DESCRIPTION

• Vaginitis is vulvovaginal inflammation with or without abnormal vaginal discharge.
  • Common symptoms: Itching, burning, irritation, pain.
  • Abnormal discharge is defined as an increased amount or change in color.
• Some amount of vaginal discharge is normal.
  • Glands in the cervix produce clear mucus that may turn white or yellow when exposed to air.

ETIOLOGY

• Bacterial vaginosis (BV):
  • The most common cause
  • Loss of normal Lactobacillus sp. (e.g., antibiotics)
  • Inability to maintain normal vaginal pH
  • Overgrowth of normally present bacteria such as Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus sp., Prevotella sp., and Peptostreptococcal
• Bacterial infections:
  • Trichomonas vaginalis (Trichomoniasis)
  • Group A strep
  • Staphylococcus aureus
• Fungal infections:
  • Candida sp. most common
  • Often underlying immune dysfunction:
    • Diabetes
    • HIV
• Chemical irritants
• Foreign body
• Atrophic vaginitis:
  • Caused by estrogen deficiency
• Hypersensitivity
• Collagen vascular disease
• Herpes simplex virus (HSV):
  • Vulvovaginitis
  • Cervicitis
• Lichen sclerosis (atrophic)
• Fistula

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Abnormal discharge
• Vaginal or vulvar irritation
• Localized pain
• Dyspareunia
• Erythema
• Edema
• Dysuria
• Pruritus
• Excoriations
• Abnormal odor
• Can be asymptomatic

History

• Description and duration of symptoms
• Description of discharge, if any
• Timing with regard to menses
• Sexual history of patient and partners
• Sexual practices
• Hygienic practices
• Use of oral contraceptives and/or antibiotics
• Likelihood of pregnancy
• Other symptoms (e.g., abdominal pain; must rule out pelvic inflammatory disease [PID])

Physical Exam

• Abdominal exam to assess for tenderness
• Inspection of vulva, vaginal os, perineal area
• Speculum and bimanual exam

ESSENTIAL WORKUP

• Pelvic exam
• Saline and KOH wet prep of vaginal discharge

DIAGNOSIS TESTS & INTERPRETATION

Lab

• β-human chorionic gonadotropin (β-hCG)
• pH of discharge with Nitrazine paper:
  • Normal in premenopauseal adults: < 4.5
  • > 4.5: BV, trichomoniasis
  • pH normal in candidiasis
• Saline wet prep of discharge:
  • Clue cells: BV
  • Motile flagellated protozoa: Trichomoniasis
  • Presence of polymorphonuclear leukocytes
• Potassium hydroxide (KOH) wet prep of discharge:
  • Pseudohyphae, budding yeast: Candidiasis
• KOH prep "Whiff" test:
  • Amine or "fishy" odor suggests BV, trichomoniasis.
• Trichomonas Rapid Test:
  • Point-of-care test
  • Immunochromatographic dipstick
• PIP test card for BV:
  • Point-of-care test
  • Detects proline aminopeptidase
• Nucleic acid probe test for Trichomonas, G. vaginalis, and Candida albicans
• Gram stain:
  • Large, gram-positive rods: Lactobacilli (normal flora)
  • Small, gram-variable coccobacilli and curved rods: Gardnerella, Prevotella, Mobiluncus (BV)
• Vaginal culture:
  • Gardnerella: Not routinely recommended
  • Candida: Recommended for recurrently symptomatic patients
  • Trichomoniasis: Gold standard
• Endocervical swab for gonorrhea (culture—Thayer–Martin media; DNA probe; amplification techniques—PCR/LCR) and chlamydia (DNA probe or amplification techniques—PCR/LCR)
• Viral cultures for HSV, DFA, or Tzanck smear for multinucleated giant cells if ulcers or vesicles are present
• Urinalysis/urine culture if c/o dysuria
• Rule out sexually transmitted infections:
  • GC/Chlamydia testing
  • Consider RPR to rule out syphilis.
  • Discuss HIV testing.

Imaging

N/A unless fistula is suspected.

DIFFERENTIAL DIAGNOSIS

• UTI
• PID
• Dermatitis
• Discharge from cervicitis can be mistaken for vaginitis
• Chlamydia trachomatis
• Neisseria gonorrhoeae

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

ED TREATMENT/PROCEDURES

• BV:
  • Metronidazole vaginal gel daily × 5 days or
  • Metronidazole 500 mg PO BID × 7 days or
  • Clindamycin vaginal cream × 7 days or
  • Clindamycin ovules PV daily × 3 days
  • Rx before certain gynecologic procedures
  • Advise against alcohol intake if taking metronidazole for 24 hrs after treatment.
  • Routine treatment of male sex partner: NO
  • Lactobacillus not found to be more effective than placebo
• Candidiasis:
  • Single-dose oral fluconazole or
  • Intravaginal imidazole drug × 7 days
  • Routine treatment of male sex partner: NO
• Chemical irritant:
  • Avoid irritant
  • Use sitz baths, cotton underwear.
• Foreign body:
  • Removal of foreign body
  • Sedation may be required for removal
  • Give appropriate antibiotics if infection present
• Chlamydia cervicitis:
  • Azithromycin 1 g PO in single dose (for cervicitis, not adequate for PID) or
  • 7 days of doxycycline, ofloxacin, levofloxacin, or erythromycin
  • Treat for presumed concurrent gonococcal infections.
  • Routine treatment of male sex partners: YES
• Gonococcal cervicitis:
  • Ceftriaxone 250 mg IM × 1 AND azithromycin 1 g PO × 1 or doxycycline 100 mg BID × 7 days.
  • Oral cephalosporins (cefixime) no longer recommended.
  • Treat for presumed concurrent chlamydial infection.
  • Routine treatment of male sex partners: YES
• HSV:
  • Acyclovir, famciclovir, or valacyclovir for 7–10 days for initial attack; 5 days for recurrences
  • Lidocaine jelly for topical relief
  • Rule out other causes of genital ulcers. Offer RPR, HIV testing, and counseling.
  • Routine treatment of male sex partners: Only if symptomatic; however, patient and partner may shed virus asymptomatically.
• Lichen sclerosis:
  • Referral to gynecologist for estrogen cream and further treatment
• Trichomoniasis:
  • Metronidazole 2 g PO once or
  • Tinidazole 2 g PO once or
  • Metronidazole 500 mg PO BID for 7 days (avoid ethanol)
  • Routine treatment of male sex partners: YES
• All sexually transmitted causes:
  • Advise patient to avoid sexual contact with partner until partner is evaluated and treated when appropriate.
  • Educate regarding STDs/safer sex/HIV/hepatitis vaccines

Pregnancy Considerations

• BV:
  • Treat symptomatic women with oral metronidazole or clindamycin
  • Insufficient evidence for screening or treatment of asymptomatic pregnant women
• Candidiasis:
  • Only topical azole drug recommended in pregnancy; no oral fluconazole.
• Chlamydia cervicitis:
  • Azithromycin is the 1st-line choice for treating chlamydia in pregnant patients
  • Do not treat with doxycycline, ofloxacin, or levofloxacin.
• Trichomoniasis:
  • Metronidazole given early in pregnancy shown to increase preterm birth.
  • Give 2 g single-dose metronidazole, preferably after 37 wk gestation.

Pediatric Considerations

• Ask about new irritants: Bubble bath, soap, and laundry detergent.
• Consider sexual assault/abuse.

MEDICATION

• Acyclovir: 200 mg PO 5 times per day × 10 days or 400 PO TID × 10 days (for initial attack); 200 mg PO 5 times per day × 5 days or 400 PO TID × 5 days (for recurrent attack)
• Azithromycin: 1 g PO × 1
• Butoconazole 2% cream: 5 g PV × 3 days
• Butoconazole SR 2% cream: 5 g PV × 1
• Ceftriaxone: 125 mg IM or 250 mg IM × 1
• Ciprofloxacin: 500 mg PO × 1
• Clindamycin 2% cream: 1 applicator PV QHS × 7 days
• Clindamycin: 300 mg PO BID × 7 days
• Clotrimazole 1% cream: 5 g PV × 7–14 days
• Clotrimazole: 100 mg vaginal tablet × 7 days
• Doxycycline: 100 mg PO BID × 7 days (class D)
• Erythromycin ethyl succinate: 800 mg PO QID × 7 days
• Erythromycin base: 500 mg PO QID × 7 days
• Famciclovir: 250 mg PO TID × 7–10 days (for initial attack); 125 mg PO BID × 5 days (for recurrent infection)
• Fluconazole: 150 mg PO × 1
• Levofloxacin: 500 mg PO per day × 7 days
• Metronidazole: 500 mg PO BID for 7 days
• Metronidazole 0.75% gel: PV daily × 5 days
• Miconazole: 1,200 mg PV × 1
• Miconazole: 200 mg PV QHS × 3 days
• Miconazole 2% cream: 5 g PV QHS × 7 days or 100 mg supp. PV QHS × 7 days
• Nystatin 100,000 unit vaginal tablet: Nightly × 14 days
• Terconazole: 80 mg supp QHS × 3 days
• Terconazole 0.8% cream: 5 g PV × 3 days
• Terconazole 0.4% cream: 5 g PV × 7 days
• Tinidazole: 2 g PO daily × 1 day
• Tioconazole 6.5% cream: 5 g PV × 1
• Valacyclovir: 1 g PO BID × 7–10 days (for initial attack); 500 mg PO BID × 3–5 days or 1 g PO per day × 5 days (for recurrent attack)

[Outline]

• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Disseminated gonococcal infection
• Sepsis secondary to foreign body
• PID toxicity
• Pain control, consequent inability to urinate or pass stool (HSV)

Discharge Criteria

Most can be discharged. Follow-up in ~1 wk is suggested.

Issues for Referral

• Vaginal discharge and vaginitis can be safely managed as an outpatient by the patient's primary physician or gynecologist:
  • Suggested follow-up in 1 wk

FOLLOW-UP RECOMMENDATIONS

• Recommend good hygiene
• Advise patient to return to the ED or see her doctor if:
  • Symptoms do not resolve in 3–5 days
  • Abdominal pain or cramping
  • Fever or chills
  • Pain during sexual intercourse
  • Lower back or flank pain
  • Difficulty urinating or urinary frequency

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• pH of BV is often > 4.5
• Candidiasis often presents right before menses and can be precipitated by antibiotic use, DM, and immunosuppression.
• Trichomoniasis often presents after menses and has similar risk factors as other sexually transmitted diseases, including number of sexual partners and sexual practices.
• Partner treatment required for gonococcal and chlamydial infection, trichomoniasis.

ICD9

• 131.01 Trichomonal vulvovaginitis
• 616.10 Vaginitis and vulvovaginitis, unspecified
• 627.3 Postmenopausal atrophic vaginitis

ICD10

• A59.01 Trichomonal vulvovaginitis
• N76.0 Acute vaginitis
• N95.2 Postmenopausal atrophic vaginitis

[Outline]

• ICD9
• ICD10

• Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. 2004;291(11):1368–1379.
• Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. 2010.
• Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000;62(5):1095–1104.
• Gore H. Vaginitis. Emedicine. October 27, 2011.
• Hainer BL, Gibson MV. Vaginitis. Am Fam Physician. 2011;83:807–815.
• Wilson JF. In the clinic. Vaginitis and cervicitis. Ann Intern Med. 2009;151:ITC3-1–ITC3-15.

Elizabeth M. Foley

Carrie Tibbles