Description

Vaginitis is a general term including several kinds of vaginal infections, which result in inflammation of the vagina. Often the vulval (outer genital) region is secondarily involved. Sometimes the urethra (passage for urine), bladder and skin around the genitals are also affected.

Most women experience one type of vaginitis; however, some suffer from several at once. Non-specific vaginitis implies that any of several germs have caused the infection.

Types of vaginitis

The most common vaginal infections are vulvovaginal candidiasis, bacterial vaginosis and trichomoniasis. There are several other forms of vaginitis, such as atrophic vaginitis, and allergic and irritative vaginitis.

Vulvovaginal candidiasis (yeast infection)

• Vulvovaginal candidiasis (VVC) is caused by a yeast-like fungus.
• VVC is not serious, but can be very annoying, since it causes itching.
• It affects females of all ages, especially after puberty.
• Candida are organisms living in the healthy vagina, rectum and mouth. When the vagina's balance is disturbed, these organisms can multiply and cause infections.
• VVC may be spread by sexual contact; symptoms of burning and itching may be worse after intercourse.
• A distinguishing symptom is a white vaginal discharge that may have a texture resembling that of cottage cheese and a yeasty smell.
• Some antifungal creams (miconazole and clotrimazole) are available over the counter, but an accurate medical diagnosis should be obtained before using these. Other non-prescription products contain antihistamines or topical anaesthetics that mask symptoms and do not treat the underlying problem. Note: some yeast medicines weaken condoms and diaphragms.
• Newer types of treatment are a single oral dose of fluconazole (Diflucan 150mg) or itraconazole.
• It is advisable to treat sexual partners with an anti-fungal cream which is applied twice daily for one week on the male genitals. Infection in the male may be asymptomatic (without symptoms)
• Candida hyphae sometimes penetrate under the vaginal epithelial cells. The infection then tends to recur repeatedly during menstruation. To prevent recurrence, vaginal suppositories or cream can be inserted into the vagina a few days before and a few days after menstruation for 2-3 months.
• Vaginal candidiasis commonly occurs during pregnancy. The infection is usually harmless, but a few cases of infection of the membranes has been reported. Treatment is with local vaginal suppositories or cream e.g. clotrimazole (such as Canesten). Oral ketoconazole (such as Nizoral) is contra-indicated during pregnancy.

Bacterial infection

• Bacterial vaginosis (BV) is also sometimes called anaerobic vaginitis, non-specific vaginitis, Gardnerella vaginitis or Haemophilis vaginitis.
• BV is vaginal inflammation due to rapid growth of several kinds of bacteria that naturally live in the vagina.
• A possible distinguishing symptom is a thin, off-white, grey vaginal discharge, and a "fishy" or "musty" odour, which is stronger during menstruation and after sex.
• The redness and itching accompanying yeast infections tend to be milder or absent with BV.
• Nearly half of women with BV report no symptoms.
• BV can probably be transmitted through sexual activity, although the organisms responsible have also been found in young women who are not sexually active.
• BV can be treated with antibiotics such as metronidazole or clindamycin (vaginally or orally), and may require long-term or repeat treatments. Many doctors believe metronidazole shouldn't be used during the first three months of pregnancy.
• BV may play a role in pelvic infections that result in infertility and tubal (ectopic) pregnancy. Gardnerella vaginalis vaginitis shows a possible association with premature rupture of the membranes.
• There is evidence that BV facilitates and enhances the transmittal of certain STDs.
• Condoms are recommended during intercourse to prevent reinfection. Both partners should be re-examined after treatment.
• In general, it is not necessary to treat male sex partners, except in intractable cases or frequent recurrences. Sometimes doctors advise antibiotic treatment for your sexual partner to prevent reinfection.
• BV may spread between female sex partners.

Trichomoniasis

• Trichomoniasis is an STD caused by the parasite Trichomonas vaginalis, which may affect men and women.
• It is not part of the normal vaginal flora.
• The vagina is the most common site of infection in women.
• Trichomoniasis may also be passed between individuals non-sexually, as it can survive in bodily fluids outside the body for a few hours.
• Trichomoniasis not infrequently involves post-menopausal women in their 60s and 70s.
• Many women and most men never have symptoms and are asymptomatic carriers.
• When symptoms occur, they usually appear within four to 20 days of exposure, although symptoms can appear years later.
• A possible distinguishing symptom is a yellow-green or grey, thin, foamy and foul-smelling vaginal discharge.
• Symptoms may worsen during menstruation.
• Although symptoms of trichomoniasis in men may disappear within a few weeks without treatment, they can still transmit the disease to their partners. It is preferable for both partners to receive treatment to eliminate the parasite.
• Treatment for trichomoniasis is usually metronidazole, which is usually prescribed in one large oral dose or several smaller doses taken over three to seven days. Note: Drinking alcohol while taking this drug can cause nausea and vomiting.
• Recurrences can be due to re-infection or relapse. Re-infection can be due to failure to treat all sexual partners. Recurrences generally require a higher dose of metronidazole and a longer treatment plan.
• Talk to your doctor about getting tested for other STDs.
• To prevent re-infection, a condom should be used during sexual intercourse until treatment is complete. Re-examination after treatment is essential.
• Trichomoniasis may increase risk of transmission of HIV.
• The organisms are not transmitted to the foetus or newborn, but there is a possible association with premature rupture of the membranes.
• Women in the first three months of pregnancy should not take medicine for trichomoniasis.
• Condoms and diaphragms may help prevent trichomoniasis.

Postmenopausal (atrophic) vaginitis

• Postmenopausal vaginitis is infection or inflammation of the vagina caused by lowered oestrogen levels that upset the vagina's normal balance.
• After menopause the vaginal tissues are no longer being stimulated by oestrogen, and may become dried out and prone to infection. Tiny sores may appear in the vaginal wall, causing a blood-tinged discharge.
• There may be a bad-smelling vaginal discharge, which is usually thin, whitish and sometimes blood-tinged.
• Treatment consists of oestrogen replacement therapy either topically, transdermally, or orally, and treatment of the secondary infection if present. A water-soluble lubricant may be used if oestrogen cannot be taken.

Other causes of vaginitis

• Other causes may include allergic and irritative factors or other STDs.
• Non-infectious allergic symptoms can be caused by chemicals in products such as spermicides, vaginal hygiene products, detergents, fabric softeners, spermicides and, more rarely, latex.
• Cervical infections are also often associated with abnormal vaginal discharge, but these infections can be distinguished from true vaginal infections by appropriate tests.
• In uninfected women, vaginal discharge may be present during ovulation and may become so heavy that it raises concern.

Cause

The healthy vagina is slightly acidic, and contains a balance of several kinds of organisms. When the natural balance is disrupted, one or more types of organism normally present in the vagina can multiply. Harmful bacteria may grow too quickly and cause infections (see above).

Symptoms

Symptoms may include:

• Abnormal vaginal discharge, which may irritate tissues and have an unpleasant odour. (The healthy vagina produces a slight discharge, which changes in amount, consistency, and colour over the course of your monthly cycle and throughout your lifetime. Discharge is usually clear, cloudy or whitish, moderate in quantity, thin or slightly viscous, and with mild odour.)
• Vaginal and vulval discomfort, which may include burning and itching
• Genital swelling
• Change in vaginal colour from pale pink to red
• Discomfort during sexual intercourse
• Frequent or painful urination
• Occasionally, pain in the lower abdomen

Prevalence

Vaginitis is a common condition, affecting about one third of women during their lifetimes. Vaginal infections are frequent causes of discomfort in post-pubertal and adult women, whether sexually active or not. Vaginitis most often occurs during the reproductive years, but can also affect infants and elderly women.

Risk factors

The following can increase the likelihood of vaginitis:

• General poor health, including lack of sleep, poor diet and stress
• Hot weather, non-ventilating clothing (especially underwear) or any condition that increases genital moisture, warmth and darkness
• Changes in hormone levels through pregnancy, breast-feeding, menopause, some oral and intramuscular contraceptives and steroid use
• Drugs or diseases that lower the body's resistance to infection - women with HIV infection, for example, are more prone to yeast infections.
• Diabetes mellitus or a prediabetic condition
• Unprotected sexual intercourse, especially with multiple partners
• Sexually transmitted diseases (STDs)
• Infection elsewhere in the body
• Douching - this can upset the natural vaginal balance, as can other chemically treated products such as "feminine hygiene" sprays
• Antibiotics - can kill beneficial vaginal bacteria
• Antibacterial soaps and topical antimicrobial agents
• Over-the-counter medications improperly used
• Spermicides
• Hereditary and genetic factors
• Obesity
• High carbohydrate intake, especially sugars and alcohol - may stimulate yeast infection
• Menstruation
• Cuts, abrasions, or other irritations to the vagina, such as sexual intercourse without enough lubrication
• Childbirth
• Poor hygiene

When to see a doctor

Consult your doctor if:

• A vaginal infection is your first
• You have a yellow or green vaginal discharge
• Symptoms persist longer than a week or worsen despite treatment
• After treatment, symptoms recur
• More than three yeast infections occur in a year
• Unusual vaginal bleeding or swelling develops
• You are pregnant - vaginitis is seldom dangerous and usually responds well to treatment, but may create special problems during pregnancy
• You have been exposed to an STD
• Complications of untreated vaginitis may include secondary infections of the vagina and other pelvic organs.

Visit preparation

To help with diagnosis:

• Schedule the exam for when you're not menstruating.
• Don't douche or use vaginal sprays 24 hours before your exam.
• If you have sex less than 24 hours before the exam, use condoms.

Diagnosis

If you have symptoms of vaginitis, a correct diagnosis is needed before the condition can be treated.

Your doctor will take a medical history, noting your own observation of symptoms, and perform a physical exam (including a pelvic exam). However, laboratory tests to allow for microscopic evaluation of vaginal fluid are required for correct diagnosis. Your doctor may insert swabs into the vagina and cervix to take samples.

Self-diagnosing and self-treating can be dangerous, and may delay correct treatment. Recurrent vaginitis may indicate a serious underlying disorder, such as diabetes or HIV infection.

Treatment

Home

If you are prone to frequent infections, an occasional acidic douche may be helpful - for example, two tablespoons of white vinegar added to a litre of warm water or a solution of baking soda and water. However, douching itself can promote vaginitis, and many doctors advise against it.

Plain yoghurt made with live cultures, either eaten or put into the vagina, may help restore the natural balance of yeast and bacteria, especially if there is an overgrowth of yeast as a result of antibiotic therapy.

Medication

Your doctor may prescribe:

• Antibiotics or antifungals, directed at the specific organism causing the infection. Yeast infections are treated with antifungal suppositories, creams and ointments. If vaginitis is caused by bacteria, antibiotics may clear up the underlying cause.
• Soothing vaginal creams or lotions for non-specific forms of vaginitis.

Use all the medication as prescribed. Disappearance of symptoms may not mean disappearance of the infection.

If you use a cream or suppository, use a small sanitary pad to protect clothing. After treatment, you may want to keep a refill of the medication so you can begin treatment quickly if the condition recurs. Keep creams or suppositories in the refrigerator. Check with your doctor about any other medication you may be taking. Some medications may make your vagina more susceptible to infection.

Other

• If urination causes burning, urinate through a tubular device, such as a toilet-paper roll, or pour a cup of warm water over the genital area while you urinate.
• Avoid overexertion, heat and excessive sweating.
• Abstain from sex until after treatment, or use condoms.
• When allergy causes vaginitis, avoiding the allergic agent may end the irritation.

Vaginitis is usually curable in two weeks with treatment. Your sexual partner may need treatment also.

Prevention

• Keep the genital area clean and dry. Use mild soap and rinse well.
• Be sure your sexual partner is clean.
• Wear loose, natural-fibre clothing, particularly cotton underpants or pantyhose. Wash them in hot soapy water, and rinse and dry thoroughly. Tight clothing and nylon underwear can trap moisture and encourage growth of organisms, especially in hot weather. Change underwear at least every 24 hours.
• Dry off thoroughly after bathing and swimming; don't stay in wet clothing for long periods.
• After urination or bowel movements, wipe from front to back to prevent bacteria from the anus entering the vagina.
• Lose weight if you are obese.
• Avoid chemical products that can upset the vagina's acidic balance such as vaginal douches and "feminine hygiene" sprays, bubble baths and coloured or scented toilet paper, soaps, detergents and sanitary towels or tampons. These products can also mask an odour signalling infection. If you want to douche, do so infrequently and use water or a vinegar and water mixture.
• If you have diabetes, adhere to your treatment program.
• Change tampons or sanitary towels frequently.
• If you use a diaphragm, don't leave it in longer than recommended. Clean your diaphragm, cervical cap, and spermicide applicators thoroughly in warm soapy water and dry.
• Avoid broad-spectrum antibiotics unless necessary. Consider using yeast medications while taking antibiotics if you get frequent yeast infections.
• Limit your number of sex partners.
• Use condoms with a new partner or with multiple partners.
• Avoid sexual activity when you have an infection.
• Birth control jellies have been found to slow the growth of bacteria that cause certain forms of vaginitis.
• Practise a healthy life-style, which includes good nutrition, adequate sleep, regular exercise and stress management.
• Eat yoghurt with live cultures, as well as buttermilk and sour cream, which may help to maintain the vaginal balance.

(Reviewed by Prof J.T. Nel)

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