Approach to women with symptoms of vaginitis
- Jack D Sobel, MD
Jack D Sobel, MD
- Wayne State University School of Medicine
Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora. Symptoms include vaginal discharge, odor, pruritus, and/or discomfort. These symptoms are extremely common and frequently lead to self-diagnosis and therapy . In a telephone survey of random women in the United States, 8 percent of Caucasian women and 18 percent of African American women reported an episode of vaginal symptoms of any severity in the previous year . A healthcare professional was consulted in 55 and 83 percent of cases, respectively, and most women purchased an over-the-counter antifungal preparation to treat their symptoms, whether or not they saw a physician.
CAUSES OF VAGINITIS
The most common infections responsible for vaginal discharge, odor, pruritus, and/or discomfort are bacterial vaginosis, Candida vulvovaginitis, and trichomoniasis. These disorders account for over 90 percent of infections .
●(See "Bacterial vaginosis".)
●(See "Candida vulvovaginitis".)
- Kent HL. Epidemiology of vaginitis. Am J Obstet Gynecol 1991; 165:1168.
- Foxman B, Marsh JV, Gillespie B, Sobel JD. Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey. J Womens Health 1998; 7:1167.
- Sobel JD. Vulvovaginitis in healthy women. Compr Ther 1999; 25:335.
- Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA 2004; 291:1368.
- Landers DV, Wiesenfeld HC, Heine RP, et al. Predictive value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol 2004; 190:1004.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis 2013; 57:e22.
- Allen-Davis JT, Beck A, Parker R, et al. Assessment of vulvovaginal complaints: accuracy of telephone triage and in-office diagnosis. Obstet Gynecol 2002; 99:18.
- Carr PL, Rothberg MB, Friedman RH, et al. "Shotgun" versus sequential testing. Cost-effectiveness of diagnostic strategies for vaginitis. J Gen Intern Med 2005; 20:793.
- Sobel JD. Erosive Vulvovaginitis. Curr Infect Dis Rep 2003; 5:494.
- Lamont RF, Sobel JD, Akins RA, et al. The vaginal microbiome: new information about genital tract flora using molecular based techniques. BJOG 2011; 118:533.
- Hull T, Hilber AM, Chersich MF, et al. Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: findings from a multicountry household survey. J Womens Health (Larchmt) 2011; 20:1097.
- Zantomio D, Grigg AP, MacGregor L, et al. Female genital tract graft-versus-host disease: incidence, risk factors and recommendations for management. Bone Marrow Transplant 2006; 38:567.
- Spiryda LB, Laufer MR, Soiffer RJ, Antin JA. Graft-versus-host disease of the vulva and/or vagina: diagnosis and treatment. Biol Blood Marrow Transplant 2003; 9:760.
- Kaser DJ, Reichman DE, Laufer MR. Prevention of vulvovaginal sequelae in stevens-johnson syndrome and toxic epidermal necrolysis. Rev Obstet Gynecol 2011; 4:81.
- Cibley LJ, Cibley LJ. Cytolytic vaginosis. Am J Obstet Gynecol 1991; 165:1245.
- Cerikcioglu N, Beksac MS. Cytolytic vaginosis: misdiagnosed as candidal vaginitis. Infect Dis Obstet Gynecol 2004; 12:13.
- Mead PB, Winn WC. Vaginal-rectal colonization with group A streptococci in late pregnancy. Infect Dis Obstet Gynecol 2000; 8:217.
- Bray S, Morgan J. Two cases of group A streptococcal vulvovaginitis in premenopausal adults in a sexual health setting. Sex Health 2006; 3:187.
- Sobel JD, Funaro D, Kaplan EL. Recurrent group A streptococcal vulvovaginitis in adult women: family epidemiology. Clin Infect Dis 2007; 44:e43.
- Subramanian C, Nyirjesy P, Sobel JD. Genital malodor in women: a modern reappraisal. J Low Genit Tract Dis 2012; 16:49.
- Begum M, McKenna PJ. Olfactory reference syndrome: a systematic review of the world literature. Psychol Med 2011; 41:453.
- Zhang J, Thomas AG, Leybovich E. Vaginal douching and adverse health effects: a meta-analysis. Am J Public Health 1997; 87:1207.
- Cottrell BH. An updated review of of evidence to discourage douching. MCN Am J Matern Child Nurs 2010; 35:102.
- Hassan S, Chatwani A, Brovender H, et al. Douching for perceived vaginal odor with no infectious cause of vaginitis: a randomized controlled trial. J Low Genit Tract Dis 2011; 15:128.
- Leclair CM, Hart AE, Goetsch MF, et al. Group B streptococcus: prevalence in a non-obstetric population. J Low Genit Tract Dis 2010; 14:162.
- Rein MF. Current therapy of vulvovaginitis. Sex Transm Dis 1981; 8:316.
- duBouchet L, Spence MR, Rein MF, et al. Multicenter comparison of clotrimazole vaginal tablets, oral metronidazole, and vaginal suppositories containing sulfanilamide, aminacrine hydrochloride, and allantoin in the treatment of symptomatic trichomoniasis. Sex Transm Dis 1997; 24:156.
- CAUSES OF VAGINITIS
- PATIENT PRESENTATION
- GENERAL PRINCIPLES
- DIAGNOSTIC EVALUATION
- Physical examination
- Diagnostic studies
- - Vaginal pH
- - Microscopy
- Saline wet mount
- Potassium hydroxide wet mount
- - Amine test
- - Options when microscopy is not available
- - Vaginal culture or NAAT
- - Cervical culture
- WOMEN WITHOUT A DIAGNOSIS AFTER THE INITIAL EVALUATION
- General approach
- - Detailed history
- Irritants and allergens
- Menopausal women
- - Atrophic vaginitis
- - Intraepithelial neoplasia and cancer
- Pruritus, with a negative Candida culture
- - Cytolytic vaginosis
- Acute onset of purulent discharge and pain
- Serosanguinous discharge and pelvic pain
- Chronic introital pain as a primary symptom
- Postcoital vulvovaginal pruritus and pain
- Desquamative inflammatory vaginitis
- Persistent genital malodor
- - Group B streptococcus
- - "Non-specific bacterial vaginitis"
- POSTDIAGNOSTIC MANAGEMENT
- MANAGEMENT OF PHYSIOLOGICAL LEUKORRHEA
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS