Vaginitis

Pathophysiology

Aerobic and anaerobic bacteria can be cultured from the vagina of prepubertal girls, pubertal adolescents, and adult women. The overgrowth of normally present bacteria, infecting bacteria, or viruses can cause symptoms of vaginitis. Chemical irritation also can be a significant factor. Atrophic vaginitis is associated with hypoestrogenism, and symptoms include dyspareunia, dryness, pruritus, and abnormal bleeding.

Frequency

United States

Vaginitis is common in adult women and uncommon in prepubertal girls. Vaginitis is one of the most common reasons for gynecologic consultation consisting of approximately 10 million office visits annually. Bacterial vaginosis accounts for 40-50% of vaginitis cases; candidiasis, 20-25%; and trichomoniasis, 15-20%.

Mortality/Morbidity

The presence of abnormal discharge, vulvovaginal discomfort, or both is required for the diagnosis of vaginitis.

Age

The age of the patient affects the anatomy and physiology of the vagina.

• Prepubertal children have a more alkaline vaginal pH than pubertal and postpubertal adolescents and women. The vaginal mucosa is columnar epithelium, vaginal mucous glands are absent, normal vaginal flora is similar to that of postmenopausal women (eg, gram-positive cocci and anaerobic gram-negatives are more common), and labia are thin with a thin hymen.
• Pubertal and postpubertal adolescents and women have a more acidic vaginal pH, stratified squamous vaginal mucosa, vaginal mucous glands, normal vaginal flora of lactobacilli, thick labia, and hypertrophied hymens and vaginal walls. Loss of vaginal lactobacilli appears to be the primary factor in the changes leading to bacterial vaginosis. Recurrences of vaginitis are associated with a failure to establish a healthy vaginal microflora dominated by lactobacilli.

Clinical

History

Adults and children must be questioned regarding specific aspects of the symptoms of vaginitis. Vaginal bleeding in prepubertal females is always abnormal and merits full investigation. Essential information to obtain during the history is the onset of symptoms, previous occurrence, associated abdominal pain, trauma, and urinary or bowel symptoms.

• The most common etiologies in adults resulting in symptoms of vaginitis include Candida albicans, Trichomonas vaginalis, and bacterial vaginosis. Elicit symptoms with attention to these possible causes.
  • Candidiasis is a fungal infection common in women of childbearing age that results in pruritus, with a thick, white vaginal discharge. Patients often have a history of recurrent yeast infections or recent antibiotic treatment. Symptoms of candidiasis often begin just before menses. Precipitating factors include immunosuppression, diabetes mellitus, pregnancy, and hormone replacement therapy. Candidiasis is usually not contracted from a sexual partner. Seventy-five percent of all women have one episode of candidiasis in their lifetime. Recurrent episodes may indicate underlying immunodeficiency or diabetes.
  • Trichomoniasis is associated with risk factors for other sexually transmitted diseases (STDs); elicit a history of multiple sexual partners. The discharge is usually copious and frothy, resulting in local pain and irritation. Pruritus might be present. Symptoms often peak just after menses. Trichomonas vaginalis is the most common nonviral STD in the world. Infection during pregnancy has been associated with preterm deliveries and low birth weight infants.
  • Bacterial vaginosis is asymptomatic in up to 50% of women. If a discharge is present, it is typically a homogeneous grayish white or yellowish white. Bacterial vaginosis is common in pregnant women and is associated with preterm birth. Treating pregnant women that have a history of preterm birth with symptomatic bacterial vaginosis early in pregnancy has been shown to decrease the incidence of preterm birth.
  • In women with chronic vaginitis, atrophic vaginitis and hypoestrogenism must be considered. Elicit an accurate menstrual history.
• Vulvovaginitis has multiple nonvenereal causes in prepubertal children; however, if a vaginal discharge suggests an STD, question all children (and/or their caretakers) regarding possible sexual abuse. Symptoms of vulvovaginitis in prepubertal girls generally include localized pain, dysuria, pruritus, erythema, and discharge.
  • Bacteria that can cause vulvovaginitis include streptococcal species (including group A streptococci), Escherichia coli, and Shigella sonnei. Symptoms (eg, pharyngitis, diarrhea) may result from infections in areas of the body other than the vagina. A Shigella infection may result in a bloody vaginal discharge without symptoms of diarrhea. A patient with group A streptococcal infection may present with itching or painful defecation. Purulent discharge may develop insidiously.
  • Viral infections may cause symptoms of vulvovaginitis. Elicit a history of recent viral infections, including varicella. Herpes simplex viruses (HSVs), particularly HSV-1 transmitted via autoinoculation from the oral mucosa, might be present; elicit a history of recurrent oral herpes or digital herpes in the caretaker of a child in diapers.
  • Consider helminthic infections (eg, Enterobius vermicularis infections) resulting in pruritus of the genital area. Ask about contact with pinworm-infected children, itching (particularly at night), and vaginal pain.
  • Ask questions to exclude the possibility of a foreign body in the vagina, chemical irritation (eg, recent bubble baths, washing hair with shampoo while bathing, douching, feminine hygiene sprays), latex, semen, mechanical irritation, and poor hygiene. Foreign bodies in the vagina result in a persistent, foul-smelling, serosanguineous discharge. Contact dermatitis from unusual exposures may occur; ask about this possibility and about bathing patterns.
  • Obtain a history of recent trauma to the vaginal area and a history of urination and defecation patterns and problems to exclude possible anatomic abnormalities (eg, rectovaginal fistula).
  • Lichen sclerosis et atrophicus may be seen in prepubertal children and in postmenopausal women. Symptoms of chronic fissures, pain, or pruritus are often present. Rectal fissures may lead to chronic constipation in children.
  • If candidal vulvovaginitis is considered (rare in healthy prepubertal girls), the history should include recent antibiotic use, possible diabetes mellitus, immunosuppression, and underlying skin disease. Ask about a family history of mucocutaneous candidiasis.
  • Trichomoniasis is rare in prepubertal children. Sexual abuse should be suspected if symptoms are present. Symptoms include a copious frothy discharge, local pain, irritation, and, occasionally, pruritus.

Physical

The physical examination of pubertal and adult women should include a complete pelvic examination. The Tanner stage of development should be noted. The examination for prepubertal girls should be performed as described in Pediatrics, Child Sexual Abuse.

• Infectious causes of vaginitis may have the following specific physical findings:
  • Candidiasis may present with a well-demarcated erythema of the vulva with satellite lesions surrounding the redness. The vulva, vagina, and surrounding areas may be edematous and erythematous, possibly accompanied by excoriations and fissures. A clumpy adherent discharge may be seen.
  • Physical findings for trichomoniasis include a copious frothy discharge (white to greenish-yellow) and a raised punctate erythema of the cervix and upper portion of the vagina (strawberry cervix).
  • Physical findings in bacterial vaginosis include a homogeneous grayish white to yellowish white vaginal discharge. Typically, no underlying erythema exists. Bacterial vaginosis can be diagnosed if 3 of the 4 Amsel criteria are present: increased vaginal pH (>4.5), grayish white homogenous discharge, an amine smell with or without potassium hydroxide, and clue cells.
  • Physical findings associated with cervicitis from STDs include excessive vaginal discharge, erythema, and edema of the cervix.
  • Cervical ectopy or eversion may cause discharge with no apparent infectious etiology.
  • Physical findings associated with atrophy, dysplasia, and vulvar vestibulitis syndrome include localized atrophy or infection in skin and mucous membranes.
  • Vaginal foreign bodies in adults include forgotten tampons; in children, pieces of toilet tissue typically are found. Findings of foul odor and irritation with a purulent discharge are common.
  • A patient with pinworms may present with few physical findings. Occasionally, there may be erythema and excoriations around the perianal area. In severe cases, eggs and/or dead female nematodes may be seen on examination of the anal area.
  • Perianal streptococcal dermatitis usually results in a beefy red perineal area that is edematous and tender. Fissures, drainage, and hemorrhagic spotting may be present.

Causes

• Causes of vulvovaginitis vary depending on the following:
  • Age
  • Sexual activity (or abuse)
  • Hormonal status
  • Hygiene
  • Immunologic status
  • Anatomy of the genital area
  • Underlying skin diseases