Veginal infection

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Vaginal Infections (Vaginitis)

Vaginal infections are among the most common gynecologic complaints. Most women experience at least one episode during their childbearing years. The three main infectious types are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis. Non-infectious causes include atrophic vaginitis and contact/allergic vaginitis.

1. Bacterial Vaginosis (BV)

Most common cause of vaginal infection.

Pathophysiology: Normal Lactobacillus-dominant flora is replaced by overgrowth of anaerobic bacteria - primarily Gardnerella vaginalis, Prevotella, Mobiluncus, and other anaerobes. The vaginal pH rises, and there is NO significant inflammatory response (hence "vaginosis," not "vaginitis").

Symptoms:

Malodorous, thin, homogeneous white or gray discharge ("milk consistency")
Characteristic fishy odor, especially after intercourse
Usually no itching or burning

Diagnosis - Amsel Criteria (3 of 4):

Criterion	Sensitivity	Specificity
pH > 4.5	89%	74%
Positive whiff test (fishy odor with KOH)	67%	93%
Clue cells >20% on wet mount	74%	86%
Thin homogeneous discharge	79%	54%
3 of 4 criteria met	69%	93%

Clue cells = vaginal epithelial cells coated with bacteria, giving a stippled "ground glass" appearance
No significant PMNs (white cells) in the discharge

Treatment:

Metronidazole 500 mg PO twice daily x 7 days (first-line)
Intravaginal metronidazole gel 0.75%
Clindamycin (oral or intravaginal)
Partner treatment is NOT beneficial and not recommended
A 2025 systematic review (PMID: 40352249) found probiotics may help reduce recurrence

2. Vulvovaginal Candidiasis (VVC)

Second most common cause; lifetime prevalence of 70-75% in women.

Cause: Candida albicans (80-90%); less commonly C. glabrata, C. tropicalis.

Risk factors: Antibiotic use (disrupts normal flora), diabetes (especially Type 1 - strongest risk factor), pregnancy, high-estrogen states, immunosuppression, OCP use, recent oral sex.

Symptoms:

Intense vulvar itching/pruritus and burning
Thick, white, "cottage cheese" or curdled discharge (adheres to vaginal walls)
Vulvovaginal inflammation and erythema
NO foul odor
Dyspareunia, external dysuria

Diagnosis:

pH usually ≤4.5 (normal or slightly elevated)
KOH preparation showing budding yeasts and pseudohyphae (sensitivity 65-85%)
Culture is the gold standard for recurrent/resistant cases
Self-diagnosis by patients is incorrect ~50% of the time

Treatment:

Uncomplicated: Single oral dose fluconazole 150 mg OR intravaginal azole (clotrimazole, miconazole, tioconazole) - 1, 3, or 7-day regimens are equivalent
Recurrent VVC (≥4 episodes/year, affects 5-8% of women): 10-14 day initial treatment followed by fluconazole 150 mg weekly x 6 months (suppressive therapy)
Partner treatment NOT needed (not sexually transmitted)
Lactobacillus, boric acid, and douching do NOT prevent recurrence

3. Trichomoniasis

Cause: Trichomonas vaginalis - a flagellated protozoan. This is a sexually transmitted infection (STI) that can also infect male partners (urethritis or silent infection).

Symptoms:

Profuse, malodorous, frothy yellow-green discharge
Vulvar irritation and burning
Dyspareunia
May show "strawberry cervix" (cervical petechiae) on exam - pathognomonic but seen in only ~2% visually

Diagnosis:

pH > 5.0
Wet mount: motile trichomonads + many PMNs (sensitivity only 51-65% - use warm saline and examine promptly)
NAAT (nucleic acid amplification test) from vaginal/endocervical/urine specimen - sensitivity 95-100% - preferred method
Rapid point-of-care antigen test: sensitivity 82-95%

Treatment:

Metronidazole 500 mg PO twice daily x 7 days OR tinidazole 2 g single dose
Partner treatment is mandatory - both partners must be treated
Abstain from sexual intercourse until both partners complete treatment and symptoms resolve
Secnidazole 2 g single oral dose is a newer approved option

4. Atrophic Vaginitis

Cause: Estrogen deficiency, most commonly postmenopausal women.

Symptoms: Vaginal dryness, burning, irritation, dyspareunia; may increase risk of recurrent UTIs.

Treatment: Intravaginal estrogen (cream, ring, or tablet).

Comparison Table

Feature	Bacterial Vaginosis	Trichomoniasis	Candidiasis
Pathogen	G. vaginalis + anaerobes	T. vaginalis (protozoan)	Candida spp. (fungus)
Discharge	Thin, white-gray, homogeneous	Frothy, yellow-green, profuse	Thick, white, curd-like
Odor	Fishy (positive whiff)	May be fishy	None
pH	>4.5	>5.0	≤4.5
Inflammation	No	Yes	Yes
Microscopy	Clue cells, no PMNs	Motile trichomonads + PMNs	Budding yeast, pseudohyphae
Treatment	Metronidazole/clindamycin	Metronidazole/tinidazole	Azole antifungals/fluconazole
Treat partner?	No	Yes (STI)	No

Key Clinical Notes

Syndromic management (treating based on clinical signs without lab confirmation) is used in resource-limited settings, with metronidazole covering both BV and trichomoniasis
Mixed infections are possible - always perform a full evaluation (pH, wet mount, KOH)
Recurrent symptoms warrant culture to exclude non-albicans Candida species that may be resistant to standard azoles
In pregnancy: BV and trichomoniasis are associated with preterm birth; treatment is recommended even in asymptomatic pregnant women with BV. Metronidazole is acceptable after the first trimester
Douching is associated with increased pelvic infections and should be avoided

Sources: Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed. | Textbook of Family Medicine, 9th Ed. | Jawetz, Melnick & Adelberg's Medical Microbiology, 28th Ed. | The Harriet Lane Handbook, 23rd Ed. | Park's Textbook of Preventive and Social Medicine

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