Vaginitis

Definition
Vaginitis is inflammation of the vagina resulting in symptoms such as discharge, itching, irritation, and sometimes pain. It is a clinical syndrome caused by infection, irritation, or hormonal changes, and is one of the most common reasons for women to seek gynaecological care.

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Main Types and Causes

1. Infectious vaginitis

   • Bacterial vaginosis (BV) – overgrowth of anaerobic bacteria, most commonly Gardnerella vaginalis, with reduced lactobacilli

   • Vulvovaginal candidiasis – Candida albicans (most common), other Candida spp.

   • Trichomoniasis – Trichomonas vaginalis, a protozoan STI

2. Non-infectious vaginitis

   • Atrophic vaginitis – due to low estrogen (postmenopausal, postpartum, lactation)

   • Allergic/irritant vaginitis – from soaps, douches, spermicides, latex, perfumed hygiene products

   • Inflammatory vaginitis – idiopathic, possibly immune-mediated

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Risk Factors

• Multiple or new sexual partners (BV, trichomoniasis)

• Antibiotic use (predisposes to candidiasis)

• Uncontrolled diabetes mellitus

• Immunosuppression (HIV, corticosteroids)

• Hormonal changes (menopause, pregnancy, lactation)

• Use of irritants (scented products, douches)

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Clinical Features
Symptoms vary by cause:

Cause	Discharge	Odour	pH	Other symptoms
Bacterial vaginosis	Thin, homogenous, grey-white	Fishy smell (↑ with KOH “whiff test”)	>4.5	Mild irritation, often asymptomatic
Candidiasis	Thick, white, “cottage cheese-like”	None	Normal (≤4.5)	Intense itching, burning, vulval erythema
Trichomoniasis	Frothy, yellow-green	Often present	>4.5	Itching, dysuria, “strawberry cervix”
Atrophic vaginitis	Scant, watery	None	>4.5	Vaginal dryness, burning, dyspareunia
Allergic/irritant	Variable	None	Variable	Burning, redness, temporal link to exposure

Diagnosis

• History and pelvic examination – discharge appearance, odour, associated symptoms

• Speculum examination – assess vaginal mucosa and cervix

• Microscopy of vaginal fluid:

  • Saline wet mount (for clue cells in BV, motile trichomonads in trichomoniasis)

  • KOH prep (for fungal hyphae in candidiasis)

• Vaginal pH testing – elevated in BV and trichomoniasis; normal in candidiasis

• Culture or NAAT – for confirmation, especially in recurrent or atypical cases

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Treatment

A. Bacterial vaginosis

• Metronidazole 500 mg orally twice daily for 7 days

• OR Metronidazole 0.75% gel intravaginally once daily for 5 days

• OR Clindamycin 2% cream intravaginally at bedtime for 7 days

B. Vulvovaginal candidiasis

• Topical azoles (clotrimazole, miconazole) intravaginally for 1–7 days

• OR Fluconazole 150 mg orally single dose

• Recurrent cases: longer courses and/or maintenance therapy

C. Trichomoniasis

• Metronidazole 2 g orally single dose

• OR Tinidazole 2 g orally single dose

• Treat sexual partners simultaneously

D. Atrophic vaginitis

• Vaginal moisturisers/lubricants

• Topical vaginal oestrogen cream, pessary, or ring

E. Allergic/irritant vaginitis

• Avoid offending agent

• Symptomatic relief with emollients or mild topical corticosteroids if needed

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Prevention

• Safe sex practices (condom use, STI screening)

• Avoid douching and scented products

• Manage underlying conditions (e.g., diabetes)

• Use of probiotics has limited but emerging evidence for BV prevention