Vaginosis

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Diagnosis of Vaginitis
MARI E. EGAN, M.D., and MARTIN S. LIPSKY, M.D.
Northwestern University Medical School, Chicago, Illinois

Vaginitis is the most common gynecologic diagnosis in the primary care setting. In approximately 90 percentof affected women, this condition occurs secondary to bacterial vaginosis, vulvovaginal candidiasis or trichomoniasis. Vaginitis develops when the vaginal flora has been altered by introduction of a pathogen or by changes in the vaginal environment that allow pathogens to proliferate. The evaluation of vaginitis requires a directed history and physical examination, with focus on the site ofinvolvement and the characteristics of the vaginal discharge. The laboratory evaluation includes microscopic examination of a saline wet-mount preparation and a potassium hydroxide preparation, a litmus test for the pH of vaginal secretions and a "whiff" test. Metronidazole is the primary treatment for bacterial vaginosis and trichomoniasis. Topical antifungal agents are the first-line treatments forcandidal vaginitis. (Am Fam Physician 2000;62:1095-104.)
Vaginitis is the most frequent gynecologic diagnosis encountered by physicians who provide primary care to women.1-5 Accurate diagnosis can be elusive, complicating treatment.6-9 Furthermore, the availability of over-the-counter medications increases the likelihood of inappropriate or partial treatment of vaginitis.10
Epidemiology
Theprevalence and causes of vaginitis are uncertain, in part because the condition is so often self-diagnosed and self-treated. In addition, vaginitis is frequently asymptomatic or has more than one cause. Most experts believe that up to 90 percent of vaginitis cases are secondary to bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis.4,8 Noninfectious causes include vaginal atrophy,allergies and chemical irritation.
Bacterial Vaginosis
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The most common causes of vaginitis are bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis, vaginal atrophy, allergies and chemical irritation. |
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In the United States, bacterial vaginosis is currently the most common cause of vaginitis, accounting for 40 to 50 percent of cases in women of childbearing age.11,12This infection is believed to be caused by proliferation of a number of organisms, including Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis and Peptostreptococcus species.1,11
Determining the prevalence of bacterial vaginosis is difficult because one third to three quarters of affected women are asymptomatic.2,12,13 In addition, reported prevalences vary based on the populationstudied. Bacterial vaginosis has been found in 15 to 19 percent of ambulatory gynecology patients, 10 to 30 percent of pregnant patients and 24 to 40 percent of patients in sexually transmitted disease clinics.8,11-15
Even though higher rates of bacterial vaginosis have been reported in sexually transmitted disease clinics and in women with multiple sexual partners, the role of sexual transmission isunclear. Studies indicate that treating the male sexual partner of a woman with bacterial vaginosis is not beneficial and that even women who are not sexually active can have the infection.12,16 Additional risk factors for bacterial vaginosis include the use of intrauterine devices (IUDs), douching and pregnancy.1,11-13,17
Evidence suggests that bacterial vaginosis is a risk factor forpremature rupture of membranes and preterm labor. Treating the infection in pregnancy decreases this risk.8,18-21 Additional possible adverse outcomes include an increased frequency of abnormal Papanicolaou (Pap) smears, pelvic inflammatory disease and endometritis.22-24 Vaginal cuff cellulitis, pelvic inflammatory disease and endometritis can occur if invasive gynecologic procedures or surgeries are...