Vaginitis

Vaginitis is the term used to describe inflammatory conditions affecting the female vagina. It is sometimes called vaginal mucositis. Vaginitis may be associated with vulval (genital skin) conditions.

Vaginitis may result in vaginal soreness, itching, discharge, malodour, fissuring and bleeding. It may hurt to pass urine (dysuria). It may prevent sexual intercourse (apareunia) or result in painful or uncomfortable sexual intercourse (dyspareunia).

What are the causes of vaginitis?

Although most often due to infection, vaginitis may be due to one or more causes. These include:

• Injury to vagina, including after childbirth, intercourse, sexual assault, trauma or surgery
• Infection, tumour or injury resulting in a fistula from the bladder draining urine or from the rectum leaking faeces
• Foreign body within the vagina, e.g., retained tampon
• Contact irritant reaction e.g., to douching with water and/or soap or bubblebath, or contact with semen, saliva, lubricant, fragrance or topical medicament (see contact irritant dermatitis)
• Contact allergic reaction e.g., to rubber condom (latex or accelerators), fragrance, to preservative or medicament in vaginal cream or pessary (see allergic contact dermatitis)
• Pelvic inflammatory disease due to sexually transmitted infection, e.g., chlamydia, gonorrhoea
• Infection or excessive proliferation of bacteria (e.g., haemolytic streptococcal infection, cytolytic vaginosis, bacterial vaginosis); yeast (e.g., vulvovaginal candidiasis); or parasite (e.g., trichomoniasis).
• Viral infection with intravaginal or cervical genital herpes or genital warts
• Pinworm infection, especially in young girls
• Inflammatory disease such as desquamative vaginitis or erosive lichen planus
• Benign or malignant tumour of the womb (endometrium) e.g., fibroids, endometrial cancer or cervical cancer

Menstrual bleeding usually occurs for a few days at regular monthly intervals. Intermenstrual spotting can be quite normal. However, vaginal bleeding after established menopause may be serious and requires investigation as it may be an important sign of early cancer.

Vaginal dryness

Vaginal dryness is a common problem that significantly reduces women's enjoyment of sex. It is due to reduced vaginal natural lubrication.

Normal vaginal discharge is produced by mucus glands in the cervix and vagina, which mix with desquamating cells from the lining of the vagina. During arousal (orgasm), additional musk-smelling fluid is produced by the Bartholin glands at the entrance to vagina to reduce friction caused by penetration of a penis.

Lack of oestrogen due to menopause (atrophic vaginitis) or infancy reduces vaginal mucus production. This may cause atrophic vaginitis, resulting in postmenopausal dryness, burning and lack of sexual desire (decreased libido).

Vaginal dryness in premenopausal women may be caused by menstrual cycle hormonal fluctuations, pregnancy or Sjögren syndrome. Certain medications may dry up normal vaginal fluids, such as some oral contraceptive pills, depot progesterone injections, sedatives, heart pills, cold or allergy medicines.

Investigations

Vaginitis always requires thorough speculum examination of the vagina and cervix, as well as an examination of the abdomen, groin and genital skin (vulva). In some case examination under anaesthetic (EUA) is necessary, including hysteroscopy (examination of the inside of the womb).

Wet smear and high vaginal swabs should be taken for laboratory microscopy, culture and sensitivity. The results may be difficult to interpret as bacteria and yeasts may be found in the normal vaginal flora.

Additional tests may include midstream urine microscopy and culture.

Treatment

In general, the vagina does not need to be washed (douched), as it regularly cleans itself. Gently cleanse the outside skin with water. A non-soap cleanser may be used.

Water-based vaginal lubricant before and during sex, and/or a vaginal moisturiser inserted several times each week can make intercourse easier and less uncomfortable.

Treatment of vaginitis depends on the underlying cause. It may include:

• Topical or oral antibiotics
• Topical or oral antifungal agents
• Topical oestrogen cream, pessary or vaginal ring
• Topical steroid e.g., hydrocortisone foam