Author:
Elizabeth M.Foley
Carrie D.Tibbles
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:
- Gland s 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 Peptostreptococcus sp
- Bacterial infections:
- Fungal infections:
- Cand ida sp. most common
- Often underlying immune dysfunction:
- Chemical irritants
- Foreign body
- Atrophic vaginitis:
- Caused by estrogen deficiency
- Hypersensitivity
- Collagen vascular disease
- Herpes simplex virus (HSV):
- Lichen sclerosis (atrophic)
- Fistula
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
Diagnostic Tests & Interpretation
Lab
- β-human chorionic gonadotropin (β-hCG)
- pH of discharge with Nitrazine paper:
- Normal in premenopausal adults: <4.5
- >4.5: BV, trichomoniasis
- pH normal in cand idiasis
- 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: Cand idiasis
- 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 Cand ida 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
- Cand ida: Recommended for recurrently symptomatic patients
- Trichomoniasis: Gold stand ard
- 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
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 d
- Abdominal pain or cramping
- Fever or chills
- Pain during sexual intercourse
- Lower back or flank pain
- Difficulty urinating or urinary frequency
- and ersonMR, KlinkK, CohrssenA. Evaluation of vaginal complaints . JAMA. 2004;291(11):1368-1379.
- HainerBL, GibsonMV. Vaginitis . Am Fam Physician. 2011;83(7):807-815.
- Palmeira-de-OliveiraR, Palmeira-de-OliveiraA, Martinez-de-OliveiraJ. New strategies for local treatment of vaginal infections . Adv Drug Deliv Rev. 2015;92:105-122.
- TomasME, GetmanD, DonskeyCJ, et al. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department . J Clin Microbiol. 2015;53(8):2686-2692.
- WilsonJF. In the clinic. Vaginitis and cervicitis . Ann Intern Med. 2009;151(5):ITC3-1-ITC3-15; Quiz ITC3-16.
See Also (Topic, Algorithm, Electronic Media Element)
Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. 2015. www.cdc.gov/std/tg2015/default.htm