During pregnancy, bacterial vaginosis and trichomoniasis are associated with an increased risk of premature rupture of membranes, preterm labor, ^[7] low birth weight, and preterm delivery.

Systemic disease resulting from the spread of gonorrhea may occur.