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Causes of vulvovaginitis include infections, irritants, allergies, reaction to foreign bodies, and atrophy. The normal vaginal flora help maintain an acidic pH between 3.8 and 4.5, which decreases pathogen growth.


Bacterial vaginosis (BV) is the most common cause of malodorous vaginal discharge. However, up to 50% of infected women are asymptomatic. BV occurs when vaginal lactobacilli are replaced by anaerobes such as Gardnerella vaginalis, Mycoplasma, and Ureaplasma.

Clinical Features

The most common symptom is malodorous or “fishy smelling” vaginal discharge. Vaginal irritation, excoriation, fissures, and edema are uncommon. A combination of history, vaginal examination, and point-of-care testing confirm the diagnosis.

Diagnosis and Differential

The diagnosis can be made if three of the following four criteria are present: (1) vaginal discharge, (2) vaginal pH greater than 4.5, (3) positive amine test (fishy odor when 10% KOH is added to the discharge), and (4) clue cells seen on saline wet preparation.

Emergency Department Care and Disposition

Treat with metronidazole 500 mg PO twice daily for 7 days. Clindamycin 2% intravaginal cream at night for 7 days or metronidazole 0.75% intravaginal gel daily for 5 days are alternatives. Treatment is not recommended for male partners or asymptomatic women. To avoid a disulfram-like reaction, patients treated with metronidazole should refrain from alcohol use during treatment and for 24 hours after ending treatment.

All symptomatic pregnant women should be treated, and women at high risk of preterm labor should be considered for treatment. Preferred treatment in pregnancy is metronidazole 250 mg PO twice daily for 7 days.


Candida albicans is the second most common cause of infectious vaginitis. Conditions that promote Candida vaginitis include systemic antibiotics, diabetes, pregnancy, hormone replacement therapy, and birth control pills. Incidence is decreased in postmenopausal patients. Candidiasis is not typically considered a sexually transmitted disease, though it can be transmitted sexually.

Clinical Features

The most common symptom of Candida vaginitis is pruritus. Other symptoms include vaginal discharge, external dysuria, and dyspareunia. Exam may reveal vulvar and vaginal edema, erythema, and a thick “cottage cheese” discharge.

Diagnosis and Differential

Diagnosis is confirmed if vaginal pH is 4 to 4.5 and budding yeast or pseudohyphae are present on microscopy. Ten percent KOH dissolves vaginal epithelial cells, leaving yeast buds and pseudohyphae intact and easier to see. Use of KOH increases the sensitivity to 80%, with a specificity approaching 100%.

Emergency Department Care and Disposition

Single-dose treatment with fluconazole, 150 mg PO, is as effective as topical treatments. Almost all topically applied azoles are equally efficacious and available ...

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