In the primary care setting, vaginitis is the most common gynecologic diagnosis. Vaginitis is an inflammatory condition of the vagina characterized by vaginal discomfort, pruritis, and discharge. Infection causes 90% of cases and the offending organisms include bacteria, fungi, and parasites, and most of these infections are not sexually transmitted. Bacterial vaginosis (40-50% of cases) is the most common cause of vaginitis, followed by vulvovaginal candidiasis (20-25% of cases) and trichomoniasis (15-20% of cases).
Bacterial vaginosis is typically caused by an overgrowth of Gardnerella vaginalis, although other bacteria, especially anaerobes, may play a role. G. vaginalis is sometimes sexually transmitted. Up to 50% of women colonized with G. vaginalis are asymptomatic. Candida albicans causes 80% to 90% of vaginal yeast infections. Another cause of vaginitis is Trichomonas vaginalis, a parasite that is almost always sexually transmitted. Noninfectious causes of vaginitis include atrophic vaginitis, allergy, chemical irritation, desquamative inflammatory vaginitis, lichen planus, and collagen vascular disease.
The symptoms of vaginitis are nonspecific and include vaginal discharge and pain or pruritis that may be exacerbated by urination. The dysuria of vaginitis is described as external, occurring when urine touches the vulva. The dysuria of cystitis is usually described as a more internal pain that begins before urine leaves the urethra. About 25% of women with T. vaginalis and 50% with G. vaginalis are asymptomatic. The history in women with vaginitis should also include questions regarding menstrual history, sexual history, abdominal or pelvic pain, and fever.
Although not diagnostic, the physical examination is important in localizing the site of involvement to the vagina, vulva, or cervix. In cases of candidal infection, the vulva and vagina are erythematous and edematous, with fissures and a thick, white, adherent discharge. In cases of trichomoniasis, the vulva and vagina are also erythematous and edematous, but the discharge tends to be frothy and purulent. Up to 25% of women with trichomoniasis will also have “strawberry cervix. In cases of bacterial vaginosis, the vulvar and vaginal tissues appear normal but have a gray, adherent, malodorous discharge.