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

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


Clinical Summary

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.

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