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 evaluation of vaginal secretions. Treatment is directed at the cause and at any severe symptoms.
Etiology of Vaginitis
The most common causes of vaginitis vary by patient age. Vulvitis and vulvovaginitis have some of the same causes.
Children
In children, vaginitis usually involves infection with gastrointestinal tract flora (nonspecific vulvovaginitis). A common contributing factor in girls aged 2 to 6 years is poor perineal hygiene (eg, wiping from back to front after bowel movements; not washing hands after bowel movements; frequent touching of the perineum or vagina, particularly in response to pruritus).
Chemicals in bubble baths or soaps may cause vulvovaginal inflammation.
Occasionally, children place small objects into body cavities, including the vagina. Such 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 species; occasionally, pinworm).
Sexual abuse can result in sexually transmitted infections, including trichomonal vaginitis, in children.
Women of reproductive age
In women of reproductive age, vaginitis is usually infectious. The most common types are
Trichomonal vaginitis, which is sexually transmitted
Normally in women of reproductive age, species is the predominant constituent of normal vaginal flora. Colonization by these bacteria maintains vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of pathogenic bacteria. Also, high serum estrogen levels maintain vaginal epithelial thickness, bolstering local defenses.
Factors that predispose to overgrowth of bacterial vaginal pathogens include the following:
An alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli
Poor hygiene
Douching
Vaginitis may result from foreign bodies (eg, forgotten tampons). Inflammatory vaginitis, which is noninfectious, is uncommon.
Women who are postmenopausal
In women who are postmenopausal, a marked decrease in estrogen usually causes thinning of the vaginal epithelium, increasing vulnerability to infection and inflammation. Some treatments (eg, oophorectomy, pelvic radiation, certain chemotherapy agents) result in ovarian insufficiency with a decrease in serum estrogen. Decreased estrogen predisposes to inflammatory (particularly atrophic) vaginitis.
Hypoestrogenism can result in a more alkaline vaginal pH, which can predispose to overgrowth of vaginal pathogenic bacteria.
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 and candidal vaginitis are uncommon among women who are postmenopausal but may occur in those with risk factors. Older women tend to have fewer sexually transmitted infections (STIs), including trichomonal vaginitis.
Women of all ages
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.
At any age, conditions that cause vaginal epithelial damage or increased exposure to pathogens predispose to vaginal or vulvar infection, including
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
Symptoms and Signs of Vaginitis
Vaginitis causes a vaginal discharge that must be distinguished from normal (physiologic) discharge.
In children, normal discharge is common when estrogen levels are high—eg, during the first 2 weeks of life because maternal estrogen crosses the placenta during pregnancy (slight vaginal bleeding often occurs in infants as estrogen levels abruptly decrease because exposure to maternal estrogen ceases) and during the few months before menarche, when estrogen production increases.
Normal vaginal discharge is commonly milky white or mucoid, odorless, and nonirritating. The overall volume is small, but it can result in vaginal wetness that dampens underwear. Normal vaginal discharge may occur daily or intermittently. Many women have a clear, sticky discharge during ovulation, which is ovulatory cervical mucus.
Discharge due to vaginitis is accompanied by pruritus, erythema, and sometimes burning, pain, or mild bleeding. Volume may be small or may increase and even be copious. Pruritus may be severe, even interfering with sleep. Dysuria or dyspareunia may occur.
In atrophic vaginitis in postmenopausal women or other patients with inflammatory 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 |
|---|---|---|---|---|
Yellow-green or gray, thin, fishy-smelling discharge; no dyspareunia Uncommonly, pruritus and irritation | Three of the following (Amsel criteria):
| Saline wet mount*: Clue cells, decreased lactobacilli, increased coccobacilli | Trichomonal vaginitis | |
Thick, white discharge; vaginal and sometimes vulvar pruritus with or without burning, irritation, or dyspareunia | Typical discharge, pH < 4.5, and microscopic findings Culture if clinical suspicion is high and microscopic findings are negative or symptoms recur or persist after treatment | Potassium hydroxide wet mount†: Budding yeast, pseudohyphae, or mycelia | Contact irritant or allergic vulvitis Vulvodynia | |
Profuse, malodorous, yellow-green discharge; dysuria; dyspareunia; erythema | NAAT
Identification of causative organism by microscopy Culture if NAAT or microscopy is not available | Saline wet mount*: Motile, flagellated protozoa, increased PMNs | Bacterial vaginosis 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 | |
† Potassium hydroxide wet mount slide is prepared with 10% potassium hydroxide solution. | ||||
NAAT = nucleic acid amplification test; PMN = polymorphonuclear leukocyte. | ||||
By permission of the publisher. From Spitzer M, Mann M. In Atlas of Clinical Gynecology: Gynecologic Pathology. Edited by M Stenchever (series editor) and B Goff. Philadelphia, Current Medicine, 1998. (Courtesy of the International Society for the Study of Vulvar Disease, from the collection of the late Dr. Herman Gardner.)
Vulvitis can cause erythema, pruritus, and sometimes tenderness and discharge from the vulva.
Diagnosis of Vaginitis
History and pelvic examination
Vaginal pH and saline and potassium hydroxide (KOH) wet mounts
Sometimes nucleic acid amplification testing (NAAT) or other molecular diagnostic tests or culture
Vaginitis is diagnosed using clinical criteria and in-office or laboratory testing.
A pelvic examination is performed using a water-lubricated speculum (gel lubricants can be bacteriostatic), and vaginal secretions are obtained with a swab.
A sample of vaginal discharge is tested with pH paper; pH is measured in 0.2 intervals from 4.0 to 6.0 (normal vaginal pH is 3.8 to 4.2). Then, secretions are placed on 2 slides:
Potassium hydroxide (KOH) wet mount prepared with 10% potassium hydroxide
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 slide is also examined for clue cells and polymorphonuclear leukocytes.
The KOH wet mount is checked for a fishy odor (whiff test), which results from amines produced in trichomonal vaginitis or bacterial vaginosis. Potassium hydroxide is also used to test for Candida; KOH dissolves most cellular material except for yeast hyphae, making identification easier.
Candida. Also, some molecular diagnostic tests are commercially available for clinical use (1–5).
Nucleic acid amplification testing (NAAT) is the preferred method to diagnose trichomonal vaginitis, but microscopy may be used. Culture is used when NAAT and microscopy are not available.
If women have bacterial vaginosis or trichomonal vaginitis (and thus are at increased risk of sexually transmitted infections), cervical tests for Neisseria gonorrhoeae and Chlamydia trachomatis, common causes of sexually transmitted pelvic inflammatory disease (PID), are done.
If contact irritant or allergic vulvitis is suspected, the patient should systematically eliminate potential irritants or allergens to identify the cause. Severe dermatitis or allergic reactions require evaluation by an allergist or dermatologist.
Other causes of discharge should be ruled out, including
A foreign body: If children have vaginal discharge, a vaginal foreign body may be present.
Cervicitis: Cervical discharge due to cervicitis can resemble that of vaginitis.
PID: An upper genital tract infection may also cause cervical discharge. Abdominal pain, cervical motion tenderness, or cervical inflammation suggests PID.
Cancer: Discharge that is watery, bloody, or both may result from vulvar, vaginal, or cervical cancer; cancers can be differentiated from vaginitis by examination, Papanicolaou (Pap) tests, and biopsy.
Skin disorders: Vaginal pruritus and/or discharge may result from vulvar dermatoses (eg, lichen planus, lichen sclerosus) or other vulvar skin disorders (eg, psoriasis, tinea versicolor), which can usually be differentiated from infectious vaginitis by history and skin findings.
By permission of the publisher. From Judson F. In Atlas of Infectious Diseases: Sexually Transmitted Diseases. Edited by G Mandell (series editor) and MF Rein. Philadelphia, Current Medicine, 1996.
By permission of the publisher. From Hillier S. In Atlas of Infectious Diseases: Sexually Transmitted Diseases. Edited by G Mandell (series editor) and MF Rein. Philadelphia, Current Medicine, 1996.
Image obtained from the Public Health Image Library of the Centers for Disease Control and Prevention.
In children, pelvic examination must be done by an experienced clinician. Speculum examination, if required, is usually done under anesthesia. If children have trichomonal vaginitis, evaluation for sexual abuse is required. Abuse should also be considered if they have unexplained vaginal discharge, which may be due to a sexually transmitted infection.
Diagnosis references
1. Cartwright CP, Lembke BD, Ramachandran K, et al: Development and validation of a semiquantitative, multitarget PCR assay for diagnosis of bacterial vaginosis. J Clin Microbiol 50 (7):2321–2329, 2012. doi: 10.1128/JCM.00506-12
2. Schwebke JR, Gaydos CA, Nyirjesy P, et al: Diagnostic performance of a molecular test versus clinician assessment of vaginitis. J Clin Microbiol 56 (6):e00252-18, 2018. doi: 10.1128/JCM.00252-18
3. Gaydos CA, Beqaj S, Schwebke JR, et al: Clinical validation of a test for the diagnosis of vaginitis. Obstet Gynecol 130 (1):181–189, 2017. doi: 10.1097/AOG.0000000000002090
4. Schwebke J, Merriweather A, Massingale S, et al: Screening for Trichomonas vaginalis in a large high-risk population: Prevalence among men and women determined by nucleic acid amplification testing. Sex Transm Dis 45 (5):e23-e24, 2018. doi: 10.1097/OLQ.0000000000000757
5. Coleman JS, Gaydos CA: Molecular diagnosis of bacterial vaginosis: An update. J Clin Microbiol 56 (9):e00342–e00318, 2018. doi: 10.1128/JCM.00342-18
Treatment of Vaginitis
Treatment of cause
Symptomatic treatment
Infectious vaginitis (eg, bacterial vaginosis, candidal vaginitis, trichomoniasis) or any other cause is treated.
If a foreign body is present, it is removed.
For contact irritant or allergic vulvitis, any identified irritant or allergen should be avoided. In general, vaginal douching and unnecessary topical preparations (eg, feminine hygiene sprays) should be avoided.
If chronic vulvar inflammation is due to being bedbound or incontinent, vulvar hygiene and skin care measures may help. Prepubertal girls should be taught vulvar hygiene (eg, wiping front to back after bowel movements and voiding, washing hands, avoiding frequent touching of the vulvovaginal area).
Infectious, irritant, or allergic vulvovaginitis may cause significant discomfort until adequately treated. Intermittent use of ice packs or warm sitz baths with or without baking soda may reduce soreness and pruritus.
Key Points
Common age-related causes of vaginitis include nonspecific (often hygiene-related) vaginitis and chemical irritation in children and older patients who are bedbound or incontinent; bacterial vaginosis and candidal and trichomonal vaginitis in women of reproductive age; and atrophic vaginitis in women who are postmenopausal.
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 vulvar hygiene with patients, as appropriate.
