Vaginitis

Vaginitis, also known as vaginal infection and vulvovaginitis, is an inflammation of the vagina and possible vulva.^[1][2] It can result in discharge, itching and pain,^[2] and is often associated with an irritation or infection of the vulva. Infected women may also be asymptomatic.

It is usually due to infection.^[3] The three main kinds of vaginitis are bacterial vaginosis (BV), vaginal candidiasis, and trichomoniasis.^[4] A woman may have any combination of vaginal infections at one time. Testing for vaginal infections is not a part of routine pelvic exams. If there is discomfort in the vulvovaginal area, women can request their health care providers evaluate for the presence of an infection.^[4]

Signs and symptoms

A woman may have vaginal itching or burning and may notice a discharge.^[5]

The discharge may be excessive in amounts or abnormal in color(such as yellow, gray, or green).^[6]

The following symptoms may indicate the presence of infection:^[4]

• irritation and/or itching of the genital area
• inflammation (irritation, redness, and swelling caused by the presence of extra immune cells) of the labia majora, labia minora, or perineal area
• vaginal discharge
• foul vaginal odor
• pain/irritation with sexual intercourse

Causes

Vaginitis is the disruption of the healthy vaginal microbiota. The vaginal microbiota consists of those organisms which generally do not cause symptoms, infections, and results in good pregnancy outcomes, and is dominated mainly by Lactobacillus species.^[7] The disruption of the normal microbiota can cause a vaginal yeast infection. Vaginal yeast infection can affect women of all ages and is very common. Specific forms of vaginal inflammation include the following types:

Infection

Infectious vaginitis accounts for 90% of all cases in reproductive age women:

• Candidiasis: vaginitis caused by proliferation of Candida albicans, Candida tropicalis, Candida krusei^[8]
• Bacterial vaginosis: vaginitis caused by increased growth of Gardnerella (a bacterium).^[7]

Other less common infections are caused by gonorrhea, chlamydia, Mycoplasma, herpes, Campylobacter, improper hygiene, and some parasites, notably Trichomonas vaginalis.^[9] Women who have diabetes develop infectious vaginitis more often than women who do not.^[10]

Vaginal infections often have multiple causes (varies between countries between 20 to 40% of vaginal infections), which present challenging cases for treatment. Indeed, when only one cause is treated, the other pathogens can become resistant to treatment and induce relapses and recurrences. Therefore, the key factor is to get a precise diagnosis and treat with broad spectrum anti-infective agents (often also inducing adverse effects).

Further, either a change in pH balance or introduction of foreign bacteria in the vagina can lead to infectious vaginitis. Physical factors that have been claimed to contribute to the development of infections include the following: constantly wet vulva due to tight clothing, chemicals coming in contact with the vagina via scented tampons, antibiotics, birth control pills, or a diet favoring refined sugar and yeast.^[11]

Before puberty

• Bacterial vaginosis: vaginitis caused by Streptococcus spp..
• Improper hygiene, which may introduce bacteria or other irritants from the anal region to the vaginal area.

The pH balance in adolescent girls' bodies is not conducive to the growth of Candida albicans, so they are unlikely to contract a yeast infection.

Hormonal

Hormonal vaginitis includes atrophic vaginitis usually found in postmenopausal or postpartum women. Sometimes it can occur in young girls before puberty. In these situations the estrogen support of the vagina is poor.

Irritation/allergy

Irritant vaginitis can be caused by allergies to condoms, spermicides, soaps, perfumes, douches, lubricants, and semen. It can also be caused by hot tubs, abrasion, tissue, tampons, or topical medications.

Foreign body vaginitis (most common foreign bodies are retained tampons or condoms) may cause extremely malodorous vaginal discharges. Treatment consists of removal, for which ring forceps may be useful. Further treatment is generally not necessary.

Diagnosis

Women should inform their doctors of symptoms that may indicate infection, so that a diagnosis may be made.^[4] Diagnosis is made with microscopy (mostly by vaginal wet mount) and culture of the discharge after a careful history and physical examination have been completed. The color, consistency, acidity, and other characteristics of the discharge may be predictive of the causative agent. Determining the agent is especially important because women may have more than one infection, or have symptoms that overlap those of another infection, which dictates different treatment processes to cure the infection.^[4] For example, women often self-diagnose for yeast infections but due to the 89% misdiagnosis rate, self-diagnoses of vaginal infections are highly discouraged.^[12]

The International Statistical Classification of Diseases and Related Health Problems codes for the several causes of vaginitis are:

Another uncommon type of vaginitis, called desquamative inflammatory vaginitis also exists, and is underdiagnosed. The cause behind this type is still poorly understood.^[13]

Prevention

Prevention of candidiasis, the most common type of vaginitis, includes using loose cotton underwear. The vaginal area should be washed with water. Perfumed soaps, shower gels, and vaginal deodorants should be avoided.^[14] Douching is not recommended. The practice upsets the normal balance of yeast in the vagina and does more harm than good.^[15]

Prevention of bacterial vaginosis includes healthy diets and behaviors as well as minimizing stress as all these factors can affect the pH balance of the vagina.^[16]

Prevention of trichomoniasis revolves around avoiding other people's wet towels and hot tubs, and safe-sex procedures, such as condom use.^[4]

Some women consume good bacteria in food with live culture, such as yogurt, sauerkraut and kimchi, or in probiotic supplements either to try to prevent candidiasis, or to reduce the likelihood of developing bacterial vaginitis following antibiotic treatment. There is no firm evidence to suggest that eating live yogurt or taking probiotic supplements will prevent candidiasis.^[14]

Studies have suggested a possible clinical role for the use of standardized oral or vaginal probiotics in the treatment of bacterial vaginosis, either in addition to ^[17] or in place of ^[18] the typical antibiotic regimens. However, recent articles^[19][20] question their efficacy in preventing recurrence compared with other means, or conclude that there is insufficient evidence for or against recommending probiotics for the treatment of bacterial vaginosis.

Treatment

The cause of the infection determines the appropriate treatment. It may include oral or topical antibiotics and/or antifungal creams, antibacterial creams, or similar medications. A cream containing cortisone may also be used to relieve some of the irritation. If an allergic reaction is involved, an antihistamine may also be prescribed. For women who have irritation and inflammation caused by low levels of estrogen (postmenopausal), a topical estrogen cream might be prescribed.

The following are typical treatments for trichomoniasis, bacterial vaginosis, and yeast infections:

• Trichomoniasis: Single oral doses of either metronidazole, or tinidazole.^[4] "Sexual partner(s) should be treated simultaneously. Patients should be advised to avoid sexual intercourse for at least 1 week and until they and their partner(s) have completed treatment and follow-up."^[21]
• Bacterial vaginosis: The most commonly used antibiotics are metronidazole, available in both pill and gel form, and clindamycin available in both pill and cream form.^[16]
• Yeast infections: Local azole, in the form of ovula and cream. All agents appear to be equally effective.^[22] These anti-fungal medications, which are available in over the counter form, are generally used to treat yeast infections. Treatment may last anywhere between one, three, or seven days.^[12]

Complications

Vaginal infections left untreated can lead to further complications, especially for the pregnant woman. For bacterial vaginosis, these include "premature delivery, postpartum infections, clinically apparent and subclinical pelvic inflammatory disease, [as well as] postsurgical complications (after abortion, hysterectomy, caesarian section), increased vulnerability to HIV infection and, possibly, infertility".^[16] Studies have also linked trichomoniasis with increased likelihood of acquiring HIV; theories include that "vaginitis increases the number of immune cells at the site of infection, and HIV then infects those immune cells." ^[4] Other theories suggest that trichomoniasis increases the amount of HIV genital shedding, thereby increasing the risk of transmission to sexual partners. While the exact association between trichomoniasis infection and HIV genital shedding has not been consistently demonstrated, "there is good evidence that TV treatment reduces HIV genital shedding. Five studies were reported in the literature and, of these, four found a decrease in HIV genital shedding after TV treatment."^[23]

Further, there are complications which lead to daily discomfort such as:

• persistent discomfort
• superficial skin infection (from scratching)
• complications of the causative condition (such as gonorrhea and candida infection)

See also

• List of bacterial vaginosis microbiota

References

Further reading