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Vaginitis. By. Prof. Dr. Professor of Obest. & Gynecology Tanta University. Amal E. Mahfouz. Vaginitis. WHAT IS VAGINITIS? I t is a term applied to any kind of vaginal inflammation that cause abnormal discharge and pruritis .

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Prof. Dr.

Professor of Obest. & Gynecology

Tanta University

Amal E. Mahfouz



It is a term applied to any kind of vaginal inflammation that cause abnormal discharge and pruritis .

It is one of the most common reasons for a women to seek Gynecological care.

The 5th World Conference on Vaginitis1 - 3 May 2008Ritz CarltonIstanbul,Turkey

Classification of vaginitis according to the age
Classification of Vaginitis according to the age


  • Occur in children usually caused by gonococi and chlamydia


  • Occur in child-bearing age


  • In post-menopausal women


Causes of vaginitis
Causes of Vaginitis

1- ALLERGIC VAGINITIS:caused by spermicidal creams, bath oils or soaps.


A-Trichomoniasis(30%of cases).

B-Candidiasis(candida albicans) 20-30 %.

C- Bacterial vaginosis(Gardnerella vaginitis) 40-50%.

D- Miscellaneous organisms (herpes simplex, HPV, gonorrhea &$).


4-Parasitic vaginitis:caused by Entropius Vermicularis

5-Foreign Body Vaginitis:retained tampons or condoms cause malodorous vaginal discharges.


persistent discomfort

Superficial skin infection (from scratching)

Complications of the causative condition as gonorrhea and candida infection

Trichomonas vaginitis
Trichomonas Vaginitis

Causative organism:

Unicellular flagellated protozoan (Trichomonas vaginalis) that causes up to10-30% of vaginitis.


* Vagina, skene ducts & lower urinary tract.


1-Sexual intercourse

2-Vulvo-vaginal contamination by bath, towels or wet bathing suits.

  • The disease is worse immediately after menstruation and most acute during pregnancy.


1- Asymptomatic

2- Acute

3- chronic


1-Discharge, copious, greenish-yellow, frothy and foul-smelling (fishy odor).

2-Pruritis,Edema, Erythema, especially in acute stage.

3-Urinarysymptoms may be present due to urethro-cystitis.

Profuse purulent frothy vaginal discharge  

Thin, water, cervical discharge of trichomonas infection

  • SIGNS:

  • Vulvar edema and erythema

  • Strawberry Cervix (2-3% of cases)

  • Punctate hemorrhages or Petechiae

Prof.Dr. Amal E. Mahfouz

External Exam

Frothy" Discharge seen around the cervix

  • LAB:

    1- Vaginal pH > 5.0

    2- Skiff Test positive

    - Fishy odor of discharge when KOH added.

    3- Wet preparation(from vaginal vault, not endocervix).

    - Motile pear shaped Trichomonads with flagella (70%).

    4- Gram Stain

    - White Blood Cells over 10 per high powered field.

    5- Culture of Trichomonas vaginalis

    - Grown on Kupfierberg medium.


1-Single dose of oral metronidazol (2gm).

2- Metronidazol 500mg bid for 7 days.

3- Intravaginal metronidazol supp. 500mg (bid) for 7 days.

4- Secnidazol (2 gm) oral single dose.


Treatment of both partners is mandatory.

The antibiotic Paromomycin cream is an effective, alternative treatment option for women with hard-to-treat vaginal trichomoniasis




Candida albicans,is a common organism found in the vagina of healthy women.

Predisposing causes:

  • Antibiotics which cause reduction of phagocytosis of the candida, or reduction of antibodies to the organism. High-risk antibiotics that more commonly lead to candidal infection are reportedly ampicillin, tetracyclines, clindamycin, and cephalosporins.

  • Diabetes, glucosuria and sweets eaters leads to glycogen deposition in the vaginal epithelium.

  • Immuno-compromisedpatients (AIDs).

  • Poor hygiene.

  • Corticosteroidsintake.

  • Pregnancydue to increase glycogen content of the vagina.

  • Hormonal contraception containing 75-150 micrograms of estrogen are most likely to cause the problem; low-dose products are seldom implicated

Certain types of clothing may predispose for Candida. Females should be cautioned to avoid wearing tight-fitting clothes and synthetic underwear.

Frequent coitus and the use of intrauterine devices may also be contributing factors.

Clinical picture
Clinical Picture

  • Discharge:thick "curdy" while, not malodorous unless mixed with infection.

  • Vulvar itching:vagina has no itch receptors, so pruritus is felt distally onto the vulva in 90% of patients.

  • Erythema of vulva:with edema of labia minora and excoriation due to scratching.

Thrush patches

Situations That Mimic Vaginal Candidal Infection

ConditionPossible Cause

Contact dematitis Soaps, deodorants, detergents, spermicides, vaginal lubricants, perfumed cleansing wipes

Irritant vulvitisExcessive use of minipads

Vulvo-vaginitisAdverse reaction to vaginal antifungal

Change in vaginal mucusThat occurs at ovulation

Coitus-related vaginitisAllergy to partner’s sperm


  • PH 4 – 4.7.

  • Microscopic examination of discharge with KOH reveled hyphae or budding yeast.

  • Increase lactobacilli in the smear.

  • Candida is recovered form the stool and oral cavity of 75% of women.


  • Gentian violet 1-2% solution: is one of the oldest and most reliable treatment for candidiasis.

  • Oral Fluconazol 150 mg single dose.

  • Oral Ketoconazol 200 mg bid for 5 days.

  • Recurrent infection is due to harbouring of the fungus in the GIT.

Fluconazole is a potentantifungalknown to act against most candida species (particularly candida albican)has demonstrated effective action against both oral andvaginal candidiasiseven in cases resistant to nystatin orclotrimazole.

One of it's side effects is liver toxicity although that appears to be more common in patients with concomitant health issues and seems to be reversible on stopping the drug.

Fluconazole taken once a week for six months was found to reduce the frequency of recurrent vaginal Candida infections by more than 90%.

Antifungal vaginal medications

Antifungal creams

Antifungal tablets

Antifungal suppositories


  • An antifungal synthetic derivative of imidazole.

  • Miconazole selectively affects the integrity of fungal cell membranes.

  • It is used topically and by intravenous infusion.

  • Clotrimazole

  • An imidazole derivative with a broad spectrum antimycotic activity.

  • It inhibits biosynthesis of the sterol ergostol, an important component of fungal cell membranes.

  • Its action leads to increased membrane permeability and disruption of enzyme systems bound to the membrane.

  • Tioconazole

  • A synthetic imidazole derivative.

  • It inhibits cell wall synthesis, damaging the fungal cell membrane, altering its permeability, and promoting loss of essential intracellular elements.


GYNAZOLE vaginal cream, contains butoconazole nitrate 2%, an imidazole derivative withantifungalactivity.

Bacterial vaginosis
Bacterial Vaginosis

The term vaginosis indicates lack of an inflammatory reaction (absence of white blood cells in the discharge.

The causative organisms is Hemophilus vaginalis (Gardnerella vaginalis).

  • It is gram -ve, anaerobic, comma-shaped rods.

    Incubation period:5-10 days after inoculation.

Three points help confirm bacteria as the source of vaginitis:

The discharge is thin, homogeneous, white, and resembles skim milk adhering to vaginal walls.

(2) The pH is above 4.5 (normal vaginal pH is 3.8-4.4).

(3) When a sample of the discharge is mixed with 10% KOH, it will produce a typical "fish-like" odor (this is indicative of an increase in anaerobic activity, which yields amines such as cadaverine and putrescine)

Honey-colored pus-like vaginal discharge characteristic of either group B streptococcus or Staphylococcus aureus

Sequelae of infection
Sequelae of Infection either group B streptococcus or Staphylococcus aureus

  • Increase risk of septic abortion.

  • Premature rupture of membrane.

  • Preterm labor: due to production of phospholipase A2 by the micro-organism which in turn initiate labor.

  • Post-cesarean section endomyometritis.

  • Post hysterectomy pelvic cellulitis.

Clinical picture1
Clinical Picture either group B streptococcus or Staphylococcus aureus


  • Vary from scant to profuse (less than trichomoniasis).

  • Non inflammatory discharge (No W.B.Cs).

  • Homogenous thick in consistency (like thin flour paste).

  • Gray in color, malodorous especially during sexual intercourse.

    Irritative symptoms:pruritis and burning, less than with trichomonas infection.

Diagnosis either group B streptococcus or Staphylococcus aureus

  • Vaginal PH: 5- 5.5 .

  • Wet mountpreparationof discharge in saline, revealed typical appearance of clue cells (epithelial cells stippled with bacteria attached to its border.

  • There is absence of lacto bacilli.

Clue Cell

  • Gram stain either group B streptococcus or Staphylococcus aureussmear reveled gram –ve bacilli.

  • Cultures on Casman's blood agarthe colonies of Gardnerella are identified by diffuse B hemolysis.

  • Whiff test:positive for fishy odor when alkaline KOH solution is added.

  • Pap smearindicate Coco-bacillary shift of vaginal flora.

Gram Stain - Bacterial Vaginosis

Treatment either group B streptococcus or Staphylococcus aureus

  • Metronidazol500 mg bid for 7 days.

  • Metronidazol oral2gm single dose.

  • Metronidazol gelvaginally bid for 5 day.

  • Clindamycin cream2% per vagina for 7 days.

  • Ampicillinor Amoxicillin500 mg qid for 7 days (not as effective).

  • Intravaginal sulphonamides1 tab or applicator bid for 7-10 days.

Diagnostic Criteria either group B streptococcus or Staphylococcus aureus


Bacterial Vaginosis


Candida Vulvovaginitis

Vaginal pH

3.8 – 4.2

> 5.4


<5.4 (usually)


Thin, white (milky), gray

Yellow, green, frothy

White, curdy, cottage cheese

White, thin, floccuent

Amine odor "whiff" test






Lactobacilliepithelial cells

Clue cellsadherent cocci, no WBC's

TrichomonadWBC's /hpf>10

Budding yeast, hyphae, pseudohyphae

Differential Diagnosis of Vaginal Infections

Atrophic vaginitis
Atrophic Vaginitis either group B streptococcus or Staphylococcus aureus

  • This term is used to describe atrophic changes in the vulva and vagina as well as urethra and bladder.


  • Affect 10-40% of postmenopausal women.

Risk factors
Risk Factors either group B streptococcus or Staphylococcus aureus

  • Menopause

  • Surgical oophorectomy.

  • Ovarian destruction by radiation or chemotherapy

  • Postpartum due to loss of placental estrogen

  • During lactation.

  • Anti-estrogic druges e.g. Tamoxifen, Depot provera and LHRH antagonist.

  • Other risk factors are cigarette smoking and absent coital cavity.

Clinical picture2
Clinical Picture either group B streptococcus or Staphylococcus aureus

  • I Genital symptoms:

  • Dryness

  • Burning

  • Itching

  • Vulvar pruritus

  • Feeling of heaviness

  • Yellow malodorous discharge

II Urinary Symptoms: either group B streptococcus or Staphylococcus aureus

  • Dysuria

  • Frequency

  • urinary tract infection

  • Stress incontinence

  • Hematuria

Diagnosis either group B streptococcus or Staphylococcus aureus

  • Historyof used perfumes or lubricants, which contain irritant compounds.

  • Vagina showssignsof atrophy, pale, smooth, and shiny with patchy erythema and increased friability.

  • Introitusbecomes narrow with decreased vaginal depth.

  • Pelvic examinationcauses pain, vaginal bleeding and spotting.

Examination of external genitalia

sclerosus Lichen either group B streptococcus or Staphylococcus aureus

Examination of External Genitalia

  • Decrease elasticity of the skin.

  • Decrease pubic hair.

  • Dryness of labia.

  • Fusion of labia minora.

  • Vulvar dermatosis.

Vulvar irritation either group B streptococcus or Staphylococcus aureus

Urethral polyp



  • Signs of vulvar irritationcaused by urinary incontinence.

  • Cystocele, rectocele, or uterine prolapse, may accompany atrophicvaginitis.

  • Urethral polyp, or caruncle may be present.

Prof.Dr. Amal E. Mahfouz

Laboratory findings
Laboratory Findings either group B streptococcus or Staphylococcus aureus

  • Increase serum FSH & LH.

  • PAP smear from upper third of the vagina show increase proliferation of parabasal cells, decrease superficial cells.

  • Increase vaginal PH >5.

  • Vaginalultrasonography, shows thin endometrial lining (4-5mm)

  • No evidence of trichomonas, candida or bacterial vaginitis.

Treatment either group B streptococcus or Staphylococcus aureus

  • Estrogen replacement therapy oral or vaginal.

  • Moisturizers and lubricants.

Thank You either group B streptococcus or Staphylococcus aureus