Clinical Guide > Common Complaints > Vaginitis


January 2011

Chapter Contents


Vaginitis is defined as inflammation of the vagina, usually characterized by a vaginal discharge containing many white blood cells (WBCs); it may be accompanied by vulvar itching and irritation. Vaginosis presents with increased vaginal discharge without inflammation. Vaginitis usually is caused by an infection, but may be caused by other factors, such as chemicals or irritants. Vaginal infections are common among HIV-infected women. The presence of vaginal infections or inflammation, in the case of bacterial vaginosis in particular, may facilitate acquisition of HIV and other sexually transmitted infections (STIs), and trichomoniasis may facilitate HIV transmission to HIV-uninfected partners. This chapter focuses on two of the most common types of vaginal infections: trichomoniasis and bacterial vaginosis (BV). For information on the topic of vulvovaginal candidiasis, see chapter Candidiasis, Vulvovaginal.

S: Subjective

The patient complains of vaginal discharge with or without odor, itching, burning, pelvic pain, vulvar pain, or pain during intercourse.

Take a focused history, including the following:

O: Objective

Perform a focused physical examination of the external genitalia, including perineum and anal area, for the following:

Perform speculum examination for:

Perform a bimanual examination for masses or tenderness, if indicated.

A: Assessment

A partial differential diagnosis includes the following:

P: Plan

Diagnostic Evaluation

Treatment depends on the specific diagnosis, and in general is the same as for HIV-uninfected women.


Trichomoniasis is caused by the protozoan Trichomonas vaginalis. Many infected women have a diffuse, malodorous, yellow-green discharge. Most men who are infected with T. vaginalis have no symptoms; others have symptoms of nongonococcal urethritis. The diagnosis usually is made by visualization of motile trichomonads on microscopic examination of wet mounts. Antigen or nucleic acid assays have greater specificity and sensitivity than wet mount preparations, and may be used if microscopy is negative. Culture of vaginal secretions is the most sensitive and specific diagnostic test for T. vaginalis, and also may help to rule out other infections.

Treatment: Recommended regimen
Treatment: Alternative regimen
Treatment during pregnancy
Treatment notes:
Treatment failure

Certain strains of T. vaginalis have diminished susceptibility to metronidazole and must be treated with higher dosages. If treatment failure occurs on metronidazole, consider tinidazole as above, or if single-dose metronidazole was used initially, consider metronidazole 500 mg PO BID for 7 days. If this is not effective, consult with a specialist.

Bacterial Vaginosis

BV is a clinical syndrome resulting from loss of the normal vaginal flora, particularly Lactobacillus, and replacement with anaerobic and other bacteria such as Gardnerella vaginalis and Mycoplasma hominis. The diagnosis is made on clinical and laboratory criteria. Usually, three of the following four characteristics should be present (note: only the clue cells are specific to BV):

Vaginal culture does not help establish the diagnosis. Rapid diagnostic test cards are available in some settings.

Many studies have documented an association between BV and infections such as endometritis, PID, and vaginal cuff cellulitis after gynecologic procedures. Therefore, the U.S. Centers for Disease Control and Prevention (CDC) recommends screening for and treating BV before invasive gynecologic procedures.

The sex partners of women with BV do not need to be treated.

Treatment: Recommended regimens
Treatment: Alternative regimens
Treatment during pregnancy
Treatment notes:
Treatment failure

Consider re-treatment for 7 days with metronidazole or clindamycin. Consider the possibility of an alternative or second cause of the patient's symptoms, as multiple conditions or pathogens may present concurrently. Perform testing for other conditions as suggested by symptoms, or if symptoms to do not resolve with initial treatment:

For information on other STIs or related conditions, see the CDC treatment guidelines.

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