Vaginitis and Vaginosis

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  • “Vaginosis” and “vaginitis” are broad terms indicating any disease process of the vagina caused by or leading to infection, inflammation, or changes in the normal vaginal flora.
  • The difference between vaginitis and vaginosis is the presence (vaginitis) or absence (vaginosis) of inflammation.
  • The most common symptoms of vaginitis/vaginosis are vaginal discharge, odor, itching, burning, or pain.
  • The most common causes of vaginitis/vaginosis are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis.
  • Other causes of vaginitis can be stratified by age and are generally associated with postmenopausal vaginal atrophy or foreign bodies in the pediatric population.
  • Lichen planus, lichen sclerosus, psoriasis, and contact/allergic dermatitis may also cause vaginitis.
  • Diagnosis of vaginitis relies on thorough history, physical exam, and clinical assessment. Microscopy, cultures, DNA probes, and tissue biopsy can be helpful in confirming diagnosis.
  • BV is the most common cause of vaginal discharge in reproductive-aged women. It is caused by a disturbance in the normal vaginal flora. The normally dominant hydrogen peroxide–producing lactobacilli are overwhelmed by an overgrowth of gram-negative species causing an increase in the vaginal pH, discharge, and odor.
  • VVC is the second most common cause of vaginitis in reproductive-aged women. It is caused by invasion of the Candida organism into the superficial epithelial cells of the vagina causing mild to severe vaginal inflammation, pruritus, and discharge.


  • Vaginal symptoms are typical and common in the general population and are one of the most frequent reasons women present to their medical care providers accounting for approximately 10 million office visits each year.
  • About 30% of women with complaint of vaginal discharge or irritation remain undiagnosed despite extensive testing.
  • In the United States, BV continues to be the leading cause of vaginal complaints. The frequency of VVC is highest among women in their reproductive years.
  • Neither vaginal candidiasis nor BV is considered to be sexually transmitted diseases.
  • Vaginal trichomoniasis is a common sexually transmitted disease with 7.4 million cases diagnosed yearly in the United States, and is the most common curable, nonviral sexually transmitted infection worldwide.

Etiology and Pathophysiology

  • BV
    • BV is caused by a change in the normal vaginal flora. Dominant lactobacilli responsible for maintaining the acidic vaginal pH are overcome by an increase of the gram-negative organisms.
    • Change in the vaginal environment leads to an increase in the pH and an overgrowth of vaginal anaerobes, causing a malodorous, clear, white, or gray discharge and a fishy odor.
    • BV is highly prevalent and associated with multiple adverse outcomes, including enhanced HIV transmission.
    • The organisms generally implicated in BV infections include:
      • Gardnerella vaginalis
      • Prevotella species
      • Porphyromonas species
      • Bacteroides species
      • Peptostreptococcus species
      • Mycoplasma hominis
      • Ureaplasma urealyticum
      • Mobiluncus species
      • Fusobacterium species
      • Atopobium vaginae
  • VVC
    • VVC is caused by Candida albicans (80–92%) and Candida glabrata (<10%).
    • Candida organisms can be identified in the lower genital tract in healthy women, and it is thought to gain access via rectal and perianal colonization and migration.
    • Symptoms occur when candidal organisms overwhelm the normal vaginal flora and invade the superficial vaginal epithelial cells, causing inflammation, pruritus, and thick vaginal discharge.
    • Complicated VVC should be considered in pregnant patients, patients with diabetes, or immunocompromising conditions. Patients who experience four or more episodes of VVC in a year or who have only budding yeast on wet mount may also be considered to have complicated VVC.
  • Trichomoniasis
    • Caused by an infection via Trichomonas vaginalis, a flagellate protozoan. The organism infects the squamous epithelium of the vagina as well as the urethra and paraurethral glands. This infection is primarily transmitted during sexual intercourse.
  • Desquamative inflammatory vaginitis (DIV)
    • A chronic, purulent vaginitis occurring most commonly in the perimenopause
    • Etiology and pathogenesis uncertain
    • Diagnosis of exclusion. Estrogen deficiency should be considered and addressed.
  • Other sources of vaginitis/vaginosis are usually mediated by disruption of the vaginal squamous epithelium. This disruption can lead to inflammation, pain, and discharge.
    • Other than the three most common causes of vaginitis/vaginosis, menses, sexual activity, contraception, pregnancy, foreign bodies, estrogen levels, STDs, and use of vaginal hygiene products, topical creams, or antibiotics can contribute to vaginal symptoms.

Risk Factors

  • BV
    • Sexual activity; although BV is not considered an STD, studies show increased rates of BV in women with multiple sex partners.
    • Women who have sex with women
    • Smoking
    • Vaginal douching
    • The presence of STDs such as HSV-2 (1)
  • VVC
    • Diabetes
    • Diet high in refined sugars
    • Use of broad-spectrum antibiotics
    • Immunosuppression
    • Higher estrogen levels have been associated with increased vaginal yeast infection, explaining why it is more commonly diagnosed in reproductive-aged women and in pregnancy.
  • Trichomoniasis
    • Inconsistent use of barrier contraception
    • Multiple sex partners
    • African Americans
    • Limited education and low socioeconomic status
    • Illicit drug use
    • Smoking
  • Other risk factors associated with vaginitis/vaginosis:
    • Decreased estrogen
    • Smoking
    • Use of vaginal douches and creams
    • Tight-fitting clothing
    • Poor hygienic practice
    • Changes in diet

General Prevention

  • Vulvar hygiene
  • Except in cases of trichomoniasis, treatment of sexual partners generally is not recommended but may be considered in recurrent cases.
  • Advise patients not to douche.

Commonly Associated Conditions

  • STDs such as gonorrhea, chlamydia, or HSV
  • Vaginal intraepithelial neoplasia and cancer can present with symptoms of vaginitis.
  • DIV presents with similar symptoms but most commonly occurs in postmenopausal women.

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