Management of Vaginitis MARION K. OWEN, M.D., Emory University School of Medicine, Atlanta, Georgia TIMOTHY L. CLENNEY, CDR, MC, USN, Naval Hospital Jacksonville, Jacksonville, Florida Common infectious forms of vaginitis include bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Vaginitis also can occur because of atrophic changes. Bacterial vaginosis is caused by proliferation of Gardnerella vaginalis, Mycoplasma hominis, and anaerobes. The diagnosis is based primarily on the Amsel criteria (milky discharge, pH greater than 4.5, positive whiff test, clue cells in a wet-mount preparation). The standard treatment is oral metronidazole in a dosage of 500 mg twice daily for seven days. Vulvovaginal candidiasis can be difficult to diagnose because characteristic signs and symptoms (thick, white discharge, dysuria, vulvovaginal pruritus and swelling) are not specific for the infection. Diagnosis should rely on microscopic examination of a sample from the lateral vaginal wall (10 to 20 percent potassium hydroxide preparation). Cultures are helpful in women with recurrent or complicated vulvovaginal candidiasis, because species other than Candida albicans (e.g., Candida glabrata, Candida tropicalis) may be present. Topical azole and oral fluconazole are equally efficacious in the management of uncomplicated vulvovaginal candidiasis, but a more extensive regimen may be required for complicated infec- tions. Trichomoniasis may cause a foul-smelling, frothy discharge and, in most affected women, vaginal inflammatory changes. Culture and DNA probe testing are useful in diagnosing the infection; examinations of wet-mount preparations have a high false-negative rate. The stan- dard treatment for trichomoniasis is a single 2-g oral dose of metronidazole. Atrophic vaginitis results from estrogen deficiency. Treatment with topical estrogen is effective. (Am Fam Physician 2004;70:2125-32,2139-40. Copyright© 2004 American Academy of Family Physicians.) ▲ Patient information: aginitis is among the most com- of bacterial vaginosis, vulvovaginal candi- A handout on vaginitis, mon conditions for which women diasis, trichomoniasis, and vaginal atrophy. written by the authors of this article, is provided on seek medical care, with vaginal page 2139. discharge accounting for approxi- Diagnosis V mately 10 million office visits each year.1 Although it is tempting to treat vaginal com- See page 2131 for definitions of strength-of- Although vaginitis can have a variety of plaints empirically based on the patient’s his- recommendation labels. causes (Table 1), it most often is associated tory alone, studies2,3 have demonstrated poor with infection or atrophic changes. Com- correlation between symptoms and the final mon infectious forms of vaginitis include diagnosis. Bacterial vaginosis often is identi- bacterial vaginosis, vulvovaginal candidi- fied based on the vaginal pH and the presence asis, and trichomoniasis. Although these of clue cells on light microscopy (two of the infections generally respond to treatment, Amsel criteria4). A recent analysis3 found that misdiagnosis and, rarely, phar- examination of wet-mount preparations is macologic resistance may occur. neither highly sensitive nor specific for vul- Although it is tempting to In almost all patients with vovaginal candidiasis. Culture of the vagina is treat vaginal complaints vaginitis, it is important to per- costly, but may be the only way to ensure diag- empirically based on the form a thorough assessment that nosis of vulvovaginal candidiasis in equivocal patient’s history alone, includes speculum examina- cases. A reasonable alternative is to use a wet- studies have demon- tion, pH testing, wet-mount and mount and KOH preparation or Gram stain strated poor correlation potassium hydroxide (KOH) of the vagina in conjunction with the findings between symptoms and preparations, and cultures when of the physical examination, and to reserve the final diagnosis. indicated. This article reviews culture for cases of treatment failure.5 DNA- the diagnosis and management based diagnostic tools with varying degrees Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2004 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. TABLE 1 Causes of Vaginitis Type of vaginitis Causes and comments vaginalis, Mycoplasma hominis, and anaer- Vulvovaginal candidiasis Candida albicans, Candida glabrata, Candida tropicalis obes, including Mobiluncus, Bacteroides, Bacterial vaginosis Gardnerella vaginalis, Mycoplasma and Peptostreptococcus species. hominis, Mobiluncus species, The Amsel criteria are considered to be Bacteroides species (other than the standard diagnostic approach to bacte- Bacteroides fragilis) rial vaginosis and continue to be generally Trichomoniasis Trichomonas vaginalis reliable.7,8 The criteria are as follows: milky, Atrophic vaginitis Estrogen deficiency homogeneous, adherent discharge; vaginal Chemical irritation Soaps, hygiene products (tampons, pH greater than 4.5; positive whiff test (the sanitary napkins, latex condoms) discharge typically has a fishy smell); and Lichen planus Flat, hyperkeratotic lesions that are presence of clue cells in the vaginal fluid on (desquamative type) pruritic or painful; associated light microscopy.4 If three of the four criteria vulvar and oral lesions are met, there is a 90 percent likelihood of Allergic vaginitis Sperm, douching, hygiene products bacterial vaginosis. (tampons, sanitary napkins, latex condoms or diaphragms), dyes, The presence of small gram-negative rods inhaled allergens, occupational or gram-variable rods and the absence of exposures longer lactobacilli on a Gram stain of the Foreign body with or Tampons, contraceptive devices, vaginal discharge also is highly predictive of without infection pessary, others bacterial vaginosis.9 However, this method or trauma of diagnosis is impractical in most fam- ily physicians’ offices. Because G. vagina- lis commonly is found in asymptomatic of sensitivity and specificity also are avail- women, culture is not useful. able. Finally, a recent study6 showed that in According to guidelines from the Centers adolescents, vaginal swabs for wet-mount and for Disease Control and Prevention (CDC),10 KOH preparations may be performed reliably treatment of bacterial vaginosis is indicated without speculum examination. to reduce symptoms and prevent infectious complications associated with pregnancy Bacterial Vaginosis termination and hysterectomy. Treatment Bacterial vaginosis accounts for 10 to 30 also may reduce the risk of human immu- percent of the cases of infectious vaginitis nodeficiency virus (HIV) transmission.10 in women of childbearing age.7 In bacterial Thus, it is reasonable to treat asymptomatic vaginosis, there is a decrease in normal lac- patients who are scheduled for hysterec- tobacilli and a proliferation of Gardnerella tomy or pregnancy termination or who are at increased risk for HIV infection;10 other asymptomatic patients need not be treated. The Authors MARION K. OWEN, M.D., is in private family practice in Atlanta. She received her Treatment medical degree from the University of North Carolina at Chapel Hill School of The standard treatment for bacterial vagi- Medicine and completed a family medicine residency at Emory University School of Medicine, Atlanta. nosis is metronidazole (Flagyl) in a dos- age of 500 mg orally twice daily for seven TIMOTHY L. CLENNEY, CDR, MC, USN, is a staff family physician in the family days (Table 2).10 Although other treatments medicine residency program at the Naval Hospital Jacksonville (Fla.), as well as have been shown to have approximately assistant professor of family medicine at the Uniformed Services University of equivalent efficacy,11-16 they are associated the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Md. Dr. Clenney received his medical degree from the University of South Florida College with higher recurrence rates. These agents of Medicine, Tampa, and completed a family medicine residency at the Naval include 0.75 percent metronidazole gel Hospital Jacksonville. He also completed a faculty development fellowship and a (MetroGel-Vaginal) and 2 percent clinda- master of public health degree at Emory University. mycin cream (Cleocin). Less effective alter- Address correspondence to Timothy L. Clenney, CDR, MC, USN, 1705 Broad natives include metronidazole in a single Water Ct., Orange Park, FL 32003 (e-mail: [email protected]). Reprints are not 2-g oral dose, oral clindamycin, and intra- available from the authors. vaginal clindamycin ovules. 2126 American Family Physician www.aafp.org/afp Volume 70, Number 11 � December 1, 2004 Vaginitis BACTERIAL VAGINOSIS IN PREGNANCY many physicians hesitate to use Because Gardnerella vagi- Bacterial vaginosis has been shown to be a oral metronidazole in women who nalis commonly is found risk factor for premature labor and perina- are in the first trimester of preg- in asymptomatic women, 17 tal infection. Although evidence supports nancy. However, one meta-analy- vaginal culture is not 25 treatment of high-risk pregnant women with sis showed no increased risk of useful for diagnosing bac- bacterial vaginosis5 (defined as women who birth defect in infants exposed to terial vaginosis. previously delivered a premature infant),7 metronidazole in utero. Vaginal the benefits