Vaginitis

Vaginitis



Anita Shivadas



DEFINITION AND ETIOLOGY


Vaginitis is a term that is applied to vulvovaginal symptoms of varying causes. Symptoms of vaginitis are common and account for about 10 million office visits a year. However, the symptoms are nonspecific and multifactorial. Infection is the most common cause; some of the other causes are listed in Box 1. Careful history taking combined with physical examination and simple microscopic analysis can help ascertain a diagnosis and tailor a treatment. This can help avoid misdiagnosis and treatment failure as well as symptom recurrence.



Box 1 Causes of Vaginitis



Infectious Vaginitis



Common Causes



Bacterial vaginosis (40%-50% of cases)

Vulvovaginal candidiasis (20%-25% of cases)

Trichomoniasis (15%-20% of cases)


Less-Common Causes



Atrophic vaginitis with secondary bacterial infection

Foreign body with secondary infection

Desquamative inflammatory vaginitis (clindamycin responsive)

Streptococcal vaginitis (group A)

Ulcerative vaginitis associated with Staphylococcus aureus and toxic shock syndrome

Idiopathic vulvovaginal ulceration associated with HIV infection


Noninfectious Vaginitis



Chemical or other irritant

Allergic, hypersensitivity, and contact dermatitis (lichen simplex)

Traumatic vaginitis

Atrophic vaginitis

Postpuerperal atrophic vaginitis

Desquamative inflammatory vaginitis (steroid responsive)

Erosive lichen planus

Collagen vascular disease, Behçet’s syndrome, pemphigus syndromes

Idiopathic vaginitis


EPIDEMIOLOGY


The exact incidence of vaginitis is unknown, but it is estimated that most women experience at least one episode in their lifetime. The associated distress and discomfort often lead women to self-diagnose vaginitis and use over-the-counter preparations improperly. The three most common causes of vaginitis include bacterial vaginosis, candidal vulvovaginitis, and trichomonas vaginitis.



SYMPTOMS AND SIGNS



Clinical Signs and Symptoms


Symptoms of vaginitis include vaginal discharge, irritation, pruritus, odor, and, occasionally, dyspareunia, vaginal bleeding, and dysuria. Symptoms tend to be nonspecific and overlap among the different etiologic factors. Some historical clues can help suggest a diagnosis.


Bacterial vaginosis manifests with a scant, homogenous, sometimes malodorous discharge with limited symptoms of inflammation, such as pruritus and soreness. Women often admit to a recent change in sex partner. Bacterial vaginosis is also associated with vaginal douching.


Candida classically manifests with a scant, curdy, white discharge associated with marked pruritus and soreness. Medications that can be associated with vulvovaginal candidiasis include systemic antibiotics, oral contraceptive pills (especially those containing higher estrogen levels), oral steroids, and other immunosuppressive agents. Diabetes can cause sporadic as well as recurrent vulvovaginal candidiasis.


Trichomonas vaginitis manifests with frothy green discharge and inflammatory signs. The patient might give a history of a recent change in sex partner.


Atrophic vaginitis occurs in postmenopausal women and manifests with vaginal dryness, dyspareunia, and dysuria.



Physical Examination


Physical examination should mainly be used to evaluate for the presence of cervical inflammation (suggesting an alternative etiology) and to exclude the clinical presence of pelvic inflammatory disease.


On physical examination, the vaginal discharge is thick, white, and adherent in candidiasis; thin and fishy-smelling in bacterial vaginosis, and greenish-yellow and purulent in trichomoniasis. Candidiasis and trichomoniasis (but not bacterial vaginosis) are also associated with vulvar and vaginal erythema. Atrophic vaginitis is associated with scant, thin vaginal discharge and atrophic changes, such as thinning and loss of rugae in the vaginal mucosa.


Cervical inflammation suggests cervicitis contributing to vaginal discharge. Cervical motion tenderness suggests pelvic inflammatory disease.


Vaginal pH should be obtained at the time of the physical examination and is probably the most important diagnostic clue.



DIAGNOSIS


Due to the nonspecific nature of the symptoms and physical examination findings, the diagnosis of vaginitis is mainly made by using a combination of vaginal pH, amine test, microscopy findings, and, sometimes, vaginal cultures. Table 1 provides a summary of the differential diagnosis of vaginal discharge.



Table 1 Differential Diagnosis of Vaginitis

image


Vaginal pH


Vaginal pH is obtained by placing a drop of the vaginal discharge on a pH strip. It must be remembered that the pH can be altered by vaginal lubricants as well as other factors such as blood or urine. Vulvovaginal candidiasis is associated with a normal vaginal pH between 4.0 and 4.5. A vaginal pH greater than 4.5 suggests infections such as bacterial vaginosis and trichomonal vaginitis.



Amine Test


The amine or whiff test is done by placing a drop of the vaginal discharge on a slide and adding a drop of 10% KOH. A fishy amine odor indicates bacterial vaginosis. The odor is caused by volatilization of amines, a by-product of anaerobic metabolism. The amine test is occasionally positive with trichomoniasis.



Microscopy


Microscopy should be performed using saline and 10% KOH mounts. Figure 1 provides an illustration of various saline microscopic findings.


image

Figure 1 Microscopic examination of vaginal samples.


A, Normal saline wet mount showing a clump of three normal vaginal epithelial cells (original magnification ×600). B, Normal saline wet mount showing two clue cells (original magnification ×400). Inset, Gram stain demonstrating how coccobaccilli on the surfaces of vaginal epithelial cells create the characteristic granular appearance and indistinct borders of clue cells (original magnification ×1000). C, Normal saline wet mount showing numerous Candida hyphae (arrows) and buds (original magnification ×400). D, Normal saline wet mount showing four trichomonads. Trichomonads can often be identified easily because of their characteristic jerky motility (original magnification ×600).


(A reproduced with permission from William L. Thelmo, MD. B and C reproduced with permission from Lorna Rabe, Magee-Women’s Research Institute, Pittsburgh, Pa. D reproduced with permission from the Medical Laboratory Evaluation proficiency testing program of the American College of Physicians Services, Inc. From Anderson MR, Klink K, Cohrssen A: Evaluation of vaginal complaints. JAMA 2004;291:1368–1379.)



Saline Mount


Cells that can be seen in the saline mount include vaginal epithelial cells, rods and cocci, polymorphonuclear cells (PMNs), clue cells, motile trichomonads, and candidal hyphae. Normal vaginal epithelial cells are squamous. Parabasal cells appear in postmenopausal women and are associated with atrophic vaginitis.


Rods are the predominant microorganisms in normal vaginal discharge and with candidiasis. Loss of rods and increased coccobacilli occur with bacterial vaginosis and atrophic vaginitis.


Abundant PMNs are seen with the purulent discharge associated with trichomoniasis. Motile trichomonads, which are slightly larger than PMNs, are only seen in 60% to 70% of culture-confirmed cases of trichomoniasis.


Clue cells are the single most reliable predictor of bacterial vaginosis. These are epithelial cells studded with adherent coccobacilli and represent between 5% and 50% of the epithelial cells seen in bacterial vaginosis.

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Jul 18, 2017 | Posted by in GENERAL SURGERY | Comments Off on Vaginitis

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