75 Vaginitis

Vaginitis
The right clinical information, right where it's needed
Last updated: May 05, 2016

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 5
Prevention 6
Primary prevention 6
Screening 6
Secondary prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 9
History & examination factors 10
Diagnostic tests 12
Differential diagnosis 13
Diagnostic criteria 14
Treatment 16
Step-by-step treatment approach 16

Treatment details overview 17
Treatment options 20
Emerging 31
Follow up 32
Recommendations 32
Complications 33
Prognosis 33
Guidelines 34
Diagnostic guidelines 34
Treatment guidelines 35
Evidence scores 37
References 39
Images 43
Disclaimer 45
Summary
◊ Bacterial vaginosis continues to be a leading cause of vaginitis; other common infectious causes include
trichomoniasis and candidiasis, although non-infectious causes are also possible.
◊ Affects all age groups of women, particularly during their reproductive years. Black women are most commonly
affected.
◊ Common symptoms include discharge, pruritus, and dyspareunia.
◊ It is recommended to screen for STDs in all patients with infective vaginitis.
◊ Sexual partners of patients with Trichomonas vaginalis should be treated and offered screening for other STDs.
Vaginitis Basics
Definition
Vaginitis is inflammation of the vagina due to changes in the composition of the vaginal micro-environment from infection,
BASICS
irritants, or from hormonal deficiency (e.g., atrophic vaginitis). Bacterial vaginosis, trichomoniasis, and candidiasis are
types of infections that cause vaginitis.
Epidemiology
Vaginitis is the most common gynaecological diagnosis in the primary care setting.[2] Women presenting with vaginal
discharge account for approximately 10 million office visits each year. In approximately 90% of affected patients in the
US, this condition develops secondary to bacterial vaginosis, candidiasis, or trichomoniasis, of which bacterial vaginosis
is the most common.[3] The incidence of Trichomonas has decreased dramatically in the US during the past 15 years,
partially due to the use of metronidazole.[3] However, global data suggest that trichomoniasis is the most common
sexually transmitted infection worldwide.[4]
The incidence of vulvovaginal candidiasis has increased during the past decade, particularly the non-albicans Candida
strains.[5] In Graz, Austria, non-albicans candida was detected in 12.1% of samples from women diagnosed with vulvovaginal
candidiasis between 2000 and 2004.[6]
Black women report higher incidence of candidiasis infections compared with white women.[7]
A study of pregnant women in Havana, Cuba, revealed a prevalence of 42.3% for candidiasis and 9.84% for trichomoniasis.[8]
In Hanoi, Vietnam, the prevalence of lower genital tract infections in women, most of whom were married and sexually
monogamous, attending maternal and child health and family planning clinics was the following: Candida, 11.1%;
Trichomonas vaginalis, 1.3%; Chlamydia trachomatis, 4.4%; bacterial vaginosis, 3.5%.[9]
Atrophic vaginitis may affect up to 40% of postmenopausal women, but very few seek medical care.[10] [11]
Aetiology
An overgrowth of bacterial organisms such as Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Escherichia
coli, group B streptococci, and Peptostreptococcus species are proven to be the main cause of bacterial vaginosis.[12]
Candida albicans, the second-most common cause of vaginitis, is the principal yeast responsible for vulvovaginal candidiasis.
Species that are more resistant to treatment, like Candida glabrata and Candida tropicalis, are known to be aetiological
factors.
Trichomonas vaginalis, a highly transmissible flagellated protozoan, is associated with vaginitis. The micro-organism can
be identified in up to 80% of male partners.[13] [14]
Atrophic vaginitis occurs due to declining oestrogen levels, predominantly in women who are postmenopausal. In addition,
the micro-environment in the vagina is supported by the presence of oestrogen. In premenopausal women, atrophy is
rare, but may be due to interference with ovarian production of oestrogen: for example, anti-oestrogen medication or
surgery.[10] [11]
Situations that alter the vaginal environment, such as douching, poor or excessive hygiene, antibiotics, certain soaps,
tobacco, tampons, contraceptive devices, and HIV, will increase the chances of acquiring the condition.[1] [15]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 05, 2016.
4 BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use
of this content is subject to our disclaimer. © BMJ Publishing Group Ltd 2015. All rights reserved.
Vaginitis Basics
Pathophysiology
Altering the vaginal pH leads to overgrowth of normal micro-organisms present in the vagina. Hydrogen-peroxide producing
BASICS
lactobacilli are important in preventing overgrowth of the anaerobes normally present in the vaginal flora. During the
reproductive years, the normal pH of the vagina is 3.8 to 4.2; as long as this low pH is maintained, no overgrowth can
occur.
In postmenopausal women, declining estrogen levels lead to vaginal atrophy. The vaginal mucosa becomes thinner and
drier, less elastic and more prone to inflammation.
BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com . Use
5
Vaginitis Prevention
Primary prevention
Avoiding douching and irritants such as strong soaps or bubble baths can help prevent vaginitis. Male condoms may help
prevent spread of infection. Lactobacillus acidophilus supplements in the diet may help to prevent recurrence of infectious
vaginitis.[23]
Screening
Bacterial vaginosis
Bacterial vaginosis is known to increase the risk of pregnancy complications (for example, preterm premature rapture of
membranes, preterm birth) but the evidence does currently not support routine screening for bacterial vaginosis in
asymptomatic pregnant women.[12] [30] There is insufficient evidence to assess the trade-off between benefits and
harms of screening asymptomatic pregnant women at high risk of preterm delivery.
Although bacterial vaginosis occurs more commonly in women with female sexual partners, routine screening for bacterial
vaginosis is currently not recommended for this population.[12]
PREVENTION
Trichomonas
Screening for Trichomonas vaginalis should be considered in women at high risk for infection (i.e., women who have new
or multiple partners, have a history of STDs, exchange sex for payment, or use injection drugs).[12]
Although Trichomonas vaginalis infection is known to increase the risk of pregnancy complications (for example, preterm
premature rapture of membranes, preterm birth), the evidence does currently not support routine screening in
asymptomatic pregnant women at low risk of infection.[12]
Secondary prevention
In bacterial vaginosis, treatment of sexual partners is not recommended.6[B]Evidence
Patients who have bacterial vaginosis or trichomoniasis, and who are also HIV-positive, should receive the same treatment
regimen as those who are HIV-negative.[12]
Sexual partners of patients with Trichomonas vaginalis should be treated and offered screening for other STDs. Patients
should avoid sex until they and their sexual partners are cured, or should at least use condoms.
Vulvovaginal candidiasis is not usually acquired through sexual intercourse; treatment of sexual partners is not
recommended, but should be considered in women who have recurrent infection. If a male sexual partner presents with
symptoms (e.g., irritation), these may be managed with topical agents.[12]
Bacterial vaginosis and candidiasis are not typically sexually transmitted; however, they may occur concomitantly with
STDs (e.g., gonorrhoea and chlamydial infections) and therefore it is recommended to screen for STDs in all patients with
infective vaginitis.
Vaginitis Diagnosis
Case history
Case history #1
A 25-year-old white woman presents with a malodorous vaginal discharge and pruritus for the last 15 days. She reports
the smell is worse after intercourse and the discharge is white. She is in a stable monogamous relationship and has
never been pregnant. She denies any significant medical or gynaecological history. She reports this is the first time
she has had these symptoms and is worried about STDs. Physical examination shows a white discharge in the posterior
vaginal fornix, but there is no vaginal erythema or bleeding.
Case history #2
A 46-year-old black woman presents with complaints of white vaginal discharge, dyspareunia, pruritus, and vulvar
burning, especially when she urinates. She reports the vaginal discharge looks like cottage cheese and has no odour.
She has a 10-year history of diabetes mellitus type 2, which is treated with metformin; she denies any other medical
history. She has not had similar symptoms in the past. On physical examination, the vaginal walls are covered by white
plaques with the appearance of cottage cheese. Upon detaching them from the base, an erythematous area is left.
Hyphae and budding yeast are noted on the wet mount. There is also an erythematous area in the upper third of the
vulva, near the urethra. There is no other abnormal finding on the physical examination.
Other presentations
Patients with atrophic vaginitis present postmenopause with symptoms of dryness, dyspareunia, vaginal spotting,
and, less commonly, dysuria. Atrophic vaginitis may occur in non-menopausal women with a history of chemotherapy,
radiotherapy, or oophorectomy.
Irritant or allergic vaginitis presents with similar symptoms of vulvodynia, dyspareunia, or pruritus, with or without a
history of atopy. Patients may report douching, and/or a recent change in soaps, contraceptive devices, tampons,
and medications.[1]
DIAGNOSIS
Step-by-step diagnostic approach
Diagnosis is based on clinical findings, and confirmed with vaginal samples. Patients frequently self-diagnose vaginitis
and treat with over-the-counter medications.
Sexual partners of patients with Trichomonas vaginalis should be offered screening for other STDs. Bacterial vaginosis
and candidiasis are not typically sexually transmitted; however, they may occur concomitantly with STDs (e.g., gonorrhoea
and chlamydial infections) and therefore it is recommended to screen for STDs in all patients with infective vaginitis.
History
Precipitating factors for vaginitis include douching, poor or excessive hygiene, and antibiotic, IUD, or OCP use. In
addition, a history of recent change in feminine hygiene products and/or soaps, or use of latex condoms or diaphragms,
may be suggestive of irritant or allergic vaginitis. Infective vaginitis is more common during the reproductive years,
whereas the menopause predisposes to atrophic vaginitis. Vulvovaginal candidiasis is more frequently seen in black
women, and women with diabetes or HIV. Weaker risk factors include smoking, more frequent intercourse, and
pregnancy.
7
Vaginitis Diagnosis
The history should assess the entire spectrum of vaginal symptoms, including change in discharge, vaginal malodour,
itching, dyspareunia, and dysuria. Questions about the location of symptoms (vulva, vagina, and anus), duration, the
response to prior treatment including self-treatment and douching, and a sexual history regarding number of sexual
partners and prior sexually transmitted infections can yield important insights into the likely aetiology.[24]
Atrophic vaginitis is suggested by a history of dyspareunia, dryness, and dysuria in a postmenopausal woman and is
diagnosed clinically. Patients with vulvovaginal candidiasis often report a white, thick discharge like cottage cheese
that is odourless, whereas women with bacterial vaginosis report a malodorous, white discharge, which is often more
noticeable following sexual intercourse. In trichomoniasis, a sexually transmitted infection, the discharge is described
as green, yellow, or white; frothy; and odorous.
Vaginal bleeding may occur from cervicitis in trichomoniasis; rarely it is also related to vaginal dryness in atrophic
vaginitis.
Fever and abdominal pain are very rare presenting symptoms and are usually associated with comorbid STDs.
Examination and vaginal samples

Examination involves external inspection of the genitalia and internal examination with a speculum.
Irritant or allergic vaginitis is typically diagnosed clinically, and examination may demonstrate erythema with or without
oedema.[25]
Atrophic vaginitis is typically diagnosed clinically based on history and evidence of atrophy on examination (decreased
elasticity; dryness; friable, pale, shiny epithelium).
Candidiasis is typically diagnosed clinically with evidence of erythema and a thick, white, cottage cheese-like discharge
adherent to lateral vaginal walls, but may be confirmed by 10% potassium hydroxide (KOH) wet mount preparation
or culture.
If bacterial vaginosis or trichomoniasis is suspected, vaginal samples for vaginal pH, amine ('whiff') test, saline, and
KOH microscopy (wet mount) aid diagnosis, together with clinical findings. [Fig-1]
DIAGNOSIS
The pH and amine testing can be performed either through direct measurement or by colorimetric testing. It is
important that the swab for pH evaluations be obtained from the mid-portion of the vaginal side wall to avoid false
elevations in pH results caused by cervical mucus, blood, semen, or other products.[24]
An elevated pH is seen in bacterial infections and atrophic vaginitis.
Depending on institution preference, bacterial vaginosis may be diagnosed by vaginal Gram stain (Nugent criteria) or
by the presence of at least 3 Amsel criteria:[26] [27]
• Vaginal pH >4.5
• 'Whiff' test
• Clue cells (vaginal epithelial cells with distinctive stippled appearance in saline wet mount by being covered
with bacteria)[Fig-4]
• Adherent white vaginal discharge.
Vaginitis Diagnosis
In trichomoniasis, the wet mount reveals numerous WBCs and motile protozoa.[Fig-3] On inspection, the cervix may
have a punctate and papilliform appearance (strawberry cervix).
Laboratory tests
If the diagnosis is still uncertain, vaginal cultures or polymerase chain reaction tests for trichomoniasis or yeast may
be warranted for infections that are resistant to treatment. These techniques are not carried out routinely.
A Gram stain of vaginal secretions for Nugent scoring of the bacterial flora identifies patients with bacterial vaginosis.[27]
Other available tests for diagnosis include rapid tests for enzyme activity from bacterial vaginosis-associated
organisms.[12] [24] [28] [29]
STD testing is recommended in patients with recurrent infections and/or those who are at risk of exposure to STDs
(e.g., unprotected intercourse), and should include tests for gonorrhoea, chlamydia, syphilis, and HIV.[12] Bacterial
vaginosis and candidiasis are not typically sexually transmitted; however, they may occur concomitantly with STDs
(e.g., gonorrhoea and chlamydial infections) and therefore it is recommended to screen for STDs in all patients with
infective vaginitis.
Risk factors
Strong
douching
• May alter the flora micro-environment of the vagina, due to changes in pH.[1]
poor or excessive hygiene

• Personal hygiene may affect the microflora of the vagina.
antibiotic use
• Recent course of antibiotics may precipitate vaginitis, especially candidiasis. Results in a misbalance in vaginal
DIAGNOSIS
flora.[16]
change in feminine hygiene products and/or soap

• May be suggestive of irritant/allergic aetiology.
HIV infection
• Immunosuppression, particularly low CD4 count and high HIV viral load, is associated with vulvovaginal
candidiasis.[17]
diabetes
• There is a direct correlation between hyperglycaemia and incidence of vaginitis, particularly caused by Candida
albicans.[18]
black women
• Vulvovaginal candidiasis may be more common in this population. Unclear reason for race predilection.
IUD
• May alter the flora micro-environment of the vagina.[19]
9
Vaginitis Diagnosis
OCP use
• Alters the hormonal balance and, therefore, the flora of the micro-environment. Associated with increased risk of
vulvovaginal candidiasis infection.
latex condom/diaphragm
• Allergic vaginitis may present in women allergic to latex.
reproductive age
• Infective vaginitis is more common in these women.
menopause
• Reduced oestrogen levels alter elasticity and pH of vagina, predisposing to atrophic vaginitis.[10]
multiple or new sex partners

• Number of sexual partners and history of sexually transmitted diseases are key factors. Having multiple male or
female sex partners is a risk factor for bacterial vaginosis.[12]
Weak
tobacco
• Possible changes in vaginal pH; weak evidence.[20]
increased frequency of intercourse

• Changes in vaginal pH; weak evidence.[21]
pregnancy
• Increases oestrogen levels, possibly altering the vaginal flora. The evidence for this association is weak.[22]
History & examination factors

DIAGNOSIS
Key diagnostic factors
presence of risk factors (common)

• Strong risk factors include: douching; poor or excessive hygiene; prior antibiotic use; HIV infection; diabetes; black
women; presence of IUD; use of the OCP; women of reproductive age; menopause; and sexual activity.
vaginal discharge (common)

• Colour, odour, consistency, frequency, and amount are all important factors in diagnosing the cause.
• Commonly, discharge is white, thick, cottage cheese-like, and odourless in Candida infections; thin, malodorous,
and white in bacterial vaginosis; thin/thick, green, yellow, or white, frothy, and odorous in trichomoniasis. [Fig-1]
dysuria (common)
• Associated with candidiasis and trichomoniasis. Also associated with atrophic vaginitis.
discharge adherent to vaginal mucosa (common)

• White-to-grey discharge adherent to the vaginal mucosa in bacterial vaginosis; thick, white, cottage cheese-like
discharge adherent to lateral vaginal walls in candidiasis.
Vaginitis Diagnosis
Other diagnostic factors

prior episodes (common)
• May increase risk of future episodes, but does not help in distinguishing a particular aetiological factor.
pruritus (common)
• Associated with bacterial vaginosis, candidiasis, and trichomoniasis.
• Also a common complaint in allergic or irritant causes of vaginitis.
vulvodynia (common)
• A common complaint in women with allergic or irritant vaginitis.
vaginal dryness (common)

• Associated commonly with atrophic vaginitis.
dyspareunia (common)
• Commonly associated with atrophic vaginitis and candidiasis.
• A general presenting symptom for most types of vaginitis.
erythema (common)
• Commonly present in candidiasis and allergic or irritant vaginitis.
pale epithelium (common)

• Atrophy in atrophic vaginitis results in diminished capillary blood supply and the epithelium appears pale.
shiny epithelium (common)

• Thinning epithelium in atrophic vaginitis typically has a shiny appearance.
decreased elasticity (common)

• Skin looks dry and there is loss of turgor in atrophic vaginitis.
DIAGNOSIS
friable epithelium (common)
• May be noted on insertion of speculum in women with atrophic vaginitis.
fever (uncommon)
• Very uncommon; not necessarily indicative of severity.
• Possibly more common with trichomoniasis since it is related to other STDs.
vaginal bleeding (uncommon)

• May occur from cervicitis associated with trichomoniasis. Vaginal bleeding in atrophic vaginitis is rare, although
can be related to vaginal dryness.
abdominal pain (uncommon)

• Abdominal pain is a very rare presenting symptom, but may occur in association with pelvic inflammatory disease
due to concomitant STD.
strawberry cervix (uncommon)

• On inspection, the cervix may have a punctate and papilliform appearance in trichomoniasis.
11
Vaginitis Diagnosis
Diagnostic tests
1st test to order
Test Result
vaginal pH elevated/normal
• The normal vaginal pH in women of childbearing age is 4.5.
• In postmenopausal women, the vaginal pH is generally in the 6.0 to 7.0 range.
• Elevated pH is seen in bacterial infections, including trichomoniasis, and in
atrophic vaginitis.
• Generally, Candida infections will present with a normal range pH.
amine 'whiff' test of vaginal secretions positive in bacterial vaginosis
• The presence of volatile amines (fishy odour) is not encountered in normal
vaginal fluids.
• The presence of a fishy odour following addition of 10% potassium hydroxide
(KOH) to the vaginal sample indicates a positive result for bacterial vaginosis.
wet mount microscopy of vaginal secretions identification of bacteria and
• Vaginal samples added to two different slides, one with saline solution and one yeast infections
with KOH solution.
• Bacterial vaginosis: clue cells (vaginal epithelial cells with distinctive stippled
appearance by being covered with bacteria) are present and are seen as vaginal
epithelial cells covered with many rods and cocci, with a granular
appearance.[Fig-4] The numbers of lactobacilli are decreased and WBCs are
absent.
• Candidiasis: hyphae and budding yeast are better seen with the KOH preparation
microscopy.[Fig-2]
• Trichomoniasis: a significant number of WBCs and epithelial cells are observed.
The parasite is a motile oval or fusiform-shaped protozoan 15 micrometres
long.[Fig-3]
Gram stain of vaginal secretions Lactobacillus morphotype
reduced or absent
• Scored in accordance to Nugent classification, which involves counting the
DIAGNOSIS
bacterial morphotypes. Reduced or absent lactobacilli are indicative of bacterial

vaginosis.[27]
HIV test may be positive
• Routine to rule out HIV. Time to HIV seropositivity with a third-generation
enzyme immune assay (EIA) can be >21 days.
• Recommended in patients with recurrent infections and/or those who are at
risk of exposure to STDs (e.g., unprotected intercourse).
• Bacterial vaginosis and candidiasis are not typically sexually transmitted;
however, they may occur concomitantly with STDs (e.g., gonorrhoea and
chlamydial infections) and therefore it is recommended to screen for STDs in
all patients with infective vaginitis.
nucleic acid amplification test (NAAT) may be positive
• Recommended for diagnosis of chlamydial infection and gonorrhoea.[12]
Vaginitis Diagnosis
Test Result
VDRL may be positive
• Routine to exclude syphilis.
serum rapid plasma regain (RPR) test may be positive
• Routine to exclude syphilis.
Other tests to consider
Test Result
culture of vaginal secretions positive for
• Trichomoniasis results take approximately 3 days. Although this is the most trichomoniasis/candidiasis
specific and sensitive test for trichomoniasis, wet mount preparation remains infections
the first-line test as it is quicker.
• May aid diagnosis in treatment-resistant cases of Candida and trichomoniasis.
PCR for trichomoniasis on vaginal secretions positive if trichomoniasis
• PCR targeting the beta-tubulin genes of Trichomonas vaginalis.[28]
rapid enzyme tests of vaginal secretions positive for
trichomoniasis/bacterial
• Antitrichomonal IgA antibody in the vaginal secretions by micro-ELISA
DIAGNOSIS
vaginosis associated with
technique.[29]
Gardnerella vaginalis
• Detects proline iminopeptidase from Gardnerella vaginalis.[12]
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Gonorrhoea • Pelvic or lower abdominal pain • Neisseria gonorrhoeae grown on
and fever may be present if chocolate agar culture.
ascending infection.
Chlamydia • Many are asymptomatic; • Chlamydia trachomatis on nucleic

intermenstrual bleeding, acid amplification technique.
cervicitis, and abdominal pain may
be differentiating.
13
Vaginitis Diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Cervicitis • Intermenstrual bleeding; friable • Cervical discharge collected for
cervix on physical examination; Gram stain may indicate Neisseria
genital warts may be present if gonorrhoeae or Chlamydia
caused by HPV. trachomatis. Cervical cytological
testing may be positive for HPV.
Lichen planus • Pruritus, intense vulvodynia, and • Diagnosis is typically clinical.

dyspareunia are common • Histopathology may demonstrate
symptoms. a band-like lymphocytic infiltrate,
• Differentiating signs may include necrotic keratinocytes, and
presence of violaceous, hyperkeratosis.
flat-topped papules or plaques.
These lesions may be present
elsewhere on the body (e.g., flexor
wrists and ankles).
Other causes of vaginal • Vaginal discharge may be • Papanicolaou smear: positive for
discharge physiological, and is typically cervical cancer.
odorous, mucousy, and • CT of abdomen or pelvis with
white-to-yellowish. oral/IV contrast: demonstrates
• Other less common pathological malignancy.
causes include desquamative • Vaginal wall biopsy: features of
inflammatory vaginitis (associated acute and chronic desquamative
with purulent and copious inflammation.
discharge), pelvic irradiation,
fallopian tube cancer (palpable
pelvic mass and vaginal bleeding),
and cervical cancer (late-stage
disease may present with watery
or foul-smelling vaginal discharge
most likely from necrotic mass).
DIAGNOSIS
Diagnostic criteria
Amsel diagnostic criteria and microbial and epidemiological associations[26]

Bacterial vaginosis:
• Vaginal pH >4.5
• Whiff test
• Clue cells (vaginal epithelial cells with distinctive stippled appearance in saline wet mount by being covered with
bacteria)
• Adherent white vaginal discharge.
Nugent criteria[27]
Vaginitis Diagnosis
Vaginal Gram stain of the bacterial flora may help to identify patients with bacterial vaginosis. The Nugent score is derived
from an estimation of the different proportions of bacterial morphotypes present, to give a score between 0 and 10:
• <4 normal
• 4 to 6 intermediate
• >6 bacterial vaginosis.
DIAGNOSIS
15
Vaginitis Treatment
Step-by-step treatment approach

Treatment is initiated following diagnosis, which is based on clinical symptoms and microscopy of vaginal secretions.
Therapy depends on the aetiological organism and whether it is a first presentation or recurrence. Patients who have
bacterial vaginosis or trichomoniasis, and who are also HIV-positive, should receive the same treatment regimen as those
who are HIV-negative.[12]
Bacterial vaginosis
Treatment is indicated in all symptomatic women with bacterial vaginosis.[12] Although bacterial vaginosis is known
to increase the risk of certain pregnancy and neonatal complications, the only established benefits of treatment in
both pregnant and non-pregnant women are to relieve vaginal symptoms, reduce signs of infection, and potentially
to decrease the risk of acquiring HIV and other STDs (for example, Chlamydia trachomatis, Neisseria gonorrhoeae,
viral STDs).
In non-pregnant women, metronidazole is the treatment of choice.[12] Both topical and oral metronidazole seem
equally effective but intravaginal metronidazole may be associated with fewer adverse events.[31] [32] 1[B]Evidence
Metronidazole single-dose oral therapy has the lowest efficacy for bacterial vaginosis and is no longer
recommended.3[A]Evidence
Vaginal clindamycin cream is a useful first-line alternative in patients with contraindications to metronidazole therapy
or those who cannot tolerate metronidazole.[32] 4[C]Evidence Second-line treatment options include oral tinidazole,
oral clindamycin, and vaginal clindamycin ovules. Tinidazole has a longer serum half-life than metronidazole and also
reaches higher levels in the genitourinary tract.
For persistent or recurrent infection, metronidazole is administered for a longer period of 4-6 months after completion
of a recommended regimen.[33] 2[B]Evidence Suppressive therapy has been shown to reduce the risk of recurrences
but this benefit might not persist after discontinuation.[33]
Pregnant women can be safely treated with oral metronidazole. Oral clindamycin is an effective alternative.[12]
Patients should avoid alcohol consumption during treatment with metronidazole and tinidazole, and for 24 and 72
hours respectively after receiving the last dose. Women of childbearing age need to be aware that due to its oil-based
formula, clindamycin cream might weaken latex condoms and diaphragms for 5 days after use.
Although non-antibiotic treatments are available (e.g., benzydamine), their safety and efficacy are not well supported
by long-term scientific data.[34] There is also no significant scientific evidence to support the use of antiseptics or
disinfectants in bacterial vaginosis.[35] [36]
Trichomoniasis
Treatment of trichomoniasis results in relief of symptoms, microbiologic cure, and reduction of transmission.[12]
Isolation of the micro-organism is not necessary in all cases: for example, in a symptomatic patient with a prior history
of trichomoniasis or a known disease in sexual partner.
Single-dose therapy with metronidazole is, in most cases, enough for pregnant and non-pregnant women, and treating
TREATMENT
sexual partners will help in preventing recurrence.
For resistant organisms and persistent infection, a different treatment approach is required. This involves higher doses
of metronidazole or treatment with tinidazole. Tinidazole is available for the treatment of trichomoniasis, and may
be considered as an alternative to the traditional treatment with metronidazole.[37] Tinidazole has a longer serum
Vaginitis Treatment
half-life than metronidazole and also reaches higher levels in the genitourinary tract. Several T vaginalis isolates have
lower minimum inhibitory concentrations (MICs) to tinidazole than metronidazole.[12]
Patients should avoid alcohol consumption during treatment with metronidazole and tinidazole, and for 24 and 72
hours respectively after receiving the last dose.[12]
Condom use, although not 100% effective, should be discussed with the patient as part of sexually transmitted disease
prevention.
Vulvovaginal candidiasis
Several therapeutic options are available, both intravaginally and orally. It is important to distinguish between
uncomplicated and complicated Candida vaginitis (recurrence, severity, infection with Candida species other than
Candida albicans, pregnancy, and immunocompromise, including diabetic patients).
For uncomplicated infection, treatment with oral or topical azole antifungal agents should be started.7[A]Evidence
For complicated infections, short-course antifungal therapy (oral or topical) for infection is initiated, followed by
maintenance therapy (oral or topical) for approximately 6 months.
Pregnant women are treated only with topical azoles, for no longer than 7 days.
If the patient has concomitant diabetes, improvement in glycaemic control will also prevent recurrence.
Atrophic vaginitis
Dyspareunia may be treated with lubricant gels before intercourse and these may be initiated immediately, to be
used until successful treatment is established with topical oestrogen. For patients on HRT, concomitant use of a
lubricant may be adequate in controlling symptoms. As with initiation of HRT, a detailed discussion with the patient
should take place to explain the intended local therapy. Benefits and risks of oestrogen therapy should be carefully
weighed for each individual patient, aiming to minimise both the amount of oestrogen and length of treatment.[38]
[39] The potential adverse effects versus associated benefits of the different formulations should be considered.
While oestrogen rings provide the freedom of every 3-month replacement, the vaginal creams may offer a significant
and immediate soothing effect to the atrophic area. The easiest applicable method, at the lowest dose, for each
individual patient also needs to be considered (e.g., a patient with joint deformities from arthritis may find it difficult
to apply an oestrogen cream every night, and an oestrogen ring may be the most appropriate approach for this
patient).
Infective or allergic vaginitis

Preventive measures are the mainstay of treatment. Avoiding causative agents, such as feminine hygiene products,
latex condoms/diaphragms, douching, and irritants such as strong soaps or bubble baths, can help prevent vaginitis.
Hormone-free vaginal creams and gels, often called emollients, are available without prescription and are commonly
used to restore vaginal pH and to relieve vaginal irritation and pruritus, and to increase vaginal moisture.
Treatment details overview

TREATMENT
Consult your local pharmaceutical database for comprehensive drug information including contraindications, drug
interactions, and alternative dosing. ( see Disclaimer )
17
Vaginitis Treatment
Acute ( summary )
Patient group Tx line Treatment
non-pregnant: isolated acute episode
bacterial vaginosis 1st metronidazole
1st clindamycin: intravaginal cream
2nd clindamycin: oral preparations or intravaginal

ovules
2nd tinidazole
trichomoniasis 1st nitroimidazole therapy
uncomplicated vulvovaginal 1st antifungal therapy

candidiasis
complicated vulvovaginal 1st antifungal therapy

candidiasis
pregnant: isolated acute episode
1st clindamycin
trichomoniasis 1st metronidazole
vulvovaginal candidiasis 1st clotrimazole
atrophic vaginitis 1st oestrogen therapy
irritant or allergic vaginitis 1st irritant avoidance ± emollients
Ongoing ( summary )
non-pregnant: persistent or recurrent

symptoms

candidiasis
TREATMENT
pregnant: persistent or recurrent

symptoms
Vaginitis Treatment
Ongoing ( summary )
complicated vulvovaginal 1st antifungal therapy and consultation with an
candidiasis infectious disease specialist
TREATMENT
19
Vaginitis Treatment
Treatment options
Acute
non-pregnant: isolated acute episode

» Treatment is indicated in all symptomatic women
with bacterial vaginosis to relieve vaginal symptoms,
reduce signs of infection, and potentially to decrease
the risk of acquiring HIV and other STDs (for example,
Chlamydia trachomatis, Neisseria gonorrhoeae, viral
STDs).[12]
» Metronidazole is the treatment of choice.[32]

1[B]Evidence
» Oral and vaginal formulation have been shown to be

equally effective.8[A]Evidence Choice depends on
the patient compliance and preference.
» Alcohol consumption should be avoided during

treatment and for 24 hours after last dose.
Primary options
» metronidazole: 500 mg orally twice daily for 7

days
OR
» metronidazole vaginal: (0.75% gel) insert 5 g (one
applicatorful) into the vagina once daily at night for
5 days
1st clindamycin: intravaginal cream

STDs).[12]
» Vaginal clindamycin cream is recommended as an

alternative first-line treatment option.[12]
4[C]Evidence
» Women of childbearing age need to be aware that

due to its oil-based formula, clindamycin cream might
weaken latex condoms and diaphragms for 5 days after
TREATMENT
use.
Primary options
Vaginitis Treatment
Acute
» clindamycin vaginal: (2% cream) insert 5 g (one
7 days
2nd clindamycin: oral preparations or intravaginal

ovules
STDs).[12]
» Oral preparations or intravaginal ovules of

clindamycin may be given as second-line options.
Primary options
» clindamycin: 300 mg orally twice daily for 7 days
OR
» clindamycin vaginal: 100 mg ovule into the vagina
once daily at night for 3 days
2nd tinidazole
STDs).[12]
» Oral tinidazole may be used as an alternative

second-line regimen. It has a longer serum half-life
than metronidazole and also reaches higher levels in
the genitourinary tract.

treatment and for 72 hours after the last dose.
Primary options
» tinidazole: 2 g orally once daily for 2 days; or 1 g

orally once daily for 5 days

TREATMENT
» Treatment of trichomoniasis results in relief of

symptoms, microbiologic cure, and reduction of
transmission.[12] Isolation of the microorganism is not
necessary prior to therapy in all cases: for example, in
a symptomatic patient with previous history of
trichomoniasis or a known disease in sexual partner.
21
Vaginitis Treatment
Acute
» Systemic metronidazole is the treatment of choice
but tinidazole is an effective alternative.[12] Usually, a
2 g single dose is enough for clearance. Tinidazole has
a longer serum half-life than metronidazole and also
reaches higher levels in the genitourinary tract.
» Topical treatment is not as effective. It is believed

that the micro-organism can colonise the urethra and
associated glands and, although the topical treatment
might relieve symptoms, it is better to use systemic
medication for clearance.

treatment and for 24 hours (metronidazole) or 72 hours
(tinidazole) thereafter.
» Sexual partners of patients with Trichomonas vaginalis

should be treated and offered screening for other STDs.
Patients should avoid sex until they and their sexual
partners are cured, or should at least use condoms.
Primary options
» metronidazole: 2 g orally as a single dose
OR
» tinidazole: 2 g orally as a single dose
uncomplicated vulvovaginal 1st antifungal therapy

candidiasis » Several agents are available orally or topically.
7[A]EvidenceThese formulations are available
over-the-counter in some countries.
» Uncomplicated candidiasis refers to: Candida albicans,

sporadic episodes, mild to moderate symptoms, and
healthy non-pregnant women.
» This can be treated with a short-course (1 to 3 days)

topical antifungal agent.
» Creams and suppositories in this regimen are

oil-based and might weaken latex condoms and
diaphragms.
» There is no preference between agents. Choice is

based on patient compliance/comfort (between topical
and oral). Cost and availability might also need to be
taken into consideration.
TREATMENT
» Vulvovaginal candidiasis is not usually acquired

through sexual intercourse; treatment of sexual
partners is not recommended, but should be
considered in women who have recurrent infection. If
a male sexual partner presents with symptoms (e.g.,
Vaginitis Treatment
Acute
irritation), these may be managed with topical agents.
[12]
Primary options
» butoconazole vaginal: (2% cream) insert 5 g (one

3 days
OR
» clotrimazole vaginal: (1% cream) insert 5 g (one
7-14 days
OR
» clotrimazole vaginal: 100 mg vaginal tablet into
the vagina once daily at night for 7 nights, or insert
200 mg (two vaginal tablets) into the vagina once
daily at night for 3 nights
OR
» miconazole vaginal: (2% cream) insert 5 g (one
7 days
OR
» miconazole vaginal: 100 mg vaginal suppository
into the vagina once daily at night for 7 days
OR
into the vagina once daily at night for 3 days
OR
into the vagina once daily at night as a single dose
OR
» tioconazole vaginal: (6.5% ointment) insert 5 g
(one applicatorful) into the vagina once daily at
night as a single dose
OR
» fluconazole: 150 mg/dose orally as a single dose
TREATMENT
OR
» nystatin vaginal: 100,000 unit vaginal tablet into
the vagina once daily at night for 14 days
23
Vaginitis Treatment
Acute
candidiasis » Several agents are available orally or
topically.7[A]Evidence
» Complicated candidiasis refers to: non-albicans

candidiasis, more than 4 episodes a year, and women
with uncontrolled diabetes, debilitation, or
immunosuppression.
» Treatment for complicated disease should be initiated

with a short course of antifungal therapy, followed by
maintenance therapy.[12]
» There is no preference between agents; choice is

and oral), and additional considerations might be cost
and availability.

[12]
Primary options

the vagina once daily at night for 7 days
OR
» fluconazole: 150 mg orally every 3 days for a total
of 3 doses
pregnant: isolated acute episode

with bacterial vaginosis.[12] Although bacterial
vaginosis is known to increase the risk of certain
pregnancy and neonatal complications, the only
established benefits of treatment in pregnant women
are relief of vaginal symptoms, reduced signs of
infection, and potentially a decreased risk of acquiring
HIV and other STDs (for example, Chlamydia
TREATMENT
trachomatis, Neisseria gonorrhoeae, viral STDs).
» Oral metronidazole is the treatment of choice.[12]

Vaginitis Treatment
Acute
Primary options
» metronidazole: 250 mg orally three times daily

for 7 days; or 500 mg orally twice daily for 7 days
1st clindamycin
with bacterial vaginosis.[12] Although bacterial
vaginosis is known to increase the risk of certain
pregnancy and neonatal complications, the only
established benefits of treatment in pregnant women
are relief of vaginal symptoms, reduced signs of
infection, and potentially a decreased risk of acquiring
HIV and other STDs (for example, Chlamydia
trachomatis, Neisseria gonorrhoeae, viral STDs).
» Oral clindamycin is an effective alternative to

metronidazole.[12]
Primary options
» clindamycin: 300 mg orally twice daily for 7 days

» Systemic metronidazole is the treatment of
choice.[12] [40] Single dose is preferred in pregnancy.

» In pregnancy, delaying use is recommended until

after first trimester.


» Patients should avoid sex until they and their sexual

Primary options
TREATMENT
» metronidazole: 2 g orally as a single dose
vulvovaginal candidiasis 1st clotrimazole

» Topical azole antifungal therapies are recommended
for use in pregnant women, for courses of 7 days.[12]
Clotrimazole is the topical azole antifungal of choice.
25
Vaginitis Treatment
Acute
irritation), these may be managed with topical
agents.[12]
Primary options

the vagina once daily at night for 7 nights
atrophic vaginitis 1st oestrogen therapy

» Benefits and risks of oestrogen therapy should be
carefully weighed for each individual patient, aiming
to minimise both the amount of oestrogen and length
of treatment.[38] [39]
» There is no clinical preference between different

options.[41] Many patients will prefer the silicone ring
for easier use than tablets or cream; the efficacy and
safety have been proven to be the same.[42] [43]
» Administration may be symptomatic, continuous, or

cyclic (3 weeks on and 1 week off).
» The ring should be removed after 3 months and, if

appropriate, replaced by a new ring. The need to
continue treatment should be assessed at 3- to
6-month intervals.
Primary options
» oestradiol vaginal: (50-100 micrograms/24 hours)

insert ring into vagina and change every 3 months
as required; place the ring into the posterior vaginal
fornix; it is to remain in place continuously for 3
months
OR
» oestrogens, conjugated vaginal: (0.625 mg/g)
insert 0.5 to 2 g into the vagina once daily at night
for 1-2 weeks
TREATMENT
irritant or allergic vaginitis 1st irritant avoidance ± emollients

» Preventive measures are the mainstay of treatment.
Avoiding causative agents, such as feminine hygiene
products, latex condoms/diaphragms, douching, and
irritants such as strong soaps or bubble baths, can help
prevent vaginitis. Hormone-free vaginal creams and
Vaginitis Treatment
Acute
gels, often called emollients, are available without
prescription and are commonly used to restore vaginal
pH and to relieve vaginal irritation and pruritus, and to
increase vaginal moisture.
Ongoing
non-pregnant: persistent or recurrent
symptoms

» If multiple recurrences do occur, it is recommended
that metronidazole gel 0.75% twice per week is given
for 4-6 months, after completion of a recommended
regimen.[12] Suppressive therapy has been shown to
reduce the risk of recurrences but this benefit might
not persist after discontinuation.[33]
Primary options
» metronidazole vaginal: (0.75% gel) apply to the

vagina twice a week for 4-6 months

» If, after a single high dose of metronidazole or a short
course of metronidazole, treatment is unsuccessful,
high-dose metronidazole for 5 days is
recommended.[12] Tinidazole may be considered as
an alternative. It has a longer serum half-life than
metronidazole and also reaches higher levels in the
genitourinary tract.


treatment and for 24 hours (metronidazole) or 72 hours
(tinidazole) after the last dose.

TREATMENT

Primary options
» metronidazole: 2 g orally once daily for 5 days
27
Vaginitis Treatment
Ongoing
OR
» tinidazole: 2 g orally once daily for 5 days

candidiasis » Several agents are available orally or
topically.7[A]Evidence

immunosuppression.
» Treatment for complicated disease may involve

longer duration of initial oral or topical treatment,
followed by maintenance therapy for 6 months.[44]
» There is no preference between agents; choice is

and oral), and additional considerations might be cost
and availability.

partners should be considered in women who have
recurrent infection. If a male sexual partner presents
with symptoms (e.g., irritation), these may be managed
with topical agents.[12]
Primary options
» clotrimazole vaginal: 500 mg vaginal suppository

into the vagina once weekly at night for 6 months
OR
» fluconazole: 150 mg orally once weekly for 6
months
pregnant: persistent or recurrent

symptoms

» If, after a short course of metronidazole, treatment
is unsuccessful, high-dose metronidazole for 7 days is
recommended.

TREATMENT
Primary options

days
Vaginitis Treatment
Ongoing
» If a single high dose of metronidazole treatment is
unsuccessful, high-dose metronidazole for 7 days is
recommended.


» Sexual partners of patients withTrichomonas vaginalis

Primary options

days
complicated vulvovaginal 1st antifungal therapy and consultation with an

candidiasis infectious disease specialist
immunosuppression. Consultation with an infectious
disease specialist might be required to discuss further
culture and sensitivity testing.
» Treatment for complicated disease may involve

longer duration of initial topical treatment, followed by
maintenance therapy for 6 months.[44]
» Fluconazole is sometimes used in pregnant women.

Although there is very little risk of teratogenicity, some
experts prefer not to use systemic fluconazole in
pregnancy.[45] The US Food and Drug Administration
(FDA) are currently reviewing the use of fluconazole in
pregnancy because of a study that found fluconazole
was associated with an increased risk of
miscarriage.[46]

TREATMENT

[12]
29
Vaginitis Treatment
Ongoing
Primary options
» fluconazole: consult specialist for guidance on

dose
TREATMENT
Vaginitis Treatment
Emerging
Vitamin C vaginal tablets
May be beneficial in the management of bacterial vaginitis, but there is very little evidence as yet and long-term studies
are required.[47]
TREATMENT
31
Vaginitis Follow up
Recommendations
Monitoring
FOLLOW UP
Bacterial vaginosis
• Follow-up is not recommended if symptoms resolve. Recurrence of bacterial vaginosis is not unusual and women
should be advised to return for additional therapy if symptoms recur.2[B]Evidence
• A treatment regimen different from the original regimen may be used to treat recurrent disease.
Trichomoniasis
• Follow-up is not recommended if couples are asymptomatic after treatment. If symptoms persist, tinidazole is
a reasonable alternative.
Vulvovaginal candidiasis
• Patients should be instructed to follow up if symptoms persist or recur within 2 months of onset of initial
symptoms.
Patient instructions
Infective vaginitis
• Diet: Lactobacillus acidophilus supplements in the diet may help to prevent vaginitis.[23]
• Activity: abstinence from douching and sexual activity is recommended until completion of treatment. If the
patient remains sexually active, advise use of condoms as a precaution; some of the topical treatments are
oil-based and can break condoms (e.g., clindamycin cream is oil-based and might weaken latex condoms and
diaphragms for 5 days after use). Check with condom manufacturer.
• Alcohol: patients should avoid consuming alcohol while on metronidazole and for 24 hours after last dose.
• Pregnant women: topical clindamycin preparations should not be used in the second half of pregnancy.
Atrophic vaginitis
• Encourage continued sexual activity as it may help postpone worsening atrophy.
Allergic or irritant vaginitis
• Avoiding causative agents, such as feminine hygiene products, latex condoms/diaphragms, douching, and
irritants such as strong soaps or bubble baths, can help prevent vaginitis.
Vaginitis Follow up
Complications
FOLLOW UP
Complications Timeframe Likelihood
bacterial vaginosis/Trichomonas-related: preterm birth variable medium
In pregnant women, bacterial vaginosis and trichomoniasis have been associated with premature deliveries.[48] [49]
5[C]Evidence However, current recommendations do not advise routine screening for bacterial vaginosis in pregnant
women at risk for preterm delivery.[30] [50]
bacterial vaginosis/Trichomonas-related: preterm premature variable medium

rupture of membranes
In pregnant women, bacterial vaginosis and trichomoniasis have been associated with premature rupture of the
membranes.[49]
bacterial vaginosis/Trichomonas-related: low birth weight variable medium
In pregnant women, bacterial vaginosis and trichomoniasis have been associated with low birth weight.[48] [49]
5[C]Evidence
bacterial vaginosis/Trichomonas-related: increased susceptibility variable low

to sexually transmitted infections
Bacterial vaginosis raises the risks of infections with Neisseria gonorrhoeae, HIV, Chlamydia trachomatis, and Herpes
simplex virus-2;[12] trichomoniasis increases the risk of HIV-1 acquisition 1.52-fold.[51] [52]
Prognosis
Overall, with the proper treatment, the prognosis is very good for all types of vaginitis.
33
Vaginitis Guidelines
Diagnostic guidelines
Europe
Management of Trichomonas vaginalis infection

Published by: British Association for Sexual Health and HIV Last published: 2014
Summary: Provides recommendations on the diagnosis of Trichomonas vaginalis infection including presenting signs
and symptoms. Diagnostic tests include microscopy and culture on vaginal swabs in females, and urethral swabs or
first-void urine in males. PCR has been used but is not yet available in the UK.
Vaginal discharge: quick reference guide

Published by: Public Health England Last published: 2014
UK national guideline for the management of bacterial vaginosis

GUIDELINES
Summary: Provides recommendations on the diagnosis of bacterial vaginosis at first presentation as well as recurrence.
Discusses 2 approaches to diagnosis, using the Amsel criteria or assessment of the Gram-stained vaginal smear with
the Hay/Ison criteria or the Nugent criteria.
Management of vaginal discharge in non-genitourinary medicine settings

Published by: Royal College of Obstetricians and Gynaecologists; British AssociationLast published: 2012
for Sexual Health and HIV
Summary: Provides recommendations on the evaluation and diagnosis of women presenting with vaginal discharge.
European (IUSTI/WHO) guideline on the management of vaginal discharge

Published by: International Union Against Sexually Transmitted Infections; World Last published: 2011
Health Organization
Summary: Covers the presentation and clinical findings of bacterial vaginosis, trichomoniasis, and candidiasis, and
outlines the differential diagnoses. Recommendations are made for investigations based on currently available evidence.
Antenatal care
Published by: National Institute for Health and Care Excellence Last published: 2008
Summary: The guidelines state that pregnant women should not be offered routine screening and treatment for
asymptomatic bacterial vaginosis as evidence has shown that treatment does not reduce preterm birth risk or prevent
other adverse sequelae.
North America
Sexually transmitted diseases treatment guidelines 2015

Published by: Centers for Disease Control and Prevention Last published: 2015
Summary: Guidelines for the management of STDs, including recommendations for diagnosis of vaginitis.
North America
Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis,

and bacterial vaginosis
Published by: Society of Obstetricians and Gynaecologists of Canada Last published: 2015
Summary: Evidence-based recommendations on screening for vulvovaginal candidiasis, trichomoniasis, and bacterial
vaginosis.
Laboratory medicine practice guidelines: evidence-based practice for point-of-care testing:

infectious disease
Published by: National Academy of Clinical Biochemistry Last published: 2007
Summary: Covers point-of-care testing of Chlamydia trachomatis and Trichomonas vaginalis infection, gonorrhoea
(Gram-stain), and bacterial vaginosis in pregnant women; no recommendations made due to insufficient evidence for
Candida.
GUIDELINES
Oceania
Australian STI management guidelines for use in primary care

Published by: Australasian Sexual Health Alliance Last published: 2015
Treatment guidelines
Europe
Management of Trichomonas vaginalis infection

Summary: Provides recommendations on the treatment of Trichomonas vaginalis infection and prevention of further
infection.
UK national guideline for the management of bacterial vaginosis

Summary: Provides recommendations on the treatment of bacterial vaginosis for women who are symptomatic or
due to undergo certain surgical procedures. The recommended regimen is oral metronidazole. Alternative regimens
include intravaginal metronidazole, intravaginal clindamycin, oral clindamycin, or oral tinidazole. Also provides general
advice to avoid use of shower gels, antiseptic agents, and douching. Treatment of recurrent bacterial vaginosis is also
covered.
Management of vaginal discharge in non-genitourinary medicine settings

Published by: Royal College of Obstetricians and Gynaecologists; British AssociationLast published: 2012
for Sexual Health and HIV
Summary: Provides treatment recommendations for women evaluated for vaginal discharge.
35
Europe
European (IUSTI/WHO) guideline on the management of vaginal discharge

Published by: International Union Against Sexually Transmitted Infections; World Last published: 2011
Health Organization
Summary: Recommendations for management of bacterial vaginosis, trichomoniasis, and candidiasis based on
currently available evidence, including the management of persistent and recurrent infections.
Antenatal care
Published by: National Institute for Health and Care Excellence Last published: 2008
Summary: The guidelines, commissioned by the National Institute for Health and Clinical Excellence (NICE), state
that pregnant women should not be offered routine screening and treatment for asymptomatic bacterial vaginosis as
evidence has shown that treatment does not reduce preterm birth risk or prevent other adverse sequelae.
GUIDELINES
North America
Sexually transmitted diseases treatment guidelines 2015

Published by: Centers for Disease Control and Prevention Last published: 2015
Summary: Guidelines for the management of STDs, including recommendations for treatment of vaginitis.
Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis,

and bacterial vaginosis
Published by: Society of Obstetricians and Gynaecologists of Canada Last published: 2015
Summary: Recommendations on the management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis.
Oceania
Australian STI management guidelines for use in primary care

Published by: Australasian Sexual Health Alliance Last published: 2015
Vaginitis Evidence scores
Evidence scores
1. Cure rates: there is medium-quality evidence that intravaginal antibacterial treatment with metronidazole gel or
clindamycin cream is more effective at increasing cure rates at 25-39 days compared with placebo in non-pregnant
women with bacterial vaginosis. Oral metronidazole has been associated with nausea and a metallic taste.
Evidence level B: Randomized controlled trials (RCTs) of <200 participants, methodologically flawed RCTs of >200
participants, methodologically flawed systematic reviews (SRs) or good quality observational (cohort) studies.
2. Recurrence: there is medium-quality evidence that recurrence of bacterial vaginosis is likely to occur after
antibacterial treatment.
3. Cure rates: there is good-quality evidence that a twice-daily regimen of the oral antibacterial metronidazole is more
effective at increasing cure rates at 7 days compared with a single dose.
Evidence level A: Systematic reviews (SRs) or randomized controlled trials (RCTs) of >200 participants.
4. Cure rates: there is poor-quality evidence that clindamycin may be as effective at increasing cure rates at 7-10 days
compared with metronidazole in non-pregnant women with bacterial vaginosis. Intravaginal clindamycin has been
associated with mild to severe colitis and with vaginal candidiasis.
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized controlled
trials (RCTs) of <200 participants.
5. Complications in pregnant women: there is poor-quality evidence that antibacterials may reduce the risk of low
birth weight in pregnant women who have had a previous preterm birth, but we don't know if they are more effective
at reducing the risk of preterm birth.
Evidence level C: Poor quality observational (cohort) studies or methodologically flawed randomized controlled
trials (RCTs) of <200 participants.
6. Preventative action: there is medium-quality evidence that treating a steady male partner with oral antibacterials
is no more effective at reducing the rate of recurring infections in women with bacterial vaginosis, who are also
receiving antibacterial treatment, than not treating the male partner.
7. Clinical cure: there is good-quality evidence that there is no difference in clinical cure rate between intravaginal
EVIDENCE SCORES
and oral azole treatments for candidiasis. However, adverse effects have been found for both types of treatment.
More info from BMJ Clinical Evidence
37
Vaginitis Evidence scores
8. Clinical cure: there is good-quality evidence that intravaginal metronidazole is as effective as oral metronidazole
in treating bacterial vaginosis and results in fewer adverse events.
EVIDENCE SCORES
Vaginitis References
Key articles
REFERENCES
• Workowski KA, Bolan GA; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment
guidelines, 2015. MMWR Recomm Rep. 2015;64:1-137. Full text Abstract
• Chollet JA. Efficacy and safety of ultra-low-dose Vagifem (10 mcg). Patient Prefer Adherence. 2011;5:571-574. Full
text Abstract
References
1. Ness RB, Hillier SL, Richter HE, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria
in the vagina. Obstet Gynecol. 2002;100:765-772. Full text Abstract
2. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician. 2000;62:1095-1104. Abstract
3. Kent HL. Epidemiology of vaginitis. Am J Obstet Gynecol. 1991;165:1168-1176. Abstract
4. World Health Organization. Global prevalence and incidence of selected curable sexually transmitted infections.
Geneva, Switzerland: WHO; 2001. Full text
5. Rivera-Sanchez R, Flores-Paz R, Arriaga-Alba M. Identification of Candida species causing vaginitis in Mexican

patients. Enferm Infecc Microbiol Clin. 2006;24:634-636. [in Spanish] Abstract
6. Paulitsch A, Weger W, Ginter-Hanselmayer G, et al. A 5-year (2000-2004) epidemiological survey of Candida and
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10. Pandit L, Ouslander JG. Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci. 1997;34:228-231.
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39
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Abstract
22. Tolosa JE, Chaithongwongwatthana S, Daly S, et al. The International Infections in Pregnancy (IIP) study: variations
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Am J Obstet Gynecol. 2006;195:1198-1204. Abstract
23. Van Kessel K, Assefi N, Marrazzo J, et al. Common complementary and alternative therapies for yeast vaginitis and
bacterial vaginosis: a systematic review. Obstet Gynecol Surv. 2003;58:351-358. Abstract
24. ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin. Clinical management guidelines for
obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. 2006;107:1195-1206. Abstract
25. Hainer BL, Gibson MV. Vaginitis. Am Fam Physician. 2011;83:807-815. Full text Abstract
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samples. J Clin Microbiol. 1998;36:3205-3210. Full text Abstract
29. Sharma P, Malla N, Gupta I, et al. A comparison of wet mount, culture and enzyme linked immunosorbent assay for
the diagnosis of trichomoniasis in women. Trop Geogr Med. 1991;43:257-260. Abstract
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Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;148:214-219. Full text Abstract
31. Brandt M, Abels C, May T, et al. Intravaginally applied metronidazole is as effective as orally applied in the treatment
of bacterial vaginosis, but exhibits significantly less side effects. Eur J Obstet Gynecol Reprod Biol. 2008;141:158-162.
Abstract
32. Oduyebo OO, Anorlu RI, Ogunsola FT, et al. The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant
women. Cochrane Database Syst Rev. 2009;(3):CD006055. Full text Abstract
33. Sobel JD, Ferris D, Schwebke J, et al. Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to
prevent recurrent bacterial vaginosis. Am J Obstet Gynecol. 2006;194:1283-1289. Abstract
34. Boselli F, Petrella E, Campedelli A, et al. Efficacy and tolerability of fitostimoline (vaginal cream, ovules, and vaginal
washing) and of benzydamine hydrochloride (tantum rosa vaginal cream and vaginal washing) in the topical treatment
of symptoms of bacterial vaginosis. ISRN Obstet Gynecol. 2012;2012:183403. Full text Abstract
35. Verstraelen H, Verhelst R, Roelens K, et al. Antiseptics and disinfectants for the treatment of bacterial vaginosis: a
systematic review. BMC Infect Dis. 2012;12:148. Full text Abstract
36. Weissenbacher ER, Donders G, Unzeitig V, et al. A comparison of dequalinium chloride vaginal tablets (Fluomizin®)
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efficacy and safety. Gynecol Obstet Invest. 2012;73:8-15. Full text Abstract
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a randomised, double blind, placebo controlled clinical trial. Arzneimittelforschung. 2011;61:260-265. Abstract
48. Svare JA, Schmidt H, Hansen BB, et al. Bacterial vaginosis in a cohort of Danish pregnant women: prevalence and
relationship with preterm delivery, low birthweight and perinatal infections. BJOG. 2006;113:1419-1425. Abstract
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51. St John E, Mares D, Spear GT. Bacterial vaginosis and host immunity. Curr HIV/AIDS Rep. 2007;4:22-28. Abstract
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Abstract
Vaginitis Images
Images
IMAGES
Figure 1: Trichomonas vaginitis with copious purulent discharge emanating from the cervical os
CDC Image Library
Figure 2: Vaginal smear identifying Candida albicans using a wet mount technique
CDC Image Library; Dr Stuart Brown
43
Vaginitis Images
Figure 3: Phase contrast wet mount micrograph of a vaginal discharge revealing the presence of Trichomonas vaginalis
protozoa
IMAGES
CDC Image Library
Figure 4: Photomicrograph revealing bacteria adhering to vaginal epithelial cells, known as clue cells
CDC Image Library; M. Rein
Vaginitis Disclaimer
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Group Ltd ("BMJ Group") tries to ensure that the information provided is accurate and up-to-date, but we do not warrant
that it is nor do our licensors who supply certain content linked to or otherwise accessible from our content. The BMJ
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45
Contributors:
// Authors:
Diego S. Illanes, MD, FACOG, FACS

Division Director of Urogynecology
Department of Obstetrics & Gynecology, Reliant Medical Group, Chief of Obstetrics and Gynecology, Saint Vincent Hospital,
Assistant Professor of Obstetrics and Gynecology, University of Massachusetts Medical School, Worcester, MA
DISCLOSURES: DSI declares that he has no competing interests.
// Peer Reviewers:
David Chelmow, MD
Chair
Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA
DISCLOSURES: DC declares that he has no competing interests.
Jonathon Solnik, MD
Director
Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
DISCLOSURES: JS declares that he has no competing interests.

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Vaginitis

The right clinical information, right where it's needed

Last updated: May 05, 2016

Step-by-step treatment approach 16

◊ Common symptoms include discharge, pruritus, and dyspareunia.

◊ It is recommended to screen for STDs in all patients with infective vaginitis.

Examination and vaginal samples

An elevated pH is seen in bacterial infections and atrophic vaginitis.

• Adherent white vaginal discharge.

poor or excessive hygiene

change in feminine hygiene products and/or soap

multiple or new sex partners

increased frequency of intercourse

History & examination factors

Key diagnostic factors

presence of risk factors (common)

vaginal discharge (common)

discharge adherent to vaginal mucosa (common)

Other diagnostic factors

vaginal dryness (common)

pale epithelium (common)

shiny epithelium (common)

decreased elasticity (common)

vaginal bleeding (uncommon)

abdominal pain (uncommon)

strawberry cervix (uncommon)

bacterial morphotypes. Reduced or absent lactobacilli are indicative of bacterial

Other tests to consider

Condition Differentiating signs / Differentiating tests

Chlamydia • Many are asymptomatic; • Chlamydia trachomatis on nucleic

Condition Differentiating signs / Differentiating tests

Lichen planus • Pruritus, intense vulvodynia, and • Diagnosis is typically clinical.

Amsel diagnostic criteria and microbial and epidemiological associations[26]

• Adherent white vaginal discharge.

• >6 bacterial vaginosis.

Step-by-step treatment approach

sexual partners will help in preventing recurrence.

Infective or allergic vaginitis

Treatment details overview

non-pregnant: isolated acute episode

bacterial vaginosis 1st metronidazole

1st clindamycin: intravaginal cream

2nd clindamycin: oral preparations or intravaginal

trichomoniasis 1st nitroimidazole therapy

uncomplicated vulvovaginal 1st antifungal therapy

complicated vulvovaginal 1st antifungal therapy

pregnant: isolated acute episode

bacterial vaginosis 1st metronidazole

trichomoniasis 1st metronidazole

vulvovaginal candidiasis 1st clotrimazole

atrophic vaginitis 1st oestrogen therapy

irritant or allergic vaginitis 1st irritant avoidance ± emollients

non-pregnant: persistent or recurrent

bacterial vaginosis 1st metronidazole

trichomoniasis 1st nitroimidazole therapy

complicated vulvovaginal 1st antifungal therapy

pregnant: persistent or recurrent

bacterial vaginosis 1st metronidazole

trichomoniasis 1st metronidazole

bacterial vaginosis 1st metronidazole

» Metronidazole is the treatment of choice.[32]

» Oral and vaginal formulation have been shown to be

» Alcohol consumption should be avoided during

» metronidazole: 500 mg orally twice daily for 7