Vaginitis for the ABIM
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Vaginitis for the American Board of Internal Medicine Exam
Definition and Classification
- Definition
- Vaginitis is inflammation of the vaginal mucosa, typically resulting in discharge, pruritus, pain, and/or malodor.
- The three most common causes are:
- Bacterial Vaginosis (BV): Overgrowth of anaerobic bacteria.
- Vulvovaginal Candidiasis (VVC): Fungal infection, primarily caused by Candida albicans.
- Trichomoniasis: A sexually transmitted infection (STI) caused by Trichomonas vaginalis.
- Epidemiology
- Vaginitis is one of the most common gynecologic complaints, with BV and VVC most frequently seen in reproductive-age women.
- Trichomoniasis is the most prevalent non-viral STI worldwide.
Pathophysiology
- Bacterial Vaginosis (BV):
- Occurs due to a decrease in lactobacilli, resulting in reduced production of lactic acid and hydrogen peroxide.
- This pH shift encourages the overgrowth of anaerobic bacteria, including Gardnerella vaginalis, Mobiluncus, Prevotella, and Mycoplasma species.
- BV is associated with sexual activity, though it is not considered an STI.
- Vulvovaginal Candidiasis (VVC):
- Overgrowth of Candida species (primarily C. albicans), which is a part of the normal vaginal flora.
- Imbalances in the vaginal environment—due to factors like antibiotic use, diabetes, or immunosuppression—can promote fungal overgrowth.
- Trichomoniasis:
- Caused by Trichomonas vaginalis, a flagellated protozoan.
- Transmission occurs through sexual contact, with high rates of reinfection due to untreated partners.
Clinical Manifestations
- Bacterial Vaginosis (BV):
- Thin, homogeneous, gray-white vaginal discharge with a characteristic “fishy” odor, particularly noticeable after intercourse.
- Vaginal itching or burning may occur, though symptoms can also be mild or asymptomatic.
- Vulvovaginal Candidiasis (VVC):
- Thick, white, “cottage cheese”-like vaginal discharge, usually odorless.
- Associated with intense pruritus, erythema, and vulvar swelling; dysuria and dyspareunia are also common.
- Trichomoniasis:
- Frothy, yellow-green discharge with a foul odor.
- Vaginal pruritus, erythema, and occasionally “strawberry cervix” (punctate hemorrhages on the cervix) may be seen on examination.
Diagnosis
- Clinical History and Physical Examination:
- Detailed symptom history (e.g., discharge characteristics, odor, itching, pain) and assessment of risk factors.
- Physical examination of the vulva and vagina, including speculum examination to assess discharge and vaginal mucosa.
- Microscopy:
- BV: Clue cells (epithelial cells with adherent bacteria) and absence or decrease of lactobacilli; addition of KOH produces a characteristic “fishy” odor (positive whiff test).
- VVC: Pseudohyphae and budding yeast visible with KOH preparation.
- Trichomoniasis: Motile, flagellated trichomonads can be observed on a wet mount.
- pH Testing:
- BV and Trichomoniasis: Vaginal pH >4.5.
- VVC: Vaginal pH remains normal (≤4.5).
- Point-of-Care and Laboratory Testing:
- Nucleic Acid Amplification Tests (NAATs): High sensitivity for diagnosing trichomoniasis.
- Vaginal Culture: May be used to identify Candida species in recurrent VVC cases.
- Affirm VPIII: Molecular test that detects Gardnerella, Candida, and Trichomonas.
Management
- Bacterial Vaginosis (BV):
- First-Line Therapy:
- Metronidazole: 500 mg orally twice daily for 7 days or metronidazole gel 0.75% intravaginally once daily for 5 days.
- Clindamycin Cream: 2% intravaginally once daily for 7 days.
- Alternative Therapy: Clindamycin orally, tinidazole orally, or secnidazole.
- Pregnancy Considerations: Metronidazole and clindamycin are safe for use in pregnancy.
- Recurrent BV: Metronidazole gel twice weekly for up to 4-6 months may reduce recurrence.
- Vulvovaginal Candidiasis (VVC):
- Uncomplicated VVC:
- Topical azoles (e.g., clotrimazole, miconazole) for 1-7 days or oral fluconazole 150 mg as a single dose.
- Complicated VVC: Includes cases in immunocompromised patients, diabetes, severe symptoms, or recurrent VVC.
- Extended therapy with topical azoles for 7-14 days or fluconazole 150 mg orally every 3 days for 3 doses.
- Recurrent VVC: Defined as four or more episodes within a year.
- Induction therapy with fluconazole followed by maintenance fluconazole once weekly for 6 months.
- Trichomoniasis:
- First-Line Therapy:
- Metronidazole: 2 g orally in a single dose or 500 mg twice daily for 7 days.
- Tinidazole: 2 g orally in a single dose.
- Pregnancy Considerations: Metronidazole 2 g orally is safe for use in pregnancy, though single-dose treatment may be preferred.
- Partner Treatment: Sexual partners should be treated to prevent reinfection.
- Test of Cure: Recommended in 3 months for women due to high reinfection rates.
Complications
- Bacterial Vaginosis:
- Increased risk for pelvic inflammatory disease (PID), preterm birth, and susceptibility to other STIs, including HIV.
- Vulvovaginal Candidiasis:
- Recurrence can significantly impact quality of life but typically does not lead to long-term complications.
- Trichomoniasis:
- Associated with preterm birth, low birth weight, and increased susceptibility to HIV.
- Untreated infection may lead to chronic pelvic discomfort and increased risk for cervical neoplasia.
Prevention
- Sexual Health and Hygiene:
- Practicing safe sex and limiting the number of sexual partners may reduce the risk of trichomoniasis and BV.
- Avoid douching, as it disrupts the natural vaginal flora and increases the risk of BV.
- Management of Recurrence:
- In BV and recurrent VVC, maintenance therapy may be used to prevent relapse.
- For trichomoniasis, consistent partner treatment and follow-up testing are crucial to avoid reinfection.
Key Points
- Vaginitis is commonly caused by BV, VVC, and trichomoniasis, each with distinct pathophysiology and clinical presentation.
- Symptoms:
- BV: Thin, gray-white discharge with fishy odor; pH >4.5.
- VVC: Thick, white “cottage cheese” discharge; intense pruritus; pH ≤4.5.
- Trichomoniasis: Frothy, yellow-green discharge with foul odor; pH >4.5.
- Diagnosis:
- Wet mount microscopy, pH testing, and nucleic acid amplification tests (NAATs) are key tools for diagnosis.
- Treatment:
- BV: Metronidazole or clindamycin, with metronidazole gel used for recurrent cases.
- VVC: Topical azoles or oral fluconazole for uncomplicated cases; extended treatment for recurrent or complicated cases.
- Trichomoniasis: Single-dose metronidazole or tinidazole; partner treatment is essential.
- Complications:
- BV and trichomoniasis are associated with increased risk for preterm birth, PID, and susceptibility to STIs.
- Prevention:
- Safe sexual practices, avoidance of douching, and appropriate maintenance therapy in recurrent cases help reduce vaginitis recurrence and complications.