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Infectious Vaginitis (DRAFT)

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Overview

Vaginitis is characterized by vaginal discharge, odour, irritation, and pruritus, and is a common reason for gynaecologic primary care visits. The three main infective causes of vaginitis are bacterial vaginosis (BV; 40–50% of cases), vulvo-vaginal candidiasis which may be caused by several Candida species (VVC; 20–25%) and Trichomonas vaginitis (or Trichomoniasis) cause by the protozoan Trichomonas vaginalis (TV; 15–20%). Non-infectious causes, including atrophic, irritant, allergic, and inflammatory vaginitis account for 5–10% of cases. If left untreated, vaginitis can lead to complications, including pelvic inflammatory disease, which is associated with chronic pelvic pain, ectopic pregnancy, and infertility.

Diagnosis

BV is a dysbiosis characterised by replacement of the normal vaginal microflora dominated by Lactobacillus species with a variety of anaerobic bacteria. The white discharge has an offensive fishy smell. VVC presents with vulval itch, sometimes with soreness or burning sensation, and a non-offensive discharge. Recurrent VVC is also seen. Trichomoniasis typically results in a frothy yellow discharge with vulval itching, dysuria, and offensive odour. However signs and symptoms are overlapping and non-specific; the cause of vaginitis cannot be determined by clinical examination alone.

Laboratory diagnosis of BV is traditionally based on microscopic examination of a vaginal smear. VVC is also diagnosed by microscopy or by culture (though no longer recommended, except for recurrent VVC). Diagnosis of Trichomoniasis by culture or microscopy to identify motile protozoa lacks sensitivity due to loss of viability of the organism during transit to the laboratory, and nucleic acid amplification tests (NAAT) are increasingly used to detect T. vaginalis.

In BNSSG diagnosis of the main three causes of infectious vaginitis is moving from traditional methodology based on microscopy and culture to NAAT, thus harmonising vaginitis testing with other tests for bacterial STIs. BV and TV NAAT is now available on ICE. VVC is currently diagnosed by culture. STI and Vaginitis NAAT can be ordered from the Infection Sciences ICE menu by selecting the STI/Genital samples option on the General tab, which gives the testing options below.

Please note that using the A-Z search on ICE may not give the full range of options, depending on the search text used.

For patients at risk of STI, please select “Chlam/GC/TV ands BV NAAT”. For patients at low risk of STI, please select TV and BV NAAT. In both cases select “Genital sample for MCS” for Candida culture.

Please see “Infection Sciences Test Sample Quick Guide” for sample types

Infection Sciences Test Sample Quick Guide (Remedy BNSSG ICB)

Treatment

For antimicrobial treatment and other options for management of infectious vaginitis please refer to BASHH guidelines.

Although BV is not classified as a sexually transmissible infection, sexual exchange of BV-associated bacteria between partners may occur, and recent evidence suggests that concurrent antimicrobial treatment of male partners may improve treatment response rates.

Resources

BASHH guidance on the management of BV:

BASHH BV guideline 2011 (currently being updated)

Vulvovaginal Candidiasis 2019 | BASHH

Trichomonas Vaginalis 2021 | BASHH

Male-Partner Treatment to Prevent Recurrence of Bacterial Vaginosis | New England Journal of Medicine

Patient Information

Bacterial vaginosis | Health topics A to Z | CKS | NICE

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.