Vaginitis

Vaginitis: Excerpt from The 5-Minute Pediatric Consult

Marianne Ruby, MDGary A. Emmett, MD

Vaginitis - BASICS

Vaginitis - description

• Vaginitis is an inflammatory process of the vagina often caused by infection, but also caused by foreign bodies and other irritants.
• Vulvovaginitis is inflammation of the vulva and vagina; it is more common in prepubertal girls.
• Bacterial vaginosis is an overgrowth of vaginal flora, primarily anaerobic, associated with an elevation in vaginal pH, a malodorous discharge, and often a sensation of burning. This condition has been referred to as gardnerella, Haemophilus, and nonspecific vaginitis.
• Vaginal discharge is a vaginal secretion that may or may not be associated with inflammation or infection.

Any infection that raises suspicion of sexual abuse must be reported to the local authorities immediately.

Vaginitis - epidemiology

• Candidiasis may present cyclically with menses, possibly owing to changing estrogen levels.
• Gonorrhea is more likely to be symptomatic at the time of menses owing to easier access to the upper reproductive tract.
• Body mass index (BMI) at the extremes is associated with increased risk of vulvovaginitis.
• The epidemiology of bacterial vaginosis is not well known because it is not a reportable disease, and 50% of cases may be asymptomatic.

Vaginitis - incidence

The exact incidence of vaginitis is unknown.

Vaginitis - risk factors

Vaginitis - genetics

There is no clear genetic pattern for vaginitis or vulvovaginitis.

Vaginitis - pathophysiology

• Physiologic leukorrhea is a normally occurring vaginal discharge that is clear or white, nonpruritic, nonirritating, and rarely malodorous.
  • The amount of discharge markedly varies from individual to individual and may be profuse.
  • In menstruating girls, as a result of varying estrogen levels, the volume of discharge varies with the menstrual cycle and is especially heavy at the time of ovulation.
• Candidiasis occurs more commonly when the glycogen level in the vaginal mucosa is increased, as in pregnancy and diabetes.
  • Use of antibiotics also increases the occurrence of candidiasis by eliminating competitive organisms.
• For bacterial vaginosis, the inciting cause is not known, but the etiologic cascade involves a decline in levels of lactobacillus leading to an increased pH and increased overgrowth of normal bacterial flora. The change in the vaginal environment decreases the normal defenses against pathogens.
• The normal trauma of sexual intercourse may increase the likelihood of vaginitis by causing microscopic breakdown of the mucosal surface.
• During toileting, wiping from the anus toward the vagina may introduce bacteria not normal for the vagina and induce a vaginitis.

Vaginitis - etiology

• All ages:
  • Chemical irritants such as soaps, bubble baths, detergents, and fabric softeners
  • Allergic reactions
  • Foreign material, such as paper products, sand, soil, and small objects
  • Candida albicans, especially if exposed to antibiotics
  • Trauma from repeated rubbing, such as with masturbation
  • Sexual abuse
• Prepubertal females:
  • Diapers and nonbreathable clothing
  • Coliform bacteria from the child’s toileting practices
  • β-hemolytic group A streptococcus
  • Infestations, including pinworms and scabies
• Postpubertal females:
  • Noninflammatory, physiologic leukorrhea
  • Bacterial vaginosis
  • Trichomonas
  • Chlamydia trachomatis
  • Gonorrhea
  • Herpes simplex virus, types I and II
  • Human papilloma virus (HPV)
  • Chancroid
  • Lymphogranuloma venereum (LGV)
  • Behcçet disease
  • Epstein–Barr virus

Vaginitis - DIAGNOSIS

Vaginitis - signs & symptoms

Vaginitis - history

• Presence, color, odor, and duration of discharge
• Child is itchy or having a burning sensation or dysuria:
  • Itching and burning may be signs of vaginal inflammation.
  • Dysuria raises the suspicion for a urinary tract infection; but burning at the start of micturition (urination) may be seen with vulvovaginal inflammation.
• Conditions that make symptoms better or worse: Inflammation may be related to specific clothing, especially tight pants. Nighttime itching/discomfort may signal pinworm infestation.
• Treatment that has worked in the past may work again.
  • The success or failure of over-the-counter products may affect the treatment choices.
  • Over-the-counter treatment may affect culture results for Candida.
• Any other recent health problems: Recent respiratory or gastrointestinal distress increases the risk for group A streptococcal infection.
• Any new medication, especially an antibiotic, introduced around the time of symptom onset:
  • Antibiotics increase the risk for candidal vaginitis.
• STIs should be considered if there is known sexual activity and should be considered even when sexual activity is denied.
• If appropriate, character and timing of the last menses: Gonorrhea is associated with increased symptoms at the time of menses. Some girls may have cyclic yeast infections associated with menses.
• Any new chemical exposures such as soaps, spermicides, or feminine hygiene products: Vaginitis often follows vaginal exposure to cleaning and other chemical agents.
• Any chronic illnesses such as diabetes, inflammatory bowel disease, or immunocompromised conditions: Vaginitis is much more common in these situations.
• Previously similar symptoms: Some people have a tendency toward repeated vaginal inflammation, especially candidiasis.

Vaginitis - physical exam

• Vital signs including height, weight, and temperature
• Calculate the BMI.
• Tanner pubertal development scores
• Examine the entire skin for other lesions or dermatoses.
• Abdominal examination to assess for abdominal pain and masses
• Evaluate external genitalia for tenderness, erythema, discharge, ulceration, edema, excoriation, traumatic injuries, warts (HPV), lymphadenopathy, and pigmentary changes.
• Evaluate vagina for findings above, if possible.

Vaginitis - tests

Vaginitis - lab

The following common gynecologic tests may help with differentiating normal physiologic leukorrhea from three common etiologies:

• Odor/”whiff” or “amine” test: Prepared with 10% KOH
• Wet mount of the vaginal discharge is mixed with saline for microscopic evaluation (see Physical Exam).
• Nitrazine paper measures pH with lateral vaginal wall specimen.
• Chlamydial polymerase chain reaction (PCR) assay should be performed on all sexually active patients.
• Gonorrhea PCR or culture from cervical specimen
• Culture for fungi (yeast)
• Pap test if sexually active for >2 years

Vaginitis - differencial diagnosis

• Bacterial vaginosis
• Chlamydia
• Gonorrhea
• Trichomonas
• Candidiasis
• Herpes simplex virus infection
• HPV
• Physiologic leukorrhea
• Psoriasis
• Lichen sclerosis (hypotrophic dystrophy of the vulva)
• Congenital abnormalities, such as ectopic ureter
• Sexual abuse

Vaginitis - TREATMENT

Vaginitis - general measures

• Removal of irritant/foreign body: In vaginitis caused by chemical irritants or foreign materials, the practitioner should attempt to identify and remove the cause. On occasion, especially in younger children, intravaginal foreign bodies may have to be removed under anesthesia.
• Promoting good hygiene: Girls should be educated in good toilet hygiene and proper front-to-back wiping.
• Sitz baths: Local treatment should include sitz baths (sitting in plain warm water) followed by air drying of the vulvar area, use of topical emollients (Vaseline or Aquaphor), and topical low-potency steroids (short course) to control inflammation.
• Trauma from repeated rubbing or other causes is treated in the same manner.
• Congenital abnormalities, such as ectopic ureter, will respond to the above regimen but will eventually need definitive surgical treatment.

Vaginitis - medication

• Topical steroids:
  • Lichen sclerosis requires very-high-potency topical steroids for amelioration. Apply to vulva b.i.d. for 2–4 weeks. Overuse may lead to thinning of the skin. Steroids can also promote the growth of yeast.
  • In moderate inflammation of the vulva caused by irritants, apply low-potency steroids lightly to vulva b.i.d. for 5–14 days, until symptoms have subsided for 2 days. Extreme overuse may also lead to skin thinning.
• Antifungal agents including topical butoconazole, miconazole, terconazole applied as directed will relieve vaginal candidiasis: As an alternative, oral fluconazole 6 mg/kg in one dose to maximum dose of 150 mg may be effective.
• Antibiotics are used in many causes of vaginal infection:
  • Bacterial vaginosis is treated in older children with metronidazole 500 mg PO b.i.d. for 7 days or topically with metronidazole gel or clindamycin cream or suppository.
  • In infections with coliform bacteria, treat with amoxicillin at 40 mg/kg/d to maximum of 500 mg b.i.d. β-hemolytic group A streptococcus will usually respond to the same dosage of amoxicillin.
  • In patients with penicillin allergy, trimethoprim/sulfa, azithromycin, or ciprofloxacin (in older children) is appropriate in either type of bacterial infection.
    • Chlamydia is treated with either azithromycin 1,000 mg PO in a single dose or doxycycline 100 mg PO b.i.d. for 7 days.
    • Uncomplicated gonorrhea is treated with ceftriaxone 125 mg IM or ciprofloxacin 500 mg PO in a single dose. Treat for chlamydia simultaneously unless the child is known not to have chlamydia.
    • Trichomonas responds to metronidazole, 2 g in a single dose.
• Other anti-infective agents used in vaginitis include the following:
  • Herpes simplex virus is treated with famciclovir 250 mg t.i.d. for 7–10 days, with valacyclovir 1 g PO b.i.d. for 7–10 days, or with acyclovir 400 mg t.i.d. for 7–10 days. In recurring herpes simplex virus, prolonged use of these agents may be useful.
  • In pinworms, mebendazole 100 mg is taken once by mouth. May be recommended for entire family, but is not used in pregnancy

Vaginitis - FOLLOW UP

Vaginitis - prognosis

When treated, patients with vaginitis, vulvovaginitis, and bacterial vaginosis generally do well.

Vaginitis - complications

• Pelvic inflammatory disease (PID)
• Scarring in the female reproductive tract
• Pelvic pain syndrome and infertility
• Untreated bacterial vaginosis has been associated with premature labor, premature rupture of membranes, and increased risk of acquiring STIs.

Vaginitis - patient monitoring

• Follow-up appointment or phone call should be arranged 1 week following the initial diagnosis.
• To prevent recurrence in younger children, avoid irritants such as bubble bath, encourage proper wiping technique, and avoid unnecessary antibiotics.
• In sexually active adolescents, consistent use of condoms should be stressed to prevent the spread of STIs.

• Antibiotic use may result in the development of candidiasis.
• Over-the-telephone therapy of vaginal pruritus as candidiasis may be incorrect. If a patient using an antifungal is not better in 5 days, she must see the practitioner.

Vaginitis - bibliography

1. Brook I. Microbiology and management of polymicrobial female genital tract infections in adolescents. J Pediatr Adolesc Gynecol. 2002;15:217–226.
2. Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1–94.
3. Eckert LO. Clinical practice: Acute vulvovaginitis. N Engl J Med. 2006;355:1244–1252.
4. Freeto JP, Jay MS. “What’s really going on down there?” A practical approach to the adolescent who has gynecologic complaints. Pediatr Clin North Am. 2006;53(3):529–545.
5. Jaquiery A, Stylianopoulos A, Hogg G, et al. Vulvovaginitis: Clinical features, aetiology, and microbiology of the genital tract. Arch Dis Child. 1999;81:64–67.
6. Nasraty S. Infections of the female genital tract. Prim Care. 2003;30(Mar):193–203, vii.
7. Nyirjesy P. Vaginitis in the adolescent patient. Pediatr Clin North Am. 1999;46:733–745.
8. Quint EH, Smith YR. Vulvar disorders in adolescent patients. Pediatr Clin North Am. 1999;46:593–606.
9. Schwebke JR. Gynecologic consequences of bacterial vaginosis. Obstet Gynecol Clin North Am. 2003;30:685–694.
10. Syed T, Braverman P. Vaginitis in adolescents. Adolesc Med Clin. 2004;15(2):235–251.

Vaginitis - CODES

Vaginitis - icd9

616.10 Vaginitis and vulvovaginitis, unspecified

Vaginitis - FAQ

• Q: Is the presence of gardnerella on vaginal culture sufficient to diagnose bacterial vaginosis?
• A: No. The diagnosis of bacterial vaginosis requires three of the following criteria: Elevated pH, fishy odor, clue cells on a wet mount, vaginal discharge, and/or a positive Gram stain.
• Q: Can vaginitis be confused with a urinary tract infection?
• A: Yes. Prominent vulvar and vestibular inflammation would strongly suggest a vulvovaginal source.
• Q: Can girls be asymptomatic for herpes simplex virus and HPV infections?
• A: Yes, sexually active girls may carry these diseases without symptoms.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Vaginitis

• Back to disease: Vaginitis: Introduction
• Next Book Extract About Vaginitis: Surveys relating to Vaginitis
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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