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Many women come to the ED with the chief complaint of vaginal discharge. This may or may not be associated with vaginal discomfort and/or abdominal pain. Vaginal discharge can be secondary to a wide variety of pathologies, including vaginitis due to bacterial vaginosis, candidiasis, or trichomoniasis, as well as cervicitis, salpingitis, or pelvic inflammatory disease due to Neisseria gonorrhoeae or Chlamydia trachomatis or a combination of multiple organisms.1

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Vaginitis is a spectrum of diseases causing vulvovaginal symptoms such as burning, irritation, and itching, with or without an abnormal discharge. The factors associated with acute vaginitis are listed in Table 106-1. The most common infectious causes of vaginitis in symptomatic women include bacterial vaginosis (22% to 50%), candidiasis (17% to 39%), and trichomoniasis (4% to 35%). Vulvovaginal candidiasis, contact vaginitis, and atrophic vaginitis may occur in virgins and postmenopausal women, but other forms of infectious vulvovaginitis are generally found only in sexually active women. In about 30% of women with vaginal complaints the disorder remains undiagnosed even after comprehensive testing.2

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Table 106-1 Factors Associated with Acute Vulvovaginitis
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Factors thought to contribute to vaginitis in prepubertal females include less protective covering of the introitus by the labia majora, low estrogen concentration, exposure to irritants such as bubble bath, poor hygiene, and presence of specific pathogens. The role of poor hygiene and infection is disputed.4 Infectious causes may be more common in adolescents, especially those who are sexually active.

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The clinical diagnosis may be challenging, because women may have more than one disease, and signs and symptoms are frequently not specific to a particular etiology. Polymicrobial infection in women with vaginitis is not uncommon. Point-of-care testing may improve diagnostic speed and accuracy in the future.

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Although infectious vaginitis rarely requires hospitalization, it may have serious sequelae. Both bacterial vaginosis and trichomoniasis have been shown to be associated with premature rupture of membranes, preterm labor, and low infant birth weight.5,6 Trichomoniasis is associated with pelvic inflammatory disease in patients infected with human immunodeficiency virus (HIV)7 and an increased risk of HIV acquisition.8 When overgrowth of certain bacteria occurs, the protective effect of vaginal lactobacilli strains, which inhibit the growth of bacteria and destroy HIV in vitro, is lost.9

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In females of childbearing age, estrogen causes the development of a thick vaginal epithelium with a large number of superficial cells containing large stores of glycogen and serving a protective function. Glycogen is used by the normal flora, such as lactobacilli and acidogenic corynebacteria, to form lactic and acetic acids. The resulting acidic environment favors the normal flora and discourages the growth of pathogenic bacteria. ...

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