What are the guidelines for managing acute vaginitis?

Management of Acute Vaginitis

Diagnose acute vaginitis by measuring vaginal pH and performing microscopic examination of vaginal discharge in saline and 10% KOH preparations, then treat based on the specific etiology identified: bacterial vaginosis, vulvovaginal candidiasis, or trichomoniasis. 1

Diagnostic Approach

Initial Office-Based Testing

• Measure vaginal pH using narrow-range pH paper applied directly to vaginal secretions 1, 2:

  • pH ≤4.5 suggests vulvovaginal candidiasis 2
  • pH >4.5 indicates bacterial vaginosis or trichomoniasis 1, 2

• Perform saline wet mount to identify 1:

  • Motile Trichomonas vaginalis (confirms trichomoniasis) 1, 2
  • Clue cells (indicates bacterial vaginosis) 1, 2

• Perform 10% KOH preparation to visualize yeast or pseudohyphae (suggests candidiasis) 1

• Conduct whiff test by adding KOH to vaginal discharge; a fishy amine odor indicates bacterial vaginosis or trichomoniasis 1, 2

Critical Diagnostic Pitfall

• Up to 50% of women with bacterial vaginosis are asymptomatic, so absence of symptoms does not exclude the diagnosis 3
• Culture for T. vaginalis is more sensitive than microscopy when initial wet mount is negative 1

Treatment by Etiology

Vulvovaginal Candidiasis (VVC)

For uncomplicated VVC (mild-to-moderate, sporadic, non-recurrent disease), use either oral fluconazole or short-course topical azoles. 1

Recommended Regimens

Oral therapy:

• Fluconazole 150 mg orally as a single dose (achieves 55% therapeutic cure rate) 1, 2, 4

Intravaginal therapy (multiple equally effective options): 1

• Clotrimazole 1% cream 5g intravaginally for 7-14 days
• Clotrimazole 500 mg vaginal tablet as single dose
• Miconazole 2% cream 5g intravaginally for 7 days
• Terconazole 0.8% cream 5g intravaginally for 3 days
• Tioconazole 6.5% ointment 5g intravaginally as single application

Treatment Duration Considerations

• Reserve single-dose treatments for uncomplicated mild-to-moderate VVC 1
• Use multi-day regimens (3- or 7-day courses) for severe or complicated VVC (including recurrent disease, severe symptoms, diabetes, or non-albicans species) 1

Partner Management

• Do not treat sexual partners routinely, as VVC is not sexually transmitted and partner treatment does not reduce recurrence 1, 2

Bacterial Vaginosis (BV)

Treat with metronidazole 500 mg orally twice daily for 7 days, which achieves a 95% cure rate. 2

Key Pathophysiology

• BV results from replacement of normal H₂O₂-producing Lactobacillus species with anaerobic bacteria (Prevotella, Mobiluncus), Gardnerella vaginalis, and Mycoplasma hominis 1, 3

Partner Management

• Do not treat male sexual partners, as this has not been beneficial in preventing recurrence 1, 3, 2

Important Caveat

• BV has a 50-80% recurrence rate within one year, likely because beneficial Lactobacillus species fail to recolonize after antibiotic treatment 3

Trichomoniasis

Treat with metronidazole 2 grams orally as a single dose, which achieves a 90-95% cure rate. 2

Critical Partner Management

• Sexual partners must be treated simultaneously to prevent reinfection 1, 2
• This is the only common cause of vaginitis requiring partner treatment 2

Special Populations

HIV-Infected Women

• Treat with identical regimens as HIV-negative women for all three conditions (bacterial vaginosis, candidiasis, and trichomoniasis) 1, 2

Pregnant Women

• Use only 7-day topical treatments for bacterial vaginosis and candidiasis 2
• Avoid oral fluconazole during pregnancy; use topical azoles instead 1

Over-the-Counter Self-Treatment

• Advise OTC preparations only for women previously diagnosed with VVC who experience recurrence of identical symptoms 1
• Available OTC options include miconazole and clotrimazole intravaginal preparations for 7 days 1
• Any woman whose symptoms persist after OTC treatment or who has recurrence within 2 months should seek medical care 1

When Diagnosis Remains Unclear

• Laboratory testing fails to identify the cause of vaginitis in a substantial minority of women 1
• Consider non-infectious causes including mechanical, chemical, allergic irritation, or atrophic vaginitis when vaginal pathogens are absent but vulvar inflammation is present 1