Vaginitis: Diagnosis and Treatment

 

Am Fam Physician. 2018 Mar 1;97(5):321-329.

  Patient information: See related handout on vaginitis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Vaginitis is defined as any condition with symptoms of abnormal vaginal discharge, odor, irritation, itching, or burning. The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. Bacterial vaginosis is implicated in 40% to 50% of cases when a cause is identified, with vulvovaginal candidiasis accounting for 20% to 25% and trichomoniasis for 15% to 20% of cases. Noninfectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis, are less common and account for 5% to 10% of vaginitis cases. Diagnosis is made using a combination of symptoms, physical examination findings, and office-based or laboratory testing. Bacterial vaginosis is traditionally diagnosed with Amsel criteria, although Gram stain is the diagnostic standard. Newer laboratory tests that detect Gardnerella vaginalis DNA or vaginal fluid sialidase activity have similar sensitivity and specificity to Gram stain. Bacterial vaginosis is treated with oral metronidazole, intravaginal metronidazole, or intravaginal clindamycin. The diagnosis of vulvovaginal candidiasis is made using a combination of clinical signs and symptoms with potassium hydroxide microscopy; DNA probe testing is also available. Culture can be helpful for the diagnosis of complicated vulvovaginal candidiasis by identifying nonalbicans strains of Candida. Treatment of vulvovaginal candidiasis involves oral fluconazole or topical azoles, although only topical azoles are recommended during pregnancy. The Centers for Disease Control and Prevention recommends nucleic acid amplification testing for the diagnosis of trichomoniasis in symptomatic or high-risk women. Trichomoniasis is treated with oral metronidazole or tinidazole, and patients' sex partners should be treated as well. Treatment of noninfectious vaginitis should be directed at the underlying cause. Atrophic vaginitis is treated with hormonal and nonhormonal therapies. Inflammatory vaginitis may improve with topical clindamycin as well as steroid application.

Vaginitis is characterized by vaginal symptoms, including discharge, odor, itching, irritation, or burning.1 Most women have at least one episode of vaginitis during their lives,2 making it the most common gynecologic diagnosis in primary care. Studies have shown a negative effect on quality of life in women with vaginitis, with some women expressing anxiety, shame, and concerns about hygiene, particularly in those with recurrent symptoms.38

WHAT IS NEW ON THIS TOPIC

Vaginitis

A 2013 meta-analysis showed that oral or topical antibiotic treatment of bacterial vaginosis in pregnancy does not prevent preterm birth, even in women with a history of preterm labor in previous pregnancies.

Newer laboratory tests such as DNA and antigen testing for bacterial vaginosis and vulvovaginal candidiasis, or vaginal fluid sialidase testing for bacterial vaginosis, may have similar or better sensitivity and specificity compared with traditional office-based testing. However, comparative cost-effectiveness has not been studied.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Symptoms alone cannot differentiate between the causes of vaginitis. Office-based or laboratory testing should be used with the history and physical examination findings to make the diagnosis.

C

1012

Do not obtain culture for the diagnosis of bacterial vaginosis because it represents a polymicrobial infection.

C

9

Nucleic acid amplification testing is recommended for the diagnosis of trichomoniasis in symptomatic or high-risk women.

C

9

Treatment of bacterial vaginosis during pregnancy improves symptoms but does not reduce the risk of preterm birth.

A

44, 45

In nonpregnant women, oral and vaginal treatment options for uncomplicated vulvovaginal candidiasis have similar clinical cure rates.

B

47


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Symptoms alone cannot differentiate between the causes of vaginitis. Office-based or laboratory testing should be used with the history and physical examination findings to make the diagnosis.

C

1012

Do not obtain culture for the diagnosis of bacterial vaginosis because it represents a polymicrobial infection.

C

9

Nucleic acid amplification testing is recommended for the diagnosis of trichomoniasis in symptomatic or high-risk women.

C

9

Treatment of bacterial vaginosis during pregnancy improves symptoms but does not reduce the risk of preterm birth.

A

44, 45

In nonpregnant women, oral and vaginal treatment options for uncomplicated vulvovaginal candidiasis have

The Authors

show all author info

HEATHER L. PALADINE, MD, MEd, is an assistant professor of medicine in the Center for Family and Community Medicine and director of the Family Medicine Residency Program at Columbia University Irving Medical Center, New York, NY....

URMI A. DESAI, MD, MS, is an assistant professor of medicine in the Center for Family and Community Medicine at Columbia University Irving Medical Center.

Address correspondence to Heather L. Paladine, MD, MEd, Columbia University Irving Medical Center, 610 W. 158th St., New York, NY 10032 (e-mail: hlp222@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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