Management of Vaginitis
Vaginitis management requires accurate diagnosis through pH testing and microscopic examination, followed by targeted antimicrobial therapy based on the specific pathogen identified: metronidazole for bacterial vaginosis and trichomoniasis, azole antifungals or fluconazole for candidiasis. 1
Diagnostic Approach
The diagnosis of vaginitis relies on a systematic evaluation combining clinical presentation with office-based testing 1:
Measure vaginal pH using narrow-range pH paper; pH >4.5 suggests bacterial vaginosis or trichomoniasis, while pH ≤4.5 is typical of candidiasis or physiologic discharge 2, 1
Perform wet mount microscopy by diluting vaginal discharge in 1-2 drops of 0.9% normal saline on one slide and 10% potassium hydroxide (KOH) on a second slide 2
Apply the whiff test by adding KOH to the discharge; an immediate amine (fishy) odor indicates bacterial vaginosis or trichomoniasis 2, 1
Examine saline preparation under microscopy to identify motile trichomonads or clue cells characteristic of bacterial vaginosis 2, 1
Examine KOH preparation under microscopy to identify yeast or pseudohyphae of Candida species 2, 1
Important caveat: Microscopy has limited sensitivity for trichomoniasis and candidiasis; culture or nucleic acid amplification testing should be considered when clinical suspicion remains high despite negative microscopy 3, 4
Treatment by Specific Etiology
Bacterial Vaginosis
Bacterial vaginosis results from replacement of normal hydrogen peroxide-producing lactobacilli with anaerobic bacteria, Gardnerella vaginalis, and Mycoplasma hominis 2, 1:
Diagnosis requires three of four Amsel criteria: homogeneous white discharge, pH >4.5, positive whiff test, and clue cells on microscopy 1, 5, 3
First-line treatment is oral metronidazole 500 mg twice daily for 7 days 6, 5, 3
Alternative regimens include intravaginal metronidazole or intravaginal clindamycin 3, 7
Treatment of male sexual partners has not been shown to prevent recurrence 2
Vulvovaginal Candidiasis
Candidiasis, usually caused by Candida albicans, presents with vulvar itching, irritation, white discharge, and dyspareunia 1, 5:
Diagnosis requires symptoms plus identification of yeast or pseudohyphae on KOH preparation or positive culture 1, 3
Topical azole therapy (clotrimazole, miconazole, terconazole, butoconazole, or tioconazole) applied intravaginally is equally effective as oral therapy 1, 8, 5
Oral fluconazole 150 mg as a single dose is an alternative to topical therapy and achieved 55% therapeutic cure rates in controlled trials 1, 8
Only topical azoles should be used during pregnancy; oral fluconazole is not recommended 3
Critical point: Approximately 10-20% of asymptomatic women harbor Candida species in the vagina and should not be treated in the absence of symptoms 1, 9
Trichomoniasis
Trichomoniasis, caused by Trichomonas vaginalis, presents with yellow-green discharge, malodor, irritation, and dysuria 1:
Diagnosis is made by identifying motile trichomonads on wet mount, though culture or nucleic acid amplification testing is more sensitive 1, 3, 4
Treatment is metronidazole 2 g orally as a single dose 6, 5, 7
Alternative regimen is metronidazole 500 mg twice daily for 7 days, which may be more effective for treatment failures 4
Sexual partners must be treated simultaneously to prevent reinfection, as trichomoniasis is a sexually transmitted infection 2, 1, 6
Special Considerations
Recurrent Infections
Recurrent bacterial vaginosis may benefit from extended treatment duration with first-line agents or vaginal boric acid as an alternative 4
Recurrent vulvovaginal candidiasis (≥4 episodes per year) requires extended treatment regimens and consideration of non-albicans Candida species through culture 5, 3, 4
Vaginal products containing Lactobacillus crispatus may have promise for preventing recurrent bacterial vaginosis 4
Physiologic Discharge
When all tests are negative and discharge characteristics are normal (clear to white, non-malodorous, pH ≤4.5), reassurance and avoidance of irritants is appropriate—no treatment is indicated 9
Discharge volume varies with the menstrual cycle, increasing mid-cycle with ovulation 9
Hygiene Counseling
Vaginal douching should be avoided as it disrupts normal lactobacilli and increases the risk of bacterial vaginosis 1, 9
Clean only the external vulva with water and mild soap; the vagina is self-cleaning 1
Recommend cotton underwear and avoidance of scented products or prolonged moisture exposure 9
Common Pitfalls to Avoid
Do not treat asymptomatic Candida colonization—10-20% of women have Candida without symptoms and require no treatment 1, 9
Do not rely solely on clinical presentation for trichomoniasis diagnosis; wet mount has high false-negative rates and more sensitive testing should be used 5, 3
Laboratory testing fails to identify a cause in a substantial minority of women with vaginal discharge complaints; consider non-infectious causes when standard testing is negative 2, 9
Self-medication is only appropriate for women previously diagnosed with candidiasis who experience identical symptoms; if symptoms persist after treatment or recur within 2 months, medical evaluation is necessary 1