What is the treatment for vaginitis?

Treatment of Vaginitis

Treatment of vaginitis depends on accurate identification of the causative organism through pH testing and microscopic examination, with bacterial vaginosis treated with oral metronidazole 500 mg twice daily for 7 days, vulvovaginal candidiasis with oral fluconazole 150 mg single dose or topical azoles, and trichomoniasis with metronidazole 2 g orally as a single dose. 1

Diagnostic Approach

Before initiating treatment, establish the specific cause through systematic evaluation:

• Measure vaginal pH using narrow-range pH paper; pH >4.5 suggests bacterial vaginosis or trichomoniasis, while normal pH (4.0-4.5) suggests vulvovaginal candidiasis 2, 1
• Perform saline wet mount to identify motile trichomonads (trichomoniasis) or clue cells (bacterial vaginosis) 2, 1
• Perform KOH preparation to visualize yeast or pseudohyphae (candidiasis) and conduct the whiff test (fishy odor indicates bacterial vaginosis or trichomoniasis) 2, 1
• Consider nucleic acid amplification testing for trichomoniasis when microscopy is negative but clinical suspicion remains high, as wet mount has high false-negative rates 3

Treatment of Bacterial Vaginosis

First-line therapy is oral metronidazole 500 mg twice daily for 7 days, with cure rates of 86-97%. 1, 4

Alternative regimens include:

• Metronidazole gel 0.75% intravaginally for 5 days 1
• Clindamycin cream 2% intravaginally for 7 days 1
• Metronidazole 2 g orally as a single dose (though 7-day regimen preferred) 1

Critical caveat: Patients must avoid alcohol during metronidazole treatment and for 24 hours afterward to prevent disulfiram-like reactions. 1, 4

Do not treat male sex partners, as this has not been shown to prevent recurrence of bacterial vaginosis 2, 1

Bacterial Vaginosis Diagnosis Criteria

Use Amsel criteria (requires 3 of 4):

• Homogeneous white discharge coating vaginal walls 2
• Clue cells on microscopy 2
• Vaginal pH >4.5 2
• Positive whiff test (fishy odor with KOH) 2

Treatment of Vulvovaginal Candidiasis

For uncomplicated cases, oral fluconazole 150 mg as a single dose achieves 80-90% cure rates and is equally effective as topical azoles. 1, 5

Topical alternatives (all equally effective):

• Clotrimazole 1% cream 5 g intravaginally for 7-14 days 1, 4
• Miconazole 2% cream 5 g intravaginally for 7 days 1, 4
• Terconazole 0.4% cream 5 g intravaginally for 7 days 1, 4
• Butoconazole 2% cream 5 g intravaginally for 3 days 4

For complicated vulvovaginal candidiasis (severe symptoms, non-albicans species, recurrent episodes ≥4/year, immunocompromised), use longer duration therapy (7-14 days) followed by maintenance therapy with fluconazole 150 mg weekly for up to 6 months. 1, 4

Important Caveats for Candidiasis

• Do not treat asymptomatic colonization, as 10-20% of women normally harbor Candida without symptoms 1, 4
• Self-diagnosis is unreliable; women who self-treat with over-the-counter preparations are correct only about 50% of the time 4
• Oil-based vaginal creams and suppositories weaken latex condoms and diaphragms 4
• Advise medical evaluation if symptoms persist after OTC treatment or recur within 2 months 1

Treatment of Trichomoniasis

First-line treatment is metronidazole 2 g orally as a single dose, with cure rates up to 88%. 1

Alternative regimen:

• Metronidazole 500 mg twice daily for 7 days 1, 6

Critical difference from other vaginitis: Sex partners must be treated simultaneously to prevent reinfection, as trichomoniasis is a sexually transmitted infection 1

For treatment failures, consider:

• Metronidazole resistance testing 6
• Extended 7-day course if single-dose therapy failed 6

Special Populations

Pregnancy

• Bacterial vaginosis in pregnancy: Metronidazole 2 g single dose after first trimester may reduce preterm birth risk in high-risk women 4
• Vulvovaginal candidiasis in pregnancy: Use only topical azoles (7-14 day regimens); oral fluconazole is contraindicated 1, 4
• Trichomoniasis in pregnancy: Treat with metronidazole after first trimester 6

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients for all three conditions 4

Common Pitfalls to Avoid

• Premature discontinuation of therapy leads to treatment failure; patients must complete the full course even if symptoms improve early 1
• Laboratory testing fails to identify a cause in a substantial minority of women; consider non-infectious causes (atrophic vaginitis, contact dermatitis, desquamative inflammatory vaginitis) when standard testing is negative 2, 6
• Culture for Gardnerella vaginalis is not recommended as it lacks specificity (many asymptomatic women are colonized) 2
• Cervical Pap tests have limited utility for diagnosing bacterial vaginosis due to low sensitivity 2
• Unnecessary use of OTC antifungal preparations delays proper diagnosis of other treatable causes of vaginitis 1