Vaginitis is spectrum of conditions the cause vulvovaginal symptoms such as itching, burning, irritation and abnormal vaginal discharge.
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Causes of Vaginitis
- Bacteroides
- Trichomoniasis
- vulvovaginal candidiasis.
- Chlamydia (indolent)
- Gonorrhea
- Mycoplasma
- Tuberculosis
- Ureaplasma
- Streptococci
Clinical features:
Change in color, discharge, odor, pruritus, irritation, burning sensation. Swelling, dyspareunia, dysuria.
Normal secretions are: clear, elastic and mucoid secretions (midcycle); and thick, white secretions adhere to vaginal wall (Luteal phase/pregnancy).
Work up and Diagnosis:
Vaginal pH, whiff test, wet mount and KOH preparations.
If purulent discharge, numerous leucocytes on wet preparations, cervical friability and symptoms suggesting PID like lower abdominal pain, uterine tenderness, adnexal tenderness, cervical motion tenderness; cultures of Neisseria gonorrhoeae, Chlamydia trachomatis is recommended.
If many WBC on wet preparations and no organism on saline smear, suspect Chlamydia trachomatis.
AMESL criteria for bacterial vaginosis:
- Creamy discharge
- Fishy odor
- pH >4.5
- Clue cells on wet mount
3 out of 4 is diagnostic to bacterial vaginosis.
Incidence, clinical features, symptoms, examination findings and treatment are etiology specific.
Comparison of different causes of vaginal discharge
| Bacterial vaginosis | Trichomonas | Fungal | |
| Risk factors | Multiple sexual partners. Pregnancy. Frequent douching. | Multiple sex partners. Unprotected sexual activity. | Immunosuppressed condition (HIV, Diabetes mellitus, corticosteroids). OCP use. Antibiotic use. Multiple sex partners, increased frequency of intercourse. Tight fitting clothes. |
| Organism | Not infection. Due to shift of vaginal flora. Increased number anaerobes (Gardenella vaginalis). | Trichomonas vaginalis | Commonly Candida albicans. Albicans cause uncomplicated vaginitis, where non albicans species cause recurrent severe infections usually in immunocompromised individual. |
| Pathophysiology | Normally vaginal epithelium is covered with normal flora (Lactobacillus). When number of lactobacilli is decreased, vaginal flora may get shifted to anaerobes (Gardenella vaginalis). | Is sexually transmitted disease (STD). Infection with flagellated protozoa Trichomonas vaginalis. | Infection with fungus. Most commonly Candida albicans. |
| Clinical presentation | Homogenous, creamy, grayish white discharge with fishy odor. Mild vulvar irritation. | Yellow green colored, frothy, malodorous, profuse discharge. Severe pruritus, dysuria. Colpitis macularis: Strawberry petechiae in upper vagina and cervix. | Thick, white, curdy textured discharge without odor. Out of proportion pruritus, dysuria, burning sensation. Excoriated, erythematous vulva. Plaques on vaginal wall which on removal reveal petechiae. |
| Investigation & Diagnosis | Wet mount: epithelial cells covered with bacteria. KOH preparation: Whiff test is positive. | Wet mount: Motile flagellated organism slightly larger than white blood cell. | Wet mount: Budding yeast and hyphae. KOH preparation: pseudohyphae. |
| Treatment | Per oral/ vaginal metronidazole. Vaginal clindamycin. No sexual transmission. | Oral metronidazole, tinidazole, secnidazole. Treat partner also. | Topical azoles. Per oral fluconazole. |
| Complications | Can cause chorioamnionitis, preterm delivery in pregnant woman. Pelvic inflammatory disease. Endometritis. | Similar to bacterial vaginosis | Secondary bacterial skin infections from scratching, recurrent infections. Dyspareunia. |
References:
- Jawetz, Melnick & Adelberg’s Medical Microbiology Twenty-Ninth Edition.
- DC Dutta’s Textbook of Gynecology, 9th edition.
- Williams Gynecology, Fourth Edition.
