Vaginitis

Definition | Types of Vaginitis | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Vaginitis refers to inflammation of the vagina, often accompanied by symptoms such as itching, discharge, and discomfort. It is a common condition with various causes, including infections, irritants, and hormonal changes.

Types of Vaginitis

Vaginitis can be classified into several types based on the underlying cause:

• Bacterial Vaginosis (BV): The most common cause of vaginitis, resulting from an imbalance in the vaginal flora, where there is an overgrowth of anaerobic bacteria, particularly Gardnerella vaginalis.
• Candidiasis (Yeast Infection): Caused by an overgrowth of Candida species, particularly Candida albicans, leading to symptoms like itching, thick white discharge, and irritation.
• Trichomoniasis: A sexually transmitted infection (STI) caused by the protozoan Trichomonas vaginalis, resulting in a frothy, yellow-green discharge with a strong odour.
• Atrophic Vaginitis: Common in postmenopausal women due to oestrogen deficiency, leading to thinning of the vaginal walls, dryness, and irritation.
• Allergic or Irritant Vaginitis: Caused by allergic reactions or irritation from products like soaps, detergents, spermicides, or synthetic fabrics.

Aetiology

The causes of vaginitis vary depending on the type:

• Bacterial Vaginosis: An overgrowth of anaerobic bacteria, particularly Gardnerella vaginalis, disrupts the normal balance of vaginal flora.
• Candidiasis: Overgrowth of Candida species, often triggered by factors such as antibiotic use, high oestrogen levels (e.g., pregnancy or oral contraceptive use), diabetes, or a weakened immune system.
• Trichomoniasis: A sexually transmitted infection caused by the protozoan Trichomonas vaginalis.
• Atrophic Vaginitis: Oestrogen deficiency leads to thinning and drying of the vaginal walls, often occurring in postmenopausal women.
• Allergic or Irritant Vaginitis: Caused by exposure to allergens or irritants, such as perfumes, soaps, or latex.

Risk Factors

Several factors increase the likelihood of developing vaginitis:

• Sexual Activity: Increases the risk of sexually transmitted infections, including trichomoniasis.
• Antibiotic Use: Disrupts the natural balance of vaginal flora, increasing the risk of bacterial vaginosis and candidiasis.
• Hormonal Changes: Pregnancy, menopause, and the use of hormonal contraceptives can alter the vaginal environment, increasing the risk of vaginitis.
• Diabetes: Poorly controlled diabetes increases the risk of candidiasis due to elevated blood glucose levels.
• Use of Irritants: Products like scented soaps, douches, and synthetic fabrics can irritate the vaginal area and lead to vaginitis.
• Weakened Immune System: Conditions that weaken the immune system, such as HIV, increase the risk of recurrent vaginitis.

Clinical Presentation

Vaginitis presents with a range of symptoms, which can vary depending on the underlying cause:

• Vaginal Discharge: The type and colour of discharge can vary:
  • Bacterial Vaginosis: Thin, grey or white discharge with a fishy odour.
  • Candidiasis: Thick, white, "cottage cheese-like" discharge without a strong odour.
  • Trichomoniasis: Frothy, yellow-green discharge with a foul smell.
• Itching and Irritation: Common in all types of vaginitis, often accompanied by redness and swelling of the vulva.
• Dysuria: Painful urination, which may occur with candidiasis or trichomoniasis.
• Dyspareunia: Pain during sexual intercourse, particularly in atrophic vaginitis.
• Vaginal Dryness: A common symptom of atrophic vaginitis.

Investigations

Diagnosis of vaginitis is based on clinical assessment and laboratory investigations:

• Pelvic Examination: A physical examination to assess the appearance of the vaginal walls and cervix, and to evaluate the nature of the discharge.
• Microscopy: A sample of vaginal discharge can be examined under a microscope:
  • Wet Mount: To identify Trichomonas vaginalis or clue cells indicative of bacterial vaginosis.
  • Gram Stain: To assess the bacterial flora and confirm the presence of Candida species.
• pH Testing: Vaginal pH can help differentiate between types of vaginitis:
  • Bacterial Vaginosis and Trichomoniasis: Typically present with a higher pH (>4.5).
  • Candidiasis: Usually has a normal pH (4.0-4.5).
• Culture: A culture may be performed if the diagnosis is unclear or if there is recurrent infection.
• NAAT (Nucleic Acid Amplification Test): Used for the detection of sexually transmitted infections, including Trichomonas vaginalis.

Management

The treatment of vaginitis depends on the underlying cause:

Bacterial Vaginosis

• Metronidazole: Oral or vaginal gel, typically 400-500 mg twice daily for 7 days, or as a gel applied once daily for 5 days.
• Clindamycin: Vaginal cream applied once daily for 7 days or as an oral alternative if metronidazole is not suitable.

Candidiasis

• Fluconazole: A single oral dose of 150 mg is effective for most cases.
• Topical Antifungals: Options include clotrimazole or miconazole, available as creams, pessaries, or tablets.

Trichomoniasis

• Metronidazole or Tinidazole: A single oral dose of 2 g, or metronidazole 500 mg twice daily for 7 days.
• Partner Treatment: Sexual partners should also be treated to prevent reinfection.

Atrophic Vaginitis

• Topical Oestrogen: Vaginal oestrogen cream, tablets, or rings to alleviate symptoms of dryness and irritation.
• Moisturisers and Lubricants: Regular use of vaginal moisturisers and lubricants to reduce discomfort.

Allergic or Irritant Vaginitis

• Avoidance of Irritants: Identifying and avoiding the causative irritants or allergens.
• Topical Corticosteroids: May be used to reduce inflammation and irritation.

When to Refer

Referral to a specialist may be necessary in the following situations:

• Recurrent or persistent vaginitis that does not respond to standard treatment.
• Uncertainty in diagnosis, particularly if there is a suspicion of non-infectious causes or co-existing conditions.
• Severe symptoms that significantly impact the patient's quality of life.
• Postmenopausal women with recurrent or severe atrophic vaginitis not responding to first-line treatments.

References

1. NHS (2024) Vaginitis. Available at: https://www.nhs.uk/conditions/vaginitis/ (Accessed: 26 August 2024).
2. Royal College of Obstetricians and Gynaecologists (2024) Management of Vaginitis. Available at: https://www.rcog.org.uk/guidance/vaginitis-management/ (Accessed: 26 August 2024).
3. British Medical Journal (2024) Vaginitis: Clinical Review. Available at: https://www.bmj.com/content/350/bmj.h2535 (Accessed: 26 August 2024).

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