What is 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, for example, retained tampon
- Contact irritant reaction eg, 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 eg, 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, eg, chlamydia, gonorrhoea
- Infection or excessive proliferation of aerobic bacteria (aerobic vaginitis, desquamative vaginitis, haemolytic Group A streptococcal infection, cytolytic vaginosis); yeast (vulvovaginal candidiasis); or parasite (trichomoniasis)
- Viral infection with intravaginal or cervical genital herpes or genital warts
- Pinworm infection, especially in young girls
- Inflammatory disease such as erosive lichen planus
- Benign or malignant tumour of the womb (endometrium) eg, fibroids, endometrial cancer or cervical cancer.
Note that bacterial vaginosis does not cause vaginitis; bacterial vaginosis causes non-inflammatory and malodorous vaginal discharge.
Clues to some causes of vaginal discharge
- Normal: thin to thick, clear or slightly white or yellow, minimal to profuse discharge
- Retained tampon: increasingly foul-smelling, bloody discharge
- Candidiasis: cottage cheese-like, thick discharge
- Bacterial vaginosis: fishy, greyish discharge
- Aerobic vaginitis: yellow/green malodorous discharge
- Trichomoniasis: foul-smelling, thick discharge
- Desquamative vaginitis: culture negative, bloody discharge
- Erosive lichen planus: intense soreness, burning
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 cervical or endometrial cancer.
Vaginal dryness is a common problem that significantly reduces women's enjoyment of sex. It is due to reduced vaginal natural lubrication, and it can also be a sign of vaginitis.
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 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 for vaginitis
Vaginitis is evaluated by speculum examination of the vagina and cervix, as well as an examination of the abdomen, groin and genital skin (vulva). In some cases, examination under anaesthetic (EUA) is necessary, including hysteroscopy (examination of the inside of the womb). Other investigations may include:
- Evaluation of vaginal pH
- Wet mount and high vaginal swabs for microscopy, culture and sensitivity.
- Midstream urine microscopy and culture
Microscopy of a wet smear evaluates epithelial cells and patterns of micro-organisms. The results may be difficult to interpret, as bacteria and yeasts may be found in the normal vaginal flora.
- Parabasal cells are characteristic of atrophic vulvovaginitis, but may be present in aerobic vaginitis and trichomoniasis.
- Lack of lactobacilli might indicate atrophic vulvovaginitis.
- Yeasts (elongated hyphae and round spores) indicate candida vulvovaginitis.
- Clue cells (granularity) indicate bacterial vaginosis.
- Motile organisms reveal trichomoniasis.
- White cells are absent in bacterial vaginosis and present in aerobic vaginitis and infections.
Measurement of pH can help determine the likelihood of a particular cause of vaginitis.
- Atrophic vulvovaginitis
- Erosive lichen planus
- Desquamative inflammatory vaginitis
- Mucous membrane pemphigoid
Normal or acidic pH is associated with candida vulvovaginitis, Group A streptococcal vaginitis (rare), and normal microbiome. Symptoms may be due to vulval and external conditions, such as contact allergic or irritant dermatitis, seborrhoeic dermatitis, and flexural psoriasis.
Treatment of vaginitis
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 eg, hydrocortisone foam.
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.