What is the evidence-based approach to diagnosing and treating vaginitis?

From the Guidelines

Diagnosing Vaginitis

The diagnosis of vaginitis is made by pH and microscopic examination of fresh samples of the discharge, as stated in the 1993 study by the Centers for Disease Control and Prevention 1. The pH of the vaginal secretions can be determined by narrow-range pH paper for the elevated pH (greater than 4.5) typical of bacterial vaginosis (BV) or trichomoniasis.

Laboratory Tests

Laboratory tests, such as wet mount, pH testing, and cultures, can be used to identify the underlying cause of vaginitis. A scored Gram stain for BV, wet mount for Trichomonas vaginalis (TV), and 10% KOH microscopic examinations for vulvovaginal candidiasis (VVC) can be performed from a vaginal discharge specimen 1.

Treatment

Treatment typically involves antimicrobial or antifungal medications, and in some cases, lifestyle modifications to reduce symptoms and prevent recurrence. The 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology provides guidance on the diagnosis and treatment of genital infections, including vaginitis 1.

Special Populations

Special populations, such as pregnant women and individuals with HIV, may require special consideration when diagnosing and treating vaginitis. The 2022 review of the evidence for the Centers for Disease Control and Prevention of sexually transmitted infections treatment guidelines provides guidance on the diagnosis and treatment of vulvovaginal candidiasis in these populations 1.

Potential Pitfalls

Potential pitfalls in diagnosing and treating vaginitis include:

• Inconsistent microscopic examination of vaginal specimens and interpretation
• Wide variation of sensitivities for TV and VVC using smear examination
• Resistance of pathogens to antimicrobials
• Disruption of the vaginal microbiome by certain medications, such as antibiotics

Decision Forks

Decision forks that may change management include:

• Identification of the underlying cause of vaginitis, such as BV, VVC, or TV
• Presence of underlying hematological conditions, such as anemia or immunodeficiency disorders
• Use of certain medications, such as antibiotics, that can disrupt the vaginal microbiome
• Pregnancy or HIV status, which may require special consideration when diagnosing and treating vaginitis

Some key points to consider when diagnosing and treating vaginitis include:

• The use of point-of-care tests, such as pH strip tests and scored Gram stains, can be helpful in diagnosing vaginitis, but may have variable sensitivity and specificity 1
• The presence of pseudohyphae and motile trichomonads can allow for a diagnosis of VVC and TV, respectively 1
• Proficiency in microscopic examination is essential for accurate diagnosis 1
• Recent publications utilizing nucleic acid amplification tests (NAATs) highlight the prevalence of Trichomonas as equal to or greater than Chlamydia and Gonorrhea in certain patient populations 1

From the Research

Diagnosing Vaginitis

The diagnosis of vaginitis involves a combination of physical examination, laboratory tests, and medical history. According to 2, the role of the microbiome in vaginitis and evidence-based approaches for diagnosis and treatment of vaginitis are crucial. The following points should be considered:

• The use of point-of-care tests, such as pH strip tests and scored Gram stains, can be helpful in diagnosing vaginitis, but may have variable sensitivity and specificity
• The presence of pseudohyphae and motile trichomonads can allow for a diagnosis of VVC and TV, respectively
• Proficiency in microscopic examination is essential for accurate diagnosis
• Recent publications utilizing nucleic acid amplification tests (NAATs) highlight the prevalence of Trichomonas as equal to or greater than Chlamydia and Gonorrhea in certain patient populations

Laboratory Tests

Laboratory tests, such as wet mount, pH testing, and cultures, can be used to identify the underlying cause of vaginitis. As stated in 3, a literature search within biomedical databases PubMed and SCieLo was conducted to develop algorithms for diagnosis and treatment of vaginitis. The following points should be considered:

• The combination of anamnesis, gynecological examination, and complementary tests remains the basis of a proper diagnostic and therapeutic approach
• Different age groups and specific contexts should be considered when developing algorithms for diagnosis and treatment of vaginitis
• Periodic updates of these algorithms are warranted as new evidence becomes available

Treatment

Treatment typically involves antimicrobial or antifungal medications, and in some cases, lifestyle modifications to reduce symptoms and prevent recurrence. According to 4, molecular diagnostic testing is widely used in clinical practice, although vaginitis experts have reservations about its use for vaginitis diagnosis. The following points should be considered:

• The use of molecular diagnostics can provide rapid, accurate, and more flexible diagnosis of vaginitis conditions
• The cost to the health system is a large concern when using molecular diagnostics
• The benefits of adopting newer molecular diagnostics into routine gynecologic practice should be weighed against the potential drawbacks

Special Populations

Special populations, such as pregnant women and individuals with HIV, may require special consideration when diagnosing and treating vaginitis. As stated in 5, the diagnosis and treatment of vaginitis in nonpregnant patients should be guided by evidence-based principles. The following points should be considered:

• The treatment of vaginitis in patients with human immunodeficiency virus (HIV) is covered elsewhere
• Guidelines are subject to change, and the most up-to-date information on vaginitis diagnosis and treatment should be consulted

Potential Pitfalls

Potential pitfalls in diagnosing and treating vaginitis include:

• Inconsistent microscopic examination of vaginal specimens and interpretation
• Wide variation of sensitivities for TV and VVC using smear examination
• Resistance of pathogens to antimicrobials
• Disruption of the vaginal microbiome by certain medications, such as antibiotics
• Underdiagnosis of aerobic vaginitis, as stated in 6

Decision Forks

Decision forks that may change management include:

• Identification of the underlying cause of vaginitis, such as BV, VVC, or TV
• Presence of underlying hematological conditions, such as anemia or immunodeficiency disorders
• Use of certain medications, such as antibiotics, that can disrupt the vaginal microbiome
• Pregnancy or HIV status, which may require special consideration when diagnosing and treating vaginitis
• The presence of desquamative inflammatory vaginitis (DIV), which is the most severe form of aerobic vaginitis, as stated in 6

Some key points to consider when diagnosing and treating vaginitis include:

• The use of point-of-care tests, such as pH strip tests and scored Gram stains, can be helpful in diagnosing vaginitis, but may have variable sensitivity and specificity
• The presence of pseudohyphae and motile trichomonads can allow for a diagnosis of VVC and TV, respectively
• Proficiency in microscopic examination is essential for accurate diagnosis
• Recent publications utilizing NAATs highlight the prevalence of Trichomonas as equal to or greater than Chlamydia and Gonorrhea in certain patient populations
• The ideal diagnostic approach and treatment for AV/DIV are yet to be established, as stated in 6