Candidal vaginitis is characterized by a thick, clumping, white discharge and vulvar discomfort. Intense vulvar erythema, pruritus, and/or burning are often present. Predisposing factors may include oral contraceptive, antibiotic, or corticosteroid use; pregnancy; and diabetes. A microscopic slide prepared with 10% potassium hydroxide yielding characteristic branched chain hyphae and spores establishes the diagnosis. Sexually transmitted diseases are not usually associated with isolated Candidal vaginitis.
Trichomonas vaginitis presents as a persistent, thin, copious discharge that is often frothy, green, or foul-smelling. The amount of vaginal and cervical erythema and inflammation varies considerably. Diagnosis may be made by the presence of motile flagellates on normal saline wet-mount microscopy, but this is only 60% to 70% sensitive. New nucleic acid tests are emerging with ~95% specificity. Multiple petechiae on the vaginal wall or cervix (strawberry spots/strawberry cervix) are pathognomonic but only occasionally seen.
Bacterial vaginosis is characterized by a malodorous, homogeneous discharge with an amine (fishy) odor that can be briefly accentuated by mixing with a drop of KOH solution. The presence of clue cells on normal saline wet mount establishes the diagnosis. Other associated vaginal or abdominal complaints are minimal and, if significant, suggest the presence of another disease process.
Although the above infectious causes are responsible for most cases of vaginitis, other possible etiologies including local chemical irritants or allergens, vaginal foreign bodies, and atrophic vaginitis should be considered in the differential diagnosis.
Management and Disposition
For Candidal vaginitis, treat with topical antifungals (eg, clotrimazole: 1% cream, 5 g for 7 to 14 days or two 100-mg vaginal tablets for 3 nights). Oral fluconazole (150 mg as a single dose) is also effective, but has a higher risk of adverse effects.
For Trichomonas vaginitis, a single dose of metronidazole (2 g orally) is generally curative but is associated with a disulfiram-like reaction when taken with alcohol. Although metronidazole was previously considered contraindicated in pregnancy, the Centers for Disease Control and Prevention (CDC) now recommends its use due to the association of Trichomonas infections with preterm rupture of membranes, low birth weight, and increased risk of prematurity.
For bacterial vaginosis, metronidazole (500 mg orally twice daily for 7 days) is recommended. Treatment for asymptomatic infection or for male sexual partners is not generally recommended. The equivocal risk of metronidazole teratogenicity must be weighed against the likelihood of alleviating symptoms and discomfort.
Diabetes mellitus or immunosuppression should be considered in refractory or recurrent cases of candidal vaginitis.
A history of balanitis in the sexual partner should be sought and treated if present.
Trichomonas should be considered a sexually transmitted infection. Therefore, it is generally recommended that concomitant culturing for Neisseria gonorrhoeae and Chlamydia be performed. Serologic testing for syphilis, HIV, and hepatitis B should also be considered for patient and partner.
Candidal Vaginitis. Thick, curdy white discharge secondary to candidal vaginitis. (Photo contributor: Kevin J. Knoop, MD, MS.)
Trichomonas Vaginitis. Thin vaginal discharge suggestive of trichomonas vaginitis. (Photo contributor: H. Hunter Handsfield. Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)
Gardnerella Vaginosis. Thin, milky white discharge suggestive of Gardnerella vaginosis. (Photo contributor: Curatek Pharmaceuticals.)
Bacterial Vaginosis. Thin, milky white discharge suggestive of bacterial vaginosis. (Photo contributor: David Effron, MD.)
Candida Vulvovaginitis. Intense vulvar erythema with thick white clumping discharge consistent with candida vulvovaginitis. (Photo contributor: David Effron, MD.)
TABLE 10.1CHARACTERISTICS OF INFECTIOUS VAGINITIS ||Download (.pdf) TABLE 10.1 CHARACTERISTICS OF INFECTIOUS VAGINITIS
|Disease ||Discharge Qualities ||Vaginal pH ||Microscopic Findings |
|Candida spp. ||White, thick, clumping ||<4.5 ||Hyphae and spores in KOH |
|Trichomonas vaginitis ||Green, thin, frothy, foul ||>4.5 ||Flagellates in wet mount |
|Bacterial vaginosis ||Thin, white, “fishy” odor in KOH ||>4.5 ||Clue cells |