Evaluation of women with symptoms of vaginitis

Sobel JD. Evaluation of women with symptoms of vaginitis. Uptodate. 20.3 ed: UpToDate, Inc; 2012.



Evaluation of women with symptoms of vaginitis
Author
Jack D Sobel, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Vanessa A Barss, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Oct 2012. | This topic last updated: Sep 5, 2012.
INTRODUCTION Symptoms of vaginitis are extremely common, accounting for over 10
million office visits per year [1] and frequently leading to self-diagnosis and therapy. In a
random telephone survey in the United States, 8 percent of Caucasian women and 18 percent of
African American women reported an episode of vaginal symptoms of any severity in the
previous year [2]. A healthcare professional was consulted in 55 and 83 percent of cases,
respectively, and most women purchased an over-the-counter antifungal preparation to treat their
symptoms, whether or not they saw a physician.
Since symptoms of vaginitis are nonspecific, laboratory documentation of a specific disorder is
mandatory before initiating therapy [3]. Empiric therapy should be avoided because of frequent
misdiagnosis and inappropriate therapy when assessment is based on history and physical
examination alone.
CAUSES OF VAGINITIS Vaginitis may be related to infection or inflammation; signs and
symptoms are generally similar, irrespective of the underlying etiology. Phase of the menstrual
cycle, sexual activity, contraceptive choice, pregnancy, foreign bodies, estrogen level, and use of
hygienic products or antibiotics can disrupt the normal ecosystem, leading to vaginitis.
The most common causes of vaginitis symptoms are bacterial vaginosis, candida vulvovaginitis,
and trichomoniasis. These disorders account for over 90 percent of cases [4].
Less common causes of vaginitis symptoms include cervicitis, atrophic vaginitis, foreign body
with secondary infection, and irritants and allergens.
Rare causes of one or more vaginitis symptoms include group A streptococcal infection,
Behets syndrome, cytolytic vaginosis, desquamative inflammatory vaginitis, erosive lichen
planus, pemphigus vulgaris, cicatricial pemphigoid, and dysplasia or cancer.
PATIENT PRESENTATION Women with vaginitis typically present with one or more of the
following vulvovaginal signs and symptoms:
Change in the volume, color, or odor of vaginal discharge
Pruritus
Burning
Irritation
Erythema
Dyspareunia
Spotting
Dysuria
In reproductive aged women, normal vaginal discharge consists of 1 to 4 mL fluid (per 24
hours), which is white or transparent, thick or thin, and mostly odorless. This physiologic
discharge is formed by mucoid endocervical secretions in combination with sloughing epithelial
cells, normal vaginal flora, and vaginal transudate. The discharge may become more noticeable
at times (physiological leukorrhea), such as at midmenstrual cycle close to the time of
ovulation or during pregnancy or use of estrogen-progestin contraceptives. Diet, sexual activity,
medication, and stress can also affect the volume and character of normal vaginal discharge.
Although normal discharge may be yellowish, slightly malodorous, and accompanied by mild
irritative symptoms [5], it is not accompanied by pruritus, pain, burning or significant irritation,
erythema, local erosions, or cervical or vaginal friability. The absence of these signs and
symptoms distinguish it from discharge related to a pathological process, such as vaginitis or
cervicitis. (See 'Management of physiological leukorrhea' below.)
GENERAL PRINCIPLES The three main steps in the evaluation of women with symptoms of
vaginitis are:
Obtain a history and perform a physical examination. (See 'History' below and 'Physical
examination' below.)
Test for bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis since these
disorders account for over 90 percent of vaginitis in premenopausal women and can be
diagnosed by pH testing, microscopy, and/or culture (or rapid antigen and nucleic acid
amplification tests) [4]. (See 'Diagnostic studies' below.)
If this evaluation does not lead to a diagnosis, then evaluate for less common and rare
causes of vaginitis. (See 'Women without a diagnosis after the initial evaluation' below.)
DIAGNOSTIC EVALUATION Both the history and findings on physical examination are
relatively nonspecific. Nevertheless, certain features often suggest a particular diagnosis (table
1), which should be confirmed in the office by microscopic examination of vaginal secretions
and, if necessary, culture (or rapid antigen and nucleic acid amplification tests). A literature
review concluded that initial office evaluation (history and physical examination, vaginal pH,
wet mount microscopy, whiff test) correctly diagnosed 60 percent of Candida vaginitis, 70
percent of Trichomonas vaginitis, and 90 percent of bacterial vaginosis [6].
History The severity of symptoms depends upon the extent of inflammation. Candida
vulvovaginitis often presents with marked inflammatory symptoms (pruritus and soreness), but
scant discharge, while bacterial vaginosis is associated with minimal inflammation and minimal
irritative symptoms, but discharge is often present, or presents with only malodorous vaginal
discharge and no inflammatory complaints. Dyspareunia is a common feature of atrophic
vaginitis, which is an inflammatory disorder.
The following are aspects of the history that can be important to include:
Are the symptoms acute, chronic, or recurrent? An acute process is more likely to be an
infection; a chronic process is more likely to be inflammatory. If the woman has had
several episodes of vaginitis, look up the results of past diagnostic testing, the type of
therapy she received, and her response to this therapy.
Does the patient have pelvic pain? Pelvic pain is suggestive of pelvic inflammatory
disease and suprapubic pain is suggestive of cystitis; both are rare with vaginitis. (See
"Clinical features and diagnosis of pelvic inflammatory disease" and "Acute
uncomplicated cystitis and pyelonephritis in women".)
What are the patients sexual practices? What is the gender of her sex partner? Women
who have sex with women are at increased risk of bacterial vaginosis. Has there been
exposure to a new sexual partner? A new sexual partner increases the risk of acquiring
sexually transmitted infections such as Trichomonas vaginalis, or cervicitis related to
Neisseria gonorrhoeae or Chlamydia trachomatis. (See "Screening for sexually
transmitted infections".)
When did the symptoms start in relation to menses? Symptoms of candida vulvovaginitis
often occur in the premenstrual period, while symptoms of trichomoniasis often occur
during or immediately after the menstrual period.
What medications (prescription and nonprescription) are being used? Antibiotics
predispose to candida vulvovaginitis; estrogen-progestin contraceptives can increase
physiologic discharge; pruritus and burning unresponsive to antifungal agents may be due
to vulvovaginal dermatitis. (See "Dermatitis of the vulva".)
What are the patient's hygienic practices? Mechanical, chemical, or allergic irritation may
cause vulvovaginal symptoms (pruritus, burning) mistakenly attributed to an infectious
source. Vaginal symptoms can result from irritants (eg, scented panty liners, spermicides,
povidone-iodine, soaps and perfumes, and some topical drugs) and allergens (eg, latex
condoms, topical antifungal agents, seminal fluid, chemical preservatives) that produce
acute and chronic hypersensitivity reactions, including contact dermatitis.

Careful assessment of the woman's personal practices is the best way to detect potential
irritants and allergens in her environment and habits unhealthy for the vulvar skin. Patient
symptom/contact diaries may be helpful. (See "Dermatitis of the vulva".)
Is the woman menopausal or otherwise hypoestrogenic? Atrophic vaginitis is a common
cause of vaginitis in hypoestrogenic women. In premenopausal women, hypoestrogenic
settings include the postpartum period, lactation, and during administration of
antiestrogenic drugs (and sometimes with low estrogen oral contraceptives). Menopausal
women who are receiving hormone therapy may not have adequate vaginal estrogen
levels. (See "Clinical manifestations and diagnosis of vaginal atrophy".)
Does the patient have a history of an oral mucosal, ocular, cutaneous, or systemic disease
that could affect the vulvovaginal area?
Physical examination None of the findings in the history allows a definitive diagnosis since
there is considerable overlap among the different disorders [5,7]. Thus, a physical examination
and some diagnostic studies are necessary in all women.
The physical examination should focus upon the degree of vulvovaginal inflammation and
characteristics of the vaginal discharge; the presence of lesions or foreign bodies; signs of
cervical inflammation; and pelvic or cervical motion tenderness.
The vulva usually appears normal in bacterial vaginosis. Erythema, edema, or fissures
suggest candidiasis, trichomoniasis, or dermatitis. Atrophic changes suggest
hypoestrogenemia, and the possibility of atrophic vaginitis. Changes in vulvar
architecture (eg, scarring) suggest a chronic inflammatory disease, such as erosive lichen
planus or cicatricial pemphigoid.
Speculum examination may reveal a lesion. A foreign body (eg, retained tampon) is
easily detected and can be associated with vaginal discharge, intermittent bleeding or
spotting, and/or an unpleasant odor due to inflammation and secondary infection.
Removal of the foreign body is generally adequate treatment. Antibiotics are rarely
indicated.

Vaginal warts are skin-colored or pink, and range from smooth flattened papules to a
verrucous, papilliform appearance (picture 1). When extensive, they can be associated
with vaginal discharge, pruritus, bleeding, burning, tenderness, and pain. (See
"Condylomata acuminata (anogenital warts)" and "Treatment of vulvar and vaginal
warts".)

Granulation tissue or surgical site infection can cause vaginal discharge after
hysterectomy. Necrotic or inflammatory changes associated with malignancy in the lower
or upper genital tract can result in vaginal discharge; spotting is more common in this
setting than in infectious vaginitis.

The presence of multifocal rounded macular erythematous lesions (like a spotted rash or
bruise), purulent discharge, and tenderness suggest erosive vulvovaginitis, which can be
caused by trichomoniasis or one of several noninfectious inflammatory etiologies [8].
The characteristics of the vaginal discharge may help distinguish the type of infection, if
present (table 2). Trichomoniasis is classically associated with a greenish-yellow purulent
discharge; candidiasis with a thick, white, adherent, "cottage cheese-like" discharge; and
bacterial vaginosis with a thin, homogeneous, "fishy smelling" gray discharge.
Inflammation and/or necrosis related to malignancy of the lower or upper genital tract
can result in watery, mucoid, purulent, and/or bloody vaginal discharge.

However, the appearance of the discharge is unreliable and should never form the basis
for diagnosis [5].
Cervical inflammation with a normal vagina is suggestive of cervicitis, rather than
vaginitis. The cervix in women with cervicitis is usually erythematous and friable, with a
mucopurulent discharge (picture 2). (See "Acute cervicitis".)

Cervical erythema in cervicitis should be distinguished from ectropion, which represents
the normal physiologic presence of endocervical glandular tissue on the exocervix.
Ectropion is more common in women taking estrogen-progestin contraceptives and
during pregnancy. Ectropion may increase the volume of normal vaginal discharge. (See
"Congenital cervical anomalies and benign cervical lesions", section on 'Ectropion'.)
Vesicovaginal and rectovaginal fistulas are rare, can be hard to detect, and are a source of
chronic vaginal discharge. At-risk patients include those who are postpartum,
posthysterectomy, or have a history of inflammatory bowel disease or radiation therapy
to the pelvis. (See "Rectovaginal, anovaginal, and colovesical fistulas" and
"Vesicovaginal, urethrovaginal, and ureterovaginal fistulas".)
Bimanual examination may reveal pelvic or cervical motion tenderness suggestive of
PID. (See "Clinical features and diagnosis of pelvic inflammatory disease".)


Diagnostic studies Examination of the vaginal discharge may lead to a definitive
diagnosis [5].
(table 2)


Vaginal pH Measurement of vaginal pH is the single most important finding that drives the
diagnostic process and should always be determined. ApH test stick (or pH paper if available) is
applied to the vaginal sidewall (to avoid contamination by blood, semen, cervical mucus which
can pool in the posterior fornix) for a few seconds or this area can be swabbed with a dry swab
and then the swab rolled onto pH paper (if available). The pH of the specimen is estimated to be
stable for about two to five minutes at room temperature. The swab should not be pre-moistened,
as the moistening liquid can affect pH.
Narrow range pH paper (4.0 to 5.5) is easier to interpret than broad range paper (4.5 to 7.5). The
pH of the normal vaginal secretions in premenopausal women is 4.0 to 4.5. Under the influence
of estrogen, the normal vaginal epithelium cornifies and produces glycogen, which is the
substrate for lactic acid production by lactobacilli. The acidic environment is hostile to growth of
pathogens (bacterial and viral) and inhibits adherence of bacteria to vaginal squamous epithelial
cells.
An elevated pH in a premenopausal woman suggests infections such as bacterial vaginosis
(pH>4.5) or trichomoniasis (pH 5 to 6), and helps to exclude candida vulvovaginitis (pH 4 to
4.5).
In premenarchal and postmenopausal women in whom estrogen levels are low, the pH of the
normal vaginal secretions is 4.7. The higher pH is due to less glycogen in epithelial cells and
reduced colonization of lactobacilli. Thus measurement of pH for diagnosis of bacterial
vaginosis, trichomoniasis, or candidiasis is less useful at the extremes of age. (See "Clinical
manifestations and diagnosis of vaginal atrophy".)
Vaginal pH may be altered (usually to a higher pH) by contamination with lubricating gels,
semen, douches, and intravaginal medications.


Microscopy
Saline wet mount Vaginal discharge is generally sampled with a plastic or wood
vaginal/cervical scraper or a cotton-tipped swab. The sample of vaginal discharge is mixed with
one to two drops of 0.9 percent normal saline solution at room temperature on a glass slide.
Cover slips are then placed on the slides, which are examined under a microscope at low and
high power. Microscopy should be performed within 10 to 20 minutes of obtaining the sample to
reduce the possibility of loss of motility of any trichomonads. (See "Trichomonas vaginalis".)
Microscopic examination of normal vaginal discharge reveals a predominance of squamous
epithelial cells, rare polymorphonuclear leukocytes (PMNs), and Lactobacillus morphotype
(table 2). The primary goal of the examination is to look for candidal buds (picture 3) or hyphae
(picture 4), motile trichomonads (picture 5), epithelial cells studded with adherent coccobacilli
(clue cells; (picture 6 and picture 7)), and increased numbers of PMNs.

(picture 3

Picture 4














Picture 6

(A) Wet mount showing characteristic clue cells. Note that the epithelial cells are so heavily covered by
bacteria as to obscure the margins.
(B) A clue cell. The vaginal epithelial cell on the right has shaggy borders obscured by coccobacilli (1003
magnification). The more normal appearing epithelial cell on the left has sharper borders.



High power view of clue cells observed in a patient with bacterial vaginosis. Note the obliteration of
each epithelial cell margin by adherent G. vaginalis.

Excess PMNs without evidence of yeast, trichomonads, or clue cells suggests cervicitis. (See
"Acute cervicitis".)
Potassium hydroxide wet mount The addition of 10 percent potassium hydroxide (KOH) to
the wet mount of vaginal discharge destroys cellular elements, thus it is helpful in diagnosing
candida vaginitis. (See "Candida vulvovaginitis".)
Amine test Smelling ("whiffing") the slide immediately after applying KOH is useful for
detecting the fishy (amine) odor of bacterial vaginosis (see "Bacterial vaginosis").
Alternatives to microscopy If microscopy is not available, diagnostic testing cards are an
alternative rapid test for confirming the clinical suspicion of bacterial vaginosis or trichomonas
vaginitis. (See "Bacterial vaginosis" and "Trichomonas vaginalis".)
Vaginal culture We suggest culture for Candida or Trichomonas (or rapid antigen and nucleic
acid amplification tests), as indicated by clinical findings, if microscopy is negative because
microscopy is not sufficiently sensitive to exclude these diagnoses in symptomatic patients. In
one study, the sensitivity of microscopy for diagnosis of candida and trichomoniasis was only 22
and 62 percent, respectively, using Gram stain as the standard [3]. Sensitivity of microscopy is
50 percent compared to a standard of NAAT for trichomoniasis or culture for candida.
Pruritus and vulvovaginal erythema, with or without a white curd-like discharge, suggest
vulvovaginal candidiasis. Signs and symptoms of trichomoniasis include vulvovaginal erythema
and a purulent, malodorous, thin, green-yellow frothy discharge with associated burning,
pruritus, dysuria, frequency, and dyspareunia. (See "Candida vulvovaginitis" and "Trichomonas
vaginalis", section on 'Diagnosis'.)
The microbiology of the vagina is complex, containing 10
9
bacterial colony forming units per
gram of secretions, and potentially dozens of different isolates. The most abundant normal
isolates are lactobacilli [9], diphtheroids, and S. epidermidis. Bacterial cultures are rarely
indicated in women with vaginal discharge. In fact, they are frequently misleading since a variety
of bacterial species colonize the vagina and are not vaginal pathogens; identification of these
bacteria may lead to unnecessary antibacterial therapy. Apart from Group A streptococcus, a
clear causal relationship between any bacteria and vaginitis has not been established.
Cervical culture A diagnosis of cervicitis, typically due to Neisseria gonorrhoeae or
Chlamydia trachomatis, must always be considered in women with purulent cervical discharge
since women with this disorder may go on to develop pelvic inflammatory disease (PID) and its
potential complications. Any women with new or multiple sexual partners, a symptomatic sexual
partner, or an otherwise unexplained cervical or vaginal discharge that contains a high number of
PMNs should be tested for the presence of these organisms. (See "Acute cervicitis".)
WOMEN WITHOUT A DIAGNOSIS AFTER THE INITIAL EVALUATION If the woman
had minimal symptoms at the time of evaluation and the evaluation was nondiagnostic, the
evaluation should be repeated at a second visit when the patient is symptomatic.
In other cases, less common and rare infectious and inflammatory disorders need to be
considered.
Menopausal women
Atrophic vaginitis Menopausal women should be evaluated for atrophic vaginitis, which is a
common diagnosis in this age group. Nonspecific signs and symptoms include a watery, white or
yellow, and malodorous discharge; vaginal burning or irritation; dyspareunia; and urinary
symptoms. Physical findings include thinning of the vaginal epithelium, loss of elasticity, loss of
rugae, pH 5, vaginal erosions, and cervicovaginal friability. (See "Clinical manifestations and
diagnosis of vaginal atrophy".)
The wet mount is nonspecific, as the findings occur in other inflammatory vaginal conditions. It
shows parabasal cells, many PMNs, no lactobacilli, with or without background bacteria.
Parabasal cells are immature squamous epithelial cells that are rounded and have a large nucleus-
to-cytoplasm ratio; in contrast, mature squamous epithelial cells are larger, cuboidal, with a
smaller nucleus-to-cytoplasm ratio, and sometimes folded. The presence of epithelial cells rather
than parabasal cells and premenopausal status helps to distinguish bacterial vaginosis from
atrophic vaginitis.
Symptomatic response to topical estrogen therapy, which restores the vaginal epithelium,
supports the diagnosis. Antibiotics are not needed. (See "Treatment of vaginal atrophy", section
on 'Vaginal estrogen therapy'.)
Intraepithelial neoplasia Vaginal intraepithelial neoplasia most commonly occurs in the
menopausal age group. It is usually asymptomatic, although patients can present with postcoital
spotting or vaginal discharge. (See "Vaginal intraepithelial neoplasia".)
Vulvar intraepithelial neoplasia, which may cause pruritus, is also most common in menopausal
women (see 'Vulvar intraepithelial neoplasia' below).
Signs and symptoms suggestive of candidiasis, but negative cultures
Vulvar intraepithelial neoplasia Pruritus is the most common complaint among symptomatic
women with vulvar intraepithelial neoplasia. Other presentations include a visible lesion, a
palpable abnormality, perineal pain or burning, or dysuria. (See "Vulvar intraepithelial
neoplasia".)
Cytolytic vaginosis Cytolytic vaginosis refers to a syndrome of vaginal hyperacidity due to
overgrowth of lactobacilli, although the existence of this entity is controversial. It is rare and
characterized by pruritus, dyspareunia, vulvar dysuria, and cyclical increase in
symptoms during the luteal phase [10,11].
Diagnostic criteria include presence of white vaginal discharge, pH between 3.5 and 4.5, Gram's
stain showing overgrowth of lactobacilli, paucity of white blood cells, evidence of cytolysis
(bare nuclei, shreds of cytoplasm), and exclusion of candidal infection by culture.
Sodium bicarbonate douches have been used for treatment. A solution of one rounded teaspoon
of sodium bicarbonate in 600 mL of water is used for irrigating the vagina, once per day for 7 to
14 days. There are no data to support longer courses of therapy.
Acute onset of purulent discharge and pain Group A streptococcus (Streptococcus pyogenes
[GAS]) is an uncommon cause of vulvovaginitis [12,13]. In one series of almost 7000 pregnant
women, only 0.03 percent were colonized with GAS [12]. GAS vulvovaginitis typically occurs
in prepubertal girls and in mothers whose children suffer from active GAS infection or who
serve as GAS carriers. Carriage or exposure to a carrier is an important source of recurrent GAS
infection. GAS can colonize and be transmitted from skin (especially in individuals with chronic
dermatological conditions), nasopharynx, and the gastrointestinal tract (including the perianal
area) [14].
Clinical features include acute onset of frankly purulent discharge accompanied by pruritus,
soreness and irritation, erythema, labial edema, and possibly dysuria from burning of the skin
with voiding. Microscopy of the discharge reveals a marked increase in PMNs and Gram's stain
shows chains of gram-positive cocci.
Penicillin treatment after confirmation of the diagnosis by culture rapidly leads to cure. We use
Penicillin VK 500 mg four times daily for 10 to 14 days or clindamycin cream 2% per vaginam
for 7 to 10 days.
Irritants and allergens Vaginal discharge can result from irritants (eg, scented panty liners,
spermicides, povidone-iodine, soaps and perfumes, and some topical drugs) and allergens (eg,
latex condoms, topical antifungal agents, seminal fluid, chemical preservatives) that produce
acute and chronic hypersensitivity reactions, including contact dermatitis.
Diagnosis and management involve identifying and eliminating the offending agent by taking a
thorough history and systematically removing potential irritants and allergens from the
urogenital environment. Patient symptom/contact diaries may be helpful. Corticosteroid therapy
is indicated to control inflammation and relieve symptoms. We use a medium potency
fluorinated topical steroid two to three times per day, as needed, until symptoms resolve (table
3). (See "Overview of dermatitis", section on 'Allergic contact dermatitis' and "Overview of
dermatitis", section on 'Irritant contact dermatitis' and "General principles of dermatologic
therapy and topical corticosteroid use".)
Serosanguinous discharge and pelvic pain Women with fallopian tube carcinoma often
present in the fifth or sixth decades with vague complaints. The type and frequency of so-called
"classic" symptoms and signs associated with this malignancy are: serosanguineous vaginal
discharge (50 to 60 percent), pelvic pain (30 to 50 percent), and a pelvic mass (12 to 61 percent);
however, the full triad (Latzko's triad) is noted in fewer than 15 percent of patients. Hydrops
tubae profluens, which refers to intermittent discharge of clear or blood-tinged fluid
spontaneously or on pressure followed by shrinkage of the adnexal mass, has been described as
pathognomonic of the disease. (See "Epithelial ovarian, fallopian tube, and primary peritoneal
carcinoma: Clinical features and diagnosis", section on 'Subacute presentation'.)
Chronic introital pain as a primary symptom Vestibulodynia refers to pain on penetration of
the introitus and tenderness provoked by focal vestibular pressure. These symptoms should be
present for at least three to six months and other causes of vestibular pain, such as vaginitis,
should be excluded before making the diagnosis. Vaginal discharge and vaginal inflammation
are typical features of vaginitis, but are not part of the clinical spectrum of vestibulodynia.
Candidal vulvovaginitis may mimic localized, provoked vulvodynia, and may also be an initial
trigger for this condition. (See "Clinical manifestations and diagnosis of localized, provoked
vulvodynia (formerly vulvar vestibulitis)".)
Postcoital vulvovaginal pruritus and pain Seminal plasma allergy or hypersensitivity is a rare
disorder characterized by postcoital vulvovaginal itching, burning, edema, and erythema with or
without systemic signs and symptoms. Vaginal discharge is not a typical feature. Complaints
occur immediately or within one hour after contact with seminal plasma. Most affected women
are under age 40 and have a family history of atopy.
The diagnosis is based on absence of symptoms with condom use and on positive skin testing
with a pooled sample of seminal fluid. (See "Differential diagnosis of sexual pain in women",
section on 'Seminal plasma allergy'.)
Desquamative inflammatory vaginitis Desquamative inflammatory vaginitis is a rare, chronic
clinical syndrome of unknown etiology that usually occurs in perimenopausal women. Patients
present with purulent vaginal discharge, vulvovaginal burning or irritation, dyspareunia, and
vulvar and vaginal erythema. (See "Desquamative inflammatory vaginitis".)
The diagnosis requires all of the following criteria:
At least one of the following symptoms: vaginal discharge, dyspareunia, pruritus,
burning, irritation
Vaginal inflammation (spotted ecchymotic rash, erythema, focal or linear erosion)
Vaginal pH >4.5
Saline microscopy showing increased parabasal and inflammatory cells (ie, leukocyte to
epithelial cell ratio greater than 1:1)
Persistent genital malodor The normal odor of vaginal secretions cannot be clearly defined,
but is probably slightly sour due to lactic acid and volatile sulfur compounds. Persistent genital
malodor can seriously impair a womans quality of life; the cause is difficult to identify after
readily diagnosable causes have been excluded. These causes include [15]:
Neglected foreign body (including retained tampon)
Bacterial vaginosis
Trichomoniasis
Infectious ulcer/pelvic inflammatory disease
Pelvic fistula (rectovaginal, vesicovaginal, ureterovaginal)
Hidradenitis suppurativa
Chronic constipation
Urinary incontinence
Fecal incontinence
Poor hygiene
Malignant ulcer
Excessive genital perspiration and local bacterial colonization related to obesity
Other potential causes of malodor include metabolic disorders (see "Inborn errors of metabolism:
Epidemiology, pathogenesis, and clinical features", section on 'Abnormal odors'), olfactory
reference syndrome [16], and olfactory hallucinations (see "Nonepileptic paroxysmal disorders
in adolescents and adults", section on 'Olfactory hallucinations').
Management depends on determining a cause. In the absence of poor hygiene, frequent washing
and vaginal douching are not helpful and can be harmful. Excessive soaping of the genital area
can cause a chemical vulvitis and douching (rinsing of the vagina with vinegar or an antiseptic
with the aid of a douche bag) can increase the risk of vaginal and pelvic infection [17].
For women with an elevated vaginal pH or lack of lactobacilli on Gram stain of vaginal
discharge, a trial of antibiotics for anaerobic infection is reasonable (eg, metronidazole 500 mg
orally twice daily for seven days). For women with no identifiable abnormalities, use of a
specific medical grade stainless steel douching device (Water Works Douching Device) can be
helpful. A randomized trial including 140 women with perceived vaginal odor and no vaginal
infection reported significant improvement after douching daily for four weeks with tap water
using this device [18]. In the Water Works group, odor intensity scores fell from 7.3 to 1.8
(p<.001), which was superior to that among women who used a conventional over-the-counter
plastic douche bag, 7.2 to 3.4 (p<.003).
Other The following diagnoses are listed because clinicians sometimes attempt to diagnose
and treat women for these conditions. We do not believe they are causes of vaginitis.
Group B streptococcus Group B streptococcus (GBS) commonly colonizes the vagina:
approximately 20 percent of women are colonized with GBS [12,19]. Whether GBS is a
pathogen in vulvovaginitis is controversial. Some clinicians believe it has a pathogenic role in
vulvovaginitis and report an ameliorative effect on vulvovaginal symptoms with antibiotic
treatment (oral penicillin or clindamycin cream). We and most experts do not believe this
organism has a pathogenic role in symptomatic vulvovaginitis and that positive culture results
merely reflect colonization, which is facilitated by disruption of the normal vaginal bacterial
environment [19]. Therefore, in women with vaginitis, both GBS culture and treatment of
positive culture results should be avoided.
"Non-specific bacterial vaginitis" The concept of non-specific bacterial vaginitis is no longer
acceptable. In the past, many women with bacterial vaginosis were given the diagnosis of non-
specific vaginitis, but this should no longer occur since clear diagnostic criteria for bacterial
vaginosis are now available. (See "Bacterial vaginosis", section on 'Diagnosis'.)
Vaginal bacterial cultures are rarely indicated in women with vaginal discharge. In fact, they are
frequently misleading and therefore lead to unnecessary antibacterial therapy. Apart from Group
A streptococcus, a clear causal relationship between any bacteria and vaginitis has not been
established.
Treatment of infectious causes of vulvovaginitis should be targeted to the causative organism.
Sulfanilamide cream (eg, triple sulfa or AVC cream) has no role in the treatment of
vulvovaginitis, as it is less effective than other therapies (eg, metronidazole for trichomonas
vaginalis and bacterial vaginosis, fluconazole for candida vulvovaginitis) [20,21].
POSTDIAGNOSTIC MANAGEMENT Women with a confirmed diagnosis are treated, as
appropriate. (See individual topic reviews).
Sexual behaviors that result in STD-related vulvovaginitis (eg, trichomoniasis) increase the odds
of acquiring other STDs. (See"Screening for sexually transmitted infections"
MANAGEMENT OF PHYSIOLOGICAL LEUKORRHEA After exclusion of
pathological causes of vaginal discharge, women with a change in their normal vaginal discharge
can be reassured that changes in the volume and character of vaginal discharge are normal and
can be due to changes in diet, sexual activity, medication, stress, etc. Although hormonal
therapy, such as depot medroxyprogesterone acetate injection every three months or
norethindrone acetate 5 mg orally daily, will decrease estrogen levels and thus may decrease
physiological leukorrhea, the use of hormonal therapy for this indication alone is rarely
appropriate given the side effects and risks associated with these drugs.


SUMMARY AND RECOMMENDATIONS
Vaginitis may be caused by infection or inflammation; signs and symptoms are generally
similar, irrespective of the underlying etiology. (See 'Causes of vaginitis' above.)
Women with vaginitis typically present with one or more of the following: change in
vaginal discharge, pruritus, burning, irritation, erythema, dyspareunia, spotting, and
dysuria. (See 'Patient presentation' above.)
Testing for bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis is important
since these disorders account for over 90 percent of vaginitis in premenopausal women.
(See 'General principles' above.)
Clinical findings may suggest a particular diagnosis (table 1 and table 2). The diagnosis
should be confirmed by microscopic examination of vaginal secretions and, if necessary,
culture, before initiating treatment. Measurement of vaginal pH is the single most
important finding that drives the diagnostic process and should always be determined.
(See 'Diagnostic evaluation' above.)
Trichomonas is classically associated with a greenish-yellow purulent discharge;
candidiasis with a thick, white, adherent, "cottage cheese-like" discharge; and bacterial
vaginosis with a thin, homogeneous, "fishy smelling" gray discharge. However, the
appearance of the discharge is unreliable and should never form the basis for diagnosis.
(See 'Physical examination' above.)
Saline microscopy should be performed to look for candidal buds or hyphae (picture 4),
motile trichomonads (picture 5), epithelial cells studded with adherent coccobacilli (clue
cells suggesting bacterial vaginosis; (picture 7)), and polymorphonuclear cells. (See
'Microscopy' above.)
Initial office evaluation (history and physical examination, vaginal pH, wet mount
microscopy, whiff test) correctly diagnoses 60 percent of Candida vaginitis, 70 percent of
Trichomonas vaginitis, and 90 percent of bacterial vaginosis. (See 'Diagnostic
evaluation' above.)
We suggest culture for Candida or Trichomonas (or rapid antigen and nucleic acid
amplification tests), as indicated by clinical findings, if microscopy is negative because
microscopy is not sufficiently sensitive to exclude these diagnoses in symptomatic
patients. Bacterial cultures are rarely indicated in women with vaginal discharge. (See
'Vaginal culture' above.)
If the woman had minimal symptoms at the time of initial evaluation and the evaluation
was nondiagnostic, the evaluation should be repeated at a second visit when the patient is
symptomatic. In other cases, less common and rare infectious and inflammatory disorders
need to be considered. (See 'Women without a diagnosis after the initial
evaluation' above.)
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