Vaginitis is a general term referring to inflammation of the vagina which may manifest as pain, vulvar burning or itching, vaginal discharge, dysparunia, or dysuria.  There are various underlying etiologies which may be responsible for each individual case to include estrogen deficiency (atrophic vaginitis), fungal infection (candidiasis), protozoon infection (trichomonas), a synergistic bacterial infection (bacterial vaginosis), contact dermatitis, or an allergic reaction/ chemical irritation (deodorant soaps, laundry detergent, vaginal contraceptives, bath oils, perfumed or dyed toilet paper, hot tub/ swimming pool chemicals, or synthetic clothing).

     The work up should include physical examination of the vagina along with collection of vaginal specimens for wet mount examination using both normal saline and 10% KOH.  The KOH slide may also be used to perform the “whiff test” which is positive when an amine or fishy odor is present upon addition of the KOH.  A positive whiff test is indicative of underlying bacterial vaginosis.  The KOH and normal saline slides should then be viewed using light microscopy.  The finding of fungal hyphae on the KOH prep is diagnostic of fungal vaginitis; whereas, the normal saline prep should be examined for the presence of either clue cells or motile trichomonads which are diagnostic of bacterial vaginosis or trichomoniasis, respectively.  The vaginal sample should also be used to determine the pH of the vagina.  The normal vaginal pH is between 3.8 and 4.2.  Yeast infections do not change the vaginal pH; however, medical conditions associated with a lowered pH (diabetes mellitus, HIV, and pregnancy) display an increased incidence of candidal vaginitis.  Marked elevations in the vaginal pH should raise concern for underlying trichomoniasis or bacterial vaginosis.  The pH of a sample of vaginal secretion can be determined using pH paper.  The FemExam pH and Amines TestCard is an office based test which can be used to determine both the pH and amine concentration of a single vaginal secretion sample.

     Yeast vaginitis is most commonly the result of infection from Candida albicans; however, Candida glabrata and Candida tropicalis may also be the cause.  Predisposing factors for yeast vaginitis include pregnancy, oral contraceptive use, oral corticosteroid therapy, hyperglycemia, and recent antibiotic use.  Patients with recurrent infections should also undergo evaluation for diabetes mellitus and HIV.  Patients often complain of vaginal pruritis, vulvar burning, and a thick white curdish vaginal discharge without associated malodor.  Sexual intercourse and urination may exacerbate symptoms.  The diagnosis is established clinically and may be confirmed by the findings of a vaginal pH of less than 4.5 and the presence of fungal hyphae on examination of the KOH slide.  However, when the proper symptoms are present, the vaginal pH is less than 4.5, and there are no clue cells or trichomonads present on saline wet mount examination, the diagnosis of yeast vaginitis should still be strongly considered and an empiric trial of therapy instituted despite a lack of hyphae on KOH wet mount examination.  Therapy may be offered with oral fluconazole (150 mg PO x 1 dose), oral itraconazole (200 mg PO BID x 1to 3 days therapy), oral ketoconazole (400 mg PO BID x 5 days), or with multiple topical vaginal therapies in either pill (Clotrimazole), suppository (Miconazole, Terconazole or Boric acid No. 0), or cream/ ointment (Tioconazole 6.5%, Butoconazole 2%, Terconazole 0.4% and 0.8%, or Miconazole 2%).

     When symptoms of candidal vaginitis are recurrent and refractory to therapy, an alternate etiology of vaginitis should be considered; although, a fungal etiology may still be the cause.  To confirm the diagnosis, vaginal culture using Sabouraud dextrose agar may yield a fungal etiology.  Polymerase chain reaction (PCR) may also be used to detect Candida species in vaginal specimens.  Therapy includes acute treatment for candidiasis followed by suppressive therapy (ketoconazole 200 mg ˝ tablet PO QD) for six months duration.  Other recommendations include restricting the use of tight fitting garments or nylons, discontinuing oral contraceptive therapy, and ingesting 8 ounces of yogurt containing Lactobacillus acidophilus cultures.  The male sexual partner should be examined for the presence of balanitis, and if present, topical antifungal therapy should be initiated.  Recurrent yeast vaginitis may also be the result of a vaginal allergic response to semen components, contraceptive spermicides, vaginal douches, or medications.  When the male sexual partner has a genital tract allergic response, IgE antibodies may be transmitted to the female during intercourse and induce an allergy-related candidal vaginitis.  Use of antihistamine therapy prior to sexual intercourse may prove helpful in allergy related recurrent yeast vaginitis.

     Bacterial vaginosis (BV) is the result of a polymicrobial infection with an overgrowth of anaerobic bacteria.  It is the most common cause of vaginitis.  It is not a sexually transmitted disease and may be found in virgins and lesbian couples.  Complications of infection may include pelvic inflammatory disease, post operative infection following hysterectomy, preterm births, chorioamnionitis, premature rupture of membranes, postpartum endometritis, and low birth weight.  Symptoms of infection include vaginal discharge and a foul odor.  Vaginal specimens will demonstrate an elevated pH, a positive whiff test when 10% KOH is added, and the presence of clue cells on normal saline wet mount examination.  The FemExam test may be used to determine the pH and detect the presence of volatile amines in a single vaginal secretion sample.  Therapy includes metronidazole, either orally (500 mg BID or 250 mg TID x 7 days or a single 2 gram dose) or intravaginally (0.75% gel qHS to BID x 5 days), or clindamycin in either oral (clindamycin HCl 300 mg PO BIDx 7 days) or topical (clindamycin phosphate cream 2% BID for 5 days or QHS for 7 days) form.

     Trichomonas vaginitis is a sexually transmitted, protozoan infection.  Symptoms include a voluminous watery vaginal discharge that may or may not be associated with a foul odor.  Physical examination may reveal a “strawberry cervix” (punctate hemorrhages and ulcerations).  The diagnosis may be established by finding an elevated vaginal pH and motile trichomonads on normal saline wet mount examination.  Metronidazole (a single 2 gram dose vs 375 mg or 500 mg PO BID x 7 days) is the only recommended therapy.  Sexual partners should also receive treatment.