Continuing Education Activity

Vaginitis is a common condition characterized by inflammation of the vagina, often resulting in symptoms such as itching, burning, discomfort, and abnormal discharge. This condition affects women across life stages and can be caused by various factors, including infections, hormonal changes, and irritants. Common types of vaginitis include bacterial vaginosis, yeast infections, and trichomoniasis, each with distinct causes and treatments. Understanding the underlying cause is crucial for effective management and relief. Given its prevalence and impact on women's health, proper diagnosis and treatment of vaginitis are essential for maintaining the overall well-being and quality of life of those affected.

This course is designed to provide healthcare professionals with the comprehensive knowledge to effectively diagnose, treat, and manage this common condition. Participants gain insights into the various types of vaginitis, understand their distinct etiologies, clinical presentations, and treatment protocols, and enhance their ability to differentiate between these conditions, prescribe appropriate therapies, and offer patient-centered care. This activity covers the latest advancements in diagnostic techniques and therapeutic options, preparing healthcare professionals to address the complexities of vaginitis. This activity also highlights the role of the interprofessional team in providing well-coordinated care to enhance patient quality of life.

Objectives:

• Differentiate between the various types of vaginitis based on clinical presentation and diagnostic findings.

• Identify common and uncommon causes of vaginitis using appropriate diagnostic tools.

• Implement evidence-based treatment protocols tailored to the specific type of vaginitis.

• Collaborate with an interprofessional healthcare team to strategize ways to improve the coordination of care as well as outcomes for females affected with vaginitis.

Introduction

Vaginal discharge, irritation, itching, and discomfort are common complaints of women through all stages of life. Vaginitis is a frequently encountered problem for clinicians. When evaluating a patient with a vaginal complaint, such as discharge or irritation, it is important first to understand what the range of normal findings are. Once a good understanding of normal is established, it is easier to recognize when a pathologic process is present or requires treatment.[1][2] The balance of microorganisms in the vagina plays a critical role in maintaining a healthy environment for the body, particularly in terms of reproductive health. However, the idea of what constitutes a "normal" versus an imbalanced state, known as dysbiosis, in the vaginal microbiome is a subject of ongoing discussion, especially considering that women from different ethnic backgrounds exhibit distinct microbial compositions in their vaginas, which can vary regionally. Various factors such as pregnancy, menstrual cycle, sexual behavior, age, and contraceptive methods influence this dynamic microbial environment. Typically, The vaginal flora of many women is predominantly populated by lactobacilli. These beneficial bacteria offer protective effects against potential pathogens, thus reducing the risk of urinary tract and sexually transmitted infections (STI).[3]

Etiology

The vaginal epithelium is a hormone-responsive, nonkeratinized, stratified squamous epithelium. The normal vaginal flora of reproductive-age women includes multiple aerobic, facultative anaerobic, and obligate anaerobic species. Over 50 species of bacteria are normally present in the vagina, with lactobacilli predominating in most women.[3] Anaerobic bacteria dominate aerobes 10:1. The bacteria are symbiotic with the host and can change based on the vaginal microenvironment.[4][5][6] Worldwide, scientists have conducted studies to profile the vaginal microbiome of their region of the world, concluding that the normalcy of vaginal flora varies from 1 region to another.[3]

Normal Vaginal Flora

Gram-positive aerobes:

• Lactobacillus
• Diphtheroids
• Staphylococcus aureus
• Staphylococcus epidermidis
• Group B Streptococci
• Enterococcus faecalis
• Staphylococcus spp

Gram-negative aerobes:

• Escherichia coli
• Klebsiella species
• Proteus species
• Enterobacter species
• Acinetobacter species
• Citrobacter species
• Pseudomonas species

Gram-negative anaerobes:

• Prevotella species
• Bacteroides species
• Bacteriodes fragillis species
• Fusobacterium species
• Veillonella species

Anaerobic gram-positive cocci:

• Peptostreptococcus species
• Clostridium species

Anaerobic gram-positive bacilli:

• Lactobacillus species
• Propionibacterium species
• Eubacterium species
• Bifidobacterium species
• Actinomyces israelii 

The composition of the vaginal flora is responsible for the pH of the vagina. In prepubertal girls and postmenopausal women, the lack of estrogen leads to a deficiency of glycogen and, thus, a lack of lactic acid-producing flora. Lactobacillus species are deficient and have a high bacterial diversity. The normal prepubertal and postmenopausal vaginal pH is 6 to 7.5. Women can be prone to infections in these age ranges, as the only commensal flora is mainly of skin origin. In those who are prepubertal, vulvovaginitis is the most common gynecological condition reported. Vaginitis is much more common in women during their reproductive years.[7] With estrogen comes the production of glycogen from the vaginal mucosa. Glycogen is the nutrient necessary for many vaginal ecosystem species present in reproductive-age females, including Lactobacillus. The glycogen is metabolized to lactic acid, which contributes to the normal vaginal pH of 3.8 to 4.2. This acidity suppresses the overgrowth of infectious organisms such as Mobiluncus, Prevotella, and Gardnerella vaginalis. Differences in the prevalence and diversity of lactobacilli among healthy women of reproductive age vary globally.[3] 

Changing any element of the vaginal ecology can alter the characteristics of the vaginal bacteria. For example, changes in hormonal status during menopause, pregnancy, and breastfeeding can greatly shift the makeup of the vaginal flora. Menses can act as a nutrient base for some bacterial species, leading to their overgrowth, but there is no clear evidence that this is associated with pathogens or infection. Broad-spectrum antibiotic use can lead to alterations of the vaginal bacterial flora leading to Candida species overgrowth. Douching and unprotected vaginal intercourse can increase the vaginal pH as well.[8][9] Vaginitis can be caused by the overgrowth of bacteria or yeast, or infection with trichomoniasis. Additionally, irritants like harsh soaps, scented hygiene products, and tight clothing may contribute to the development of vaginitis.[10]

Epidemiology

Vaginitis is a highly prevalent global condition that affects millions of women annually. Bacterial vaginosis is the most common cause, accounting for 40% to 50% of cases, followed by yeast infections, which affect about 20% to 25% of women at least once in their lifetime. Trichomoniasis, a sexually transmitted infection, impacts approximately 8 million women annually in the United States. The prevalence of vaginitis varies with age, sexual activity, and hormonal status, with an increased incidence noted in reproductive-aged women and during periods of hormonal change such as pregnancy and menopause. The normal vaginal flora is constantly changing and is influenced by many physiologic and environmental factors.[11] Socioeconomic factors, hygiene practices, and access to health care also influence the incidence and management of vaginitis. Eight percent of Whit and 18% of Black women report symptoms of vaginal discharge, odor, pruritus, and discomfort yearly. Further, 55% of White and 83% of Black women consult a healthcare professional when the symptoms occur, but most patients use over-the-counter antifungals as home therapy.[12][13] 

Bacterial Vaginosis 

In reproductive-aged women, bacterial vaginosis is the most common cause of vaginitis. This condition is caused by a shift in normal vaginal flora, with lactobacilli being replaced by anaerobic bacteria. Because bacterial vaginosis is not an inflammatory condition, erythema, fissuring, and bleeding may not be present on physical examination.[14] Bacterial overgrowth of Gardnerella vaginalis, Mycoplasmahoninis, Mobiluncus spp., Bacteroides spp, Prevotela spp, Peptostreptococcus spp, Fusobacterium spp and Porphyromonas spp may be present. Symptoms include foul-smelling discharge, irritation around and outside the vaginal introitus, and sometimes burning with urination.[11] See StatPearls' companion reference, "Bacterial Vaginosis," for more information.

Vaginal Candidiasis

Candida vaginitis results from the overgrowth of the candida fungi. Seventy-five percent of women are affected in their lifetimes. Candida infection is the next most common type of vaginitis after bacterial vaginosis, as 55% of women have an infection of this type by age 25. Nine percent of women report 4 or more episodes annually. See StatPearls' companion reference, "Vaginal Candidiasis," for more information.

Trichomoniasis

Trichomonas vaginalis, caused by the parasite T Vaginalis, is the most frequent nonviral sexually transmitted infection. Over 1 million people in the United States are affected by this parasite annually. The incidence of trichomoniasis infections worldwide is reported at 153 million cases. Black individuals are more frequently infected with trichomonas than white individuals. Age, race, income, socioeconomic factors, and education level all contribute to the epidemiology of trichomoniasis globally.[15] See StatPearls' companion reference, "Trichomoniasis," for more information.

Desquamative Inflammatory Vaginitis 

The exact cause of desquamative inflammatory vaginitis (DIV) is not well understood, but it involves significant inflammation of the vaginal epithelium. This infrequent, noninfectious, chronic inflammatory condition is more common in White women.[16] There may be an imbalance in the normal vaginal flora, with a significant decrease in Lactobacillus species and an overgrowth of other facultative anaerobic bacteria.[17] Signs and symptoms of desquamative inflammatory vaginitis include profuse, purulent vaginal discharge, often yellow or greenish and sometimes mixed with blood. There may be an associated intense itching and burning sensation in the vulvovaginal area, redness and swelling of the vulvovaginal tissues, and dyspareunia.[16] 

Atrophic Vaginitis

Genitourinary syndrome of menopause is the current name given to vulvovaginal atrophy. This condition affects a large percentage of women who are menopausal. Signs and symptoms of atrophic vaginitis include vaginal dryness, dyspareunia, vaginal inflammation, burning, thin vaginal mucosa, loss of rugae, and occasionally purulent discharge. A wet discharge mount demonstrates many white blood cells, occasional parabasal and basal cells, decreased lactobacilli, and increased gram-positive cocci and gram-negative rods. Vaginal pH is frequently greater than 4.5.[14]

Mixed Vaginitis

Mixed vaginitis is the presence of 2 or more types of vaginal pathogens simultaneously.[18] Symptoms may be atypical, and treatment is more complicated than vaginitis from a single source. Mixed vaginitis has not been well-studied. One literature review reported that the proportion of vaginitis that is mixed ranges from just over 4% to just over 35%. Most commonly, bacterial vaginosis and candida are considered. However, study results have shown that the 3 most common types of mixed vaginitis include DIV/atrophic vaginitis/bacterial vaginosis, vulvovaginal candidiasis plus DIV/atrophic vaginitis, and vulvovaginal candidiasis plus bacterial vaginosis.[19]

Pathophysiology

Vaginitis is inflammation of the vagina, typically caused by infections, hormonal changes, or irritants. The pathophysiology of vaginitis varies by type, but common symptoms include vaginal discharge, itching, burning, and changes in vaginal pH. The specific nature of the discharge and associated symptoms aid in distinguishing between different types of vaginitis. Accurate diagnosis relies on patient history, physical examination, and laboratory testing.

Histopathology

Vaginitis can be classified as either inflammatory or noninflammatory. With inflammatory vaginitis, there are polymorphonuclear neutrophils seen in the vaginal discharge by microscopy, and erythema and edema are seen on physical exam. Noninflammatory vaginitis is associated with odor and discharge but not inflammatory changes.[14]

History and Physical

A thorough history and physical examination are essential for diagnosing vaginitis, as they help identify the underlying cause and guide appropriate treatment. During patient evaluation, key elements must be considered to ensure a comprehensive symptom assessment and diagnosis approach.

Normal Vaginal Secretions

Normal vaginal secretions serve to keep the vagina healthy and maintain its pH balance by removing dead cells and bacteria. Normal physiologic vaginal discharge varies in appearance, consistency, and volume throughout the menstrual cycle. Typically, vaginal secretions are clear to white and differ in consistency from watery to slightly thick and mucous-like, with a mild odor. During ovulation, the discharge becomes more abundant, clear, and stretchy, aiding in fertility. The normal vaginal pH is between 3.8 and 4.5; this pH level helps maintain an acidic environment that prevents infections.[20] Normal discharge should not cause itching, burning, or irritation. Significant color, consistency, odor, or symptom changes may indicate an infection or other issue warranting medical evaluation.

History

Symptoms prompting evaluation include reports of abnormal vaginal discharge, itching, vaginal irritation, odor, dysuria, and dyspareunia. The evaluation should start with a detailed patient history, focusing on the nature and timing of the symptoms. The patient should be asked about any previous episodes of similar symptoms, as well as vulvovaginal hygiene practices, including the use of lubricants, shaving, and douching. A comprehensive sexual history, noting any previous STI, should be obtained, and potential new allergen exposures should be investigated. Documenting any self-treatment attempts is essential. Finally, clinicians must review the medical history for immune suppression and other relevant medical conditions.[21] 

Physical Examination

The physical examination should begin with thoroughly evaluating the vulva and adjacent skin, looking for vulvar erythema and edema. The appearance of the vaginal discharge should be noted, although visual characteristics alone are not diagnostic. Testing of the vaginal pH should be completed by sampling the vaginal discharge from the midportion of the vaginal sidewall because cervical mucus, semen, and blood may falsely elevate the pH.[21]

Evaluation

In-office diagnostic procedures for identifying the probable cause of vaginal symptoms involve several tests, including pH testing, a potassium hydroxide (KOH) whiff test, and microscopic examination using 0.9% saline and a 10% KOH solution. Additionally, commercially available tests approved by the US Food and Drug Administration for diagnosing vaginitis may be employed.[21]

Wet Mount Microscopy

The optimal sampling location for vaginal discharge remains unclear, with variations in results depending on the site sampled. Sampling from the posterior vaginal fornix may pose disadvantages due to exposure to cervical secretions, resulting in higher pH and an increased likelihood of inflammatory cells. Recent research suggests that sampling from multiple vaginal sites, particularly the lower third of the vagina and anterior fornix, may improve detection rates for different vaginal conditions. Avoid touching the uterine cervix during sampling, as cervical mucus contamination can be identified by the presence of abundant leukocytes arranged in rows.[22] Ideally, a specimen collection is done with an endocervical brush, a plastic spatula, or a Dacron swab. Cotton swabs are not ideal, as they can leave fibers behind. A thin layer of discharge is crucial for diagnostic purposes to enhance visualization. Different methods may be employed, with some clinicians placing a tiny drop of saline on a slide and mixing it with a small amount of vaginal discharge. In contrast, other clinicians spread the discharge evenly on the slide and then add a drop of saline.[22] Patient-collected specimens have recently been shown to be as accurate as provider-collected.[23] Next, a cover slip is carefully placed on the edge of the sample to prevent air bubbles, and then it is slid into place. Excess saline should be removed with absorbent paper. Additionally, some clinicians prepare another glass slide with a droplet of 10% KOH to improve the identification of fungal structures by destroying epithelial cells. The slide should be viewed within 10 minutes of collection because cooling limits the mobility of trichomonads. The 400X magnification is used to count organisms and cells per high-power field.[22]

• Squamous epithelial cells are polygonal cells. The central nucleus is roughly the size of a red blood cell (RBC). There is a large amount of irregular cytoplasm. The cells' margins are distinct. They are present in large numbers in the vaginal secretions of healthy women.  
• Clue cells are an abnormal variation of the squamous epithelial cell. They are distinguished by coccobacillus bacteria attached in clusters to the cell surface, which makes the cells' edges stippled and the borders indistinct. The cells are granular and irregular. When present in abundance (greater than 20% of squamous epithelial cells), Clue cells indicate Gardnerella vaginalis overgrowth.
• White blood cells (WBCs) appear one-half to one-third of the size of squamous epithelial cells. They exhibit a granular cytoplasm. The multi-lobed nucleus lends to the name polymorphonuclear leukocytes. In normal secretions, they are present in small numbers. Of there is a greater than 3% count of WBCs suggests vaginal candidiasis, atrophic vaginitis, or infections with trichomonas, chlamydia, gonorrhea, or herpes simplex virus.
• RBCs are one-half the size of WBCs and are smooth, non-nucleated biconcave disks. RBCs can be confused with yeast, but KOH lyses them while yeast cells remain on the KOH mount.
• Parabasal cells are larger than a WBC but smaller than squamous epithelial cells. They are round to oval shaped with a nucleus-to-cytoplasm ratio of 1:1 or 1:2. The cytoplasm contains basophilic granulation or amorphic basophilic structures. These are rarely seen in normal vaginal secretions unless women are menstruating or postmenopausal. Parabasal cells present with many WBCs indicate DIV. Basal cells are roughly the same size as WBCs but with round nuclei. The nucleus-to-cytoplasm ratio is 1:2. These are not typically found in vaginal secretions. Their presence can indicate vaginal atrophy or in the presence of excessive WBCs, DIV.
• Lactobacillus species should be the predominant organism in the healthy reproductive age vagina. These appear as large, nonmotile rods.
• Trichomonas vaginalis is a flagellated protozoan slightly larger than a WBC. There are 4 anterior flagella and an undulating membrane that extends half the body length. An axostyle bisects the trophozoite longitudinally and protrudes from the posterior end. This enables the organism to attach to the vaginal mucosa. As many as 70% of women infected with trichomonas have no symptoms. When discharge is present, it is described as yellow to green and frothy, with a pH >4.5. The cervix may have a punctate, strawberry appearance.[14] 
• Yeast cells (blastospores) are similar in size to RBCs. Pseudohyphae are multiple buds that form chains instead of detaching. Yeast is best observed with the 10-fold objective.

A separate slide is used for the KOH prep. The saline-diluted specimen is added to the slide along with a drop of 10% KOH. Increased numbers of anaerobic bacteria (G vaginalis, Mobiluncus, and Trichomonas, as opposed to a predominance of lactobacilli) lead to the production of amines. KOH leads to the volatilization of these amines, leading to a "fishy" amine odor, thus the name "whiff test." After performing the whiff test, place the coverslip and leave the slide to rest for 5 minutes. Allowing the slide to rest allows the epithelial cells and the RBCs to dissolve. The microscopic exam can then be performed to search for yeast pseudohyphae and blastospores without interference from other cell types.

Gram Stain

Gram stain remains the gold standard for identifying the causative agent for bacterial vaginosis but is only routinely used in research. The Gram stain slide must be heat-fixed and evaluated using the Nugent score. The Nugent score is calculated based on the observed quantities of Lactobacillus acidophilus, Gardnerella vaginalis, Bacteroides species, and Mobiluncus species.

Cultures

Cell culture is limited in evaluating vaginitis; it remains the gold standard for detecting yeast. Unfortunately, the results are not timely. The culture of Gardnerella vaginalis is not useful as it is part of the normal flora in 50% of women. Trichomonas vaginalis can be cultured, but it requires a specific medium, Diamond medium, and is time-consuming and labor-intensive. Beyond recurrent yeast, culture is not clinically important to evaluating vaginitis.

Deoxyribonucleic Acid Technologies

Deoxyribonucleic acid hybridization probes are available for G vaginalis, Candida species, and Trichomonas vaginalis and are being used increasingly in the evaluation of abnormal vaginal discharge. The sensitivities are very high, and the turnaround is quick. Various point-of-care tests for Trichomonas vaginalis and Gardnerella vaginalis are commercially available. Most require in-house equipment (except OSOM® for trichomonas, which has the lowest sensitivity), but the turnaround time is 15 to 60 minutes. Their sensitivities are 90% or higher.[24][25][26]

Desquamative Inflammatory Vaginitis

DIV is a purulent vaginitis that is difficult to differentiate from other forms of inflammatory vaginitis and is often a diagnosis of exclusion.[14] Physical examination shows inflammation, discharge, and desquamation. Wet mount microscopy may reveal parabasal cells, an abundance of inflammatory cells, and the absence or significant reduction of lactobacilli. Vaginal pH is typically elevated (>4.5), and the amine test is negative.

Atrophic Vaginitis

Signs and symptoms of atrophic vaginitis include vaginal dryness, dyspareunia, vaginal inflammation, thin mucosa, loss of rugae, and occasionally purulent discharge.[27] A wet mount demonstrates large WBCs, occasional parabasal and basal cells, decreased lactobacilli, and increased Gram-positive cocci and Gram-negative rods. The vaginal pH is 5.0 to 5.5 or greater. No pathogens are present. More than 1 WBC per epithelial cell is seen on wet prep. Parabasal cells are present, and superficial vaginal cells are decreased in quantity or even absent.[17]

Mixed Vaginitis

The symptoms of mixed vaginitis may vary from person to person and are not specific. Patients with mixed vaginitis experienced a range of symptoms. The most commonly reported issues are alterations in discharge (such as changes in color, consistency, and odor), genital itching, and a burning sensation.[19]

Treatment / Management

Effective treatment of vaginitis requires a targeted approach based on the specific underlying cause. The various therapeutic options tailored to manage and resolve different types of vaginitis are outlined.

Recommended Regimens per the Centers for Disease Control and Prevention

Bacterial Vaginosis 

• Metronidazole 500 mg orally twice a day for 7 days
• Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally, once a day for 5 days
• Clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days [14]

Alternative Regimens for Bacterial Vaginosis

• Tinidazole 2 g orally once daily for 2 days
• Tinidazole 1 g orally once daily for 5 days
• Secnidazole 2 g orally as a single dose
• Clindamycin 300 mg orally twice daily for 7 days
• Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days

Patients are no longer advised to abstain from alcohol use during treatment with metronidazole, as the disulfiram-like reaction has not been supported by evidence.[28] Eighty percent to 90% cure rates are expected 1 week after treatment. No routine follow-up is necessary for the asymptomatic patient after treatment, though 30% recurs at 3 months or later. With recurrent disease, the first step is to confirm the diagnosis of bacterial vaginosis again. For recurrence, women can be treated with the same regimen again or use 1 of the alternative regimens. Multiple recurrences after completion of a recommended regimen can be treated with 0.75% metronidazole gel twice weekly for 4 to 6 months. While this has been shown to reduce recurrences, the benefit does not persist when suppressive therapy is discontinued. Another option for persistent or recurrent disease is an oral nitroimidazole followed by intravaginal boric acid 600 mg daily for 21 days and then suppressive 0.75% metronidazole gel twice weekly for 4 to 6 months.[14]

Trichomoniasis 

• Metronidazole 500 mg orally twice per day for 7 days
• Tinidazole 2 gm orally once

Nitroimidazoles are the only class of antimicrobial medications effective against vaginalis infections. Only the US Food and Drug Administration cleared metronidazole and tinidazole for the oral or parenteral treatment of trichomoniasis. Metronidazole gel does not reach therapeutic levels in the urethra, vagina, and paravaginal glands and is not recommended for the treatment of trichomoniasis.[14] Tinidazole is avoided in pregnancy and contraindicated in the first trimester. The recommended metronidazole regimens have cure rates of approximately 84% to 98%, and the tinidazole regimen has rates of approximately 92% to 100%. Metronidazole resistance occurs in 4% to 10% of cases of vaginal trichomoniasis, and tinidazole resistance in 1%, but most cases of “persistent” infection are from reinfection. If routine treatment regimens fail, consider referral to an infectious disease specialist and susceptibility testing.[23]

Yeast Vulvovaginitis

Yeast vulvovaginitis is often secondary to Candida albicans, but less common pathogens include Candida glabrata, Candida parapsilosis, Candida tropicalis, and Candida krusei. While candida is a normal constituent of the vagina, risk factors for pathogenic overgrowth include antibiotic uses, combination oral contraceptives, estrogen therapy, pregnancy, diabetes, corticosteroid use, and all forms of immune compromise. The infection is most common during the childbearing years when estrogen is plentiful. Glycogen is key to facilitating candida growth and adherence. Signs and symptoms of yeast vulvovaginitis include genital burning, pruritis, dyspareunia, dysuria, and a thick, white, curd-like discharge. The wet prep is 60% to 70% sensitive to yeast vaginitis. Budding yeasts, pseudohyphae, large numbers of WBCs, lactobacilli, and clumps of epithelial cells are seen on the wet mount. The pH is <4.5, and the amine whiff test is negative. A yeast culture is rarely needed but can be ordered if non-Candida albicans species are suspected. Candida glabrata does not form pseudohyphae and is difficult to recognize on microscopy. DNA testing is also available to identify species.

Uncomplicated Candida Vaginitis 

Uncomplicated: For uncomplicated vulvovaginal candidiasis, a short course (1—or 3-day course) of over-the-counter topical antifungals (clotrimazole, miconazole, tioconazole, butoconazole, and itraconazole) results in cure rates of 80% to 90%. A single oral dose of fluconazole 150 mg is also effective. If the symptoms resolve, no follow-up is needed.

Complicated Candida Vaginitis Disease 

Recurrent candidiasis: A course of 7 to 14 days of topical therapy or a 100 mg, 150 mg, or 200 mg oral dose of fluconazole every third day for 3 doses [days 1, 4, and 7]) can be used. The first-line maintenance regimen is oral fluconazole (ie, 100 mg, 150 mg, or 200 mg dose) weekly for 6 months. Thirty percent to 50% of women have recurrent disease after maintenance therapy is discontinued.

• Severe candidiasis: A 7- to 14-day topical azole or 150 mg of fluconazole in 2 sequential oral doses 72 hours apart is often effective.
• Non-Candida albicans candidiasis: A 7- to 14-day regimen of a non-fluconazole azole (oral or topical) as first-line therapy and be prescribed. If recurrence occurs, 600 mg of boric acid in a gelatin capsule is recommended, administered vaginally once daily for 2 weeks.

Desquamative Inflammatory Vaginitis 

Treatment involves topical steroids to reduce inflammation, although randomized trials have not been completed. If bacterial overgrowth is suspected, clindamycin or other antibiotics may be prescribed. Initial therapy with 2% clindamycin cream every other night for 2 weeks can be tried. Alternatively, 10% hydrocortisone suppositories or 25 mg hydrocortisone suppositories nightly for 1 week is suggested. Prolonged therapy up to 2 months may be needed.[14] Topical estrogen therapy can be beneficial, particularly in postmenopausal women. Desquamative inflammatory vaginitis can be a chronic condition that requires long-term management. Patients may experience periods of relapse and remission. Regular follow-up with a healthcare professional is essential for managing symptoms and adjusting treatment.[17]

Atrophic Vaginitis

Many women do not seek evaluation or therapy for atrophic vaginitis, although it can significantly affect sexual health and quality of life.[17] This condition is initially treated with lubricant use during intercourse and personal vaginal moisturizers. If these remedies do not give satisfactory results, then local vaginal estrogen therapy using either a cream, suppository, or vaginal ring (7.5 μg dose) can be used. Intravaginal dehydroepiandrosterone is also an available treatment.[27] Vaginal treatment with radiofrequency and lasers is not recommended due to lack of efficacy studies.[17] More recently, a selective estrogen receptor agonist called ospemifene has been approved for use in patients with vulvovaginal atrophy of menopause; this medication is taken once daily by mouth at a dose of 60 mg. This medicine is an estrogen agonist in the vulvovaginal tissue and specifically promotes epithelial lining proliferation in this tissue.[29]

Mixed Vaginitis

Mixed vaginitis is challenging to treat, and standard treatment regimens have not been established. Recurrence is common. Each pathogen requires treatment for complete eradication of vaginitis that is caused by 2 or more vaginal pathogens.[19] Several small clinical studies have shown the efficacy and safety of topical fenticonazole as a treatment for mixed bacterial and fungal vaginitis as an alternative to multiagent treatment regimens.[18]

Differential Diagnosis

When evaluating a patient with vaginitis symptoms, it is crucial to consider a broad range of differential diagnoses. The following list encompasses various conditions that can mimic vaginitis. Consideration of these differential diagnoses helps to ensure accurate diagnosis and appropriate management.

Sexually Transmitted Infections 

• Chlamydia and Gonorrhea: These infections can cause vaginal discharge, irritation, and discomfort similar to vaginitis.
• Herpes Simplex Virus: Genital herpes can cause pain, itching, and vesicles, which might be mistaken for vaginitis.
• Human Papillomavirus: Some strains cause genital warts and changes in vaginal discharge.

Urinary Tract Infections 

Urinary tract infections can cause burning, urgency, and frequency of urination, which may be confused with the symptoms of vaginitis.

Pelvic Inflammatory Disease

Pelvic inflammatory disease can cause lower abdominal pain, fever, and unusual vaginal discharge, overlapping with vaginitis symptoms.

Dermatologic Conditions

• Lichen sclerosus and lichen planus: These chronic skin conditions can cause itching, discomfort, and changes in the vulvar skin that may be mistaken for vaginitis.
• Eczema and psoriasis: These entities can cause irritation and itching in the genital area.
• Vulvodynia: Chronic pain or discomfort around the vulva can be mistaken for the discomfort associated with vaginitis.
• Allergic reactions to products such as soaps, detergents, or feminine hygiene products can cause irritation and discharge similar to vaginitis.

Foreign Bodies

Retained tampons or other foreign objects can cause discharge, odor, irritation, and infection.

Prognosis

In most women, vaginitis has an excellent outcome, and a cure is likely. Most cases of vaginitis, including bacterial vaginosis, yeast infections, and trichomoniasis, respond well to medication, such as antibiotics or antifungals, depending on the underlying cause. However, recurrence is common and can lead to excoriations, chronic irritation, and scarring. In addition, these symptoms also lead to low libido and a decline in sexual function. Both emotional stress and psychosocial issues are not uncommon.[30][31] Certain risk factors, such as immunocompromised conditions or repeated irritant exposure, may affect the prognosis and recurrence. Early diagnosis and prompt treatment are crucial for achieving a favorable prognosis and preventing complications. Atrophic vaginitis as part of genitourinary syndrome of menopause affects up to 77% of women, worsens over time, and persists lifelong. Local therapies, as discussed, improve symptom severity by up to 80%, and the prognosis is excellent with continued treatment.[27] Desquamative inflammatory vaginitis, however, is a chronic process that is difficult to diagnose and does not respond well to currently known therapies. The cure rate is just under 35% at 2 years. Relapse is common, and continued therapy may be needed in over 50% of affected women.[16] 

Complications

If left untreated or improperly managed, vaginitis can lead to several complications. These include PID, which can result from untreated bacterial vaginosis or STIs like trichomoniasis, leading to chronic pelvic pain, ectopic pregnancy, and infertility. Vaginitis also increases the risk of contracting and transmitting STIs, including human immunodeficiency virus, by disrupting the normal mucosal barrier and immune defenses. In pregnancy, infections such as bacterial vaginosis and trichomoniasis are associated with preterm labor, low birth weight, and amniotic fluid infection (chorioamnionitis), posing risks to both mother and baby. Chronic vaginitis can cause persistent symptoms like itching, burning, and discomfort, affecting daily activities and sexual intercourse, leading to distress and relationship issues. Recurrent inflammation and irritation can damage vulvar and vaginal tissues, increasing susceptibility to other infections and skin conditions. Psychosocial impacts, including anxiety, depression, and decreased sexual confidence, can also occur. Misdiagnosis or incorrect treatment may exacerbate symptoms and lead to unnecessary antibiotic use, contributing to resistance. Therefore, proper diagnosis, timely treatment, and preventive measures are essential to avoid these complications.

Consultations

Patients with vaginitis may require consultations with specialists depending on the complexity or severity of their condition. Gynecologists are often consulted for cases refractory to initial treatment, recurrent infections, or when underlying gynecological issues are suspected. Infectious disease specialists may be involved in cases of treatment-resistant or recurrent infections, especially when considering less common pathogens or antibiotic-resistant strains. In cases where STIs are suspected, consultation with a specialist in sexual health or genitourinary medicine may be warranted to ensure comprehensive evaluation and management. Collaboration between primary care clinicians and specialists ensures a multidisciplinary approach, optimizing patient care and outcomes in managing vaginitis.

Deterrence and Patient Education

Deterrence and patient education play crucial roles in preventing vaginitis and promoting vaginal health. Patients should be advised to maintain good hygiene by washing the genital area regularly with mild soap and water, avoiding douching, and wearing breathable cotton underwear. Safe sexual practices, including condom use and regular STI screenings, are essential. Patients should also be educated about the proper use of antibiotics, avoiding irritants like scented feminine products, and the importance of a healthy lifestyle. Women should be taught proper toileting and wiping techniques to prevent recurrent infections. Patients should be reminded that douching also increases the risk of vaginitis. Understanding common symptoms, recognizing risk factors, and adhering to treatment plans are key components of patient education to ensure timely intervention and management of vaginitis. Providing educational resources empowers patients to take proactive steps in maintaining optimal vaginal health. Considering the anticipated global prevalence and economic impact of vaginitis in the coming decade, high-income countries must find better solutions and enhance the quality of care for affected women. With the growing interest in human microbiota, probiotic treatments have gained significant attention recently. As technology advances, a deeper understanding of the vaginal microbiome's composition and its preventive and therapeutic effects on vaginitis is expected to emerge.[32]

Pearls and Other Issues

Clinical pearls for vaginitis offer valuable insights and practical tips that enhance diagnostic accuracy and treatment efficacy. Key takeaways and best practices for managing vaginitis in clinical settings include the following:

• Effective management of vaginitis hinges on accurate diagnosis, tailored treatment, and patient education.                                                                                                                                              
• The diagnosis should be confirmed with laboratory tests to differentiate between bacterial, fungal, and protozoal infections.
• The patient's history of recent antibiotic use, which can predispose to yeast infections, must be considered.
• Sexual activity and the use of contraceptives must be inquired about, as these influence the vaginal flora.
• Clinicians must diligently differentiate vaginitis from other gynecological conditions to avoid misdiagnosis pitfalls.
• Treatment should address the underlying cause, and follow-up appointments ensure treatment efficacy and patient compliance.
• Sexually active patients with vaginitis symptoms should be screened for STIs.
• Even if symptoms improve early, the importance of completing prescribed treatments should be emphasized.
• Coexisting conditions, such as diabetes, which can predispose patients to recurrent vaginitis, should be monitored and managed.
• Patients should have follow-ups to ensure symptom resolution and address any ongoing concerns.
• Recurrent infections, which may indicate an underlying condition or the need for a longer treatment course, should be checked for.
• Appropriate disposition, including hospitalization or specialist referral, may be necessary in severe or complicated cases.
• Preventive measures, such as practicing good hygiene, safe sexual practices, and avoiding douching, can help reduce the risk of vaginitis. Patient education is crucial.
• Addressing hormonal imbalances and undergoing regular screenings can aid in prevention and improve patient outcomes.

Enhancing Healthcare Team Outcomes

A collaborative approach among healthcare professionals is essential for patient-centered care and optimal outcomes when managing vaginitis. Physicians lead diagnosis and treatment planning, while advanced care practitioners provide primary care services and assist with assessments and education. Nurses offer hands-on care, patient advocacy, and medication administration, while pharmacists ensure safe medication use and provide medication counseling. Pharmacists should also educate women on the proper use of over-the-counter products and when to see a healthcare provider.[33][34] Effective interprofessional communication facilitates information sharing and care coordination, ensuring seamless transitions and holistic care. Upholding ethical standards, including informed consent and patient autonomy, and coordinating services to optimize resources and minimize duplication is paramount. Together, these efforts enhance patient safety, outcomes, and overall team performance in vaginitis management.