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Overview of Vaginitis

by David E. Soper, MD

Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema. Diagnosis is by in-office testing of vaginal secretions. Treatment is directed at the cause and at any severe symptoms.

Vaginitis is one of the most common gynecologic disorders. Some of its causes affect the vulva alone (vulvitis) or in addition (vulvovaginitis).

Etiology

The most common causes vary by patient age.

Children

In children, vaginitis usually involves infection with GI tract flora (nonspecific vulvovaginitis). A common contributing factor in girls aged 2 to 6 yr is poor perineal hygiene (eg, wiping from back to front after bowel movements; not washing hands after bowel movements; fingering, particularly in response to pruritus).

Chemicals in bubble baths or soaps may cause inflammation.

Foreign bodies (eg, tissue paper) may cause nonspecific vaginitis with a bloody discharge.

Sometimes childhood vulvovaginitis is due to infection with a specific pathogen (eg, streptococci, staphylococci, Candida sp; occasionally, pinworm).

Women of reproductive age

In these women, vaginitis is usually infectious. The most common types are

Normally in women of reproductive age, Lactobacillus sp is the predominant constituent of normal vaginal flora. Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of pathogenic bacteria. Also, high estrogen levels maintain vaginal thickness, bolstering local defenses.

Factors that predispose to overgrowth of bacterial vaginal pathogens may include the following:

  • An alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli

  • Poor hygiene

  • Frequent douching

Vaginitis may result from foreign bodies (eg, forgotten tampons). Inflammatory vaginitis, which is noninfectious, is uncommon.

Postmenopausal women

Usually, a marked decrease in estrogen causes vaginal thinning, increasing vulnerability to infection and inflammation. Some treatments (eg, oophorectomy, pelvic radiation, certain chemotherapy drugs) also result in loss of estrogen. Decreased estrogen predisposes to inflammatory (particularly atrophic) vaginitis.

Poor hygiene (eg, in patients who are incontinent or bedbound) can lead to chronic vulvar inflammation due to chemical irritation from urine or feces or due to nonspecific infection.

Bacterial vaginosis, candidal vaginitis, and trichomonal vaginitis are uncommon among postmenopausal women but may occur in those with risk factors.

Women of all ages

At any age, conditions that predispose to vaginal or vulvar infection include

  • Fistulas between the intestine and genital tract, which allow intestinal flora to seed the genital tract

  • Pelvic radiation or tumors, which break down tissue and thus compromise normal host defenses

Noninfectious vulvitis accounts for up to 30% of vulvovaginitis cases. It may result from hypersensitivity or irritant reactions to hygiene sprays or perfumes, menstrual pads, laundry soaps, bleaches, fabric softeners, fabric dyes, synthetic fibers, bathwater additives, toilet tissue, or, occasionally, spermicides, vaginal lubricants or creams, latex condoms, vaginal contraceptive rings, or diaphragms.

Symptoms and Signs

Vaginitis causes vaginal discharge, which must be distinguished from normal discharge. Normal discharge is common when estrogen levels are high—eg, during the first 2 wk of life because maternal estrogen is transferred before birth (slight bleeding often occurs when estrogen levels abruptly decrease) and during the few months before menarche, when estrogen production increases.

Normal vaginal discharge is commonly milky white or mucoid, odorless, and nonirritating; it can result in vaginal wetness that dampens underwear. Discharge due to vaginitis is accompanied by pruritus, erythema, and sometimes burning, pain, or mild bleeding. Pruritus may interfere with sleep. Dysuria or dyspareunia may occur. In atrophic vaginitis, discharge is scant, dyspareunia is common, and vaginal tissue appears thin and dry. Although symptoms vary among particular types of vaginitis, there is much overlap (see Table: Common Types of Vaginitis).

Common Types of Vaginitis

Disorder

Typical Symptoms and Signs

Criteria for Diagnosis

Microscopic Findings

Differential Diagnosis

Bacterial vaginosis

Gray, thin, fishy-smelling discharge, often with pruritus and irritation; no dyspareunia

Three of the following: Gray discharge, pH > 4.5, fishy odor, and clue cells

Clue cells, decreased lactobacilli, increased coccobacilli

Trichomonal vaginitis

Candidal vaginitis

Thick, white discharge; vaginal and sometimes vulvar pruritus with or without burning, irritation, or dyspareunia

Typical discharge, pH <4.5, and microscopic findings*

Budding yeast,pseudohyphae, or mycelia; best examined with 10% K hydroxide diluent

Contact irritant or allergic vulvitis

Chemical irritation

Vulvodynia

Trichomonal vaginitis

Profuse, malodorous, yellow-green discharge; dysuria; dyspareunia; erythema

Identification of causative organism by microscopy* (occasionally by culture)

Motile, flagellated protozoa, increased PMNs

Bacterial vaginosis

Inflammatory vaginitis

Inflammatory vaginitis

Purulent discharge, vaginal dryness and thinning, dyspareunia, dysuria; usually in postmenopausal women

pH > 6, negative whiff test, and characteristic microscopy findings

Increased PMNs, parabasal cells, and cocci; decreased bacilli

Erosive lichen planus

*Culture is needed if microscopic findings are negative or symptoms persist.

Vulvitis can cause erythema, pruritus, and sometimes tenderness and discharge from the vulva.

Diagnosis

  • Clinical evaluation

  • Vaginal pH and saline and KOH wet mounts

Vaginitis is diagnosed using clinical criteria and in-office testing. First, vaginal secretions are obtained with a water-lubricated speculum, and pH paper is used to measure pH in 0.2 intervals from 4.0 to 6.0. Then, secretions are placed on 2 slides with a cotton swab and diluted with 0.9% NaCl on one slide (saline wet mount) and with 10% K hydroxide on the other (KOH wet mount). The KOH wet mount is checked for a fishy odor (whiff test), which results from amines produced in trichomonal vaginitis or bacterial vaginosis. The saline wet mount is examined microscopically as soon as possible to detect trichomonads, which can become immotile and more difficult to recognize within minutes after slide preparation. The KOH dissolves most cellular material except for yeast hyphae, making identification easier.

If clinical criteria and in-office test results are inconclusive, the discharge may be cultured for fungi or trichomonads.

Other causes of discharge are ruled out. If children have vaginal discharge, a vaginal foreign body is suspected. Cervical discharge due to cervicitis (see Cervicitis) can resemble that of vaginitis. Abdominal pain, cervical motion tenderness, or cervical inflammation suggests PID (see Pelvic Inflammatory Disease (PID)). Discharge that is watery, bloody, or both may result from vulvar, vaginal, or cervical cancer; cancers can be differentiated from vaginitis by examination and Papanicolaou (Pap) tests. Vaginal pruritus and discharge may result from skin disorders (eg, psoriasis, tinea versicolor), which can usually be differentiated by history and skin findings.

If children have trichomonal vaginitis, evaluation for sexual abuse is required. If they have unexplained vaginal discharge, cervicitis, which may be due to a sexually transmitted disease, should be considered. If women have bacterial vaginosis or trichomonal vaginitis (and thus are at increased risk of sexually transmitted diseases), cervical tests for Neisseria gonorrhoeae and Chlamydia trachomatis, common causes of sexually transmitted PID, are done.

Treatment

  • Hygienic measures

  • Symptomatic treatment

  • Treatment of cause

The vulva should be kept as clean as possible. Soaps and unnecessary topical preparations (eg, feminine hygiene sprays) should be avoided. Intermittent use of ice packs or warm sitz baths with or without baking soda may reduce soreness and pruritus.

If symptoms are moderate or severe or do not respond to other measures, drugs may be needed. For pruritus, topical corticosteroids (eg, topical 1% hydrocortisone bid prn) can be applied to the vulva but not in the vagina. Oral antihistamines decrease pruritus and cause drowsiness, helping patients sleep.

Any infection or other cause is treated. Foreign bodies are removed. Prepubertal girls are taught good perineal hygiene (eg, wiping front to back after bowel movements and voiding, washing hands, avoiding fingering the perineum). If chronic vulvar inflammation is due to being bedbound or incontinent, better vulvar hygiene may help.

Key Points

  • Common age-related causes of vaginitis include nonspecific (often hygiene-related) vaginitis and chemical irritation in children; bacterial vaginosis and candidal and trichomonal vaginitis in women of reproductive age; and atrophic vaginitis in postmenopausal women.

  • Diagnose vaginitis based mainly on clinical findings, measurement of vaginal pH, and examination of saline and KOH wet mounts.

  • Treat infectious and other specific causes, treat symptoms, and discuss ways to improve hygiene as appropriate with patients.

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