Treatment of Vaginitis
For effective treatment of vaginitis, specific antimicrobial therapy should be targeted to the causative organism, with metronidazole 500 mg orally twice daily for 7 days as the first-line treatment for bacterial vaginosis, oral fluconazole 150 mg as a single dose for vulvovaginal candidiasis, and metronidazole for trichomoniasis. 1
Types of Vaginitis and Their Treatment
Bacterial Vaginosis (BV)
BV is the most common cause of vaginal discharge (40-50% of cases) and results from replacement of normal hydrogen peroxide-producing lactobacilli with anaerobic bacteria.
Diagnosis:
- Requires 3 of 4 Amsel criteria:
- Homogeneous white discharge coating vaginal walls
- Presence of clue cells on microscopy
- Vaginal pH > 4.5
- Positive whiff test (fishy odor with KOH) 2
Treatment Options:
- First-line: Metronidazole 500 mg orally twice daily for 7 days 2, 1
- Alternatives:
- Metronidazole 2 g orally in a single dose (less effective with 84% vs 95% cure rate) 2
- Clindamycin cream 2%, one applicator (5 g) intravaginally at bedtime for 7 days 2
- Metronidazole gel 0.75%, one applicator (5 g) intravaginally, twice daily for 5 days 2
- Clindamycin 300 mg orally twice daily for 7 days 2
- Tinidazole (FDA-approved for BV in adult women) 3
Important note: Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward due to potential disulfiram-like reaction 2, 1
Vulvovaginal Candidiasis (VVC)
Accounts for 20-25% of vaginitis cases, typically caused by Candida albicans.
Diagnosis:
- Symptoms: pruritus, vaginal discharge, soreness, burning, dyspareunia
- Normal vaginal pH (<4.5)
- Visualization of yeast/pseudohyphae on microscopy or positive culture 1, 4
Treatment Options:
Uncomplicated VVC:
- Oral fluconazole 150 mg as a single dose 1
- Topical azoles (various formulations available):
- 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
- Single-application options: clotrimazole 500 mg vaginal tablet or tioconazole 6.5% ointment 1
Recurrent VVC (≥4 episodes/year):
- Initial: 14-day course of topical azole or oral fluconazole
- Maintenance: fluconazole 150 mg weekly for 6 months 1
Non-albicans Candida:
- Boric acid 600 mg intravaginally daily for 14 days
- Nystatin intravaginal suppositories 100,000 units daily for 14 days 1
Trichomoniasis
Accounts for 15-20% of vaginitis cases, caused by Trichomonas vaginalis.
Diagnosis:
- Diffuse, malodorous, yellow-green discharge
- Vaginal pH > 5.4
- Motile trichomonads on saline microscopy
- Nucleic acid amplification testing recommended 1, 4
Treatment:
- Metronidazole or tinidazole orally
- Important: Sex partners should be treated simultaneously to prevent reinfection 1, 3
Non-infectious Vaginitis
Atrophic Vaginitis:
- Symptoms: vaginal dryness, itching, irritation, dyspareunia
- Treatment: topical or systemic estrogen therapy 5
- Moisturizing vaginal lubricants (e.g., Replens, K-Y) applied every 2-3 days 1
Allergic/Irritant Vaginitis:
- Treatment: Identify and remove irritant
- Topical 1% hydrocortisone cream applied to external vulva twice daily for 7-14 days 1
- Avoid potential irritants, wear cotton underwear, use mild fragrance-free cleansers 1
Special Considerations
Pregnancy
- Clindamycin vaginal cream is preferred for BV during first trimester
- Oral metronidazole can be used in second and third trimesters 2
- Topical azole medications preferred for VVC; avoid oral antifungals 1
Treatment Failure
- For persistent symptoms, reevaluation is necessary to confirm diagnosis
- Consider alternative diagnoses or non-infectious causes
- For recurrent BV, alternative treatment regimens may be used 2, 1
- Avoid repeated antifungal treatment without reassessment 1
Partner Treatment
- Not routinely recommended for BV unless recurrence is an issue
- Not necessary for VVC as it's not typically sexually transmitted
- Essential for trichomoniasis 1
Important Caveats
- Oil-based creams and suppositories may weaken latex condoms and diaphragms 1
- Asymptomatic colonization with Candida should not be treated 1
- Unnecessary use of OTC antifungal preparations can delay proper diagnosis 1
- Consider non-infectious causes like dermatologic conditions (lichen sclerosus, contact dermatitis) when symptoms persist despite treatment 1