Description

• “Vaginosis” and “vaginitis” are broad terms indicating any disease process of the vagina caused by or leading to infection, inflammation, or changes in the normal vaginal flora. The difference between vaginitis and vaginosis is the presence (vaginitis) or absence (vaginosis) of inflammation.
• Common symptoms of vaginitis/vaginosis are vaginal discharge, odor, itching, burning, or pain.
• The most common causes of vaginitis/vaginosis are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis. Noninfectious causes (<10%) can include atrophic, irritant, allergic and inflammatory vaginitis.
• Diagnosis of vaginitis relies on a thorough history, physical exam, and clinical assessment. Microscopy, cultures, and DNA probes can be helpful in confirming the diagnosis.
• Normal physiologic vaginal discharge is clear to white, not malodorous, not associated with pain or pruritus, and the quantity varies during the menstrual cycle.

Epidemiology

• Vaginal symptoms are typical and common in the general population and are one of the most frequent reasons women present to their medical care providers accounting for approximately 10 million office visits each year (1).
• BV is the most common cause of vaginal discharge in reproductive-aged women (2).
• VVC is the second most common cause of vaginitis in reproductive-aged women (2).

Incidence
An estimated 7.4 million cases of BV occur yearly in the United States (1).

Prevalence

• Prevalence rates of BV are in the range of 15% in pregnant women, 20–25% young females at student health clinics, and up to 30–40% among women seen at sexually transmitted disease (STD) clinics (1).
• The prevalence of BV in the United States is estimated to be 21.2 million among women ages 14 to 49 based on a nationally representative sample of women who participated in NHANES 2001 to 2004.
• Nonwhite women have higher rates of BV (African-American 51%, Mexican Americans 32%) than white women (23%).
• 29–40% of all females report at least one episode of VVC.
• VVC is uncommon in prepubescent girls and postmenopausal women and is often overdiagnosed in these populations.
• Recurrent VVC (four or more documented episodes in 1 year) occurs in <5% of the population.
• Vaginal trichomoniasis is a common STD with 3 to 5 million cases diagnosed in the United States yearly (2).
• African-American women are 10 times more commonly affected by vaginal trichomoniasis when compared to white and Hispanic women (2).
• Desquamative inflammatory vaginitis (DIV) is found in 2–20% of pregnant and nonpregnant women (1).

Etiology and Pathophysiology

• BV is caused by a change in the normal vaginal flora, it is neither a true infectious nor inflammatory state (2). Dominant lactobacilli responsible for maintaining the acidic vaginal pH are overcome with an overgrowth of facultative anaerobic organisms and lack of hydrogen peroxide producing lactobacilli (2).
  • Change in the vaginal environment leads to an increase in the pH, causing a malodorous, clear, white, or gray discharge and a fishy odor.
  • The organisms generally implicated in BV infections: Gardnerella vaginalis, Prevotella species, Porphyromonas species, Bacteroides species, Peptostreptococcus species, Mycoplasma hominis, Ureaplasma urealyticum, Mobiluncus species, Fusobacterium species, Atopobium vaginae
  • Not directly caused by the sexual transmission of a single pathogen
• VVC is caused by Candida species, particularly Candida albicans (80–92%) and Candida glabrata (<10%).
  • Candida organisms can be identified in the lower genital tract in healthy women, and it is thought to gain access via rectal and perianal colonization and migration.
  • C. albicans can be found in normal flora as a commensal agent in 10–25% of asymptomatic women.
  • Symptoms occur when candidal organisms overwhelm the normal vaginal flora and invade the superficial vaginal epithelial cells, causing inflammation, pruritus, and thick vaginal discharge.
  • Complicated VVC should be considered in pregnant patients, patients with diabetes, or immunocompromising conditions. Patients who experience four or more episodes of VVC in a year or who have only budding yeast on wet mount may also be considered to have complicated VVC.
• Trichomoniasis caused by an infection via Trichomonas vaginalis, a flagellate protozoan. The organism infects the squamous epithelium of the vagina as well as the urethra and paraurethral glands. This infection is primarily transmitted during sexual intercourse.
• DIV—a chronic, purulent vaginitis occurring most commonly in the perimenopause with an uncertain etiology or pathogenesis. Inflammation is cardinal feature. The vagina is colonized with facultative bacteria, not the obligate anaerobic bacteria that colonize the vagina in BV (1). The microflora in DIV consist of Escherichia coli, Staphylococcus aureus, group B streptococcus, and Enterococcus faecalis.
• Atrophic vaginitis—genitourinary symptoms resulting from a lack of estrogen
• Irritant/allergic vaginitis—vaginal symptoms can result from mechanical, chemical, or allergic irritation.

Genetics
No genetic component known at this time

Risk Factors

• BV
  • Sexual activity; although BV is not considered an STD, studies show increased rates of BV in women with multiple sexual partners.
  • Women who have sex with women, smoking, vaginal douching, low socioeconomic status, the presence of STDs such as HSV-2, use of an IUD
  • Male circumcision decreases risk.
• VVC—diabetes, recent use of antibiotics, immunosuppression, higher estrogen levels, estrogen-containing contraceptives
• Trichomoniasis
  • Inconsistent use of barrier contraception, multiple sexual partners, limited education and low socioeconomic status, illicit drug use, smoking, another coexistent STI, douching, incarceration (2)
• Other risk factors associated with vaginitis/vaginosis:
  • Decreased estrogen; smoking; use of vaginal douches, creams, gels, or lubricants; tight-fitting clothing; poor hygienic practice; changes in diet; condoms, sex toys, tampons

General Prevention

• Vulvar hygiene with warm water and unscented cleanser; advise patients not to douche. Wear cotton underwear.
• Except in cases of trichomoniasis, treatment of sexual partners generally is not recommended but may be considered in recurrent cases.

Commonly Associated Conditions

• STDs such as gonorrhea, chlamydia, HSV, or HIV
• Vaginal intraepithelial neoplasia and cancer can present with symptoms of vaginitis.