VAGINITIES

Vaginitis is an inflammation of the vagina. It can result in discharge, itching and pain, and is often associated with an irritation or infection of the vulva. It is usually due to infection. The three main kinds of vaginitis are bacterial vaginosis (BV), vaginal candidiasis, and trichomoniasis. A woman may have any combination of vaginal infections at one time. The symptoms that arise vary with the infection, although there are general symptoms that all vaginitis infections have and infected women may also be asymptomatic. Testing for vaginal infections is not a part of routine pelvic exams; therefore, women should neither assume their health care providers will know of the infection, nor that they will provide appropriate treatment without their input

Signs and symptoms

A woman with this condition may have itching or burning and may notice a discharge. The following symptoms may indicate the presence of infection, which should be followed up with a professional health care practitioner for diagnosis and treatment:

• irritation and/or itching of the genital area
• inflammation (irritation, redness, and swelling caused by the presence of extra immune cells) of the labia majora, labia minora, or perineal area
• vaginal discharge
• foul vaginal odor
• pain/irritation with sexual intercourse

Causes of Vaginities

Vulvovaginitis can affect women of all ages and is very common. Specific forms of vaginitis are:

Infection

Infectious vaginitis accounts for 90% of all cases in reproductive age women and is represented by the triad:

• Candidiasis: vaginitis caused by Candida albicans (a yeast).
• Bacterial vaginosis: vaginitis caused by Gardnerella (a bacterium).

Other less common infections are caused by gonorrhea, chlamydia, Mycoplasma, herpes, Campylobacter, improper hygiene, and some parasites, notably Trichomonas vaginalis.

Vaginal infection are often (varies between countries between 20 to 40% of vaginal infections) a mix of various etiologies, which present challenging cases for treatment. Indeed, when only one cause is treated, the other pathogens can gain in resistance and induce relapses and recurrences. The key factor is therefore to get a precise diagnosis and treat with broad spectrum anti-infective (often also inducing adverse effects).

Further, either a change in pH balance or introduction of foreign bacteria in the vagina can lead to infection known as vaginitis. There are physical factors that can contribute to development of infection, such as constantly wet vulva due to tight clothing, chemicals coming in contact with the vagina via scented tampons, antibiotics, birth control pills, or a diet favoring refined sugar and yeast.

Pre-pubescent girls

• Bacterial vaginosis: vaginitis caused by Streptococcus spp..
• Improper hygiene, which may introduce bacteria or other irritants from the anal region to the vaginal area.

The pH balance in adolescent girls' bodies is not conducive to the growth of Candida albicans, so they are unlikely to contract a yeast infection.

Hormonal

Hormonal vaginitis includes atrophic vaginitis usually found in postmenopausal or postpartum women. Sometimes it can occur in young girls before puberty. In these situations theestrogen support of the vagina is poor.

Irritation/allergy

Irritant vaginitis can be caused by allergies to condoms, spermicides, soaps, perfumes, douches, lubricants and semen. It can also be caused by hot tubs, abrasion, tissue,tampons or topical medications.

Foreign body vaginitis: foreign bodies (most commonly retained tampons or condoms) cause extremely malodorous vaginal discharges. Treatment consists of removal, for which ring forceps may be useful. Further treatment is generally not necessary.

Diabetes

Women who have diabetes develop infectious vaginitis more often than women who do not.^[8]

Diagnosis

Women should inform their doctors of symptoms that may indicate infection, so that a diagnosis may be made. Diagnosis is made with microscopy (mostly by vaginal wet mount) and culture of the discharge after a careful history and physical examination have been completed. The color, consistency, acidity, and other characteristics of the discharge may be predictive of the causative agent.Determining the agent is especially important because women may have more than one infection, or have symptoms that overlap those of another infection, which dictates different treatment processes to cure the infection.^[4] For example, women often self-diagnose for yeast infections but due to the 89% misdiagnosis rate, self-diagnoses of vaginal infections are highly discouraged.

The International Statistical Classification of Diseases and Related Health Problems codes for the several causes of vaginitis are:

Condition	Description	pH
Candida vaginitis (B37.3)	Commonly referred to as a yeast infection, Candidiasis is a fungal infection that usually causes a watery, white, cottage cheese-like vaginal discharges. The discharge is irritating to the vagina and the surrounding skin.	low (4.0–4.5)
Atrophic vaginitis (or Senile vaginitis) (N95.2)	usually causes scant vaginal discharge with no odor, dry vagina and painful intercourse. These symptoms are usually due to decreased hormones usually occurring during and after menopause.
Bacterial vaginitis (B96.3).	Gardnerella usually causes a discharge with a fish-like odor. It is associated with itching and irritation, but not pain during intercourse.	elevated
Trichomonas vaginalis(A59.0)	can cause a profuse discharge with a fish-like odor, pain upon urination, painful intercourse, and inflammation of the external genitals.	elevated (5.0–6.0)

Another uncommon type of vaginitis, called desquamative inflammatory vaginitis also exists, and is underdiagnosed. The cause behind this type is still poorly understood.

Complications

Recent studies have shown that vaginal infections left untreated can lead to further complications, especially for the pregnant woman. For bacterial vaginosis, these include "premature delivery, postpartum infections, clinically apparent and subclinical pelvic inflammatory disease, [as well as] postsurgical complications (after abortion, hysterectomy, caesarian section), increased vulnerability to HIV infection and, possibly, infertility" Studies have also linked trichomoniasis with increased likelihood of acquiring HIV; theories include that "vaginitis increases the number of immune cells at the site of infection, and HIV then infects those immune cells." 

Further, there are complications which lead to daily discomfort such as:

• persistent discomfort
• superficial skin infection (from scratching)
• complications of the causative condition (such as gonorrhea and candida infection)

Prevention

Prevention of candidiasis, the most common type of vaginitis, starts with good hygiene: drying completely after bathing, wearing fresh undergarments, and wiping from front to rear after defecation all help to prevent contamination of the vagina with harmful bacteria. The vaginal area should be washed with water: perfumed soaps, shower gels, and vaginal deodorants should be avoided. Douching is never recommended, as it often does more harm than good, by upsetting the normal balance of yeast in the vagina.

Prevention of bacterial vaginosis includes healthy diets and behaviors as well as minimizing stress as all these factors can affect the pH balance of the vagina.

Prevention of trichomoniasis revolves around avoiding other people's wet towels and hot tubs, and safe-sex procedures, such as condom use.

Some women consume good bacteria in food with live culture, such as yogurt, sauerkraut and kimchi, or in probiotic supplements either to try to prevent candidiasis, or to reduce the likelihood of developing bacterial vaginitis following antibiotic treatment. There is no firm evidence to suggest that eating live yogurt or taking probiotic supplements will prevent candidiasis.

Studies have suggested a possible clinical role for the use of standardized oral or vaginal probiotics in the treatment of bacterial vaginosis, either in addition to  or in place of the typical antibiotic regimens. However recent articles question their efficacy in preventing recurrence compared with other means, or conclude that there is insufficient evidence for or against recommending probiotics for the treatment of bacterial vaginosis.

Treatment

The cause of the infection determines the appropriate treatment. It may include oral or topical antibiotics and/or antifungal creams, antibacterial creams, or similar medications. A cream containing cortisone may also be used to relieve some of the irritation. If an allergic reaction is involved, an antihistamine may also be prescribed. For women who have irritation and inflammation caused by low levels of estrogen (postmenopausal), a topical estrogen cream might be prescribed.

The following are typical treatments for trichomoniasis, bacterial vaginosis, and yeast infections:

• Trichomoniasis: Single oral doses of 2 grams of either metronidazole, or tinidazole.

• Bacterial vaginosis: The most commonly used antibiotics are metronizadole, available in both pill and gel form, and clindamycin available in both pill and cream form.

• Yeast infections: Local azole, in the form of ovula and cream. These anti-fungal medications, which are available in over the counter form, are generally used to treat yeast infections. Treatment may last anywhere between one, three, or seven days.