What are the symptoms of vaginitis and how can the associated pain be managed?

Symptoms of Vaginitis and Pain Management

Vaginitis symptoms include vaginal discharge, itching, burning, soreness, dyspareunia (painful intercourse), and external dysuria (pain during urination), with specific symptoms varying by the type of vaginitis. 1, 2

Common Types of Vaginitis and Their Specific Symptoms

Bacterial Vaginosis (BV)

• Homogeneous, white discharge adhering to vaginal walls
• Fishy or musty vaginal odor, especially after intercourse
• Positive "whiff test" (fishy odor when KOH is added to discharge)
• Vaginal pH > 4.5
• Presence of clue cells on microscopy
• Usually minimal itching or irritation 1, 3

Vulvovaginal Candidiasis (VVC)

• Intense vulvovaginal itching (pruritus)
• White, thick discharge resembling cottage cheese
• Vaginal soreness and vulvar burning
• Painful intercourse (dyspareunia)
• External dysuria (pain during urination)
• Normal vaginal pH (≤4.5)
• Erythema (redness) in the vulvovaginal area 2, 3

Trichomoniasis

• Diffuse, malodorous, yellow-green discharge
• Vulvar irritation
• Some women may have minimal or no symptoms
• Vaginal pH > 5.4
• Positive whiff test 2, 4

Pain Management for Vaginitis

Treatment Based on Cause

For Bacterial Vaginosis:

• First-line treatments:

  • Metronidazole 500 mg orally twice daily for 7 days (95% cure rate)
  • Metronidazole gel 0.75% intravaginally once daily for 5 days
  • Clindamycin cream 2% intravaginally at bedtime for 7 days 1

• Alternative treatment:

  • Metronidazole 2g orally in a single dose (84% cure rate) 1

For Vulvovaginal Candidiasis:

• Topical treatments:

  • Butoconazole 2% cream 5g intravaginally for 3 days
  • Clotrimazole 1% cream 5g intravaginally for 7-14 days
  • Miconazole 2% cream 5g intravaginally for 7 days
  • Terconazole 0.4% cream 5g intravaginally for 7 days 2

• Oral treatment:

  • Fluconazole 150 mg oral tablet, single dose 2, 5
  • For severe or recurrent cases, longer duration therapy may be needed 2

For Trichomoniasis:

• Metronidazole 500 mg twice daily for 7 days (preferred regimen)
• Both patient and sexual partners should be treated
• Avoid sexual intercourse until both partners are cured 2, 6

Symptomatic Relief Measures

• For itching and irritation:

  • Cool compresses to the vulvar area
  • Sitz baths with plain warm water
  • Avoiding scented products, douches, and tight clothing
  • Wearing cotton underwear and loose-fitting clothes 3, 4

• For pain and discomfort:

  • Over-the-counter pain relievers like acetaminophen or ibuprofen
  • Avoiding sexual intercourse until symptoms resolve 7

Special Considerations

Pregnancy

• Pregnant women with BV should receive treatment and follow-up evaluation one month after completion of treatment 2, 1
• For VVC during pregnancy, only topical azole therapies are recommended for 7 days 2
• Metronidazole is contraindicated in the first trimester of pregnancy for trichomoniasis 2

Recurrent Infections

• For recurrent BV, extended treatment with first-line agents is recommended
• For recurrent VVC, maintenance antifungal regimens for 6 months may be needed 2, 6

HIV Infection

• Patients with vaginitis and HIV should receive the same treatment regimens as those without HIV 2, 1

Common Pitfalls to Avoid

• Self-diagnosis and self-medication without proper evaluation
• Using OTC preparations for self-diagnosed VVC when symptoms persist beyond 7 days or recur within 2 months 2
• Douching, which increases the risk of BV 1
• Testing too soon after treatment completion (less than 3-4 weeks) 1
• Ignoring the high recurrence rate (50-80% within one year for BV) 1
• Overlooking non-infectious causes of vaginitis such as atrophic, irritant, allergic, or inflammatory vaginitis 3, 4

By identifying the specific type of vaginitis and following appropriate treatment protocols, most women can expect relief from symptoms and improved quality of life.