I VAGINITIS ^406

Vaginitis is defined as the spectrum of conditions that cause vulvovaginal symptoms, such as itching, burning, irritation, and abnormal discharge. Vaginal symptoms are common in the general population and are one of the most frequent reasons for patient visits to obstetrician-gynecologists.

Evaluation of women with vaginitis should include a focused history about the entire spectrum of vaginal symptoms, including change in dis­charge, vaginal malodor, itching, irritation, burning, swelling, dyspareunia, and dysuria. Questions about the location of symptoms (the vulva, vagina, and anus), duration, relation to the menstrual cycle, response to prior treatment (including self-treatment and douching), and sexual history can yield important insights into the likely cause. Evaluation may be compro­mised by patient self-treatment with nonprescription medications. Because self-diagnosis of vaginitis is unreliable, clinical evaluation of women with vaginal symptoms should be encouraged, particularly for women who fail to respond to self-treatment with a nonprescription antifungal agent.

Because many patients with vaginitis have vulvar manifestations of dis­ease, the physical examination should begin with a thorough evaluation of the vulva. During speculum examination, samples should be obtained for vaginal pH determination, an amine (“whiff ”) test, and saline (wet mount) and 10% potassium hydroxide microscopy evaluation. The pH and amine testing can be performed either through direct measurement or by colori­metric testing. It is important that the swab for pH evaluation be obtained from the midportion of the vaginal side wall to avoid false elevations in pH results caused by cervical mucus, blood, semen, or other substances.

In selected patients, vaginal cultures or polymerase chain reaction tests for Trichomonas species or yeast are helpful. Vaginal Gram staining for Nugent scoring of the bacterial flora may help to identify patients with bacterial vaginosis. Other currently available ancillary tests for diagnosing vaginal infections include rapid tests for enzyme activity from bacterial vaginosis-associated organisms and for Trichomonas vaginalis antigen, along with point-of-care testing for DNA of Gardnerella vaginalis, T vagi­nalis, and Candida species. Depending on risk factors, DNA amplification tests can be obtained for Neisseria gonorrhoeae and Chlamydia trachomatis.

Bacterial Vaginosis

Bacterial vaginosis is a polymicrobial infection marked by a lack of hydro­gen peroxide-producing lactobacilli and an overgrowth of facultative anaer­obic organisms. Organisms that are found with greater frequency and num­bers in women with bacterial vaginosis include G vaginalis, Mycoplasma hominis, Bacteroides species, Peptostreptococcus species, Fusobacterium spe­cies, Prevotella species, Atopobium vaginae, and other anaerobes. Because these organisms are part of the normal flora, the mere presence of them, especially of G vaginalis, on a culture does not mean that the patient has bacterial vaginosis.

Patients with bacterial vaginosis, when symptomatic, may report an abnormal vaginal discharge and a fishy odor, especially after sexual inter­course or completion of menses. A clinical diagnosis of bacterial vaginosis requires the presence of three of the four Amsel criteria:

1. Abnormal gray discharge

2. Vaginal pH higher than 4.5

3. A positive amine test result

4. Clue cells that compromise more than 20% of the epithelial cells

Because bacterial vaginosis is an overgrowth of facultative and obligate anaerobic bacteria derived from the patient’s own endogenous vaginal flora, the intent of treatment is not to eradicate these bacteria but to reduce their numbers and allow for the lactobacilli to become dominant.

Vulvovaginal Candidiasis

Physical manifestations of vulvovaginal candidiasis range from asymptom­atic colonization to severe symptoms. Symptomatic women may report itching; burning; irritation; dyspareunia; burning with urination; and a whitish, thick discharge.

Multiple studies conclude that a reliable diagnosis cannot be made on the basis of history and physical examination alone. Diagnosis requires the presence of either of the following two criteria: 1) visualization of blastospores or pseudohyphae on saline or 10% potassium hydroxide microscopy or 2) a positive culture result in a symptomatic woman. The diagnosis can be classified further as uncomplicated or complicated vulvo­vaginal candidiasis (see Box 4-4). This classification system has treatment implications, because complicated vulvovaginal candidiasis is more likely to fail standard antifungal therapy.

Uncomplicated Vulvovaginal Candidiasis

Women with uncomplicated vulvovaginal candidiasis can be treated successfully with any of the prescription or over-the-counter options rec­omm ended by the Centers for Disease Control and Prevention (CDC). Preferred over-the-counter intravaginal preparations include butoconazole, clotrimazole, miconazole, and tioconazole. Recommended prescription treatments include the intravaginal agents butoconazole (single-dose preparation), nystatin, and terconazole and the oral agent fluconazole. Because all listed antifungal treatments seem to have comparable safety and efficacy, the choice of therapy should be individualized to the specific

Box 4-4. Classification of Vulvovaginal Candidiasis[‡‡‡‡‡] ^

Uncomplicated (presence of any of the following):

Sporadic or infrequent episodes

Mild-to-moderate symptoms or findings

Suspected Candida albicans infection

Infection in nonimmunocompromised women

Complicated (presence of any of the following):

Recurrent episodes (four or more per year)

Severe symptoms or findings

Non-C albicans infection

Infection in women with uncontrolled diabetes, debilitation, or immunosuppression

Trichomoniasis

Vaginal trichomoniasis is a common sexually transmitted infection with an estimated annual incidence of 3.7 million cases in the United States. Symptomatic women with trichomoniasis may have an abnormal frothy gray or yellow-green discharge, itching, burning, or postcoital bleeding; some women are asymptomatic.

Although metronidazole has been the mainstay of treatment for uncom­plicated trichomoniasis in the United States, tinidazole also has been approved for single-dose therapy. Both treatments seem to be equally effec­tive. Trichomoniasis is almost always sexually transmitted. Male partners of women with trichomoniasis also should be treated. To prevent reinfection, women with trichomoniasis should avoid intercourse until they and their partners have received treatment.

Other Causes of Vaginal Symptoms

Although bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis are the predominant causes of vulvovaginal symptoms, other causes may include a broad range of conditions, such as vulvar diseases, atrophic vagi­nitis, foreign bodies, and rarer forms of vaginitis.

Contact or Irritant Vulvovaginitis

If a patient reports pruritus and has a normal pH and negative potassium hydroxide microscopy test result and yeast vaginal culture findings, the diagnosis of contact or irritant vulvovaginitis should be considered.

Atrophic Vaginitis

Patients with atrophic vaginitis may have an abnormal vaginal discharge, dryness, itching, burning, or dyspareunia. Although more common in postmenopausal and perimenopausal women, atrophic vaginitis can occur in the setting of other hypoestrogenic states, such as lactation, treat­ment with gonadotropin-releasing hormone agonists, use of injectable depot medroxyprogesterone acetate, and, rarely, with oral contraceptives. Diagnosis can be made on the basis of an elevated vaginal pH and the pres­ence of parabasal or intermediate cells on microscopy. An amine test result will be negative. Atrophic vaginitis is best treated with topical estrogen, but local water-based moisturizing preparations or systemic estrogen also can be used.

Desquamative Inflammatory Vaginitis

Of the rarer forms of vaginitis, the best defined seems to be desquamative inflammatory vaginitis. Symptoms include burning, dyspareunia, and copi­ous yellow or green discharge. Examination reveals a purulent discharge with varying amounts of vestibular and vaginal erythema. The vaginal pH is elevated, and the amine test result is negative. Microscopy reveals large amounts of polymorphonuclear cells and parabasal cells. This condition easily is mistaken for trichomoniasis; however, in cases of desquamative inflammatory vaginitis, no motile trichomonads are present, and cultures for T vaginalis are negative. Although no randomized, controlled studies have been performed, a 14-day course with a 2% clindamycin cream often achieves a cure. However, relapse after therapy is fairly common.

Bibliography­

centers for Disease Control and Prevention. Sexually transmitted disease surveil­lance 2011.

Vaginitis. ACOG Practice Bulletin No. 72. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1195-206. [PubMed] [Obstetrics & Gynecology]

Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. Centers for Disease Control and Prevention [published erratum appears in MMWR Morb Mortal Wkly Rep 2011;60:18]. MMWR Recomm Rep 2010;59:1-110. [PubMed] [Full Text]

Resources

American College of Obstetricians and Gynecologists. Disorders of the vulva. Patient Education Pamphlet AP088. Washington, DC: American College of Obstetricians and Gynecologists; 2013.

American College of Obstetricians and Gynecologists. Vaginitis. Patient Education Pamphlet AP028. Washington, DC: American College of Obstetricians and Gyne­cologists; 2010.

Centers for Disease Control and Prevention. Bacterial vaginosis. CDC Fact Sheet. Available at: http://www.cdc.gov/std/bv/STDFact-Bacterial-Vaginosis.htm. Retrieved August 9, 2013.

Centers for Disease Control and Prevention. Genital/vulvovaginal candidiasis (VVC). Available at: http://www.cdc.gov/fungal/diseases/Candidiasis/genital/index. html. Retrieved August 9, 2013.

Centers for Disease Control and Prevention. Trichomoniasis. CDC Fact Sheet. Available at: http://www.cdc.gov/std/trichomonas/STDFact-Trichomoniasis.htm. Retrieved August 9, 2013.