VAGINITIS – Evaluation of Abnormal Vaginal Discharge
Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora. Symptoms include vaginal discharge, odor, itching, and/or discomfort. These symptoms are extremely common and frequently lead to self-treatment. In a survey of random women in the United States, a healthcare professional was consulted in only 50-80% of the situations and most women purchased an over-the-counter antifungal preparation to treat their symptoms, whether or not they saw a physician.
The vaginal epithelium (or lining) in women of reproductive age is rich in glycogen. Lactobacilli help maintain the vaginal pH between 4.0 to 4.5 (acidic) with the help of strain of lactobacilli called Doderlein’s bacteria. This acidity is needed to maintain the normal vaginal flora and prevent the growth of pathogenic organisms. Disruption of the normal ecosystem can lead to conditions favorable for development of vaginitis. Some of these disruptive factors include phase of the menstrual cycle, sexual activity, contraceptive choice, pregnancy, foreign bodies, estrogen level, sexually transmitted diseases, and use of hygienic products or antibiotics.
Normal discharge may be yellowish, slightly malodorous, and accompanied by mild irritative symptoms. However, if it is not accompanied by itching, pain, burning or significant irritation. Presence of the latter associated symptoms signifies pH imbalance and presence of vaginal infection or vaginitis.
The severity of symptoms correlates with the extent of inflammation. Candida vulvovaginitis (yeast) often presents with marked irritative symptoms such as itching and soreness, but scant discharge (thick, white, odorless, and curd-like). In contrast, Bacterial Vaginosis is associated with only minimal inflammation and minimal irritative symptoms, but the thin, gray or yellow, malodorous discharge is a prominent complaint. Women may complain of a fishy smell or yellowish green discharge. Trichomoniasis is characterized by purulent, malodorous, thin discharge, which may be accompanied by burning, itching, painful urination, frequency, and/or painful intercourse. The vulva also may be affected by candidiasis or yeast infection but not by bacterial vaginosis. Symptoms of candidal vulvovaginitis often occur in the premenstrual period, while symptoms of trichomoniasis often occur during or immediately after the menstrual period.
Vaginal pH — Measurement of vaginal pH is the single most important finding that drives the diagnostic process and should always be determined. A pH test stick (or pH paper if available) is applied for a few seconds to the vaginal sidewall (to avoid contamination by blood, semen, or cervical mucus which pool in the posterior fornix and distort results). Alternatively, the vaginal sidewall can be swabbed with a dry swab and then the swab rolled onto pH paper (if available). The pH of the specimen is stable for about two to five minutes at room temperature. The swab should not be pre-moistened, as the moistening liquid can affect pH.
Narrow range pH paper (4.0 to 5.5) is easier to interpret than broad range paper (4.5 to 7.5). An elevated pH in a premenopausal woman suggests infections such as bacterial vaginosis (pH>4.5) or trichomoniasis (pH 5 to 6), and helps to exclude candida vulvovaginitis (pH 4 to 4.5).
The pH of the normal vaginal secretions in premenopausal women is 4.0 to 4.5 because these women have relatively high estrogen levels. Under the influence of estrogen, the normal vaginal epithelium stabilizes and produces glycogen. In the age groups of women before puberty and after menopause, the pH of the normal vaginal secretions is ≥4.7. The higher pH is due to less glycogen in epithelial cells and reduced lactic acid production. Thus measurement of pH for diagnosis of bacterial vaginosis, trichomoniasis, or candidiasis is less useful at the extremes of age.
Vaginal pH may be altered (usually to a higher pH) by contamination with lubricating gels, semen, douches, and intravaginal medications. In pregnant women, leakage of amniotic fluid raises vaginal pH.
DIAGNOSTIC OPTIONS
Microscopy- Taking a sample of the fluid and examining under the microscope used to be the standard method of evaluation of abnormal vaginal discharge. However, now there are many modern techniques available to accurately diagnose the type of infection to help in the right treatment.
The commercially available tests include rapid antigen and nucleic acid amplification tests are used for confirming the clinical suspicion of bacterial vaginosis or trichomonas vaginitis. The PCR tests can be used for typing and identification of various species of Candida (yeast)
Cervical culture — A diagnosis of cervicitis, typically due to Neisseria Gonorrhea or Chlamydia trachomatis, must always be considered in women with purulent cervical discharge since women with this disorder may go on to develop PID and its potential complications. Any women with new or multiple sexual partners, a symptomatic sexual partner, or an otherwise unexplained cervical or vaginal discharge that contains a high number of white cells should alert the physician for the presence of these organisms, by culture or an alternative sensitive test.
Your health care provider will take a vaginal swab while doing a speculum examination of the vagina. It is like a “pap” exam but the type of swab used by the provider is different. The doctor may also use a pH strip to test the pH of the vaginal secretions to help aid diagnosis. The swab is then sent for testing to the lab via the techniques mentioned above. The results take approximately 3-7 days. The physician may treat if the discharge is highly suggestive and then offer follow up treatment if the cultures show differently.
Difficult diagnosis: Even after a thorough evaluation, 25 to 40 percent of women with genital symptoms may not reveal a specific cause.
Non-infective causes
Irritants and allergens — Vaginal discharge can result from irritants (e.g., scented panty liners, spermicides, povidone-iodine, soaps and perfumes, and some prescription and nonprescription topical medications) and allergens (e.g., latex condoms, topical antifungal agents, seminal fluid, chemical preservatives) that produce acute and chronic hypersensitivity reactions, including contact dermatitis. Women from the developing world may have vaginal practices or use traditional products and medicines that have adverse effects [12].
Diagnosis and management involve identifying and eliminating the offending agent by taking a thorough history and systematically removing potential irritants and allergens from the urogenital environment. Symptom/contact diaries may be helpful.
Estrogen status – Is the woman menopausal or otherwise hypo estrogenic? Atrophic vaginitis is a common cause of vaginitis in hypo estrogenic women. In premenopausal women, hypo estrogenic settings include the postpartum period, lactation, and during administration of antiestrogenic drugs (and sometimes with low estrogen levels related to contraceptives). Menopausal women receiving hormone therapy may not have adequate estrogen levels for vaginal health and thus remain prone to atrophic vaginitis. Nonspecific signs and symptoms include a watery, white or yellow, and malodorous discharge; vaginal burning or irritation; dyspareunia; and urinary symptoms. Physical findings include thinning of the vaginal epithelium, loss of elasticity, pH ≥5 and pain during examination or intercourse.
Treatment outline
- Do not self-treat.
- Do not treat yourself for all possible infections without proper evaluation, culture and diagnosis. The blanket treatment can lead to altering the vaginal pH and lead to either worsening of infection or improper diagnosis and treatment.
- The following information is vital to reaching the root cause of the problem.
- Duration of symptoms, the triggering factors, site of symptoms (vulva versus vagina), recent change in sexual partner, recent intake of oral contraceptives, antibiotics, travel, stress or diagnosis of other medical conditions such as diabetes may play an important role in triggering these conditions.
- Treating the symptoms without delineating the causative factor or agent will not help. The condition will keep recurring and be a source of frustration for both the patient and the health care provider.
Rare causes of persistent vaginal irritation once Candida vaginitis, bacterial vaginosis, and trichomoniasis have been ruled out:
- If pH is increased, non-infectious causes, such as vaginal atrophy, atrophic vaginitis, erosive lichen planus, lichen sclerosus, desquamative inflammatory vaginitis, bacterial vaginosis should be considered.
- If pH is normal, the vagina is likely to be normal with normal bacterial environment, so focus needs to be on the most common vulvar and external causes of vulvovaginal symptoms, such as contact or irritant dermatitis and seborrheic or eczematoid dermatitis etc.
- Group A streptococcal vaginitis is associated with a normal or mildly increased pH, but this is a rare disease.
Stay tuned for a follow up segment on treatment and prevention of vaginal infections/ itching/ abnormal discharges etc.
Adeeti Gupta MD, FACOG