vaginitis--%20trichomoniasis,%20candidiasis,%20bacterial%20vaginosis
VAGINITIS: TRICHOMONIASIS, CANDIDIASIS, BACTERIAL VAGINOSIS

Trichomoniasis is caused by a flagellated protozoan, Trichomonas vaginalis. It is always sexually transmitted.

Bacterial vaginosis is the most common cause of vaginitis, vaginal discharge or malodor. It results from overgrowth of anaerobic bacteria.

Vulvovaginal candidiasis is caused by overgrowth of yeasts where 70-90% of cases are secondary to Candida albicans. It most commonly occurs when the vagina is exposed to estrogen (ie, reproductive years, pregnancy) and may be precipitated by antibiotic use.

Introduction

  • Altered vaginal discharge in women of reproductive age may be secondary to non-sexually transmitted infections (eg bacterial vaginosis, vulvovaginal candidiasis), sexually transmitted infections (eg Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Herpes simplex virus), or non-infective causes (eg foreign bodies, cervical polyps or ectopy, genital tract malignancy, fistula, allergies)
  • Please see Chlamydia - Uncomplicated Anogenital Infection, Genital Herpes, and Gonorrhea - Uncomplicated Anogenital Infection Disease Management Charts for details

Definition

Trichomoniasis
  • Caused by a flagellated protozoan, Trichomonas vaginalis (TV)
  • Considered the most common non-viral sexually transmitted infection (STI)   
  • Most infections present with minimal or no symptoms and if left untreated may last for months to years  
  • Always sexually transmitted
Bacterial Vaginosis (BV)
  • Most common cause of vaginitis, vaginal discharge or malodor
  • Results from overgrowth of anaerobic bacteria (eg Prevotella sp, Mobiluncus sp), Gardnerella vaginalis, Ureaplasma sp, Mycoplasma hominis replacing the normal hydrogen peroxide-producing Lactobacillus sp in the vaginal flora
    • Presence of Gardnerella alone is not conclusive to diagnose bacterial vaginosis because it is a commensal organism in some asymptomatic women
  • Considered to be sexually associated but not truly sexually transmitted
    • May coexist with trichomoniasis and other STIs 

Vulvovaginal Candidiasis (VVC) 

  • Caused by overgrowth of yeasts where 70-90% of cases are secondary to Candida albicans
  • Most commonly occurs when the vagina is exposed to estrogen (ie reproductive years, pregnancy) and may be precipitated by antibiotic use
    • Immunocompromised and diabetic women are also at risk
  • Immunocompetent patients with sporadic or infrequent vulvovaginal candidiasis, mild to moderate vulvovaginal candidiasis, and with C albicans infection are considered to have uncomplicated vulvovaginal candidiasis
  • Immunocompromised or debilitated patients with recurrent (>4 episodes/year), severe, or non-albicans vulvovaginal candidiasis are classified to have complicated vulvovaginal candidiasis
  • Though sexually associated, it is not an STI

Signs and Symptoms

Clinical Observations Associated with Vaginal Infections

Trichomoniasis

  • 10-50% of patients are asymptomatic
  • Scanty to profuse offensive vaginal discharge may be present
  • Patient may complain of vulval itching, dysuria and rarely, lower abdominal discomfort
  • Pelvic exam may reveal vulval erythema (“strawberry cervix”), vaginitis, cervicitis, vulvitis, or frothy, malodorous, yellow vaginal discharge pooled at the posterior fornix

Bacterial Vaginosis

  • 50% of patients are asymptomatic 
  • Thin discharge with fishy/offensive odor may be present
  • Pelvic exam may reveal white/gray homogenous discharge that coats the walls of vagina and vestibule

Vulvovaginal Candidiasis

  • 10-20% of patients are asymptomatic
  • Patient may complain of vulval itching and soreness, superficial dyspareunia, external dysuria, and non-offensive vaginal discharge
  • Pelvic exam may show vulval erythema and fissuring, curdy (cottage cheese-like) vaginal discharge, satellite skin lesions and vulval edema
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