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Nuchal Cord. Hand placement prior to applying downward traction to deliver the anterior shoulder1. A loose nuchal cord is seen. (Photo contributor: William Leininger, MD.)


1The authors acknowledge the special contributions of Robert G. Buckley, MD, and Sean Lisse, MD for contributions to prior editions.

Clinical Summary

Candidal vaginitis may present with vulvar erythema, pruritus, and/or burning and is characterized by a thick, clumping, white discharge. Risk factors include oral contraceptive, antibiotic, or corticosteroid use; pregnancy; and diabetes or other immunocompromising conditions. It is uncommon in postmenopausal women and is not typically a sexually transmitted infection (STI). Diagnosis is confirmed with a wet mount slide prepared with 10% potassium hydroxide (KOH) that shows characteristic branched chain hyphae and spores.

Trichomonas vaginitis presents as a gray/green, thin, foul-smelling discharge with varying amounts of erythema and inflammation. Diagnosis by rapid antigen tests and nucleic acid amplification has generally replaced saline wet mount microscopy, which is less than 60% sensitive. Multiple petechiae on the vaginal wall or cervix (strawberry spots/strawberry cervix) are pathognomonic but not common.

Bacterial vaginosis (BV) also presents with a gray, thin, malodorous discharge, typically without other vaginal symptoms. Diagnosis is made based on clinical findings, an amine (fishy) odor accentuated by the addition of a drop of KOH, vaginal pH greater than 4.5, and the presence of clue cells on normal saline wet mount. BV is often associated with other STIs and increases the risk of pregnancy loss and other complications.

The majority of vaginitis is caused by infectious etiologies, as described above. However, other possible etiologies that should be considered include local chemical irritants or allergens, vaginal foreign bodies, and atrophic vaginitis.

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Video 10-01: Trichomonas
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Management and Disposition

For Candida vaginitis, treatment with a single dose of oral fluconazole (150 mg) is very effective and is the treatment of choice if treatment compliance is a concern. Topical antifungal medication, such as clotrimazole or miconazole, should be considered in pregnant patients or for those with allergy to or difficulty tolerating fluconazole.


For Trichomonas vaginitis or other BV, oral metronidazole (500 mg orally twice daily for 7 days or 2 g once) is the treatment of choice. Patients should be advised of the potential for a disulfiram-like reaction when taken with ...

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