Vaginitis

In patients with recurrent symptoms of vaginal discharge and/or perineal itching, have a broad differential diagnosis (e.g., lichen sclerosus et atrophicus, vulvar cancer, contact dermatitis, colovaginal fistula), take a detailed history, and perform a careful physical examination to ensure appropriate investigation or treatment. (Do not assume that the symptoms indicate just a yeast infection.)
In patients with recurrent vaginal discharge, no worrisome features on history or physical examination, and negative tests, make a positive diagnosis of physiologic discharge and communicate it to the patient to avoid recurrent consultation, inappropriate treatment, and investigation in the future.
When bacterial vaginosis and candidal infections are identified through routine vaginal swab or Pap testing, ask about symptoms and provide treatment only when it is appropriate.
In a child with a vaginal discharge, rule out sexually transmitted infections and foreign bodies. (Do not assume that the child has a yeast infection.)
In a child with a candidal infection, look for underlying illness (e.g., immunocompromise, diabetes).

DDx

Infectious vaginal discharge
- Bacterial vaginosis (most common cause of vaginal discharge 30%)
- Candida vulvovaginitis
- Trichomonas vaginalis (STI)
- Cervicitis (Gono/Chlam)
Non-infectious vaginal discharge
- Physiologic
- Atrophic vaginitis (scant discharge)
- Foreign body
Non-infectious vulvovaginal pruritus without discharge
- Irritant or allergic contact dermatitis (latex, soaps, perfumes)
- Lichen planus
- Lichen sclerosus
- Vulvar cancer
- Psoriasis
- Colovaginal fistula

Diagnosis
- Malodorous, green/yellow frothy discharge, pruritus, dyspareunia, petechiae - strawberry cervix
- Motile trichomonads on wet mount microscopy, NAAT PCR vaginal swabs, culture
Treatment
- Metronidazole 2g PO x1 or Metronidazole 500mg PO BID x7d
- High-dose therapy may be needed for resistance
- Partner treatment enhances cure rates
- Abstain from intercourse until both patients treated and asymptomatic

Diagnosis
- Erythema, edema of vulvovaginal tissues with thick, white clumped vaginal discharge, pH<4.5
- Budding yeast and pseudohyphae on wet mount microscopy (negative in 50%)
- Consider culture in negative microscopy or persistent/recurrent symptoms after treatment
Treatment
- Uncomplicated (Sporadic, infrequent ≤3/y, healthy, immunocompetent, nonpregannt)
  - Fluconazole 150mg PO x1 or topical intravaginal/suppository (clotrimazole, miconazole)
    - Topical antifungal azoles may require longer courses, but are first-line in pregnancy
      - eg. Clotrimazole Combi Pak (Canesten 500mg vag tab/1% cream) or cream 10% x 1
- Complicated
  - Fluconazole 150mg PO x3 doses 72h apart (day 1, 4, 7)
    - Consider maintenance with Fluconazole 150mg PO weekly x 6 months
    - Monitor for hepatotoxicity with long-term use and drug interactions
Non-albicans species may not respond to fluconazole
- For C glabrata, consider vaginal boric acid capsules at compounding pharmacist (avoid in pregnancy)
- For C krusei, consider topical clotrimazole

Non-specific (most common)
- Causal factors
  - Thin vaginal mucosa
  - Moisture (tight clothing)
  - Irritants (soap, bubble bath, prolonged contact with urine/feces)
Bacterial
- Group A beta-hemolytic strep
- H. influenzae
- E. coli
- Candida (unusual)
Dermatologic
- Lichen sclerosis
- Psoriasis
- Atopic dermatitis
Foreign body, usually toilet paper (recurrent symptoms or bloody discharge)
- Flush with sterile saline or refer to gyne for vaginoscopy
Pinworms (nocturnal perineal pruritus)
- Treat with mebendazole
Systemic infection (varicella, measles, rubella, diphtheria, shigella)
Rule out STIs and sexual abuse, especially in recurrent cases

Introital (not vaginal) swab if profuse discharge
- Bacterial culture (GAS, Haemophilus influenzae, Gardnerella)
  - If positive bacterial culture, can treat with antibiotics
- Candida unusual, consider if immunosuppression

References:

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