Symptoms of Vaginitis
The typical symptoms of vaginitis vary by etiology: bacterial vaginosis presents with thin, gray-white malodorous discharge and a fishy odor; vulvovaginal candidiasis causes intense vulvar itching with thick, white "cottage cheese-like" discharge; and trichomoniasis produces a frothy, yellow-green discharge with prominent vulvar irritation. 1
Bacterial Vaginosis Symptoms
- Thin, homogeneous, white or gray-white discharge that smoothly coats the vaginal walls is the hallmark presentation 2, 1
- A characteristic fishy or musty odor, particularly noticeable after intercourse or during menstruation, distinguishes BV from other infections 2, 3
- The fishy odor becomes more pronounced when 10% KOH is added to the discharge (positive "whiff test"), which is one of the diagnostic Amsel criteria 2, 1
- Notably, up to 50% of women with BV are completely asymptomatic, meaning absence of symptoms does not exclude the diagnosis 4
- Vulvar inflammation is typically absent or minimal in BV, as it is a non-inflammatory condition 2, 1
Vulvovaginal Candidiasis Symptoms
- Intense vulvar and vaginal pruritus (itching) is the predominant symptom, often described as the most bothersome complaint 1, 3
- Thick, white "cottage cheese-like" or "curdled" discharge that adheres to the vaginal walls 1, 3
- Vulvar and vaginal erythema (redness) and swelling are common physical findings 3, 5
- Burning sensation, painful intercourse (dyspareunia), and stinging on urination (dysuria) frequently accompany the infection 3, 6
- Vaginal pH remains normal (≤4.5), which helps differentiate candidiasis from BV and trichomoniasis 1, 7
Trichomoniasis Symptoms
- Profuse, frothy, yellow-green or greenish discharge is the classic presentation 1, 3
- Prominent vulvar and vaginal itching and irritation accompany the discharge 1, 8
- A diffuse, malodorous discharge is typical, though the odor differs from the fishy smell of BV 1
- "Strawberry cervix" (punctate red hemorrhagic lesions on the cervix) may be visible on speculum examination, though this finding is present in only a minority of cases 1
- Vaginal pH is elevated above 4.5, similar to BV 1, 7
Key Diagnostic Distinctions
- Vaginal pH measurement is critical for differentiation: pH >4.5 suggests BV or trichomoniasis, while pH ≤4.5 points toward candidiasis 2, 1, 7
- The character of discharge provides important clues: thin and homogeneous (BV), thick and white (candidiasis), or frothy and green (trichomoniasis) 1, 7
- Presence or absence of inflammation matters: candidiasis and trichomoniasis cause vulvar erythema and irritation, whereas BV does not 2, 1
Common Pitfalls
- Relying on symptoms alone is inadequate for diagnosis—a pelvic examination with office laboratory testing (pH, wet mount, KOH preparation) is essential for accurate identification 1
- Wet-mount microscopy for trichomoniasis has only 60-70% sensitivity, so nucleic acid amplification testing (NAAT) should be ordered when clinical suspicion is high despite negative microscopy 1, 7
- Asymptomatic presentation does not rule out infection, particularly with BV where half of affected women have no symptoms 4
- Multiple infections can coexist, so a thorough diagnostic workup should evaluate for all three common causes simultaneously 6