- The most common cause for females to seek a medical doctor – around 60%. Vaginal infections have numerous symptoms, which include: abnormal vaginal discharge, foul smell, itching, irritation, burning, painful intercourse, painful urination, and being asymptomatic – without any of the above-mentioned symptoms.
Three different types of organisms can infect the female genital tract and cause Vaginal infections, vaginitis/vaginosis.
1) Bacteria – Vaginal Bacterial Infection
2) Yeast – Candidiasis – Vaginal Yeast Infection
3) Trichomonas – Trichomoniasis
Candida, the species of yeast that causes vaginal yeast infections, is also known as vaginitis and/or candidiasis.
Vaginal Bacterial Vaginosis
- Vaginal bacterial vaginosis – The most common type of vaginal infection.
- The cause of vaginal bacterial vaginosis is an excess of one or more types of bacteria.
- There is simply an imbalance of the natural flora / natural bacteria that are normally found in the vagina. This normal flora is changed in vaginal bacterial vaginosis.
- The vagina normally contains a variety of bacteria that help keep the vagina healthy, for example by preventing pathogenic bacteria from growing in the vagina by overpopulating them. One particularly important bacterium is lactobacillus, which keeps the vagina slightly acidic. The acidity of the vagina helps to reduce the growth of other harmful bacteria, as well as other organisms, such as yeast and trichomonas.
- Women with vaginal bacterial vaginosis have a large increase in the number of harmful, not normal bacteria in the vagina, and a decrease in the normal bacteria, such as lactobacillus.
- Vaginal bacterial vaginosis usually happens in females who have had multiple partners, recently changed partners, and in women who started having intercourse at an early age. Bacterial vaginosis, however; can also be found in women who have never had intercourse but at much lower levels, more than half of all women have no symptoms
- Symptomatic women with vaginal bacterial vaginosis have increased vaginal discharge.
- Vaginal discharge is white to grey with a milky thick consistency that can even stain undergarments. Unpleasant foul-smelling discharge – ‘fishy smell’. This smell is usually increased following intercourse. Diagnosis is usually by characteristics of the vaginal discharge, itchiness and irritation does not occur with bacterial vaginosis – therefore if you have these symptoms – look for another cause – yeast vaginosis or trichomonas, bacterial infections require antibiotics
Vaginal Yeast Infections
Yeast Vaginosis
- Vaginal yeast infections are another form of vaginitis.
- Vaginal yeast infections are caused by a fungus called Candida – infection with Candida is referred to as Candidiasis
- Symptoms of vaginal yeast infection include:
- Cottage cheese-like vaginal discharge
- Itching
- Vaginal discharge has no smell in yeast infections
- A burning sensation during intercourse is usually felt with yeast infections
- Treatment of vaginal yeast infections usually entails over-the-counter products
Trichomoniasis
- trichomoniasis is a sexually transmitted disease caused by a parasite
- trichomonad is the parasite that causes trichomoniasis
- trichomoniasis accounts for 5-15% of all vaginal infections/vaginosis
- transmitted by sexual intercourse
- women with trichomoniasis usually will have a green-yellow vaginal discharge
- foul-smelling discharge
- vulvar irritation
- itching
- burning
- painful intercourse
- painful urination
- trichomoniasis requires specific antibacterial treatment
Diagnosis of Vaginal Infections Includes the Following:
Healthcare providers detect these infections as follows:
– assessment of the color and appearance of the vaginal secretions – normal secretions are clear or white
– vaginal acid level is measured using pH paper
– doing a sniff test – which consists of adding the chemical potassium hydroxide to the vaginal secretions – this produces characteristic smells for each of the infections
– examination of the vaginal secretions under a microscope may be done if the previous tests do not reveal anything – cells of the bacteria, trichomonad, and yeast may be seen
– a Pap smear may also reveal the causative organism
Treatment of these infections is essential in order to prevent complications such as PID pelvic inflammatory disease. Pelvic inflammatory disease can subsequently lead to infertility, constant and chronic pelvic pain, and ectopic pregnancies.
The main treatment of bacterial vaginosis is metronidazole, an antibiotic.
pH Test of Vaginal Secretions
- pH measurement unreliable with blood or semen present
- this is done by applying a small amount of vaginal fluid/secretions from the side of the vaginal wall to a piece of pH paper
- normally, the vagina has a pH that is acidic <4.5
- yeast infections cause the pH to be lower or normal
- Trichomonas vaginalis infection causes an elevation of the pH
Wet Mount
- microscopic examination of vaginal fluids/secretions while being mixed with normal saline or 10% KOH
- the normal saline slide will show vaginal flora, bacteria, immune cells, epithelial cells
- KOH is used to lyse cells and allow for any yeast/fungi to be seen
KOH Whiff Test
- a swab of vaginal fluid/secretions dipped into 10% KOH is passed under the nose
- KOH liberates the amines produced by bacteria, like Trichomonas
- With bacteria, the smell will be strong, and ‘fishy-like’
Human Papilloma Virus (HPV)
Vaginal Infections – Genital Warts
Diagnosis of warts is done through inspection
In the near future, HPV DNA testing will be available to diagnose harmful bacteria versus benign ones. In addition, a new HPV vaccine will come into play soon and be available to females aged 12-14, in order to form immunity to HPV and prevent not only warts but more importantly cervical cancer.
The reason for Pap smears, and colposcopy, is to reveal the presence of cellular changes due to HPV viral infections. HPV viruses produce a special protein once inside host cells, the E2 protein. This protein binds to a cell cycle regulator known as the retinoblastoma protein, and subsequently, inhibits the cell from stopping its growth. The cells, therefore, replicate uncontrollably, leading to localized warts.
Genital Wart Treatments
- Imiquimod 5% cream also known as Aldara, is an immune modulator/cytokine inducer that is applied 3 times per week for 3 months. Side effects are mainly skin irritation
- Podofilox 5% solution applied twice a day for 4 weeks
- Dermatologist applied Podophyllin, trichloroacetic acid (TCA), liquid nitrogen
- The last resort is surgical removal
Herpes Simplex Virus
Diagnosis of herpes is through viral culture, detecting the DNA through PCR, and/or detecting antibodies for herpes through ELISAs.
Treatment of Herpes
- The first episode is treated with Acyclovir 400 mg three times a day (or famciclovir/valacyclovir)
- Recurrent herpes is treated with acyclovir 400 mg three times a day for about 5 days (or famciclovir/valacyclovir)
- Patients with more than six attacks of herpes a year should consider continuous prophylaxis with acyclovir 400 mg twice a day (or famciclovir/valacyclovir) every day in order to prevent herpes from flaring
What else can vaginal itch or vaginitis be?
The vaginal itch can also be termed infectious vaginitis. This means CANDIDA (Yeast infection), BACTERIAL VAGINOSIS (basically asymptomatic except for abnormal discharge and odor), Gardnerella vaginalis, and TRICHOMONAS VAGINITIS (which is an STD, sexually transmitted disease).
NON-INFECTIOUS VAGINITIS is a term used for vaginitis not caused by bacteria, fungi, yeast, or trichomonas. These include ATROPHIC VAGINITIS, which is seen in post-menopausal females, due to loss of tissue structure and composition of the vagina secondary to loss of estrogen which maintains the vagina. Also, CHEMICAL and IRRITANT effects on the vagina can cause vaginitis.
SYMPTOMS ASSOCIATED WITH VAGINAL INFECTIONS, AND VAGINITIS:
Symptoms of vaginitis include:
DISCHARGE – Quantity, Colour, Consistency, etc
– curd-like “cottage cheese” suggests Yeast
– profuse thin greyish discharge suggests Gardnerella (BACTERIAL VAGINITIS)
– greenish suggests Trichomonas
ODOUR (Bacterial Vaginosis smells fishy, Trichomonas smells rancid, no smell with yeast infections)
ITCHINESS (suggestive of Yeast infection)
PAIN WITH INTERCOURSE (Yeast and Trichomonas infections)
PAIN WITH URINATION (occurs in Yeast and Trichomonas infections, not in Bacterial Vaginosis)
POST-INTERCOURSE SPOTTING (atrophic vaginitis, post-menopausal vaginitis)
GENITAL INFLAMMATION and SWELLING (suggestive of Yeast infection)
RED FLAGS (things to watch out for that mean something more serious is occurring):
ABNORMAL VAGINAL BLEEDING – which is worrisome for cancer of the vagina or vulva
FEVER – seen with infections that have entered the bloodstream and are severe
PELVIC PAIN – must worry about pelvic inflammatory disease, in which the female genital tract may have become infected
WEIGHT LOSS – similar to abnormal vaginal bleeding, must worry about cancer or systemic process
DOES DISCHARGE CHANGE WITH THE CYCLE? – if present, this may be just physiological discharge
RECENT CHANGE IN DETERGENTS, SOAPS, LUBRICANTS – if present, this is likely irritant vaginitis
RECENTLY BEEN IN HOT TUBS OR SAUNAS? – these pose a risk for Trichomonas infection
PREVIOUS INSTANCES AND HOW TREATED? – maybe a recurrence of past poorly or not completely removed infection
LAST MENSTRUAL PERIOD, MIGHT YOU BE PREGNANT?
– increases the risk of Yeast infection AND may influence the decision to treat or not to treat if pregnant
USE OF BIRTH CONTROL PILL? – leads to an increase in the risk of yeast infections
DO YOU DOUCHE? – can lead to irritant vaginitis
SEXUAL HISTORY – this helps to rule out sexually transmitted diseases, STDs – such as Trichomonas, Gonorrhea, and Chlamydia)
ARE YOU SEXUALLY ACTIVE?
HOW MANY PARTNERS?
SAFE SEX? TYPES OF CONTRACEPTION? – intrauterine devices, IUDs, can increase the risks of having an infection
VISUAL PROBLEMS? – Signs of an infection often
JOINT PAIN? – a sign of infection often – post-infectious arthritis, also known as Reiters and Reactive Arthritis
PAST MEDICAL HISTORY
Past medical history is important as it may point to the infection and its causes, as similar infections usually occur. Previous INSTANCES AND Treatments, Sexually Transmitted Diseases (STDs). Trichomonas is an STD. Having Trichomonas increases the risk of gonorrhea and Chlamydia infections. DIABETES and IMMUNOSUPPRESSION increase the risk of having yeast infections.
MEDICATIONS THAT CAN PREDISPOSE YOU TO VAGINITIS
BIRTH CONTROL PILL (increases the risk of yeast infections), STEROIDS (causes immunosuppression which can lead to yeast infections), ANTIBIOTICS (increases the risk of Yeast infections since antibiotics kill normal vaginal bacterial flora that helps prevent yeast from growing), SMOKING is believed to contribute to vaginitis
LABS/INVESTIGATIONS: CERVICAL AND VAGINAL SWABS FOR:
There are numerous investigations and laboratory tests that can be done to identify the cause of vaginitis and vaginal itch. The KOH WET MOUNT test is an examination of vaginal tissue and discharge under the microscope with the addition of KOH (potassium hydroxide). This shows the presence of hyphae and spores if there is an infection with yeast. The WHIFF TEST is a test for the smell of the discharge and liquid of the vagina.
If there is a fishy smell, or amine odor, with the addition of KOH, then there is BACTERIAL VAGINOSIS or TRICHOMONAS. Measuring the pH reveals some information. Normally it is usually less than 5 is normal. If less than 5, most likely a Yeast infection (i.e. normal). If pH is ~ 6 then Gardnerella or Trichomonas infection. SALINE WET MOUNT can be used to visualize the cells of the vagina. If there are CLUE CELLS, these are seen with Gardnerella infection.
FLAGELLATED ORGANISMS, bugs with tails, and lots of white blood cells are seen with Trichomonas infections. Sexually transmitted disease tests are used to rule out gonorrhea or chlamydia infection. URINALYSIS, which is an analysis of the urine is done to rule out a possible Urinary tract infection. URINE B-hCG is done to rule out a possible pregnancy.
MANAGEMENT AND TREATMENT OF VAGINITIS, VAGINAL ITCH, VAGINAL INFECTIONS:
Management and treatment of Vaginitis, Vaginal itch, and Vaginal infections require numerous issues. EDUCATION is essential. This consists of HYGIENE and SAFE SEXUAL PRACTICES. SYMPTOMATIC RELIEF with DOUCHING. ANTIFUNGALS should be used if there is a yeast infection. VARIOUS “AZOLES” IN SUPPOSITORIES or CREAMS are used for 1-7 days. ORAL FLUCONAZOLE can be used as a single-dose therapy.
NYSTATIN is used if the patient is pregnant. ANTIBIOTICS are used for GARDNERELLA OR TRICHOMONAS. These include TOPICAL OR ORAL METRONIDAZOLE, CLINDAMYCIN, or AMPICILLIN OR AMOXICILLIN if the patient is PREGNANT. HORMONAL THERAPY FOR ATROPHIC VAGINITIS (Estrogen and Progesterone topical or in oral pill forms. Also can be injected.)
