Vaginitis--%20trichomoniasis,%20candidiasis,%20bacterial%20vaginosis Signs and Symptoms

• Altered vaginal discharge in women of reproductive age may be secondary to non-sexually transmitted infections (eg bacterial vaginosis, vulvovaginal candidiasis), sexually transmitted infections (eg Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Herpes simplex virus), or non-infective causes (eg foreign bodies, cervical polyps or ectopy, genital tract malignancy, fistula, allergies)
• Please see Chlamydia - Uncomplicated Anogenital Infection, Genital Herpes, and Gonorrhea - Uncomplicated Anogenital Infection disease management charts for further information

Trichomoniasis 

• Caused by a flagellated protozoan, Trichomonas vaginalis (TV)
• Considered the most common non-viral sexually transmitted infection (STI)   
• Most infections present with minimal or no symptoms (10-50%) and if left untreated may last for months to years  
• Almost always sexually transmitted

Bacterial Vaginosis (BV)

• Most common cause of vaginitis, vaginal discharge or malodor
• Results from overgrowth of anaerobic bacteria (eg Prevotella sp, Mobiluncus sp, Gardnerella vaginalis, Atopobium vaginae, Ureaplasma sp, Mycoplasma hominis) replacing the normal hydrogen peroxide-producing Lactobacillus sp in the vaginal flora
  • Presence of Gardnerella alone is not conclusive to diagnose BV because it is a commensal organism in some asymptomatic women
• Considered to be sexually associated but not truly sexually transmitted
  • May coexist with trichomoniasis and other STIs 

Vulvovaginal Candidiasis (VVC) 

• Caused by overgrowth of yeasts where 70-90% of cases are secondary to Candida albicans
• Most commonly occurs when the vagina is exposed to estrogen (ie reproductive years, pregnancy) and may be precipitated by antibiotic or corticosteroid use
  • Immunocompromised and diabetic women are also at risk
• Immunocompetent patients with sporadic or infrequent VVC, mild to moderate VVC, and with C albicans infection are considered to have uncomplicated VVC
• Immunocompromised or debilitated patients with recurrent (>4 episodes/year), severe, or non-albicans VVC are classified to have complicated VVC
• Though sexually associated, it is not an STI

Clinical Observations Associated with Vaginal Infections

Trichomoniasis

• >50% of patients are asymptomatic or have minimal symptoms 
• Scanty to profuse, offensive vaginal discharge may be present
• Patient may complain of vulval itching, dysuria and rarely, lower abdominal discomfort
• Pelvic exam may reveal vulval erythema (“strawberry cervix”), vaginitis, cervicitis, vulvitis, or frothy, malodorous, yellow vaginal discharge pooled at the posterior fornix

Bacterial Vaginosis (BV)

• 50% of patients are asymptomatic 
• Thin discharge with fishy/offensive odor may be present
• Pelvic exam may reveal white/gray homogenous discharge that coats the walls of vagina and vestibule

Vulvovaginal Candidiasis (VVC)

• 10-20% of patients are asymptomatic
• Patient may complain of vulval itching and soreness, superficial dyspareunia, external dysuria, and non-offensive vaginal discharge
• Pelvic exam may show curdy (cottage cheese-like) vaginal discharge, satellite skin lesions and, if with severe VVC, vulval erythema, fissuring, edema and erosion