MARIA V. GIBSON, MD, PhD Medical Director, University Family Medicine, Charleston, SC;
and Assistant Professor, Department of Family Medicine, Medical University of South Carolina, Charleston.
TABLE 1. Common causes of vaginitis
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Vaginitis is among the most common reasons for visits to primary care physicians, although the incidence is unclear because
it is not a reportable disease, and many women self-diagnose their symptoms and treat them with OTC preparations.1 The infectious causes—bacterial vaginosis (BV), candidiasis, and trichomoniasis—account for most cases of vaginitis in women
of reproductive age in the United States. The most common noninfectious cause of vaginal symptoms in postmenopausal women
is vaginal atrophy (see Table 1).2,3 BV is diagnosed in 40% to 50% of women of reproductive age with vaginal pain and abnormal discharge, vulvovaginal candidiasis
in 20% to 25%, and trichomoniasis in 15% to 20%. BV and trichomoniasis are more common in African American women, and candidiasis
is more prevalent in whites.
Predisposing factors for infectious and noninfectious causes of vaginitis include multiple sex partners, intercourse without
barrier protections, antibiotic use, decreased estrogen level caused by menopause, postpartum loss of placental estrogen,
elevated prolactin levels during lactation, medications with antiestrogen properties, immunocompromised status, uncontrolled
diabetes, pregnancy, debilitation, and allergy to intravaginal and hygiene products.
Evaluating vaginal symptoms
A patient's description of her vaginal symptoms is insufficient to make a diagnosis, which requires physical examination and
laboratory studies including pH and microscopic examination with and without potassium hydroxide (KOH) prep and, in some cases,
culture.4,5 Results of these studies, together with the clinical picture, will help to identify the causative pathogen.
TABLE 2. Key characteristics of vaginal discharge
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Vaginal discharge that is unusual in appearance, odor, or consistency is a hallmark of vaginitis and often the first clue
to the cause of the symptoms (see Table 2). The patient may also complain of pain, pruritus, and irritation. Dysuria, dyspareunia,
and vaginal bleeding are not usually associated with the most common causes of vaginitis discussed in this article. Candidiasis
is associated with pruritus, cheeselike discharge, and erythema. A patient with BV may complain of heavy, malodorous discharge—little
or no discharge makes a diagnosis of BV unlikely. Malodorous discharge occurs in BV, but not in candidiasis. (Note that inflammation
is relatively specific for candidiasis but is not always present and also occurs with trichomoniasis.)
Normal physiologic vaginal discharge consists of cervical and vaginal epithelium, normal bacterial flora, water, electrolytes,
and other chemicals. Normal vaginal secretions are white to gray, flocculent, and odorless. Estrogen stimulates the glycogen
production in the vaginal epithelial cells that metabolizes to lactic acid and maintains the vaginal pH level at 3.5 to 4.5.
Increased vaginal pH levels predispose the vagina to infection with both aerobic and anaerobic organisms.
The sensitivity of wet mount microscopy is 38% to 83% for candidiasis and 62% for trichomoniasis.6,7 The specimens should be obtained from the junction of the upper third and lower two thirds of the vaginal side wall and
prepared with normal saline and 10% KOH. The saline wet prep is examined for motile trichomonads, clue cells, leukocytes,
and Lactobacilli organisms, and the KOH prep is examined for hyphae and buds. A Gram's stain of the smear may demonstrate the bacteria needed
to make the diagnosis of BV. Although microscopic identification of trichomonads is diagnostic for trichomoniasis, other causes
should not be ruled out by negative findings. Clue cells makes candidiasis less likely.
Vaginal cultures are rarely indicated in vaginitis but may be helpful in complicated, treatment-resistant, or recurrent cases.
Vulvar biopsy should be performed if lesions are observed on the vulvar skin, and when atrophic vaginitis in a postmenopausal
woman does not respond to estrogen therapy. Despite time-consuming clinical and laboratory assessments, approximately 30%
of women undergoing a complete evaluation for vaginal complaints are not given a diagnosis, often because laboratory test
results are normal due to low sensitivity.5,8
Case report: Malodorous discharge
A 21-year-old patient presents with a complaint of recurrent malodorous vaginal discharge. She is sexually active with one
partner and uses oral contraception. Visits 3 and 6 months earlier resulted in a diagnosis of BV that was treated with oral
and vaginal clindamycin (Cleocin, Clindamax, Clindesse). The findings from recent tests for Neisseria gonorrhoeae, Chlamydia trachomatis, and HIV were negative. Physical examination revealed a moderate amount of gray discharge in the posterior vault. Saline wet
prep microscopy demonstrated 2 to 3 leukocytes, few bacterial organisms, few clue cells, and no evidence of Trichomonas vaginalis.
Clinical question
What is the appropriate treatment for recurrent BV?
Discussion
Recurrent BV is a common complaint that is associated with multiple sex partners and douching and is characterized microscopically
by few vaginal Lactobacillus acidophilus organisms and overgrowth with anaerobic bacteria. The most commonly reported symptoms of BV include pruritus and malodorous
discharge.
Amsel's clinical criteria has a 92% sensitivity for BV.7,9 The clinical diagnosis of BV is made when 3 of the 4 following Amsel's clinical criteria are met:
- Thin, gray, malodorous discharge that adheres to the vaginal wall
- Vaginal pH level that is greater than 4.5
- Clue cells and decreased number of Lactobacilli organisms
- Positive amine (whiff) test.
A Gram's stain is frequently helpful for a differential diagnosis. Although performing a culture for Gardnerella vaginalis is neither specific nor recommended, a probe assay for high concentrations of G vaginalis may be used. Other commercially available tests that may help in making the diagnosis of BV include card tests used to evaluate
pH, trimethylamine, and prolineaminopeptidase.
TABLE 3. Pharmacotherapy for bacterial vaginosis
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The CDC recommends first-line treatment of BV with oral metronidazole (Flagyl, Protostat), 500 mg bid for 7 d, which is effective,
as are alternative treatments using clindamycin (see Table 3). A 10- to 14-day course of antibiotic therapy has been recommended
for treating relapses.
A disadvantage of clindamycin treatment is the potential for development of clindamycin-resistant bacteria that are associated
with recurrent BV.9 Investigators in a randomized controlled trial involving 110 nonpregnant patients with BV found that metronidazole and clindamycin
are equally effective treatments with 75% to 90% cure rates, but fewer than 1% of patients showed resistance to metronidazole
both before and after therapy, and resistance to clindamycin was found in 80% of isolates 90 days after the treatment.10,11 Suppressive therapy such as intravaginal metronidazole (Metrogel) twice weekly may also be considered as maintenance therapy
to prevent recurrences but is not recommended by CDC guidelines. Consuming yogurt or using lactobacilli-containing suppositories
to recolonize the vagina to prevent recurrences is under investigation. The use of oral supplements and lactobacilli suppositories
without antibiotic treatment have been shown to briefly resolve BV, but recurrence rates with lactobacilli treatment alone
are high. Some authors recommend a trial of lactobacilli treatment, especially in women who have failed standard therapy.12
Other antibiotics that have shown in vitro efficacy for treating the spectrum of microbes associated with BV are amoxicillin/clavulanic
acid (Augmentin) and imipenem (Primaxin). Treatment of the male sex partner has not been beneficial in preventing the recurrence
of BV.9,11
Case resolution
The patient presented with similar symptoms 3 months after a 7-day course of intravaginal metronidazole and cessation of
douching. A 14-day course of oral metronidazole resolved her symptoms. She also chose to try oral lactobacilli supplementation
110 mg 2 to 4 times a day for 1 month.
Case report: Vaginal discharge after antibiotic use
A 38-year-old married patient with diabetes presents with a complaint of increased vaginal discharge following a course of
antibiotic therapy for cystitis. Physical examination reveals erythema and excoriations of the labia minora and a thick, white
vaginal discharge. KOH microscopy demonstrates hyphae. Probe assays for C trachomatis and N gonorrhoeae were negative. The current complaint was the patient's third episode of candidiasis in the preceding 12 months.
Clinical question
What is the most appropriate approach to the evaluation and management of recurrent vulvovaginal candidiasis?
TABLE 4. Differentiating vulvovaginal candidiasis
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Discussion
In addition to white, adherent discharge, clues to vulvovaginal candidiasis include pruritus, vulvar edema, and dysuria.
Established risk factors for vulvovaginal candidiasis include uncontrolled diabetes, recent antibiotic use, and HIV infection.
The use of panty liners or panty hose, consumption of cranberry juice, a history of BV, frequent oral intercourse, and age
younger than 40 years are associated with symptomatic disease.13,14 Approximately 75% of women will have had at least one prior episode, and 40% to 45% of these women will have had 2 or more
episodes. Table 4 differentiates complicated and uncomplicated disease, based on microbiology, host factors, and response
to therapy.9Candida albicans causes uncomplicated (vaginal) disease in 80% to 90% of patients. The common approach to making the diagnosis of vulvovaginal candidiasis involves examining a sample taken from the vaginal
wall microscopically, with and without KOH preparation. A recent study suggests, however, that this approach is neither highly
sensitive nor specific.15 Although costly, culture may be the only way to ensure an accurate diagnosis in recurrent and complicated cases, particularly
in women with typical symptoms and negative microscopic findings on the KOH prep. Identification of Candida species by culture in an asymptomatic patient is insufficient evidence to initiate treatment, because 10% to 20% of women
harbor Candida species and other yeasts in the vagina.9
TABLE 5. Recommended regimens for uncomplicated vulvovaginal candidiasis
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Uncomplicated candidiasis usually responds promptly to short-course oral or topical treatment (see Table 5). The first-line
therapies include vaginal imidazoles and produce a clinical cure in approximately 80% of cases.6,9 No difference in outcomes has been seen with the various imidazoles or with treatment durations of 1 to 14 days. A single
dose of fluconazole (Diflucan), 150 mg po, is the most commonly used treatment. Oral and vaginal azoles show similar efficacy,
but oral agents are associated with more side effects.13,15 Resistance should be suspected if imidazole therapy fails to control symptoms. Resistance to azoles also may be demonstrated
by in vitro susceptibility testing. Cross-resistance to topical and oral azoles such as fluconazole has been documented.
Complicated disease typically involves immunocompromise, comorbid diabetes, and recurrent infection. The causative organism
is usually Candida glabrata or Candida tropicalis, and azole therapy is unreliable for these organisms. Treatment includes control of comorbid conditions and induction therapy
with 2 weeks of a topical or oral azole, followed by a maintenance regimen for 6 months of oral fluconazole, 150 mg once weekly;
ketoconazole (Nizoral), 100 mg/d; or itraconazole (Sporanox), 100 mg qod or 400 mg once a month.
Although suppressive maintenance with antifungal therapy can minimize recurrences of vulvovaginal candidiasis, 30% to 40%
of women will have a recurrence after maintenance therapy is discontinued. C glabrata and the other non-C albicans infections frequently respond to boric acid, intravaginal 600 mg/d for 10-14 d; high-dose triazoles such as itraconazole,
200-400 mg/d for 14 d; intravaginal gentian violet; oral terbinafine (Lamisil); or oral ketoconozole, 200 mg/d for 14 d. 11,16,17 These drugs are not approved by the FDA for this use, however, and safety data regarding the long-term use of these regimens
are lacking.
If non-C albicans candidiasis continues to recur, a maintenance regimen of nystatin vaginal suppositories, 100,000 U/d, may be tried.11 Patients receiving long-term ketoconazole therapy should be monitored for toxicity. In addition, clinically important interactions
occur when oral azoles are given with other drugs.
Case resolution
Fungal cultures of vaginal discharge grew C glabrata. The patient was treated with ketoconozole, 200 mg/d po for 14 d, followed by maintenance therapy with fluconazole, 150 mg
po every week for 6 months. The patient's diabetes regimen was adjusted to improve diabetes control.
Case report: Self-diagnosis
A 32-year-old woman with a history of candidiasis called her primary care office seeking renewal of a prescription for fluconazole
to treat vaginal symptoms that had developed during a recent course of antibiotic therapy for pneumonia.
Clinical question
What is the evidence regarding treatment of vaginitis based on self-diagnosis?
Discussion
A patient's request for a prescription renewal based on a self-diagnosis is a common dilemma faced by primary care physicians.
Self-treatment of vulvovaginal complaints became more common after the introduction of OTC antifungals. Although the CDC recommends
that self-medication with OTC medications be advised only for women who have been previously diagnosed with candidiasis and
who have a recurrence of the same symptoms, this approach may result in the proliferation of treatment-resistant Candida strains.9 In addition, an incorrect diagnosis has the potential to result in more office visits and increased costs, eroding any efficiencies
gained by phone management. A prospective study of outcomes of vulvovaginal complaints managed over the telephone by nursing
staff revealed poor assessment, and the researchers concluded that telephone management of these complaints should be discouraged.
The study also showed that patients had good understanding of the symptoms of candidiasis but had limited knowledge of BV
and trichomoniasis. In addition, the researchers found significant differences between patients' description of the discharge
and what the providers found on examination—a strong argument against self-treatment strategies.4
Case resolution
The patient was encouraged to be seen by her physician to obtain an accurate diagnosis and appropriate treatment. Wet mount
microscopy demonstrated clue cells, decreased lactobacilli, a pH level of 6, and no signs of yeast infection. She was treated
successfully with oral metronidazole, 500 mg bid for 7 days.
Case report: Sexually transmitted disease
A cytology specimen obtained during a routine annual physical examination of a 42-year-old woman with no vaginal complaints
demonstrated the presence of the sexually transmitted flagellated protozoan T vaginalis.
Clinical questions
What are the guidelines for screening for trichomoniasis? How should this patient's infection be managed?
Discussion
No consensus exists for trichomoniasis screening using the most sensitive test—culture—in any population, and this condition
often goes undiagnosed. Untreated trichomoniasis can lead to adverse health outcomes in both women and men, including increased
rates of HIV transmission. Sequelae of untreated disease include premature delivery, infants with a low birth weight, atypical
pelvic inflammatory disease, and cervical intraepithelial neoplasia.4
Signs and symptoms of trichomoniasis include diffuse, malodorous, yellow-green discharge, and vulvar irritation, although
some women have minimal or no symptoms. The pH level is usually greater than 4.5, and microscopy reveals motile protozoa.
Although the diagnosis of trichomoniasis is often made by microscopy of vaginal secretions, the sensitivity of this method
is less than 70%.7 Culture is the most sensitive diagnostic tool available. No FDA-approved polymerase chain reaction (PCR) assay to detect
T vaginalis is available in the United States, but such testing may be available from commercial laboratories that have developed their
own PCR tests.9 Although wet mount microscopy compares poorly with culture in making the diagnosis, culture-based universal screening is
cost-prohibitive. Routine screening for T vaginalis in the general female population is not recommended by the CDC.
CDC-recommended treatment of trichomoniasis with oral metronidazole, 2 g po in a single dose or 500 mg bid for 7 d , is associated
with a cure rate of approximately 90% to 95%. Treatment failure, however, warrants increasing the dosage to 2 g once daily
for 3 to 5 d. Because topical metronidazole is unlikely to achieve therapeutic levels in the urethra or perivaginal glands,
its use is not recommended in trichomoniasis. In cases of resistant disease, susceptibility of T vaginalis to metronidazole should be determined, and an infectious disease consultation obtained. Oral tinidazole (Tindamax) was approved
in 2004 for treatment of metronidazole-resistant trichomoniasis. Patients should be counseled to avoid intercourse until cure
is achieved.11
Case resolution
The patient's trichomoniasis was successfully treated with a single 2-g dose of oral metronidazole.
This article was contributed by Dr Gibson and edited by Julia M. Russell.
Dr Gibson discloses that she has no financial relationship with any manufacturer in this area of medicine.
REFERENCES
1. Kent HL. Epidemiology of vaginitis. Am J Obstet Gynecol. 1991; 165: 1168-1176.
2. Stenchever. Comprehensive Gynecology. 4th ed. St Louis, Mo: Mosby, Inc; 2001:668-678.
3. Mulley AG. Approach to the patient with a vaginal discharge. In: Goroll AH, Mulley AG, eds. Primary Care Medicine: Office Evaluation and Management of the Adult Patient. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000:702-707.
4. Allen-Davis JT, Beck A, Parker R, et al. Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office
diagnosis. Obstet Gynecol. 2002;99:18-22.
5. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291:1368-1379.
6. Mayaud P, ka-Gina G, Cornelissen J, et al. Validation of a WHO algorithm with risk assessment for the clinical management
of vaginal discharge in Mwanza, Tanzania. Sex Transm Infect. 1998;74 (suppl 1):S77-S84.
7. Landers DV, Wiesenfeld HC, Heine RP, et al. Predictive value of the clinical diagnosis of lower genital tract infection
in women. Am J Obstet Gynecol. 2004;190:1004-1010.
8. Soper DE. Emerging antimicrobial resistance: also a problem for the women's health practitioner. Clinical update. Fam Practice News. May 2005.
9. Workowski K, Levine W. CDC sexually transmitted diseases treatment guideline 2002. MMWR Morb Mortal Wkly Rep. 2002;51:1-80.
10. Beigi RH, Austin MN, Meyn LA, et al. Antimicrobial resistance associated with the treatment of bacterial vaginosis. Am J Obstet Gynecol. 2004;101: 1124-1129.
11. French L, Horton J, Matousek M. Abnormal vaginal discharge: what does and does not work in treating underlying causes.
J Fam Pract. 2004; 53: 890-894.
12. Ugwumadu A, Manyonda I, Reid F. Effect of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic
women with abnormal vaginal flora and bacterial vaginosis: a randomized controlled trial. Lancet. 2003;361:983-988.
13. Patel DA. Risk factors for recurrent vulvovaginal candidiasis in women receiving maintenance antifungal therapy: results
of a prospective cohort study. Am J Obstet Gynecol. 2004;190:644-653.
14. Di Bartolomeo S, Rodriguez Fermepin M, Sauka DH et al. Prevalence of associated microorganisms in genital discharge,
Argentina. [In Spanish] Rev Saude Publica. 2002;36:545-552.
15. Bornstein J, Lakorsky Y, Lavi I. The classic approach to diagnosis of vulvovaginitis: a critical analysis. Infect Dis Obstet Gynecol. 2001;9:105-111.
16. Sobel JD. Vaginitis. N Engl J Med. 1997;337:1896-1903.
17. Phillips AJ. Treatment of non-albicans Candida vaginitis with amphotericin B vaginal suppositories. Am J Obstet Gynecol. 2005;192:2009-2012.
Drugs mentioned in this article
Amoxicillin/clavulanic acid (Augmentin)
Boric acid
Butoconazole (Gynazole-1, Mycelex-3)
Clindamycin HCl (Cleocin HCl)
Clindamycin phosphate, cream (2%) (Cleocin, Clindamax, Clindesse)
Clotrimazole cream (Mycelex-7)
Fluconazole (Diflucan)
Gentian violet tampon
Imipenem (Primaxin)
Itraconazole (Sporanox)
Ketoconazole (Nizoral)
Metronidazole (Flagyl, Protostat)
Metronidazole gel (0.75%) (Metrogel)
Miconazole (Monistat, M-Zole)
Nystatin
Terbinafine (Lamisil)
Terconazole (Terzol)
Tinidazole (Tindamax)
Tioconazole (Vagistat, Monistat-1)
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