Vaginitis: Vaginal and Vulvar Infections

Yeast Infections

Yeast is a fungus that is often a normal inhabitant of the vagina. It has been found in up to 70% of healthy women.

The vagina is not a sterile environment: it plays host to a multitude of microorganisms*. In the normal state, these tiny life forms do not disturb their host. When the balance between the different organisms is disrupted, however, one overgrows the others and causes problems. This is precisely the case with yeast infections.

Roughly 80% of yeast infections are caused by Candida albicans; the remaining 20% are caused by other Candida species, such as glabrata and tropicalis. This is important because the less common species are more likely to resist common drug treatments.

What Symptoms Do Yeast Infections Cause?

When yeast overgrows, it causes itching, redness, and a thick white discharge in most women. It can occur inside the vagina, on the vulva, or in both locations at once. Systemic (throughout the body) yeast infections also occur, but they are rare in healthy women. They are see more often in people with compromised immune systems, like those with cancer or AIDS.

What Are the Risk Factors for Getting a Yeast Infection?

A yeast infection can happen at any time, but certain factors increase a woman's risk. These include taking antibiotics (for example, to treat a bladder infection), using high dose birth control pills, having diabetes, or being pregnant. Women with depressed immunity, from disease such as AIDS or because of medications (e.g., steroids), will likely have more yeast infections. Even wearing tight-fitting pants or shorts may increase a woman's chances of developing a yeast infection.

How Is Yeast Diagnosed?

The most common symptom of a yeast infection is genital itching; it can be quite intense. Many women also experience an increase in their discharge and burning with urination, caused by irritation of the vulva. They also may complain of pain during intercourse. Examination of the vagina and/or vulva often will show discharge and some degree of redness, swelling, and tenderness. There is an absence of "lumps, bumps, or craters," which might suggest warts, herpes, or other diagnoses. There is no odor from yeast.

To diagnose a yeast infection, the gynecologist will take a small sample of the thick, "curdy" discharge from the vagina or vulva and examine it under a microscope. About 80% of infected women will have yeast organisms visible on microscopic exam. A measurement of pH (acidity) of vaginal fluid also can be done to exclude other diagnoses. A woman with a yeast infection will usually have a normal pH unless she also has other infections.

It helps us make a diagnosis if no vaginal medications or douches are used for two days before the exam. This is because these chemicals obscure the signs of infection we're looking for.

How Is Yeast Treated?

Antifungal medications such as Monistat and GyneLotrimin (trade names), which can now be purchased without a prescription, are usually effective against uncomplicated yeast infections. Creams or suppositories work equally well when applied directly to the genital area. It's important to use the medication for the full treatment course (usually seven days) to avoid a relapse. In cases of extreme discomfort, a corticosteroid cream can be added. We instruct our patients to avoid intercourse until the treatment is completed.

These medications can be used without concern during a pregnancy. A longer treatment course (ten days instead of seven) may be necessary if the woman is pregnant since pregnancy promotes the growth of yeast.

New single-dose yeast infection treatments with oral fluconazole are available by prescription. There is a small risk of liver damage with these medications, but they may be the preferred treatment under certain circumstances; consultation with a doctor should be obtained before use.

Other treatments include gentian violet (a very messy purple liquid) and oral ketoconazole. Cure rates are no higher with oral treatment, and drug toxicity, (liver damage) is a small but real risk.

[Caution: Do not use over-the-counter antifungal treatments without first consulting a doctor. Young women may mistake normal vaginal fluids for an infection or misdiagnose the type of infection they have. I am aware of women who suffered severe side effects after using these products, especially when they were used when a yeast infection was not present. Yeast infections should not be taken lightly just because you can buy antifungal medications as easily as cold medications.]

What If Yeast Infections Keep Coming Back?

Frequent recurrences of yeast are a fairly common problem - and a very exasperating one. Contributing factors may be:

  • Partial treatment Women who do not use the medicine for the necessary number of days put themselves at risk for recurrence.

  • Frequent douching Women increase their risk of yeast infections if they douche more than once a month. [Women should not douche at all unless a doctor prescribes it.]

  • Use of irritating chemicals in the vagina Scented toilet paper, soaps, tampons, and vaginal sprays can "set up" yeast infections by irritating the genital area. [The only things that should come in contact with a woman's vulva and vagina are clean water and air.]

  • Clothing Tight jeans, wet bathing suits, nylon underwear, and panty hose can contribute to yeast infections. [Ideally, women should only wear dresses or skirts and no underwear so excess moisture does not collect, clothing does not irritate the delicate vulvar tissues, and the ambient temperature does not increase.]

  • Excess weight Yeast likes to grow in damp skin folds. Weight loss may help.

  • Antibiotic use Antibiotics often eliminate some of the normal bacteria of the vagina, allowing yeast to overgrow. Women taking long-term antibiotics for any reason may therefore suffer chronic yeast infections. [If your body will likely eliminate an infection on its own given the time, you may want to consider discussing with your doctor the idea of not using an antibiotic.]

  • Depressed immunity Recurrent yeast may be the result of a major systemic illness such as AIDS (sometimes the yeast infections can lead to the AIDS diagnosis). Most women with recurrent yeast and decreased immunity, however, do not have AIDS. They may have a minor defect in their immune system that predisposes them to yeast.

  • Reinfection from a sexual partner A man with oral or genital yeast can reinfect his partner after she's been treated. [Female couples may infect or reinfect one another as well.]

  • Infection with a resistant strain of Candida As mention, drug resistance is more common with certain species of Candida. A longer treatment course or use of a different antifungal may be needed. Cultures of the yeast may be helpful in deciding the best treatment in these unusual cases. [You may need to ensure that your doctor does not presume you have a common type of Candida infection by requesting a copy of your lab report (You paid for the lab tests so they belong to you, not the doctor.)]

  • Diabetes Women with diabetes are more likely to have recurrences.

How Can Yeast Recurrences Be Eliminated?

Controlling recurrences of yeast can be accomplished in most patients with the following:

  • General measures Wear cotton underwear and loose-fitting clothes; reduce sweets and dairy products; improve control of diabetes.

  • Longer treatment courses Use the treatment for ten or fourteen days instead of seven.

  • Suppressive doses of medication before recurrences Use the antifungal for three nights before a menstrual period (if that's when the yeast occurs) for six months. [Consult with your doctor before trying this.]

  • Changing other medication use Use lower-dose birth control pills or change to a different method of contraception; use an antifungal cream while taking antibiotics; stop taking systemic steroids (under your doctor's supervision).

  • Ketoconazole This systemic antifungal may be worth the small risk of toxicity if all else fails.

  • Examination and treatment of a woman's sexual partners

For more information on Yeast infections and treatments visit this link:

Infections and Insurrection: Women Treating Yeast

 

Bacterial Vaginosis

What is Bacterial Vaginosis?

Bacterial vaginosis has gone by a lot of different names in the past: nonspecific vaginitis, haemophilis vaginitis, and corynebacterium vaginitis. For a while it was known as Gardenerella, after one scientist who studied the infections extensively, Dr. Herman Gardner.

Why have so many names been used for this vaginal infection? Because bacterial vaginosis is polymicrobial: it is caused by many different species of bacteria.

In the section on yeast infections, we told you that the vagina is not sterile. When all of the normal bacteria* are suppressed, perhaps from taking an antibiotic, the yeast overgrows and causes symptoms. In the case of bacterial vaginosis, certain bacteria overgrow while other bacteria and yeast are suppressed. Organisms such as Gardenerella vaginalis multiply in great numbers and cause the characteristic symptoms associated with this infection.

During this infection, the total concentration of bacteria in the vagina increases 100-fold!

Again, as in yeast infections, the mere presence of the offending organisms doesn't mean the woman has an infection. Up to half of uninfected women studied have some of the offending bacteria in their vaginal secretions. Symptoms are produced only when the organisms multiple to numbers far greater than normal. This infection can occur in women of all ages, during pregnancy, and even after hysterectomy.

What Symptoms Does Bacterial Vaginosis Cause?

The most common symptom of women with bacterial vaginosis is a discharge with a fishy odor. This is found most often during and after a period [menstruation] or after intercourse. Mild burning or itching in the genital area may be present as well.

How Is Bacterial Vaginosis Diagnosed?

The diagnosis of bacterial vaginosis begins by noting a woman's symptoms. She will usually complain of an increase in vaginal discharge with odor and some burning or irritation in the genital area. Other symptoms, such as fevers, pelvic pain, or the presence of sores in the genital area might suggest other diagnoses. We also inquire whether she has had similar complaints in the past, and what their cause was.

Conformation of the diagnosis is made during the pelvic exam, when a small amount of the discharge is obtained for evaluation. The bacteria can be seen under the microscope, attached to vaginal cells that were shed ("clue cells"). The pH (acidity) of the vaginal fluid is often altered because of the suppression of normal acid-producing bacteria. Finally, a "whiff" test is performed: a few drops of potassium hydroxide are added to the discharge sample, and a strong fishy odor is noted.

It is possible for bacterial vaginosis to occur along with yeast or other infections. During the pelvic exam, therefore, the gynecologist will attempt to exclude the presence of any other causes of infection or inflammation. Additional lab tests are done as indicated. Any suspicious lesions are examined and biopsied if necessary.

How Is Bacterial Vaginosis Treated?

Treatment of routine bacterial vaginosis is usually simple. The best antibiotics to suppress the overgrown populations of bacteria are metronidazole or clindamycin. Metronidazole is widely more used; it is given twice a day for seven days, and has a 95% cure rate. A single (larger) oral dose is almost as effective (85%) and may be the best choice for some patients. A metronidazole vaginal gel is also available; it should be used twice a day for five days. Patients taking metronidazole cannot drinkany alcohol. This antibiotic is related to disulfiram, a medicine taken by alcoholics to remain sober; any ingestion of alcohol causes severe nausea and vomiting. Metronidazole is other wise a very safe drug.

Clindamycin is taken twice a day orally for seven days, with a cure rate of greater than 90% A two-percent clindamycin cream is just as effective when used once daily in the vagina for seven days.

As with other types of vaginitis, gynecologists recommend "pelvic rest" translation: no intercourse) until the infection has resolved.

Is This an Important Infection in Pregnant Women?

Treatment of bacterial vaginosis in pregnancy is crucial. Current research suggests an increased risk of premature birth as well as infection inside the uterus during or after delivery. Clindamycin can be used at any time during pregnancy.

Metronidazole in not used during the first three months of pregnancy because of concerns over birth defects (probably unfounded), but it can be used later. Because of the potential risks from infection, women are treated in pregnancy whether or not they have symptoms.

Nonpregnant women with bacterial vaginosis but no symptoms often are not treated. An important exception is if surgery is planned: studies show a higher rate of infection after gynecological surgery if these bacteria are present.

How Are Recurrent Episodes of Bacterial Vaginosis Treated?

Recurrent infections of bacterial vaginosis are common. The following steps may help reduce the frequency of repeat episodes:

  • repeating the antibiotic treatment, either with the same drug or with another antibiotic that the bacteria are more sensitive to;

  • using careful personal hygiene: wiping from "front to back" after using the toilet keeps bacteria fro being dragged from the rectum into the vagina;

  • treatment of sexual partners: some physicians will treat partners of women with recurrent infections even if they have no symptoms;

  • use of diluted hydrogen peroxide douche to decrease odor; [Only on the advice of your doctor]

  • use of condoms if semen seems to aggravate her condition; [I would advise against having intercourse if a woman has an infection]

  • povidone-iodine vaginal pessaries: when used for two weeks, these may be helpful. [Again, only on the advice of your doctor]

 

Trichomoniasis

The third entry in the infectious vaginitis category is trichomoniasis ("trich"). Caused by a protozoanorganism known as Trichomonas vaginalis, this infection makes up 5-10% of vaginal infections.

Trichomoniasis differs from yeast infections and bacterial vaginosis in that it is usually acquired during intercourse. Very rarely it has been found in women who have never had sex. This suggests that it also can be acquired from an infected surface. It might really be true that a woman could become infected from contact with a contaminated toilet seat.

What Symptoms Does Trich Cause?

Women with trichomoniasis (infection with Trichomonas) usually complain of a sudden increase in vaginal discharge and genital irritation. A Trichomonas infection might also go unnoticed.

How Is Trich Diagnosed?

A pelvic examination will reveal an odorous, frothy green discharge along with redness and swelling of the genital tissues. Microscopic inspection of the vaginal discharge shows the organisms "swimming" (the propel themselves by moving their tails) and an increase in white blood cells. As in bacterial vaginosis, the acidity (pH) is altered because of the suppression of normal acid-producing bacteria.

Other means of diagnosis are less commonly used. Culture for the organism is not widely available, and Pap smears are likely to be inaccurate. A monoclonal antibody (blood) test is under development. It should help in the diagnosis of difficult cases.

As mentioned earlier in this chapter [above], during the examination the gynecologist will look for any other infections or abnormalities that also may be present.

How Is Bacterial Vaginosis Treated?

Treatment of this infection is usually a simple affair. Trich is very sensitive to the antibiotic metronidazole, which can be given orally in a single large dose or in smaller does over five to seven days. See the previous [above] section on bacterial vaginosis for more information on this drug.

Pregnant women receive the same treatment unless they acquire the infection during the first trimester of pregnancy (the first twelve weeks when the organs of the baby are forming); during this time, clotrimazole cream can be used. It is important to eradicate this infection during pregnancy, since it has been associated with premature delivery and post cesarean infections.

How Are Recurrent or Resistant Infections Treated?

Resistant infections (those still present after complete course of antibiotics) are treated as follows:

  • repeating the course of antibiotics;

  • culturing the organism and testing for the antibiotic sensitivity - then retreating with an antibiotic the Trichomonas is more sensitive to;

  • treating the sexual partner(s) to avoid reinfection;

  • using vaginal treatment with metronidazole gel;

  • using intravenous metronidazole: on rare occasions, high-dose intravenous antibiotics are needed.

 

Noninfectious Vaginitis: Common Irritants

Is Vaginitis Always the Result of an Infection?

Irritation of the vagina and/or vulva from noninfectious causes is more common than most people appreciate. Genital tissues owe their exquisite sensitivity to thin skin and an abundance of nerves. It is this same anatomic makeup that causes the vagina and vulva to be sensitive to irritation and injury. Thankfully, most cases of noninfectious vaginitis heal rapidly and completely once the offending agent is removed.

What Kinds of Complaints Do These Irritants Cause?

Symptoms of this type of vaginitis may be difficult to differentiate from symptoms caused by infections, such as yeast, Trichomonas, or bacterial vaginosis. Women will often complain of an increase in their discharge with an accompanying odor. In addition, they often notice vaginal and/or vulvar itching and/or discomfort.

How Is Noninfectious Vaginitis Diagnosed?

The diagnosis begins by obtaining a thorough history of a woman's complaints. The pelvic examination will reveal redness and swelling in the genital area. Microscopic examination of her discharge will show an increase in white blood cells (the body's primary defense against infection or irritation). The gynecologist also will look for the absence of an infection or other skin lesions. Sometimes a retained tampon or other "foreign body" is found in the vagina and the mystery is easily resolved.

How Is This Form of Vaginitis Treated?

Treatment of noninfectious vaginitis is usually simple. Removing the source of the irritation is often all that's needed. Women suffering from significant discomfort can use a topical steroid cream in the genital area.

What Are the Types of Noninfectious Vaginitis?

The main causes of noninfectious vaginitis fall into three categories: chemical, physical, and atrophic vaginitis.

Chemical Vaginitis

  • feminine deodorant sprays

  • perfumed or colored toilet paper [it is best to rinse with plain water, i.e., bidet]

  • bubble bath or bath oils

  • deodorant soaps

  • laundry detergents (cold water formula) or fabric softeners with enzymes

  • hot tubs or pools [chemicals in water and resident bacteria]

  • spermicides and/or condoms (latex allergy)

  • disposable fragrant douches [douche only when advised to do so by a doctor]

  • hair conditioners, dyes, or shampoos [including hair removal products]

  • perfumes

  • talcum powder

  • over-the-counter medications

[Many of the products girls and women are told they should use are actually bad for their health! If you would not put in your mouth do not expose your vulva and vagina to it!]

Physical or Foreign-Body Vaginitis

Physical or foreign-body vaginitis can be caused by the following:

  • sanitary napkins with plastic shields

  • condoms or diaphragms

  • exercise bicycles

  • horseback riding

  • rowing machines

  • tampons

  • frequent use of small sanitary pads [panty liners]

  • synthetic underwear (non-cotton)

  • tampons or other objects left in the vagina

  • sex toys (vibrators, etc.) [presumably, from excessive use]

  • frequent masturbation [over indulgence, not daily masturbation sessions]

  • pessaries
Atropic Vaginitis

Women who have experienced menopause [natural, surgical, or prescription drug induced] have skin changes in the genital area. Since the tissues there are depend on estrogen, the decline in estrogen during menopause causes the tissues to become thinner, or "atrophic."

This weakening of the skin in the vagina and the vulva can increase the risk of infection. In addition, the atrophic vagina can produce irritative symptoms on its own.

Symptoms of atrophic vaginitis are dryness, discomfort with intercourse, and a watery yellow discharge. In an estrogen-deficient (typically postmenopausal) woman, the diagnosis is made by excluding other causes of vaginitis by history and examination. The discharge contains an increase in white blood cells when viewed under a microscope.

Treatment of atrophic vaginitis consists of estrogen replacement. Vaginal estrogen creams provide more rapid relief than oral estrogen. Often oral and vaginal estrogen are used together. Relief from the irritative symptoms may take a few weeks to months of consistent treatment.

The above information is from the book Your Guy's Guide to Gynecology: Everything you wish he knew about your body if he wasn't afraid to ask by Bruce Bekkar, MD and Udo Wahn, MD. This book was chosen as it presents the information in a simple to understand format that is easy for both men and women to comprehend. Just because you have a vulva and vagina does not mean you instinctively know more about how the female body functions than men do.

Copyright 2001 by Bruce Bekkar, M.D., Udo Wahn, M.D.
ISBN 0-9655067-7-0

Word Definitions

Fungus n. (pl. fungi) a simple plant that lacks the green pigment chlorophyll. Fungi include the yeasts, rusts, molds, and mushrooms. The single-celled microscopic yeasts are a good source of vitamin B and many antibiotics are obtained from the molds.

Bacteria pl. n. (sing. bacterium) a group of microorganisms all of which lack a distinct nuclear membrane (and hence are considered more primitive than animal and plant cells) and have a cell wall of unique composition (many antibiotics act by destrying the bacterial cell wall).

Pessary n. a plug or cylinder of cocoa butter or other soft material containing a drug that is fitted into the vagina for the treatment of gynecological disorders (e.g. vaginitis) or for the induction of labor. Also called: vaginal suppository

Protozoa n. a group of microscopic single-celled animals. Most Protozoa are free living but some are important disease-causing parasites of man


Diagnostic CriteriaNormalBacterial VaginosisTrichomonas VaginitisCandida Vulvovaginitis
Vaginal pH3.8 - 4.2> 4.5> 4.5<>
DischargeWhite to clear, flocculentThin, homogeneous, white or gray, adherent, often increasedYellow-green, frothy, adherent, increasedWhite, curdy, "cottage cheese"- like, sometimes increased
Amine odor (KOH whiff test)AbsentPresent (fishy)May be present (fishy)Absent
Primary SymptomsNoneDischarge, bad odor (may be worse after intercourse), possible itching/burningFrothy discharge, bad odor, vulvar pruritus, dysuriaItching/burning, discharge
Microscopic AppearanceLactobacilli, epithelial cellsClue cell with adherent coccoid bacteria, no WBCsTrichomonad (arrow), WBCs >10/hpfBudding yeast, hyphae, pseudohyphae (w/KOH prep)

This material is provided for educational purposes only and should not be interpreted as promotion by 3M Pharmaceuticals for the use of any of its products.

Prepared for health care professionals and consumers in the United States.

Copyright 3M National Vaginitis Association 1998
3M Center, 275-3W-01 P.O. Box 33275 Saint Paul, MN 55133-3275

 

VAGINITIS & VAGINOSIS (NOTE THE DIFFERENCES.)

Vaginitis is the most common gynecologic diagnosis in the primary care setting.

In approximately 90 percent of 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 of involvement and the characteristics of the vaginal discharge.

The laboratory evaluation includes microscopic examination of:

1.a Saline Wet-Mount Preparation

Wet-Mount Preparation

A wet-mount preparation is obtained by diluting the vaginal discharge with one or two drops of 0.9 percent normal saline (salt) solution and placing it on a slide with a coverslip. Alternatively, the vaginal discharge can be put into a 2-mL test tube containing saline solution and then placed on a slide. The slide is examined microscopically using low power (103) and high dry power (4003). The scanning of several fields for motile trichomonads has a sensitivity of 60 percent and a specificity of up to 99 percent.

Microscopic examination of a wet-mount preparation can also detect "clue cells," which are vaginal epithelial cells that are coated with the coccobacilli. When a skilled examiner performs the search for clue cells, examination of wet-mount preparations can have a sensitivity of 60 percent and a specificity of up to 98 percent for the detection of bacterial ''vaginosis''. The examination may also detect fungal hyphae, increased numbers of polymorphonuclear cells (seen in trichomoniasis) or round parabasal cells (seen in atrophic vaginitis).

2.KOH test .. Potassium Hydroxide Preparation, AND

3.'Whiff' test

A second specimen of the vaginal discharge should be placed on a slide with a 10 percent KOH solution. A coverslip is placed on the slide and air- or flame-dried before examination under a microscope using low power. This is useful for detecting candidal hyphae, mycelial tangles and spores. The test (KOH) is positive in 50 to 70 percent of women with candidal infection.

During preparation of the KOH slide, a WHIFF test can be performed. The whiff test is positive if a "fishy" or amine odor is detected when KOH is added to the vaginal discharge. The odor results from the liberation of amines and organic acids produced from the alkalization of anaerobic bacteria. A positive whiff test is suggestive of bacterial ''vaginosis''.

4. Litmus Testing for pH

The pH level can be determined by placing litmus paper in the pooled vaginal secretions or against the lateral vaginal wall. The color is then compared to the colors and corresponding pH values on a standard chart. A normal vaginal pH is between 3.8 and 4.2.

Blood and cervical mucus are alkaline and alter the pH of a vaginal sample. A pH greater than 4.5 is found in 80 to 90 percent of patients with bacterial vaginosis and frequently in patients with trichomoniasis. The pH level is also high in those with atrophic vaginitis.

Metronidazole is the primary treatment for bacterial vaginosis and trichomoniasis.

Topical antifungal agents are the first-line treatments for candidal vaginitis.

(Am Fam Physician 2000;62:1095-104.)

 

Use the following chart for vaginitis diagnostic tests when microscopy is not available (check again 2 weeks after treatment if mixed infection is suspected):

Whiff pH Hydrogen peroxide* Suspicious history
Yeast - Low - Recurrent symptoms, rash
Bacterial vaginosis + High - Sexually transmitted diseases (STDs), multiple partners
Trichomonas +/- High + STDs, multiple partners
Desquamative inflammatory vaginitis - Variable + Monogamous, no STDs

* Mixing a drop of 3% hydrogen peroxide with vaginal secretions on a microscope slide will immediately produce foaming bubbles in the presence of white blood cells typically found in Trichomonas infection and desquamative inflammatory vaginitis, but will NOT react with candidiasis or bacterial vaginosis.

Ruth H. Christos, MN, RNCS, FNP
Augusta, Ga

 

"The vagina becomes colonized soon after birth with corynebacteria, staphylococci, nonpyogenic streptococci, E. coli, and a lactic acid bacterium historically named "Doderlein's bacillus" (Lactobacillus acidophilus). During reproductive life, from puberty to menopause, the vaginal epithelium contains glycogen due to the actions of circulating estrogens. Doderlein's bacillus predominates, being able to metabolize the glycogen to lactic acid. The lactic acid and other products of metabolism inhibit colonization by all except Doderlein's bacillus and a select number of lactic acid bacteria. The resulting low pH of the vaginal epithelium prevents establishment of most bacteria as well as the potentially-pathogenic yeast, Candida albicans. This is a striking example of the protective effect of the normal bacterial flora for their human host."

© 2000 Kenneth Todar University of Wisconsin Department of Bacteriology




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