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Inflammation and infection of the vagina are common gynecologic problems, resulting from a variety of pathogens, allergic reactions to vaginal contraceptives or other products, or the friction of coitus The normal vaginal pH is 45 or less, and Lactobacillus is the predominant organism At the time of the midcycle estrogen surge, clear, elastic, mucoid secretions from the cervical os are often profuse In the luteal phase and during pregnancy, vaginal secretions are thicker, white, and sometimes adherent to the vaginal walls These normal secretions can be confused with vaginitis by concerned women
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The history and physical examination commonly suggest endometriosis or pelvic inflammatory disease (PID) Other causes may be submucous myoma, IUD use, cervical stenosis with obstruction, or blind uterine horn (rare)
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Laparoscopy is often needed to differentiate endometriosis from PID Submucous myomas can be detected most reliably by MRI but also by hysterogram, by hysteroscopy,
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When the patient complains of vaginal irritation, pain, or unusual discharge, a careful history should be taken, noting
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dysplasia and cervical cancer Vulvar cancer is also currently considered to be associated with HPV infection
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the onset of the LMP; recent sexual activity; use of contraceptives, tampons, or douches; and the presence of vaginal burning, pain, pruritus, or unusually profuse or malodorous discharge The physical examination should include careful inspection of the vulva and speculum examination of the vagina and cervix The cervix is sampled for gonococcus or Chlamydia if applicable A specimen of vaginal discharge is examined under the microscope in a drop of 09% saline solution to look for trichomonads or clue cells and in a drop of 10% potassium hydroxide to search for Candida The vaginal pH should be tested; it is frequently greater than 45 in infections due to trichomonads and bacterial vaginosis A bimanual examination to look for evidence of pelvic infection should follow
Treatment
A Vulvovaginal Candidiasis
A variety of regimens are available to treat vulvovaginal candidiasis Women with uncomplicated vulvovaginal candidiasis will usually respond to a 1- to 3-day regimen of a topical azole Women with complicated infection (including four or more episodes in 1 year, severe signs and symptoms, non-albicans species, uncontrolled diabetes, HIV infection, corticosteroid treatment, or pregnancy) should receive 7 14 days of a topical regimen or two doses of fluconazole 3 days apart (Pregnant women should use only topical azoles) 1 Single-dose regimens Miconazole, 200-mg vaginal suppository; tioconazole, 65%, 5 g; or sustained-release butoconazole, 2% cream, 5 g 2 Three-day regimens Butoconazole (2% cream, 5 g once daily), clotrimazole (two 100-mg vaginal tablets once daily), teraconazole (08% cream, 5 g, or 80-mg suppository once daily), or miconazole (200 mg vaginal suppository once daily) 3 Seven-day regimens The following regimens are given once daily: clotrimazole (1% cream or 100-mg vaginal tablet), miconazole (2% cream, 5 g, or 100-mg vaginal suppository), or teraconazole (04% cream, 5 g) 4 Fourteen-day regimen Nystatin (100,000-unit vaginal tablet once daily) 5 Recurrent vulvovaginitis (maintenance therapy) Clotrimazole (500-mg vaginal suppository once weekly or 200 mg cream twice weekly) or fluconazole (100, 150, or 200 mg orally once weekly) are effective regimens for maintenance therapy for up to 6 months
A Vulvovaginal Candidiasis
Pregnancy, diabetes, and use of broad-spectrum antibiotics or corticosteroids predispose patients to Candida infections Heat, moisture, and occlusive clothing also contribute to the risk Pruritus, vulvovaginal erythema, and a white curd-like discharge that is not malodorous are found Microscopic examination with 10% potassium hydroxide reveals filaments and spores Cultures with Nickerson s medium may be used if Candida is suspected but not demonstrated
B Trichomonas vaginalis Vaginitis
This protozoal flagellate infects the vagina, Skene s ducts, and lower urinary tract in women and the lower genitourinary tract in men It is sexually transmitted Pruritus and a malodorous frothy, yellow-green discharge occur, along with diffuse vaginal erythema and red macular lesions on the cervix in severe cases Motile organisms with flagella are seen by microscopic examination of a wet mount with saline solution
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