Vaginitis/Vaginal Infection

Vaginal infections are frequent causes of distress and discomfort in adult women.  The most common vaginal infections are bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis.  Some vaginal infections are transmitted through sexual contact, but others such as candidiasis (yeast infections) are not.

Causes and Development; Contributing Risk Factors

Bacterial vaginosis (BV) is the most common cause of vaginitis symptoms among women of childbearing age.  BV - previously called nonspecific vaginitis or Gardnerella-associated vaginitis - can be transmitted through sexual activity, although the organisms responsible have also been found in young women who are not sexually active.  BV is due to a change in the balance among different types of bacteria in the vagina.  Instead of the normal predominance of Lactobacillus bacteria, increased numbers of organisms such as Gardnerella vaginalis, Bacteroides, Mobiluncus, and Mycoplasma hominis are found in the vagina in women with BV.  Investigators are studying the role that each of these microbes may play in causing BV.  The role of sexual activity in the development of BV is not understood; intrauterine devices (IUDs) may increase the risk of acquiring bacterial vaginosis.

Trichomoniasis, sometimes referred to as "trich", is a common STD that affects 2 to 3 million Americans yearly.  It is caused by a single-celled protozoan parasite called Trichomonas vaginalis.  Trichomoniasis is primarily an infection of the urogenital tract; the urethra is the most common site of infection in men, and the vagina is the most common site of infection in women.

Vulvovaginal candidiasis (VVC), sometimes referred to as candidal vaginitis, monilial infection, or vaginal yeast infection, is a common cause of vaginal irritation.  It has been estimated that approximately 75% of all women will experience at least one episode of VVC during their lifetime.  VVC is caused by an overabundance or overgrowth of yeast cells (primarily Candida albicans) that normally colonize in the vagina.  Several factors are associated with increased rates of VVC in women, including pregnancy, uncontrolled diabetes mellitus, and the use of oral contraceptives or antibiotics.  Other factors that may increase the incidence of VVC include the use of douches, perfumed feminine hygiene sprays, topical antimicrobial agents, and tight, poorly ventilated clothing and underwear.  There is no direct evidence that VVC is transmitted by sexual intercourse.

Other Causes of Vaginitis
Although most vaginal infections in women are due to bacterial vaginosis, trichomoniasis or vulvovaginal candidiasis, it is clear that there are other possible causes.  These causes may include allergic and irritative factors or other STDs.  Noninfectious allergic symptoms can be caused by spermicides, vaginal hygiene products, detergents or fabric softeners.  Cervical infections are also often associated with abnormal vaginal discharge, but these infections can be distinguished from true vaginal infections by appropriate tests.  Finally, in uninfected women, vaginal discharge may be present during ovulation and may become so heavy that it raises concern.

Gardnerella, formerly Haemophilus, is an anaerobic bacteria that is a main contributor to bacterial vaginosis.  It is sometimes sexually-transmitted, but can stick around for years as a passive part of the vaginal flora, only to flare up.  It seems to occur in up to a quarter of relatively monogamous women and in half of women with multiple male partners.  As bacterial vaginosis, Gardnerella is one of the three main causes of vaginal discharges, along with Trichomonas and Candida albicans.  Antibiotic therapy for male partners seems of only marginal value, and the distinguishing characteristic of the infection is nearly no Lactobacillus vaginal presence, the main part of the flora that retains the lactic acid and peroxide balance so important in a healthy vagina.  Live culture yogurt, as both food and douches help the problem.

Risk Factors for vulvovaginal candidiasis:

• Recent course of antibiotics
• Uncontrolled diabetes
• Pregnancy
• High estrogen contraceptives
• Immunosuppression
• Thyroid or endocrine disorders
• Corticosteroid therapy
• A strong correlation between frequency of sexual intercourse and vulvovaginal candidiasis has been found among nonpregnant women.  Other factors such as wearing tight clothing, underwear, menstrual protection, feminine hygiene sprays and diet were not associated with candidiasis.  Decreasing the frequency of sexual intercourse seems to have more of a scientific basis than other standard advice frequently given.

Signs and Symptoms

Vaginal infections are often accompanied by vaginitis, which is an inflammation of the vagina characterized by discharge, irritation, and/or itching.

The primary symptom of bacterial vaginosis is an abnormal vaginal discharge with a fishy odor, which is especially noticeable after intercourse.  However, nearly half the women with clinical signs of BV report no symptoms.  A physician observes these signs during a physical examination and from various tests of vaginal fluid.

Trichomoniasis, like many other STDs, often occurs without any symptoms.  When symptoms occur, they usually appear within 4 to 20 days of exposure, although symptoms can appear years after infection.  The symptoms in women include a heavy, yellow-green or gray vaginal discharge, discomfort during intercourse, vaginal odor, and painful urination, or no symptoms at all.  Irritation and itching of the female genital area, and on rare occasions, lower abdominal pain also can be present.  The symptoms in men include a thin, whitish discharge from the penis and painful or difficult urination.  However, most men do not experience any symptoms.

The most frequent symptoms of vulvovaginal candidiasis in women are itching, burning, and irritation of the vagina.  Painful urination and/or intercourse are common.  Abnormal vaginal discharge is not always present and may be minimal.  The discharge is typically described as cottage-cheese-like in nature, although it may vary from watery to thick in consistency.  Most male partners of women with VVC do not experience any symptoms of the infection.  However, a transient rash and burning sensation of the penis have been reported after intercourse if condoms were not used.  These symptoms are usually self-limiting.

Diagnosis and Tests

The cause of vaginitis cannot be adequately determined solely on the basis of symptoms or a physical examination.  Laboratory tests allowing microscopic evaluation of vaginal fluid are required for a correct diagnosis.

A sample of vaginal fluid can be examined under a microscope to detect the presence of the organisms associated with bacterial vaginosis.  Diagnosis is based on the presence of numerous "clue cells" (vaginal lining cells that are coated with G.  vaginalis and other BV organisms), a fishy odor, and decreased acidity of vaginal fluid.

Trichomoniasis is usually diagnosed in women by examining vaginal fluid under the microscope for evidence of the parasite; in some cases it can be detected on a Pap smear.  Because only small numbers of parasites may be present during infection in a male, microscopic examination of discharge from the penis often does not reveal the presence of parasites.  However, a sample of fluid from the penis may be taken from which the parasite can be grown in culture in the laboratory.  Cultures may be required to establish the diagnosis in women who have no symptoms but are at high risk of infection.  Cultures can also confirm the diagnosis in symptomatic women whose microscopic examinations are negative.

Because few specific signs and symptoms are usually present, vulvovaginal candidiasis cannot be diagnosed by the patient's history and physical examination.  VVC is usually diagnosed through microscopic examination of vaginal secretions for evidence of yeast forms.

Treatment and Prevention

All women with bacterial vaginosis should be informed of their diagnosis, including the possibility of sexual transmission, and offered treatment.  Generally, male sex partners are not treated.  However, in cases of BV that do not respond to drug therapy, treatment of male partners may be helpful.  Many women with symptoms of BV do not seek medical treatment, and many women who do not display symptoms decline treatment.  Until the long-term consequences of untreated BV are known, routine treatment of all asymptomatic carriers is not necessary.

Acidophilus, "friendly" bacteria, can be reintroduced into the body both systemically, through oral acidophilus, and locally, through the douche.  Vaginitis may also be produced by bowel bacteria, such as Escherichia coli, migrating into the vagina.  Normally, the vagina's mucosal lining provides immunological protection against such bacterial infiltration, but if this lining is deficient, an infection may develop.  A deficiency may be caused by poor health, aggressive intercourse, declining hormone levels, poor diet, or abnormal microflora populations.  Several forms of vaginal douching for four consecutive nights are appropriate here.

Sample douches:

• One teaspoon of tea tree oil in two cups of water.
• 1/4 cup of 3% antiseptic hydrogen peroxide mixed in two cups of water.
• Vaginal suppositories containing goldenseal.
• An acidophilus capsule can be inserted as a vaginal suppository, or the capsule opened into 2 cups of water and douched.  Use of the capsule can be continued twice daily for 1 to 2 weeks.
• Grapefruit seed extract (10 to 20 drops in two cups of water) may also be used.  Tea tree oil and grapefruit seed extract can be caustic to the skin and should be handled carefully and used in specified amounts.

Although symptoms of trichomoniasis in men may disappear within a few weeks without treatment, men can transmit the disease to their sex partners even when symptoms are not present.  Therefore, it is preferable to treat both partners to eliminate the parasite.

Sample douches:

• One teaspoon of Melaleuca alternifolia (tea tree) oil in two cups of water.
• two week treatment regime using Betadine preparations.  These can be purchased pre diluted or one can be made from 1/2 tablespoon of a standard solution (povidone-iodine 10%) to 2 cups of water.
• An ethanol extract of propolis (150mcg per ml) has been shown to have a 100% lethal effect in tests on Trichomonas vaginalis after 24 hours of contact.  This extract has also been shown to decrease the inflammation associated with trichomonal vaginitis.
• Essential oils have well-demonstrated antimicrobial action.  Many possess strong antitrichomonal properties.  Mentha piperita (peppermint) and Lavandula angustifolia (lavender) had the fastest killing action.

Condoms and diaphragms may be helpful in preventing the spread of trichomoniasis.  Although there is some laboratory evidence that spermicides can kill STD organisms, scientists are still evaluating the usefulness of spermicides in preventing STDs.  Some studies have found that frequent use of spermicides (more than three times a week) may cause vaginal inflammation.

Women who have chronic or recurring vulvovaginal candidiasis may need to be treated for extended periods of time and oral antifungal drugs may be suggested.  They should work with their physicians to determine possible underlying causes of their chronic yeast infections.  Because there is no evidence for sexual transmission of VVC, routine treatment of male partners is unlikely to reduce recurrence.

A sufficient intake of probiotics or friendly bacteria can help keep yeast regrowth to a minimum.  Other treatments include the application of a very weak vinegar douche or application of dilute tea tree oil solution.  Since oral consumption of live acidophilus-cultured yogurt has been proven beneficial, acidophilus suppositories should have the same or a more rapid effect.  If candida is suspected of being more than a local problem, more systemic anti-candidal treatments will need to be utilized.

Complications

Researchers are investigating the role of bacterial vaginosis in pelvic infections that result in infertility and tubal (ectopic) pregnancy.  There is a growing body of evidence suggesting an increase in adverse outcomes of pregnancy such as premature and low-birth-weight infants among women with BV.

Although previously trichomoniasis was not thought to result in any important complications, recent studies have linked it to two serious consequences.  Data now suggest that trichomoniasis may increase the risk of transmission of human immunodeficiency virus (HIV), the virus that causes AIDS, and may cause delivery of low-birth-weight or premature infants.  Additional research is needed to fully explore these relationships.