November 12, 2021
By Anna Owen, MS4, Drexel University College of Medicine
Vaginitis is defined by a combination of any of the following symptoms: abnormal vaginal discharge, abnormal odor, itching, burning and irritation. While this condition can cause embarrassment, it is very common, and most women have at least one episode in their lifetime. Vaginitis occurs due to an imbalance of healthy bacteria and change in vaginal environment because of age, sexual activity, hormonal status, immunologic status and underlying disease states. Vaginas commonly have normal physiologic discharge, which for most people is clear to white, not associated with discomfort or itching, and will vary in quantity throughout the menstrual cycle. “Normal” discharge varies from person to person.
In contrast, a change in this physiologic discharge may signal vaginitis. The causes of vaginitis include bacterial vaginosis (40-50% of cases), vulvovaginal candidiasis (20-25%), trichomoniasis (15-25%) and less common conditions (atrophic, irritant, allergic, inflammatory, etc.) that combined account for 5-10% of cases.
Bacterial vaginosis (BV) is caused by an imbalance of anaerobic (non-oxygen requiring) bacteria in the vagina. Symptoms can include fishy odor, thin discharge that may worsen after intercourse, and pelvic discomfort. This is not a sexually transmitted infection (STI), but unprotected intercourse can increase the risk by disrupting the vaginal environment. Risk factors include vaginal douching, smoking, new or multiple sex partners, and women who have sex with women. For diagnosis, the vagina is swabbed with a cotton swab and “clue cells” are seen under the microscope (pictured in link below). These are cells from the vagina that are coated with various types of bacteria, giving them a distinct appearance. Lab testing can also be used to confirm the diagnosis. Treatment for this condition includes a course of oral metronidazole, intravaginal metronidazole or intravaginal clindamycin.
Vulvovaginal candidiasis (yeast infection) is caused by the Candida species of yeast, often Candida albicans. Symptoms include white, thick, cheese- or curd-like discharge, vulvar itching and burning, and vulvar redness and swelling without odor. Risk factors include recent antibiotic use, pregnancy, uncontrolled diabetes mellitus, corticosteroid use and immunosuppression. Preliminary diagnosis involves classic clinical signs and symptoms and is confirmed by microscopy utilizing potassium hydroxide solution on samples of vaginal fluid. This process reveals budding yeast typical of Candida species (pictured in link below). Lab testing can also be done to find DNA from and culture of specific species that are suspected causes. Treatment includes a course of oral fluconazole or topical azole medications, especially if the patient is pregnant.
Trichomoniasis is caused by the protozoa Trichomonas vaginalis, which is considered infectious and can be passed between sexual partners (a sexually transmitted infection). Symptoms include green/yellow and frothy discharge with foul odor as well as vaginal pain and soreness. On physical examination the vulva may appear inflamed, and the cervix can be bright red. Risk factors for this form of vaginitis include multiple sex partners, presence of other STIs, unprotected sex, drug use and smoking. Diagnosis includes visualization of motile protozoa, characteristic organisms with a moving tail on wet-mount microscopy (pictured in link below). Lab testing can also be done for DNA in symptomatic and high-risk cases. Treatment includes oral metronidazole or tinidazole for the patient and their partners.
Bacterial vaginosis clue cells
Candida budding yeast
Trichomonas motile protozoa
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