What is the treatment for vaginitis?

Treatment of Vaginitis Citolitica

For vaginitis, the most effective treatment depends on the specific cause, with metronidazole 500 mg orally twice daily for 7 days being the first-line treatment for bacterial vaginosis, which is the most common cause of vaginitis. 1, 2

Types of Vaginitis and Diagnosis

Vaginitis is characterized by vaginal discharge, vulvar itching, irritation, and sometimes odor. The three most common causes are:

• Bacterial vaginosis (BV): Accounts for 40-50% of vaginitis cases, caused by replacement of normal Lactobacillus flora with anaerobic bacteria, G. vaginalis, and M. hominis 1, 3
• Vulvovaginal candidiasis: Accounts for 20-25% of cases, usually caused by Candida albicans 1, 3
• Trichomoniasis: Accounts for 15-20% of cases, caused by T. vaginalis 3

Diagnostic Approach

Diagnosis requires:

• pH testing of vaginal secretions (pH > 4.5 suggests BV or trichomoniasis) 1
• Microscopic examination of discharge:
  • Saline wet mount: For clue cells (BV) or motile trichomonads 1, 4
  • 10% KOH preparation: For yeast or pseudohyphae (candidiasis) 1, 4
• Whiff test: Amine odor after adding KOH suggests BV 1

BV is diagnosed when 3 of 4 Amsel criteria are present:

1. Homogeneous white discharge
2. Clue cells on microscopy
3. Vaginal pH > 4.5
4. Positive whiff test 1, 5

Treatment Recommendations

For Bacterial Vaginosis

First-line treatment:

• Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 1, 5, 2

Alternative regimens:

• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 1, 5
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1, 5
• Metronidazole 2g orally in a single dose (84% cure rate) - useful when compliance is a concern 5

For Vulvovaginal Candidiasis

Recommended regimens:

• Fluconazole 150 mg oral tablet, single dose 1, 6
• Topical azoles (butoconazole, clotrimazole, miconazole) for 1-7 days depending on preparation 1, 3

For Trichomoniasis

• Metronidazole 2g orally in a single dose 7
• For resistant cases: Metronidazole 500 mg orally twice daily for 7 days 7, 3

Special Considerations

For Pregnant Women

• BV during pregnancy is associated with adverse pregnancy outcomes 1, 2
• High-risk pregnant women (history of preterm delivery) with BV should be treated to reduce risk of prematurity 1, 5
• For pregnant women, metronidazole is recommended for BV treatment 2
• For candidiasis during pregnancy, only topical azoles are recommended 2

Before Surgical Procedures

• Treatment of BV is recommended before surgical abortion procedures as it reduces post-abortion PID 1, 5
• Consider treatment before hysterectomy or other invasive gynecological procedures due to increased risk of postoperative infections 5

Management of Recurrent Vaginitis

• For recurrent BV: Consider maintenance therapy after initial treatment 8
• For recurrent vulvovaginal candidiasis: Extended treatment with fluconazole 9, 8
• For non-albicans Candida infections: Vaginal boric acid therapy is an effective option 8

Important Clinical Considerations

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 5
• Clindamycin cream is oil-based and might weaken latex condoms and diaphragms 5
• Treatment of male sex partners has not been shown to reduce recurrence rates of BV 1, 5
• If patients do not respond to initial treatment, reconsider the diagnosis and evaluate for other causes such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia 9