Pediatrics

Vaginitis

OVERVIEW: What every practitioner needs to know

Symptoms suggestive of vaginitis (vaginal discharge, vaginal itching or burning, change in vaginal odor) are a common reason adolescent and young adult women seek care; while less common, vaginitis also occurs among prepubertal girls. A careful history combined with an external genital examination and microscopic examination of vaginal fluid will usually establish the diagnosis; however, in some cases a complete pelvic examination and more extensive laboratory testing will be necessary.

Are you sure your patient has vaginitis? What are the typical findings for this disease?

Key symptoms and signs of the disease:

  1. New onset vaginal discharge or increase in normal amount; vaginal/vulvar itching/burning (external/internal)

  2. Vaginal odor or change from normal odor

  3. Dyspareunia with moderate or severe vulvar/vaginal inflammation

  4. Dysuria (urine flowing over inflamed vulva)

  5. Labial ulcers are characteristic of genital herpes, but severe vulvovaginal candidiasis (VVC) may present with extensive vulvar erythema, edema, excoriation, and fissures.

  6. Punctate hemorrhages on the cervix ("strawberry cervix") occur in 2%-5% of cases of trichomoniasis

  7. A thick, curdy discharge, especially if associated with itching, is highly predicitive of VVC. A "bubbly/frothy" greenish-yellow discharge suggests trichomoniasis. A thin, homogeneous grayish white discharge suggests bacterial vaginosis (BV).

What other disease/condition shares some of these symptoms?

Diseases/conditions that can mimic vaginitis:

  1. Cervicitis (due to infection with N. gonorrhoeae, C. trachomatis, or herpes) can produce discharge; if concomitant endometritis (pelvic inflammatory disease), purulent discharge from the cervical os may mimic vaginal discharge

  2. Retained tampon or foreign body (e.g., condom) - discharge is usually more purulent, foul-smelling, and may be bloody

  3. Physiologic leukorrhea (increase in normal vaginal secretions due to rising estrogen levels in the peripubertal period); normal increase in secretions in the periovulatory period

  4. Estrogen effect of birth control pills (including increased risk for VVC in some adolescent females); hormonal contraceptive vaginal ring may cause sense of "vaginal wetness"

  5. Stress

  6. Chemical irritants (ask about douching, use of deodorants), contact dermatitis/allergies (material in underpants, chemicals in some sanitary pads, soaps or bubblebaths, etc; latex allergy (if partner using latex condoms) or sensitivity to spermicides (nonoxynol-9), either as condom lubricated with spermicide or as stand-alone product

  7. Poor hygiene

  8. Trauma

  9. Enterobius vermicularis (pinworms) - perinanal and vaginal itching

  10. Vulvodynia/vestibulitis

  11. (Unusual but should be considered in treatment-resistant cases): psoriasis, seborrheic dermatitis, lichen simplex chronicus, lichen planus, lichen sclerosus

What caused this disease to develop at this time?

  • Puberty (physiologic leukorrhea) or mid-cycle increase in clear secretions (estrogen effect)

  • Exogenous estrogen (oral contraceptives, vaginal ring)

  • Infection (vaginal, cervical, upper genital tract [uterus/adnexa]) - inquire about location of any associated pain, burning or itching (external/at introitus, intravaginal, lower abdominal/pelvic pain)

  • Sexual activity (new onset or change in activity, including new partner within 30-60 days). BV is associated with sexual activity, including non-penetrative digito-genital contact and oral sex; however, it is not considered a sexually transmitted infection. Women who are not sexually active can get BV. Having a female sex partner increases the risk for BV.

  • Stress

  • Retained foreign body

  • Pregnancy (ask about missed period or change in periods)

  • Antibiotic use, steroids (increased risk for VVC)

  • Chemical/allergic - inquire about deodorant sprays, douching, type of menstrual pad/tampon used (scented), new soap; type of underpants (cotton or polyester)

  • Diabetes - inquire about other symptoms of diabetes; is patient obese (type 2 diabetes)

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

  • Mid-vaginal pH is an important diagnostic criterion. Normal pH is <4.5. pH >=5.0 likely indicates infection. Avoid obtaining pH from near or at the cervical os. Candidiasis usually not associated with pH >=4.5

  • Whiff test - fishy or amine-like odor released when vaginal fluid mixed with KOH suggests BV or trichomoniasis

  • Vaginal wet prep (must examine promptly to maximize likelihood of detecting trichomonads). Look for clue cells, white blood cells, trichomonads, presence or absence of lactobacilli. If 3 of the 4 following criteria are present, BV is highly likely: increased numbers of clue cells; thin, white homogenous vaginal discharge; mid-vaginal pH >= 5.0; positive whiff test. Commercial test kits for in-office detection of BV are available and have acceptable performance.

  • Presence of trichomonads (motile or stationary) diagnostic for trichomoniasis. However, wet prep is only 50 to 65% sensitive, even when performed under ideal conditions by an experienced microscopist. Culture is more sensitive than wet prep but less sensitive than DNA-based (not yet FDA approved) and FDA approved point of care tests (unamplified RNA, rapid antigen). Any woman diagnosed with trichomoniasis should be tested for C. trachomatis and N. gonorrhoeae infection. One suggested protocol for diagnosis of trichomoniasis in a population where the prevalence of infection is significant is to perform a wet prep first; if negative, perform a rapid antigen test. Culture has comparable sensitivity to rapid antigen tests, but results are available in days rather than minutes. KOH prep - presence of hyphae or buds suggests candidiasis. Hyphae and/or buds may also be seen on vaginal wet prep.

  • Large numbers of white blood cells not typically seen with VVC or bacterial vaginosis. Their presence suggests trichomoniasis or cervicitis/upper genital tract infection.

  • Women with cervicitis (mucopurulent discharge from cervical os and/or easily induced bleeding at the cervical os) should be tested for C. trachomatis and N. gonorrhoeae and, if clinically indicated, for herpes and T. vaginalis

Would imaging studies be helpful? If so, which ones?

  • Imaging studies are not indicated

If you are able to confirm that the patient has vaginitis, what treatment should be initiated?

Women being treated for bacterial vaginosis should avoid intercourse or use condoms during treatment (Table I). Women with trichomoniasis should avoid intercourse during treatment and until their sex partner(s) have been treated and are symptom-free (Table I).

Table I.

Treatment options for bacterial vaginosis and trichomoniasis.
Condition Medication Dose
Bacterial vaginosis
     Recommended Metronidazole* 500 mg PO BID for 7 days OR
Metronidazole gel 0.75% 1 full applicator (5 g) once daily for 5 days OR
Clindamycin cream 2%** 1 full applicator (5 g) intravaginally at bedtime for 7 days
    Alternatives Tinidazole* 2 g orally once daily for 2 days OR
Tinidazole* 1 g orally once daily for 5 days OR
Clindamycin 300 mg orally BID for 7 days OR
Clindamycin ovules 100 mg ovule intravaginally once at bedtime for 3 days
Trichomoniasis
    Recommended Metronidazole* 2 g orally in a single dose OR
Tinidazole* 2 g orally in a single dose
    Alternative Metronidazole* 500 mg BID for 7 days

Several treatment options are available for women with vulvovaginal candidiasis (Table II).

Table II.

Recommended treatment options for vulvovaginal candidiasis
Over-the-counter products (all administered intravaginally by applicator or suppository)
By applicator daily
Butoconazole 2% cream (5 g) for 3 days OR
Clotrimazole 1% cream (5 g) for 7-14 days OR
Clotrimazole 2% cream (5 g) for 3 days OR
Miconazole 2% cream (5 g) for 7 days OR
Miconazole 4% cream (5 g) for 3 days OR
Ticonazole 6.5% ointment once OR
By vaginal suppository daily
Miconazole 100 mg for 7 days OR
Miconazole 200 mg for 3 days OR
Miconazole 1200 mg once OR
Prescription medications
Intravaginal products
Butoconazole 2% cream (5 g) for 1 day OR
Nystatin 100,000-unit vaginal tablet daily for 14 days OR
Terconazole 0.4% cream (5 g) intravaginally daily for 7 days OR
Terconazole 0.8% cream (5 g) intravaginally daily for 3 days OR
Terconazole 80 mg vaginal suppository daily for 3 days OR
Oral medication
Fluconazole Single dose of 150 mg tablet

What are the adverse effects associated with each treatment option?

  • Metronidazole or tinidazole (oral): avoid use of alcohol during and for 24 hours after treatment with metronidazole and for 72 hours after tinidazole

  • Clindamycin cream: oil base may weaken latex condoms and diaphragms for up to 5 days

  • Topical therapy for candidiasis causes local burning in 5%-10% of patients

What are the possible outcomes of vaginitis?

  • Bacterial vaginosis: treatment is effective (80%-85%), but recurrence is common (30% by 3 months; up to 80% by one year).

  • Because re-infection following treatment of trichomoniasis is common (in one study 17% were re-infected within 3 months, and in another study 30% at one year), rescreening at 3 months can be considered.

  • A small percentage of women (<5%) will have four or more episodes of VVC in one year (recurrent vulvovaginal candidiasis or RVVC).

What causes this disease and how frequent is it?

  • Approximately 75% of women experience at least one episode of VVC; 40%-45% will have two or more. Adolescence is a typical time for a first episode. By age 25, half of all college students will have had one or more episodes of candidiasis. Risk factors include pregnancy, luteal phase of the menstrual cycle, nulliparity, recent use of broad spectrum antibiotics, use of spermicides, and age 15-19.

  • Prevalence of trichomonas infection is approximately 10%-20% (especially prevalent in women aged 16-35) but the prevalence varies widely depending on the population sampled. Risk factors include change in sex partners, intercourse twice weekly or more, 3 or more partners in the past month, and the presence of other sexually transmitted infections.

  • The prevalence of bacterial vaginosis also varies widely (10%-50%). The etiology of bacterial vaginosis is unknown, but a change in vaginal ecology (predominance of lactobacillus) results in an overgrowth of Gardnerella vaginalis and anaerobes (Prevotella spp, Peptostreptococci, Mobiluncus spp). Risk factors for bacterial vaginosis include more than one sex partner, change of partner in the last 30 days, having a female sexual partner, and douching.

How do these pathogens/genes/exposures cause the disease?

What complications might you expect from the disease or treatment of the disease?

  • Bacterial vaginosis is associated with adverse pregnancy outcomes such as preterm birth and low birthweight infants. It is also associated with increased risk for pelvic inflammatory disease, post-abortion infection and HIV infection.

  • Trichomoniasis is associated with upper genital tract infection (including pelvic inflammatory disease), post-abortion and post-delivery infections, and preterm birth. T. vaginalis increases the risk for persistent HPV infection and for acquiring herpes and HIV.

Are additional laboratory studies available; even some that are not widely available?

Nucleic acid amplification tests for detection of T. vaginalis infections

How can vaginitis be prevented?

Condoms can decrease the risk for trichomoniasis and bacterial vaginosis.

Avoid douching, use of scented products (soaps, sanitary pads) or other feminine "hygiene" products. Limit use of broad spectrum antibiotics or steroids whenever possible. Avoid wearing nylon or tight undergarments or wearing exercise clothing for long periods of time (anything that traps moisture against the perineum).

A Cochrane review concluded that there is insufficient evidence to recommend for or against the use of probiotics in the treatment of bacterial vaginosis or prevention of recurrence.

What is the evidence?

"Sexually transmitted diseases guidelines, 2010". MMWR. vol. 59. 2010. pp. 56-62.

(The definitive source and standard of care for evaluation and treatment of sexually transmitted diseases. Contains guidelines applicable to both child and adult populations.)

Eckert, LO. "Acute vulvovaginitis". New Engl J Med. vol. 355. 2006. pp. 1244-52.

(A concise review of the evaluation and managment of vulvovaginitis. Information is applicable to adults and to adolescents. Excellent tables summarize key diagnostic features, diagnostic tests available, and current treatment regimens.)

Wilson, JF. "In the clinic. Vaginitis and cervicitis". Ann Intern Med.. vol. 151. 2009. pp. ITC 3-1-ITC3-16.

(A concise review of the evaluation and management of vaginitis and cervicitis in adult women; information is applicable to adolescents.)

Huppert, JS. "Trichomoniasis in teens: an update". Curr Opin Obstet Gynecol. vol. 21. 2009. pp. 371-8.

(A comprehensive review of the epidemiology, clinical presentation, diagnosis, and treatment of trichomonas infections among adolescents.)

Nyirjesy, P. "Vulvovaginal candidiasis and bacterial vaginosis". Infect Dis Clin N Am. vol. 22. 2008. pp. 637-52.

(A thorough review of these two common infections. Data are drawn from adult studies, but information generally applicable to adolescents as well.)

Marrazzo, JM, Martin, DH. "Management of women with cercvicitis". Clin Infect Dis. vol. 44. 2007. pp. S102-10.

(Although now 5 years old, a good review of what we know and don't know about cervicitis.)

Hwang, LY, Shafer, M-A, Neinstein, LS, Gordon, CM, Katzman, DK, Rosen, DS, Woods, ER. "Adolescent Health Care. A Practical Guide". Wolters Kluwer/Lippincott Williams & Wilkins. pp. 723-32.

(An adolescent-focused chapter on vaginitis and vaginosis.)

Woods, ER, Emans, SJ, Emans, SJ, Laufer, MR, Goldstein, DP. "Pediatric and Adolescent Gynecology". Wolters Kluwer/Lippincott Williams & Wilkins. pp. 525-51.

(A comprehensive review of vulvovaginal complaints focused on adolescents.)

Senok, AC, Verstraelen, H, Temmerman, M, Botta, GA. "Probiotics for the treatment of bacterial vaginosis". Cochrane Database Syst Rev. 2009.

Ongoing controversies regarding etiology, diagnosis, treatment

  • The etiology of BV is uncertain; it is not a true vaginitis because there is no evidence of inflammation when present. BV is associated with sexual activity but is not considered a sexually transmitted infection. It is not clear whether asymptomatic women with BV who are not pregnant or about to undergo genital tract instrumentation should be treated.

  • Previous research suggested that recurrences of trichomoniasis were due to reinfection; however, more recent studies (using more sensitive detection methods) suggest that in some women, treatment temporarily suppresses levels of organisms to a level that cannot be detected, but over time symptoms recur. (See reference #3 by Huppert above for more detail).

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