Vulvovaginitis

Bacterial vaginosis

Tip

Note this is called “vaginosis” instead of “vaginitis”, because there is no inflammation.

• Epidemiology: most common vaginal infection in women (22–50% of all cases)
• Pathogen: Gardnerella vaginalis (a pleomorphic, gram-variable rod)
• Pathophysiology: lower concentrations of Lactobacillus acidophilus lead to overgrowth of Gardnerella vaginalis and other anaerobes, without vaginal epithelial inflammation due to absent immune response
• Clinical features
  • Commonly asymptomatic
  • Increased vaginal discharge, usually gray or milky with fishy odor
  • Pruritus and pain are uncommon. t
• Diagnostics: diagnosis is confirmed if three of the following Amsel criteria are met
  • Clue cells
    • Vaginal epithelial cells with a stippled appearance and fuzzy borders due to bacteria adhering to the cell surface
    • Identified on a vaginal wet mount preparation
  • Vaginal pH > 4.5
  • Positive amine test (sometimes referred to as the “whiff test”)
• Treatment
  • Treatment Threshold: c
    • Treatment is indicated only for symptomatic non-pregnant patients (thin off-white discharge, fishy odor, pH > 4.5, positive whiff test) or select high-risk obstetric/gynecologic scenarios (e.g., prior to surgical abortion or hysterectomy).
    • Asymptomatic non-pregnant women do not require treatment or further diagnostic testing, as the microflora frequently fluctuates and self-resolves.
  • First-Line:
    • Metronidazole 500 mg PO BID x 7 days OR
    • Metronidazole 0.75% gel intravaginally x 5 days OR
    • Clindamycin 2% cream intravaginally x 7 days.
  • Pregnancy: Treat symptomatic pts in any trimester with standard regimens.
  • Counseling: Avoid alcohol with Metronidazole (prevents disulfiram-like reaction).
  • Partners: Do not treat male partners; treat symptomatic female partners. c
    • Does not prevent recurrence and is not recommended (unlike Trichomonas vaginalis, which requires partner treatment).

Vaginal yeast infection (vulvovaginal candidiasis)

• Epidemiology: second most common cause of vulvovaginitis (17–39% of all cases)
• Pathogen: primarily Candida albicans
• Risk factors
  • Pregnancy
  • Immunodeficiency, both systemic (e.g., diabetes mellitus, HIV, immunosuppression) and local (e.g., topical corticosteroids)
  • Antimicrobial treatment (e.g., after systemic antibiotic treatment)
• Clinical features
  • White, crumbly, and sticky vaginal discharge that may appear like cottage cheese t and is typically odorless
  • Erythematous vulva and vagina
  • Vaginal burning sensation, strong pruritus, dysuria, dyspareunia

Trichomoniasis

• Epidemiology: 4–35% of all cases
• Pathogen: Trichomonas vaginalis
• Clinical features
  • Foul-smelling, frothy, yellow-green, purulent discharge
  • Vulvovaginal pruritus, burning sensation, dyspareunia, dysuria, strawberry cervix (erythematous mucosa with petechiae)
• Diagnostics
  • Saline vaginal wet mount (initial test): motile trophozoites with multiple flagella
    • If the wet mount is inconclusive, perform a culture or nucleic acid amplification testing (NAAT)
  • pH of vaginal discharge > 4.5
  • Routine screening in asymptomatic (nonpregnant and pregnant) patients is not recommended