Vaginitis and Vagninosis

last authored: July 2010, Kim Colangelo
last reviewed:

 

 

Introduction

A change in vaginal discharge is a frequent presenting complaint. Normal (physiologic) discharge is clear or white and odourless. If smeared on a slide it will show epithelial cells that slough off on a continuous basis and lactobacilli that are part of the normal vaginal flora. The normal vaginal pH is 3.8-4.2. Physiologic discharge can increase at various reproductive stages, particularly those that increase estrogen such as pregnancy, oral contraceptive pill use, polycystic ovarian syndrome and premenarchal.



Vulvovaginitis can be stratified into prepubertal, reproductive, and postmenopausal ages as the most likely diagnosis varies with each age. Vaginosis is different from vaginitis in that there is no inflammatory reaction, however there is overlap in symptoms between the two conditions. 

 

The three most common causes of discharge of an infectious etiology are bacterial vaginosis, candidiasis, and trichomoniasis.

 

 

 

The Case of Ms. Lyons

A 30yo female presents to her family doctor's office with a 3 day history of a white vaginal discharge. Her main concern is that the discharge smells unpleasant. There is no pruritis, rash, or dysuria. She is otherwise healthy. Gynecological history reveals a past chlamydial infection for which she was treated. 

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Causes and Risk Factors

The main organisms of bacterial vaginosis include:

  • Gardnerella vaginalis
  • Mycoplasma hominis
  • Prevotella 
  • Mobiuncus 
  • Bacteroides 

The main risk factors for BV include:

  • sexual activity 
  • douching
  • cigarette smoking

There are three possible species for candidiasis:

 

Candidiasis risk factors:

  • Immunosuppressed host (HIV, Diabetes, steroid use, etc)
  • Recent antibiotic use
  • Pregnancy and other increased estrogen states
  • Diaper use or an otherwise prolonged moist environment

Trichomoniasis is caused by Trichomonas vaginalis, which is a flagellated protozoan.

 

Trichomonas is considered a sexually transmitted infection thus it can be passed between partners.

 

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Pathophysiology

clue cells

"Clue cells" suggesting bacterial vaginosis
used with permission, Per Grinsted

Hydrogen peroxide producing lactobacilli are normally the predominant organism in the vaginal flora. When these decline, the pH rises (become more alkaline) and anaerobes proliferate. The anaerobes produce enzymes that break down substances into amines that have a foul smell; this, combined with the normal cells of the vagina sloughing off more during bacterial vaginosis, results in the discharge that is characteristic.

 

If Gardnerella vaginalis is the causative organism it can cling to the epithelial cells sloughing off and create the "clue cells" that are part of the diagnostic criteria.

 

 

 

 

Candidiasis is a fungal infection. The source may be the perianal area that gains access to the vagina or it may normally be present in the woman and because of altered host factors (such as douching) become symptomatic.

 

Trichomonas is considered a sexually transmitted infection. Trichomonas has adherence factors that allow it to adhere to the cervicovaginal epithelium and passed between partners.

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Signs and Symptoms

 All three infectious causes may be asymptomatic but seen on cultures.

 Condition

Bacterial vaginosis

Candidiasis

Trichomoniasis

 Discharge

grey, thin, watery, foul smelling, copious

white, "cottage-cheese"

yellow-green, foul smelling, copious

Other symptoms

discharge is typically the only symptom

pruritis, dysuria, dyspareunia

pruritis, dysuria, dyspareunia, burning
tender vulva

 Physical Exam

copious discharge with no inflammatory reaction

satellite vulvar erythema

swollen, inflamed vulva

strawberry cervix

diffuse vulvar erythema

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Lab Investigations

Bacterial Vaginosis is diagnosed when at least 3 of the following 4 are present (Amsel criteria):

 A vaginal culture is not necessary for diagnosing BV or candidiasis; clinical signs and symptoms alone are sufficient.  If a swab is taken for the wet mount or pH it should be taken from high in the vaginal canal to avoid contamination with organisms of the skin. The swab can then be applied to a wet mount for the whiff amine test or to look for clue cells, or to litmus paper to check the pH.

 

Bacterial Vaginosis

Candidiasis

Trichomoniasis

KOH

fishy odour produced

cells remain intact but no odour is produced

can be odour producing

pH

greatly increased

normal

increased

wet mount

 

clue cells (epithelial cells covered with bacteria)

can see budding yeast and hyphae

oscillating protozoan

numerous WBC's and inflammatory cells

gram stain

 

switch from gram positive rods to gram negative rods or curved bacteria

gram positive yeast with buds

large, gram negative protozoan

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Differential Diagnosis

The differential includes:

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Treatments

Bacterial Vaginosis

 

Candidiasis

 

Trichomoniasis

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Consequences and Course

BV and trichomoniasis are associated with a higher risk of sexually transmitted infections such as HIV, HSV, gonorrhea, and chlamydia. They are also associated with a higher risk of preterm birth and other obstetric complications in affected pregnant women and postoperative vaginal cellulitis in women undergoing pelvic surgery. BV has a high recurrence rate, maintenance antimicrobial therapy has been investigated. The use of condoms or abstinence has been associated with lower recurrence rates.

Vaginal candidiasis is not associated with adverse pregnancy outcomes.

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Resources and References

Society of Obstetricians and Gynecologist of Canada. Clinical practice guidelines. Screening and management of Bacterial Vaginosis in pregnancy. 2008.

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Topic Development

authors: Kim Colangelo, 2010

reviewers:

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