The commonest symptom in women with bacterial vaginosis is vaginal discharge. The discharge is often malodorous with a characteristic ‘fishy’ smell. The discharge is also thin, homogenous and grayish white or yellowish white in color.

Candidiasis commonly present with itching. There is also vaginal discharge which is thick, odorless and white in color. Sometimes, the vulva might be involved causing dyspareunia, dysuria and a burning sensation in the vulva [6].

Trichomoniasis presents with discharge which is usually copious and frothy. The color could be white, grey, yellow or green. Other symptoms are pain, irritation, dysuria, pruritus and post-coital bleeding. Patients may also present with symptoms of PID which is a complication if vaginitis.

• Pruritus

  CASE REPORT: A 48-year-old postmenopausal woman, with a history of hysterectomy with several comorbidities, presented with a 4-month history of bloody discharge and vulvar pruritus. [ncbi.nlm.nih.gov]

  Discharge due to vaginitis is accompanied by pruritus, erythema, and sometimes burning, pain, or mild bleeding. Pruritus may interfere with sleep. Dysuria or dyspareunia may occur. [msdmanuals.com]

• Skin Rash

  Adverse reactions which may occur include anaphylaxis, skin rashes, pustular eruptions, pruritis, flushing, urticaria, and fever. 65 In cases of true allergy, desensitization to metronidazole has been described in case reports and could be considered [doi.org]

• Vaginal Discharge

  A patient with a long history of recurrent vaginal discharge had no evidence of infection. A temporal relation between the appearance of the discharge and vaginal exposure to topical spermicidal agents was determined. [ncbi.nlm.nih.gov]

  This includes examining vaginal discharge under a microscope. In some cases, a culture of the vaginal discharge may help find out the germ that is causing the infection. [nlm.nih.gov]

• Vaginal Odor

  Diagnosis Your doctor will ask you to describe the vaginal odor and discharge. [womenshealthmag.com]

  Symptoms in women include genital itching, vaginal odor, and a heavy vaginal discharge that may be yellow-gray or green in color. OTHER CAUSES Chemicals can cause itchy rashes in the genital area. [nlm.nih.gov]

  Published: March, 2019 Bacterial vaginosis is the most common cause of abnormal vaginal odor and discharge. It is caused by a change in the type of bacteria found in the vagina. [health.harvard.edu]

  B) Bacterial Vaginosis (BV) — Typical symptoms include: Increased vaginal discharge (creamy and varying color changes); A fishy vaginal odor that may be worse after sexual relations; A burning sensation that may be worse during or after sexual relations [cliniquelactuel.com]

• Dyspareunia

  Women with BV do not have dyspareunia, while some women with severe AV do. [ncbi.nlm.nih.gov]

• Dysuria

  Dysuria or dyspareunia may occur. In atrophic vaginitis, discharge is scant, dyspareunia is common, and vaginal tissue appears thin and dry. [msdmanuals.com]

  Dysuria is a common symptom of vaginitis. It is usually external and is defined as pain and burning when urine touches the vulva. [aafp.org]

  LR (95% CI) LR– (95% CI) Patient Symptoms Vaginal odor (symptoms) Bacterial vaginosis 2.2 (1.4-3.6) 0.30 (0.24-0.38) Candidiasis 0.29 (0.20-0.43) 2.2 (1.9-2.5) Vaginal itching Candidiasis 1.5 (1.3-1.8) 0.53 (0.33-0.86) Odor, itching, vaginal burning, dysuria [jamaevidence.mhmedical.com]

• Vulvar Burning

  Vulvar burning. Bright reddish color to the vulva. Vulvar spotting. Causes/Risk Factors Bacterial, fungal, or protozoal infections. [healthcentral.com]

Women who present with abnormal vaginal discharge should have a thorough pelvic examination. Some tests that can be carried out include the Saline wet mouth which distinguishes the type of vaginitis under a microscope based on their reaction with isotonic saline. The whiff test is based on the reaction of the discharge with potassium hydroxide and it is sensitive for vaginosis. Other tests that could be carried out include tests for the pH of the vagina, culture, staining and nucleic acid amplification. Histology is also important and in cases of suspect cervical involvement, colposcopy and cervical biopsies are advised [7].

• Pyuria

  Reduction of bacteriuria and pyuria after ingestion of cranberry juice. JAMA 1994 ; 271 : 751-4. 45 Nicolle LE, Bradly S, Colgan R, et al. [revmed.ch]

Non-medical treatment of vaginitis include sitz baths, proper hygiene and proper toilet techniques. Pharmacologic therapy may be enteral, parenteral or a combination of both. Bacterial vaginosis is treated with metronidazole and clindamycin. Vaginal candidiasis requires antifungals like butoconazole, clotrimazole, miconazole, nystatin and terconazole. Fluconazole is used in complicated vaginal candidiasis. Trichomoniasis is treated with metronidazole and tinidazole [8].

The prognosis in vaginitis is generally good. Most causes of this condition are completely curable. Recurrent infections may however lead to irritation, excoriation and scar formation which can cause sexual dysfunction and lead to emotional and psychosocial stress. Complications of vaginitis include pelvic inflammatory disease (PID) and endometritis. Patients with this condition are also at risk of bad pregnancy outcomes like low birth weight and preterm labor [5].

Up to 90% of vaginitis are caused by bacterial vaginosis, vaginal candidiasis and Trichomonas vaginalis. Bacterial vaginosis is the commonest and is caused by an overgrowth of organisms like Gardnerella vaginalis and peptostreptococcus species. Factors that may predispose to this include frequent douching, pregnancy and use of intrauterine contraceptive devices (IUDs).

The second commonest cause is the candida species. They are natural inhabitants of the vagina in many women and they colonize the vagina when there is a disruption in the normal balance. This can be due to immunosuppressed states like HIV, long term antibiotic use, oral contraceptive use, receptive cunnilingus, young age at coitarche (first sexual intercourse), increased frequency of coitus and pregnancy [2].

Trichomonas vaginalis is the third commonest cause. This is usually transmitted sexually and is seen is up to 80% of male partners of infected females. Risk factors are unprotected sexual intercourse, multiple sexual partners, tobacco use and use of IUDs.

Vaginitis can also result from estrogen deficiency (atrophic vaginitis). Other causes are damp clothing, tight fitting clothing, poor hygiene and feminine sprays.

It is a strictly feminine condition. It is commoner in adult women compared to prepubertal females. In women of child bearing age, bacterial vaginosis is the most common vaginal infection and there is an estimated 7.4 million new cases recorded yearly. The rates however vary in subpopulations with the prison inmates and commercial sex workers having the highest prevalence of up to 60%. It is estimated than over a billion dollars is spent each year on self-medication and professional visits which makes this a serious public health concern [3].

Vaginitis is commoner is the black race and less common in Asians.

There are a complex blend of microorganisms that work intricately to create a balance of the normal vaginal flora. These organisms include lactobacilli, yeast and corynebacteria. When there is an alteration in the normal composition due to age, hormones, sexual activity or abuse, hygiene, skin diseases or immunologic status, there is an overgrowth of the normal flora, invading bacteria or other organisms. When the pH of the vagina is altered (normal pH is 3.8 – 4.2), there could be a distortion of the normal flora leading to an overgrowth of pathogens [4].

Prevention is through best lifestyle practices and diet choices. Acidophilus supplements and an increased intake of garlic are useful in preventing vaginitis in patients taking antibiotics. Safe sexual practices may also help in reducing the incidence. Practice good hygiene, avoid tight fitting underpants, underwear should be 100% cotton, avoid douching and feminine sprays and ensure the vaginal area is kept dry as much as possible.

There are different types of vaginitis depending on the cause. The commonest ones are bacterial vaginosis, yeast infection (candida), trichomoniasis and atrophic vaginitis which is a result of reduced estrogen levels. It is not a medical emergency and treatment is usually directed at the cause [1].

Definition

Vaginitis is an inflammation of the vagina. It is mainly a problem of women of child bearing age and is rare in prepubertal children. If seen in prepubertal children, abuse should be suspected. It is the commonest cause of visits to the gynecologist.

Cause

It is usually caused when there is an alteration in the acid balance of the vagina and when there is an imbalance in the composition if the normal vaginal microorganisms. This imbalance will lead to overgrowth of one organism or allow the entry of an external organism. Factors that contribute to this are frequent sexual intercourse with multiple partners, excessive douching, oral contraceptive use, and pregnancy amongst others.

Symptoms

The commonest symptom is vaginal discharge which could be smelly or not. Others are itching, pain, burning sensation, painful sex and bleeding after sex.

Diagnosis

Diagnosis is performed by a bedside vaginal examination to see the discharge and some laboratory tests are also carried out on the discharge to know the specific type.

Treatment

This includes the use of various antibiotics and antifungal drugs. Some non-drug treatments include proper hygiene, proper toilet practices and sitz bath.

1. Donati L, Di Vico A, Nucci M, et al. Vaginal microbial flora and outcome of pregnancy. Arch Gynecol Obstet. Apr 2010;281(4):589-600.
2. Fredricks DN, Fiedler TL, Thomas KK, Oakley BB, Marrazzo JM. Targeted PCR for detection of vaginal bacteria associated with bacterial vaginosis. J Clin Microbiol. Oct 2007;45(10):3270-6. 
3. Ip WK, Lau YL. Role of mannose-binding lectin in the innate defense against Candida albicans: enhancement of complement activation, but lack of opsonic function, in phagocytosis by human dendritic cells. J Infect Dis. Aug 1 2004;190(3):632-40.
4. Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol. Nov 2003;189(5):1297-300
5. American College of Obstetricians and Gynecologists (ACOG). Vaginitis. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); May 2006:12 p. (ACOG practice bulletin; no. 72).
6. Angotti LB, Lambert LC, Soper DE. Vaginitis: making sense of over-the-counter treatment options. Infect Dis Obstet Gynecol. 2007;2007:97424.
7. Giraldo PC, Babula O, Gonçalves AK, Linhares IM, Amaral RL, Ledger WJ, et al. Mannose-binding lectin gene polymorphism, vulvovaginal candidiasis, and bacterial vaginosis. Obstet Gynecol. May 2007;109(5):1123-8. 
8. Jones HW, Jones GS. Pelvic pain and dysmenorrhea. In: Berek JS, Adashi EY, Hillard PA, eds. Novak's Textbook of Gynecology. 1996. 12th ed. Baltimore, Md: Williams & Wilkins; 399-428.