Description

• “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 causes of vaginitis and vaginosis are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis. Noninfectious causes (<10%) can include atrophic, irritant, allergic, and inflammatory vaginitis.
• Diagnosis of vaginitis relies on a thorough history, physical exam, and clinical assessment.
• Normal physiologic vaginal discharge is clear to white, not malodorous, and not associated with pain or pruritus, and the quantity varies during the menstrual cycle.

Epidemiology

• Vaginal symptoms are 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 (1).
• BV is the most common cause of vaginal discharge in reproductive-aged women (2).
• VVC is the second most common cause of vaginitis in reproductive-aged women (2).

Incidence
An estimated 7.4 million cases of BV occur yearly in the United States (1).

Prevalence

• Prevalence rates of BV are of 15% in pregnant women, 20–25% young females at student health clinics, and up to 30–40% among women seen at sexually transmitted infection (STI) clinics (1).
• Nonwhite women have higher rates of BV (African American 51%, Mexican Americans 32%) than white women (23%).
• 29–40% of all females report at least one episode of VVC.
• VVC is uncommon in prepubescent girls and postmenopausal women and is often overdiagnosed in these populations.
• Vaginal trichomoniasis is a common STI with 3 to 5 million cases diagnosed in the United States yearly (2).
• African American women are 10 times more commonly affected by vaginal trichomoniasis when compared to white and Hispanic women (2).
• Desquamative inflammatory vaginitis (DIV) is found in 2–20% of pregnant and nonpregnant women (1).

Etiology and Pathophysiology

• BV is caused by a change in the normal vaginal flora (2). Lactobacilli responsible for maintaining the acidic vaginal pH are overcome by facultative anaerobic organisms and lack of hydrogen peroxide producing lactobacilli (2).
  • Increase in the pH and a malodorous, clear, white, or gray discharge and a fishy odor
  • Organisms generally implicated in BV infections: Gardnerella vaginalis, Prevotella species, Porphyromonas species, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, Ureaplasma urealyticum, Mobiluncus species, Fusobacterium species, Atopobium vaginae
  • Not directly caused by sexual transmission
• VVC is caused by Candida species, particularly Candida albicans (80–92%) and Candida glabrata (<10%).
  • Candida 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.
  • Complicated VVC should be considered in pregnant patients and patients with diabetes or immunocompromising conditions. Those 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 is caused by an infection via Trichomonas vaginalis. The organism infects the squamous epithelium of the vagina as well as the urethra and paraurethral glands; primarily transmitted during intercourse
• DIV—a chronic, purulent vaginitis with an uncertain etiology or pathogenesis; inflammation is the cardinal feature. The vagina is colonized with facultative bacteria, not the obligate anaerobic bacteria that colonize the vagina in BV (1).
• Atrophic vaginitis—genitourinary symptoms resulting from a lack of estrogen
• Irritant/allergic vaginitis—vaginal symptoms can result from mechanical, chemical, or allergic irritation.

Risk Factors

• BV
  • Sexual activity; although not considered an STI
  • Women who have sex with women, smoking, vaginal douching, low socioeconomic status, the presence of STIs such as HSV-2, the use of an IUD
  • Male circumcision decreases risk.
• VVC—diabetes, recent use of antibiotics, immunosuppression, higher estrogen levels, estrogen-containing contraceptives
• Trichomoniasis—inconsistent use of barrier contraception, multiple sexual partners, limited education and low socioeconomic status, illicit drug use, smoking, coexistent STIs, douching, incarceration (2)
• Other risk factors associated with vaginitis and vaginosis: decreased estrogen; smoking; use of vaginal douches, creams, gels, or lubricants; tight-fitting clothing; poor hygienic practice; changes in diet; condoms, sex toys, tampons

General Prevention

• Vulvar hygiene with warm water and unscented cleanser; advise patients not to douche. Wear cotton underwear.
• Except in cases of trichomoniasis, treatment of sexual partners is not recommended but may be considered in recurrent cases.

Commonly Associated Conditions

• STIs (gonorrhea, chlamydia, HSV, or HIV)
• Vaginal intraepithelial neoplasia and cancer can present with symptoms of vaginitis.