Vaginitis: Symptoms and Treatment
Diagnostic Approach
Accurate diagnosis requires assessment of vaginal pH, microscopic examination of vaginal discharge, and specific pathogen testing before initiating treatment. 1
Key Diagnostic Features by Type:
Bacterial Vaginosis (BV):
- Homogeneous white discharge adhering to vaginal walls 2
- Vaginal pH >4.5 2, 1
- Positive whiff test (fishy odor with KOH) 2
- Clue cells on microscopy 2, 1
- Requires 3 of 4 Amsel criteria for diagnosis 1
Vulvovaginal Candidiasis (VVC):
- Normal vaginal pH (4.0-4.5) 3, 4
- Yeast or pseudohyphae visible on KOH preparation 1, 3
- Vulvar inflammation with vaginal discharge 4
- Culture indicated for recurrent or persistent cases to identify non-albicans species 5
Trichomoniasis:
- Vaginal pH >5.4 4
- Motile trichomonads on saline wet mount 1
- More leukocytes than epithelial cells 4
- Positive whiff test 4
- Nucleic acid amplification testing is most sensitive 1, 6
Treatment Regimens
Bacterial Vaginosis
First-line treatment is oral metronidazole 500 mg twice daily for 7 days, which achieves 95% cure rates. 2, 1, 5
Alternative regimens include: 2, 1
- Metronidazole gel 0.75%, one applicator (5g) intravaginally once daily for 5 days 5
- Clindamycin cream 2%, one applicator (5g) intravaginally at bedtime for 7 days 2, 5
- Metronidazole 2g orally as single dose (84% cure rate, lower than 7-day regimen) 2, 5
Critical caveat: Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reaction. 2, 1, 5
Partner management: Treatment of male sex partners is NOT recommended as it does not prevent recurrence. 2, 1
Vulvovaginal Candidiasis
For uncomplicated VVC, treat with oral fluconazole 150 mg as a single dose, achieving 80-90% cure rates. 1, 5
Alternative topical azoles (all equally effective): 1, 5
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 5
- Miconazole 2% cream 5g intravaginally for 7 days 1, 5
- Terconazole 0.4% cream 5g intravaginally for 7 days 1, 5
- Butoconazole 2% cream 1
For complicated VVC: Use 7-14 day regimens; consider maintenance therapy with weekly oral fluconazole for up to 6 months. 1
Important warning: Oil-based creams and suppositories weaken latex condoms and diaphragms. 5
Trichomoniasis
Treat with metronidazole 2g orally as single dose OR metronidazole 500 mg twice daily for 7 days, achieving up to 88% cure rates. 1, 7
Alternative: Tinidazole (any nitroimidazole) is equally effective. 7, 4
Partner management: Sex partners MUST be treated simultaneously to prevent reinfection. 1, 7
Special Populations
Pregnancy
For VVC in pregnancy, ONLY topical azoles are recommended for 7-day regimens (more effective than shorter courses): 1, 3
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
- Miconazole 2% cream 5g intravaginally for 7 days 3
- Terconazole 0.4% cream 5g intravaginally for 7 days 3
Oral fluconazole is contraindicated in pregnancy. 3
For BV in pregnancy: Treatment may reduce preterm birth risk, especially in high-risk women. 1
Critical Pitfalls to Avoid
Do not treat asymptomatic colonization: 10-20% of women normally harbor Candida without requiring treatment. 1, 3
Complete the full treatment course: Premature discontinuation leads to treatment failure even if symptoms improve. 1
Avoid self-medication without prior diagnosis: Over-the-counter preparations should only be used by women previously diagnosed with VVC who experience identical recurrent symptoms. 1
Seek medical care if: Symptoms persist after OTC treatment or recur within 2 months. 1
Consider sequential treatment: When BV and VVC occur concurrently, sequential rather than simultaneous treatment allows better evaluation of response, as antibacterial therapy for BV may trigger yeast infections. 5
Culture for persistent/recurrent VVC: Non-albicans Candida species may require different treatment approaches. 5
Follow-up only if symptomatic: Routine follow-up visits are unnecessary if symptoms resolve. 2, 5