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Female Reproductive System ORGAN SYSTEMS

Vaginitis

Any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning.

Any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning.

  • M/C gynecologic diagnosis in primary care

Aetiology

  • Bacterial vaginosis (40-50%)
  • Vulvovaginal candidiasis (20-25%)
  • Trichomoniasis (15-20%)
  • Noninfectious causes (less common, 5-10%): Atrophic, irritant, allergic, and inflammatory vaginitis
Causes, Symptoms, and Signs of Vaginitis | Hainer, B. L., & Gibson, M. V. (2011). Vaginitis. American family physician, 83(7), 807–815.

Risk factors:

  • Bacterial vaginosis: Low socioeconomic status, vaginal douching, smoking, intrauterine contraceptive device, new/multiple sex partners, unprotected sexual intercourse, homosexual relationships, spermicide nonoxynol-9 use
  • Trichomoniasis: Low socioeconomic status, multiple sex partners, lifetime frequency of sexual activity, other STDs, lack of barrier contraceptive use, illicit drug use, smoking
  • Vulvovaginal candidiasis: Vaginal/systemic antibiotic use, diet high in refined sugars, uncontrolled diabetes mellitus
  • Atrophic vaginitis: Menopause, conditions associated with estrogen deficiency, oophorectomy, radiation therapy, chemotherapy, immunologic disorders, premature ovarian failure, endocrine disorders, antiestrogen medication
  • Irritant contact dermatitis: Soaps, tampons, contraceptive devices, sex toys, pessary, topical products, douching, fastidious cleansing, medications, clothing
  • Allergic contact dermatitis: Sperm, douching, latex condoms or diaphragms, tampons, topical products, medications, clothing, atopic history

Diagnosis

Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing.

Bacterial vaginosis: Amsel criteria

Presence of 3 out of 4 Amsel criteria
  1. Thin, homogenous vaginal discharge
  2. Vaginal pH > 4.5
  3. Positive whiff test: Fishy amine odor when 10% KOH added
  4. ≥ 20% clue cells: Vaginal epithelial cells with borders obscured by adherent coccobacilli on wet-mount preparation or Gram stain
Clue cells (400 ×). Vaginal epithelial cells with borders obscured by adherent coccobacilli seen on saline wet-mount preparation. | Hainer, B. L., & Gibson, M. V. (2011). Vaginitis. American family physician, 83(7), 807–815.

Vulvovaginal candidiasis:

  • Potassium hydroxide microscopy
  • DNA probe testing
  • Culture
Candida species (400 ×). Budding yeast visible (arrow). | Hainer, B. L., & Gibson, M. V. (2011). Vaginitis. American family physician, 83(7), 807–815.

Trichomoniasis:

  • Nucleic acid amplification testing (NAAT)
Trichomonas vaginalis (400 ×). When vaginal wet-mount preparation is promptly examined, motile trichomonads with flagella slightly larger than a leukocyte may be seen (arrow). | Hainer, B. L., & Gibson, M. V. (2011). Vaginitis. American family physician, 83(7), 807–815.

Management

Bacterial vaginosis:

  • Oral/IV metronidazole
  • Intravaginal clindamycin

Vulvovaginal candidiasis:

  • Oral fluconazole
  • Topical azoles (recommended during pregnancy)

Trichomoniasis:

  • Oral metronidazole
  • Treatment of sexual partner(s) mandatory

Noninfectious vaginitis:

Treatment directed at the underlying cause.
  • Atrophic vaginitis: Hormonal & nonhormonal therapies
  • Inflammatory vaginitis: Topical clindamycin ± steroid application

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