Vaginitis in adults: Initial evaluation

INTRODUCTION — Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora. Symptoms include abnormal vaginal discharge, odor, pruritus, and/or discomfort. The initial evaluation typically consists of a history, physical examination, and tests for specific infections, including sexually transmitted infections (STIs). Individuals whose initial evaluation confirms a diagnosis then receive targeted treatment. Those who remain without a diagnosis, or whose symptoms recur, then go through a more detailed evaluation process.

This topic will discuss the approach to individuals who present with vaginal discharge from an unknown cause. Detailed reviews of specific causes of vaginitis are presented separately:

●(See "Candida vulvovaginitis: Clinical manifestations and diagnosis".)

●(See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

●(See "Trichomoniasis: Clinical manifestations and diagnosis".)

●(See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents".)

●(See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

NORMAL VAGINAL DISCHARGE — Vaginal discharge is normal in estrogenized individuals. Abnormal vaginal discharge is a prominent symptom of vaginitis but may be difficult to distinguish from normal by volume alone in the absence of additional symptoms.

●Impact of estrogen

•With estrogen – Individuals with estrogenized vaginal tissue typically include those who are of reproductive age (menarche through menopause) and those who are postmenopausal and using supplemental estrogen (vaginal or systemic). Vaginal discharge increases during pregnancy, likely in response to increased vaginal transudate [1].

-Characteristics – In response to estrogen, normal vaginal discharge consists of 1 to 3 mL of fluid (per 24 hours), which is white or transparent, thick or thin, and mostly odorless [1,2]. The pH is typically 4.0 to 4.5 as measured with pH paper.

-Formation of discharge – Normal physiologic discharge is formed by mucoid endocervical secretions in combination with sloughing epithelial cells, normal vaginal flora, and vaginal transudate [1]. In the presence of estrogen, the nonkeratinized stratified squamous epithelium of the vagina is rich in glycogen. Glycogen from sloughed cells is the substrate for lactobacilli, which convert glucose into lactic acid, thereby creating an acidic vaginal environment (typically pH 4.0 to 4.5) [3-5]. This acidity helps maintain the normal vaginal flora and inhibits growth of pathogenic organisms that are typically present, including Gardnerella vaginalis, Escherichia coli, group B streptococci, genital Mycoplasma species, and Candida albicans [6].

•Low estrogen – Patients with low or nearly absent estrogen levels include those who are premenarchal; postpartum; lactating; postmenopausal (without estrogen use); or using estrogen-blocking drugs, such as aromatase inhibitors (eg, tamoxifen). The low levels of estrogen, and glycogen substrate, results in sparse presence of lactobacilli and an elevated vaginal pH (typically >4.5) [5].

-Premenarchal – Before ovarian estrogen production, physiologic vaginal discharge ranges from absent to scant. If present, fluid can be clear, white, or mucoid. The vaginal pH is alkaline (ie, 7). (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment".)

-Postmenopausal – The hypoestrogenic state of menopause leads to a reduction of vaginal discharge and increase in vaginal pH (typically > 4.5) [6]. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis", section on 'Effects of hypoestrogenism'.)

●Microbiota – The vaginal microbiota contains bacteria, fungi, viruses, archaea, and protozoans [7]. In many people, lactobacilli are the dominant bacterial genus, with L. crispatus, L. jensenii, L. gasseri, and L. iners being the most common species [1,8,9]. However, no single microbiologic pattern represents the normal vaginal environment of all patients [7].

●Minimal additional symptoms – Although normal discharge may be yellowish, slightly malodorous, and accompanied by mild irritative symptoms [10], it is not accompanied by pruritus, pain, burning or significant irritation, erythema, local erosions, or cervical or vaginal friability. The absence of these signs and symptoms helps to distinguish normal vaginal discharge from discharge related to a pathological process, such as vaginitis or cervicitis.

●Factors impacting normal vaginal discharge – Vaginal discharge may become more noticeable at times ("physiological leukorrhea"), such as midmenstrual cycle (ie, close to the time of ovulation), during pregnancy, or with use of estrogen-containing contraceptives. Diet, sexual activity, medication, and stress can also affect the volume and character of normal vaginal discharge. (See 'Increased vaginal discharge (leukorrhea)' below.)

ABNORMAL DISCHARGE — Disruption of the normal ecosystem can lead to vaginitis with abnormal vaginal discharge. Some of these potentially disruptive factors include sexually transmitted diseases, antibiotics, foreign body, estrogen level, use of personal care products, pregnancy, sexual activity, and contraceptive choice.

Clinical features — Individuals with abnormal vaginal discharge from vaginitis typically present with one or more of the following nonspecific vulvovaginal symptoms [11]:

•Change in the volume, color, or odor of vaginal discharge

•Pruritus

•Burning

•Irritation

•Erythema

•Dyspareunia

•Spotting

•Dysuria

Clinical significance — Vaginitis is one of the most common reasons that women access health care worldwide [1,12]. In the United States, 6 to 10 million healthcare visits occur for this indication annually [13,14]. Despite its high prevalence, less than half of cases are optimally managed. Misdiagnosis and inappropriate treatment can impact reproductive health and raise the risk of sexually transmitted infections, including HIV.

●(See "HIV and women", section on 'Bacterial vaginosis, genital ulcers, and pelvic inflammatory disease'.)

●(See "Spontaneous preterm birth: Overview of risk factors and prognosis", section on 'Infection'.)

Common etiologies — Vaginitis, which includes the symptom of abnormal vaginal discharge, is frequently caused by infection but may have other etiologies. A patient could have simultaneous infectious and noninfectious causes, co-occurrence of common infections, or coinfection with sexually transmitted infection of the cervix (eg, gonorrhea or chlamydia).

●Infectious – Infection has been estimated to cause between 70 percent and 90 percent of vaginal symptoms (incidence varies by population being studied) [10,15]. The most common vaginal infections are bacterial vaginosis (BV; 40 to 50 percent of cases), vulvovaginal candidiasis (20 to 25 percent of cases), and trichomoniasis (15 to 20 percent of cases) [16-18]. Cervicitis, typically from sexually transmitted infections (STIs), such as gonorrhea and chlamydia, can also present with nonspecific vaginal symptoms [19].

•(See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

•(See "Candida vulvovaginitis: Clinical manifestations and diagnosis".)

•(See "Trichomoniasis: Clinical manifestations and diagnosis".)

•(See "Screening for sexually transmitted infections".)

●Noninfectious – Antibiotic use, foreign body (eg, retained tampon or condom), low estrogen levels (eg, menopause), genital care products (eg, vaginal washes or douches), pregnancy, sexual activity, contraceptive choice, dermatoses, and systemic medical disorders (eg, rheumatoid arthritis and systemic lupus) can cause abnormal vaginal discharge and related symptoms. One grouping of noninfectious etiologies is mechanical, chemical, allergic, or other [12].

•(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

•(See "Vulvar lesions: Differential diagnosis of red lesions" and "Vulvar lesions: Differential diagnosis of red lesions", section on 'Irritant contact dermatitis'.)

SUMMARY OF APPROACH — The clinical evaluation consists of a history, physical examination, and testing of vaginal discharge for evidence of infection (algorithm 1) [20].

●Obtain a history and perform a physical examination – While the medical history often suggests a particular diagnosis, history alone is inadequate for making an accurate diagnosis because symptoms of common infections overlap and more than one cause may be present [10]. Physical examination includes evaluation of the vulva, clitoris, vestibule, vagina, cervix, and pelvis. (See 'History' below and 'Physical examination' below.)

●Test for vaginal and cervical infections – The vaginal discharge is tested for bacterial vaginosis (BV), vulvovaginal candidiasis, and trichomoniasis using either pH testing with microscopy and/or laboratory tests (typically nucleic acid amplification tests) [15,21]. Sexually active individuals are also tested for sexually transmitted cervical infections (eg, gonorrhea, chlamydia) as coinfection may be present.

•(See 'Test vaginal discharge' below.)

•(See 'Perform tests for STI' below.)

●Provide targeted treatment and reassess symptoms

•Identified etiology – For individuals in whom an etiology is identified and whose symptoms resolve after initial targeted treatment, no further evaluation is needed. (See 'Initial findings' below.)

•No identified etiology – Twenty-five to 40 percent of patients presenting with vaginal symptoms will not have a specific cause identified on initial diagnostic evaluation [22]. These individuals are further evaluated for less common and rare causes of vaginitis. (See 'No diagnosis after initial evaluation' below.)

•Continued or recurrent symptoms – For patients who are diagnosed and treated but continue to exhibit symptoms, we repeat testing for vaginal and cervical infections. The causes of recurrent symptoms are complex and depend on pathogen or causal mechanisms. Sexual partners can cause recurrence of cervicitis or vaginitis resulting from sexually transmitted infection (STI) pathogens (eg, trichomonas or N. gonorrhea). (See 'Unique populations' below.)

DIAGNOSTIC EVALUATION — History, physical examination, and laboratory testing are all required for diagnosis [12]. History alone is not sufficient for diagnosis and can lead misdiagnosis and mistreatment [1,12].

History — The initial history questions gather details of the patient's symptoms. Each symptom is further evaluated separately as more than one condition may be present [23]. However, none of the findings from the history allows a definitive diagnosis since there is considerable overlap in symptoms among the different etiologies of vaginitis (table 1) [10,24].

Our initial evaluation includes questions about the following:

●Discharge – If abnormal discharge is present, what is the quantity, color, consistency, and odor? Classic descriptions of the vaginal discharge associated with the three most common vaginal infections are as follows:

•Bacterial vaginosis (BV) – The discharge of BV is typically malodorous, thin, gray (never yellow), and is a prominent complaint. (See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

•Vaginal candidiasis – Vaginal candidiasis typically presents with scant discharge that is thick, white, odorless, and often curd-like. (See "Candida vulvovaginitis: Clinical manifestations and diagnosis".)

•Trichomoniasis – Trichomoniasis is characterized by purulent, malodorous discharge, which may be accompanied by burning, pruritus, dysuria, frequency, and/or dyspareunia. (See "Trichomoniasis: Clinical manifestations and diagnosis".)

●Burning, irritation, or other discomfort – Candida vulvovaginitis often presents with marked inflammatory symptoms (pruritus and soreness). In contrast, BV is associated with only minimal inflammation and minimal irritative symptoms. Burning and irritation can also be a symptom of noninfectious disorders such as vulvodynia.

•(See "Candida vulvovaginitis: Clinical manifestations and diagnosis".)

•(See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Clinical features'.)

•(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

●Pruritus – General pruritus is suggestive of a diffuse process such as infection, allergy, or dermatosis. Persistent or chronic focal pruritus is suggestive of a localized process such as neoplasia or malignancy. (See 'Pruritus' below.)

●Vaginal bleeding – Vaginal bleeding is not consistent with infectious vaginitis, with the exception of postcoital spotting, which may indicate cervicitis. If vaginal bleeding is present, the patient should be evaluated for cervicitis, erosive causes of vaginitis (eg, erosive lichen planus), and/or a uterine source.

•(See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers", section on 'Erosions, excoriations, and fissures'.)

•(See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

●Pain – Patients with predominant pain symptoms are evaluated for inflammatory causes of vaginitis or nonvaginal sources, such as pelvic floor myofascial pain or vulvodynia.

•(See 'Inflammation or irritation' below.)

•(See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)

•(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

●Dysuria or dyspareunia – These symptoms can be suggestive of inflammatory disorders, such as infection or allergy, as well vulvovaginal atrophy.

•(See 'Inflammation or irritation' below.)

•(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

●Timing of symptoms – Symptoms of Candida vulvovaginitis often occur in the premenstrual period, while symptoms of trichomoniasis and BV often occur during or immediately after the menstrual period. Symptoms that develop soon after sexual intercourse are suggestive of STIs. Symptoms that develop after gynecologic surgery such as hysterectomy can suggest a vaginal cuff infection or fistula.

●Estrogen status – Low estrogen levels can cause genitourinary syndrome of menopause (ie, vulvovaginal atrophy) that presents with symptoms of vaginitis, vaginal dryness, and dyspareunia. Menopausal individuals receiving systemic hormone therapy may not have adequate estrogen levels for vaginal health and thus remain prone to atrophic vaginitis unless additional low-dose vaginal estrogen is utilized. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

Other hypoestrogenic states include patients who are postpartum, lactating, or taking antiestrogenic drugs. Some individuals develop relatively low estrogen levels related to hormonal contraceptive use.

Physical examination — Physical examination includes evaluation of the vulva, clitoris, vestibule, vagina, cervix, and pelvis. Sites of discomfort are identified and mapped. The clinician assesses the degree of vulvovaginal inflammation, characteristics of the vaginal discharge, and presence of lesions or foreign bodies. Other significant findings include cervical inflammation and pelvic or cervical motion tenderness.

●Vulva – Findings of the vulvar examination can help guide further evaluation and diagnosis.

•Normal findings are consistent with BV or leukorrhea. (See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Clinical features'.)

•Erythema, edema, or fissures suggest candidiasis (picture 1A-B), trichomoniasis, or dermatitis.

-(See "Candida vulvovaginitis: Clinical manifestations and diagnosis", section on 'Physical examination'.)

-(See "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Female'.)

-(See "Vulvar dermatitis".)

•Atrophic changes are caused by hypoestrogenemia and suggest the possibility of atrophic vaginitis. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

•Changes in vulvovaginal architecture (eg, scarring) may be caused by a chronic inflammatory process, such as erosive lichen planus, as well as lichen sclerosus or mucous membrane pemphigoid rather than vaginitis. (See "Vulvar lichen planus".)

•Pain with application of pressure from a cotton swab ("Q-tip test") on the labia or at the vaginal introitus may indicate an inflammatory process (candidiasis, dermatosis) or provoked vulvodynia (ie, vulvar pain of unclear etiology). (See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

●Speculum examination – Speculum examination is performed to evaluate the vagina, any vaginal discharge, and the cervix.

•Vagina – The vagina is examined for the following lesions:

-A foreign body (eg, retained tampon or condom) is easily detected and is often associated with vaginal discharge, intermittent bleeding or spotting, and/or an unpleasant odor due to inflammation and secondary infection. Removal of the foreign body is generally adequate treatment. Antibiotics are rarely indicated.

-Vaginal warts are skin-colored or pink and range from smooth flattened papules to a verrucous, papilliform appearance (picture 2). When extensive, they can be associated with vaginal discharge, pruritus, bleeding, burning, tenderness, and pain. (See "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis".)

-Granulation tissue or surgical site infection can cause vaginal discharge or bleeding after hysterectomy or childbirth.

-Necrotic or inflammatory changes associated with malignancy in the lower or upper genital tract can result in vaginal discharge; spotting is more common in this setting than in infectious vaginitis.

-The presence of multifocal rounded macular erythematous lesions (like a spotted rash or bruise), purulent discharge, and tenderness suggests erosive vulvovaginitis, which can be caused by trichomoniasis or one of several noninfectious inflammatory etiologies (picture 3) [25].

•Vaginal discharge – The characteristics of the vaginal discharge may suggest the type of infection, if present (table 1). Trichomoniasis is classically associated with a greenish-yellow purulent discharge; candidiasis with a thick, white, adherent, "cottage cheese-like" discharge; and BV with a thin, homogeneous, "fishy smelling" gray discharge. Inflammation and/or necrosis related to malignancy of the lower or upper genital tract can result in watery, mucoid, purulent, and/or bloody vaginal discharge. However, the appearance of the discharge is unreliable and should never form the basis for diagnosis [10]. A sample of vaginal discharge is collected with a cotton swab and tested for pH and with microscopy. (See 'Test vaginal discharge' below.)

Vesicovaginal and rectovaginal fistulas are rare, can be hard to detect, and are a source of chronic vaginal discharge. At-risk patients include those who are postpartum, posthysterectomy, postsurgery for prolapse, or have a history of inflammatory bowel disease or radiation therapy to the pelvis. (See "Rectovaginal and anovaginal fistulas" and "Urogenital tract fistulas in females".)

•Cervix – Cervical inflammation with a normal vagina is suggestive of cervicitis rather than vaginitis. The cervix in individuals with cervicitis is usually erythematous and friable, with a mucopurulent discharge (picture 4A-B). (See "Acute cervicitis".)

Cervical erythema in cervicitis should be distinguished from ectropion, which represents the normal physiologic presence of endocervical glandular tissue on the exocervix. Ectropion is more common in individuals taking estrogen-progestin contraceptives and during pregnancy. Ectropion may increase the volume of normal vaginal discharge. (See "Benign cervical lesions and congenital anomalies of the cervix", section on 'Ectropion'.)

●Bimanual pelvic examination – Bimanual examination is performed to assess for tenderness and/or abnormal anatomy.

•Patients with vaginitis who also have pelvic or cervical motion tenderness are further evaluated for pelvic inflammatory disease (PID). (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

•Adnexal masses could represent a cyst or malignancy. (See "Approach to the patient with an adnexal mass".)

•While bimanual examination can also identify pelvic muscle spasm and tenderness reflecting pelvic muscle dysfunction, these entities are not usually associated with abnormal vaginal discharge. (See "Myofascial pelvic pain syndrome in females: Clinical manifestations and diagnosis".)

Test vaginal discharge

Test timing and selection — Ideally, the abnormal vaginal discharge is tested for evidence of BV, Candida species, and trichomonas when the patient is symptomatic. The two main test strategies include pH and microscopy or laboratory testing, typically with nucleic acid amplification tests (NAATs) (table 2) [12]. Test selection is based on provider training and availability of equipment and tests (algorithm 1). All sexually active patients are also tested for gonorrhea and chlamydia. Patients presenting for an STI evaluation or at risk for human immunodeficiency virus (HIV) acquisition are offered HIV testing [12].

The traditional gold standard tests have been culture (for candida species and trichomoniasis) and microscopy with Nugent score, followed by Amsel criteria for indeterminate tests, for BV. However, NAATs have become an established alternative to both as NAATs have similar or better test sensitivity and specificity. (See 'Nucleic acid amplification tests (NAATs)' below.)

Preferred

Nucleic acid amplification tests (NAATs) — NAATs can diagnose BV, Candida, and/or trichomonas, as well as cervicitis caused by gonorrhea and chlamydia, with sensitivities and specificities of >90 percent (table 2) [16,19,21,26]. NAATs can be used as the initial diagnostic tool or as a follow-up to negative microscopy in patients with high clinical suspicion (algorithm 1) [16,17,27,28]. Some commercial tests evaluate for single infections while others are combined tests.

●Advantages – Laboratory tests offer improved diagnostic accuracy compared with pH and microscopy, as discussed in the bullet below [16,17,27,28]. For this reason, NAATs are preferred for testing of some infections, particularly trichomoniasis [11,12]. Additional advantages include the ability to use a patient-collected specimen and lack of need for specialized clinician training (versus microscopy).

●Disadvantages – Disadvantages include delayed time for diagnosis and need for specialized and/or costly equipment.

●Diagnostic accuracy – NAATs are associated with sensitivities and specificities of greater than 90 percent for Candida species, bacterial vaginosis, T. vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis [16,17,27,28].

•In a study of females with and without vulvovaginal symptoms (n = 200 and 100, respectively) presenting to outpatient gynecologic offices and a vulvovaginal referral clinic, NAATs had a greater sensitivity for candida and trichomoniasis compared with microscopy (NAAT sensitivities of 92 and 100 percent and microscopy sensitivities of 89 and 75 percent) [16].

•A cross-sectional study of over 1500 individuals tested with a single-use, point-of-care polymerase chain reaction (PCR) device reported sensitivities and specificities of over 96 percent for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, and T. vaginalis compared with clinician-collected swabs tested with laboratory NAAT kits [26].

•A cross-sectional study of over 1700 women with vaginitis symptoms reported sensitivities and specificities of greater than 90 percent for detection of BV, candidiasis, and trichomoniasis by NAAT compared with traditional culture methods [21].

pH and microscopy — Combined results of pH testing and microscopy of the vaginal discharge are used to identify normal vaginal discharge (table 1) and diagnose common infectious etiologies (algorithm 1). While vaginal pH guides the differential diagnosis if infection is present, it is not diagnostic as it is only a marker of pathology.

Test accuracy and characteristics

●Advantages – pH and microscopy are performed at the point of care (ie, do not need a laboratory) and can provide immediate diagnostic information (table 1) [12,29]. This approach allows for immediate treatment (if results are diagnostic), is low cost, and requires minimal equipment.

●Disadvantages – Limits include the need for a clinician who is trained to perform both a pelvic exam (to obtain a specimen) and microscopy as well as availability of a microscope and supplies. Patients with negative or indeterminate microscopy results but a high clinical concern for infection will need for subsequent laboratory tests with NAAT or culture (culture or NAAT for yeast and NAAT for BV and trichomonas). Separate tests are required for gonorrhea and chlamydia. (See 'Nucleic acid amplification tests (NAATs)' above.)

●Diagnostic accuracy – Microscopy will detect BV, trichomoniasis, or yeast approximately half the time compared with NAAT or culture, although the range is wide and varies with testing platform and clinician experience [16,17,26,27].

pH measurement — Measurement of vaginal pH helps determine which infections may be contributing to the patient's symptoms (figure 1 and table 1).

●Technique – A pH test stick (or pH paper if available) is applied for a few seconds to the vaginal sidewall (to avoid contamination by blood, semen, or cervical mucus, which pool in the posterior fornix and distort results). Alternatively, the vaginal sidewall can be swabbed with a dry swab and then the swab rolled onto pH paper (if available). Narrow range pH paper (4.0 to 5.5) is easier to interpret than broad range paper (4.5 to 7.5). The pH of the specimen is stable for approximately two to five minutes at room temperature. The swab should not be premoistened as the moistening liquid can affect pH. The results of the pH test are then combined with findings from microscopy to establish a diagnosis. (See 'Interpretation of results' below.)

●Factors impacting pH – As vaginal pH rises in hypoestrogenic individuals, measurement of pH for diagnosis of BV, trichomoniasis, or candidiasis is less useful at the extremes of age. (See 'Normal vaginal discharge' above.)

Vaginal pH may be altered (usually to a higher pH) by contamination with lubricating gels, semen, blood, douches, and intravaginal medications. In pregnant persons, leakage of amniotic fluid raises vaginal pH.

Microscopy — A sample of the patient's vaginal discharge is obtained with a cotton swab, smeared onto a slide, and evaluated under a microscope with both saline and potassium hydroxide (KOH) in the steps below (figure 1). If microscopy is does not provide a diagnosis, additional laboratory testing is performed to identify candida, BV, and/or trichomoniasis [12,29].

●Saline wet mount – Vaginal discharge is generally sampled with a plastic or wood vaginal/cervical scraper or a cotton-tipped swab. The sample of vaginal discharge is mixed with one to two drops of 0.9 percent normal saline solution at room temperature on a glass slide. A cover slip is then placed on the slide, which is examined under a microscope at low and high power. Microscopy should be performed within 10 to 20 minutes of obtaining the sample to reduce the possibility of loss of motility of any trichomonads (figure 1). (See "Trichomoniasis: Clinical manifestations and diagnosis".)

•Normal findings – Microscopic examination of normal vaginal discharge reveals a predominance of squamous epithelial cells, rare polymorphonuclear leukocytes (PMNs), and Lactobacillus species morphotype (table 1 and figure 2 and figure 1). The presence of parabasal epithelial cells suggests vaginal atrophy (picture 5).

•Abnormal findings – The slide is examined for candidal buds (picture 6) or hyphae (picture 7), motile trichomonads (picture 8), epithelial cells studded with adherent coccobacilli (clue cells (picture 9 and picture 10)), and increased numbers of PMNs. Clue cells may be accompanied by Mobiluncus species (movie 1). Excess PMNs without evidence of yeast, trichomonads, or clue cells suggest cervicitis or noninfectious or inflammatory vaginitis.

●Potassium hydroxide wet mount – The addition of 10 percent potassium hydroxide (KOH) to the wet mount of vaginal discharge destroys cellular elements, thus it is helpful for identifying hyphae and budding yeast for the diagnosis of candidal vaginitis (picture 6 and picture 7). (See "Candida vulvovaginitis: Clinical manifestations and diagnosis".)

●Amine (whiff) test – Smelling ("whiffing") the slide immediately after applying KOH is useful for detecting the fishy (amine) odor of BV. (See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

Interpretation of results — The pH of the normal vaginal secretions in reproductive-age females is 4.0 to 4.5 (although higher levels have been reported) [3,4,10]. In premenarchal and postmenopausal females in whom estrogen levels are low, the pH of the normal vaginal secretions is ≥4.5. Thus, measurement of pH for diagnosis of BV, trichomoniasis, or candidiasis is less useful at the extremes of age. (See 'Normal vaginal discharge' above.)

The findings of pH measurement and microscopy are then used to identify normal vaginal discharge and common infectious etiologies (table 1 and figure 1) [11]:

•Normal vaginal discharge (estrogenized patient)

-pH 4.0 to 4.5

-Microscopy: Lactobacilli present, white cells absent

-Whiff test negative

•Vulvovaginal candidiasis

-pH 4.0 to 4.5

-Microscopy: Candida species (budding yeast, pseudohyphae, and/or hyphae visible on potassium hydroxide [KOH] wet mount)

-Whiff test negative

•Bacterial vaginosis (BV)

-pH >4.5

-Microscopy: Clue cells (at least 20 percent of epithelial cells)

-Whiff test positive

•Trichomoniasis

-pH >4.5

-Microscopy: Motile trichomonads

-Whiff test often positive but may be negative

Culture — Culture has traditionally been the gold standard for diagnosing vulvovaginal candidiasis. It may be a better choice when information on Candida species or drug susceptibility testing (yeast or trichomonas) is indicated. However, culture is being replaced by nucleic acid amplification tests (NAATs) in many acute settings because of high test concordance rates between culture and NAAT [12,16,17]. (See 'Nucleic acid amplification tests (NAATs)' above.)

By contrast, bacterial cultures are rarely indicated because a large variety of bacterial species colonize the vagina and are not vaginal pathogens [8]; identification of these bacteria may lead to unnecessary antibacterial therapy. Apart from Group A Streptococcus, a clear causal relationship between any bacteria and vaginitis has not been established in adults.

●(See "Invasive group A streptococcal infection and toxic shock syndrome: Epidemiology, clinical manifestations, and diagnosis".)

●(See "Pregnancy-related group A streptococcal infection".)

Specific test information is presented separately for each infection type:

●(See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Clinical laboratory tests'.)

●(See "Candida vulvovaginitis: Clinical manifestations and diagnosis", section on 'Molecular and other tests'.)

●(See "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)

●(See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Nucleic acid amplification'.)

●(See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Nucleic acid amplification testing (test of choice)'.)

Less preferred tests — NAATs or pH testing with microscopy are generally preferred to other diagnostic tests. However, these tests remain reasonable options and may be preferred in select clinical scenarios, such as patients with recurrent yeast or trichomonas infections.

Other clinical laboratory tests — In addition to NAAT, other clinical laboratory tests detect targeted organisms with direct probe assays (typically DNA or RNA probes), measurement of bacterial load (BV-related species), and rapid antigen tests [1]. Some of these are performed at the point-of-care using specialized equipment.

Patient self tests — Multiple tests are available for purchase by patients to perform their own self-tests.

●Direct-to-consumer NAAT– Commercial kits marketed as an "at home vaginal microbiome test" are available directly to consumers [30]. The performance of such test kits is not known and they have not been evaluated by regulatory agencies such as the US Food and Drug Administration.

●Self-test vaginal pH – While pH self-test kits are available over-the-counter and correct patient use has been reported by several studies [31-33], the author does not advise them because of lack of specificity for vaginal pH as an isolated test and patients may have coinfections. Additionally, vaginal pH can be elevated by lubricating gels, semen, blood, douches, intravaginal medications, and leakage of amniotic fluid.  

Perform tests for STI — Sexually active individuals with symptoms of vaginitis are tested for the STIs N. gonorrhoeae, C. trachomatis, and T. vaginalis (algorithm 1); individuals with symptomatic vaginitis can have more than one infection. In a study of 581 vaginal specimens evaluated with molecular-based testing, one-quarter of the specimens positive for BV or Candida vulvovaginitis also tested positive for an STI (N. gonorrhoeae, C. trachomatis, or T. vaginalis) [23].

While Mycoplasma genitalium can co-occur with chlamydia and trichomoniasis [34], routine testing for M. genitalium is not generally advised for patients with abnormal vaginal discharge unless recurrent and/or persistent cervicitis is present [12,35]. The rationale includes that data associating M. genitalium with cervicitis are limited to animal and human observational data [36,37], evidence supporting it as an isolated cause of abnormal vaginal discharge is lacking [38], the prevalence of asymptomatic infection is unknown [35], and treatment is both of unclear benefit and challenging because of antibiotic resistance [35].

The presentation and diagnosis of these infections is discussed in detail elsewhere:

●(See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Nucleic acid amplification'.)

●(See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Nucleic acid amplification testing (test of choice)'.)

●(See "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)

●(See "Mycoplasma genitalium infection".)

INITIAL FINDINGS

Alarm findings — Rarely, physical examination reveals an atypical cause of vaginitis that warrants a change in the diagnostic evaluation. Examples include an obvious vulvar, vaginal, or cervical cancer; probable pelvic inflammatory disease (PID); purulent vaginitis; vulvovaginal ulceration; and vaginal fistulae. These patients should be immediately referred for specialty evaluation and care.

●(See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment".)

●(See "Vaginal cancer".)

●(See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)

●(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

●(See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers", section on 'Ulcers'.)

●(See "Urogenital tract fistulas in females".)

●(See "Anorectal fistula: Clinical manifestations and diagnosis".)

Common diagnoses — Of individuals who present for the evaluation of vaginitis, approximately 70 percent will be diagnosed with one of three vaginal infections: bacterial vaginosis (BV; 40 to 50 percent), Candida vulvovaginitis (20 to 25 percent), or trichomoniasis (15 to 20 percent) [10,18,39]. The cervical infections gonorrhea and chlamydia are also commonly diagnosed causes of vaginitis in sexually active persons. Lastly, in addition to infectious etiologies, hypoestrogenic females can have concomitant vulvovaginal atrophy. Individuals with a specific diagnosis receive treatment targeted to the etiology.

●(See "Bacterial vaginosis: Initial treatment".)

●(See "Candida vulvovaginitis in adults: Treatment of acute infection".)

●(See "Trichomoniasis: Clinical manifestations and diagnosis".)

●(See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)

●(See "Treatment of Chlamydia trachomatis infection".)

●(See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

Those who remain without a clear diagnosis after the initial evaluation continue with a more detailed evaluation. We avoid empiric therapy, as this can aggravate symptoms without benefit. (See 'No diagnosis after initial evaluation' below.)

When to refer for specialty evaluation — We advise referral to a specialist in vulvovaginal disease for individuals whose symptoms persist in the absence of abnormal diagnostic tests and for those who experience persistent symptoms or frequent symptom recurrence following diagnostic test-directed therapy (assuming lack of compliance has been excluded).

NO DIAGNOSIS AFTER INITIAL EVALUATION — Twenty-five to 40 percent of patients with genital symptoms do not have a specific cause identified on initial diagnostic evaluation [22].

Avoid empiric therapy — Given the nonspecific nature of vaginitis symptoms (table 1), identifying the etiology is mandatory before initiating therapy [10,40]. Diagnostic testing enables targeted treatment, increases therapeutic compliance, and increases the likelihood of partner notification [12]. Empiric blind therapy can aggravate symptoms, cause misdiagnosis, and result in inappropriate therapy [10,41,42]. In one study of over 300 symptomatic individuals, 47 percent of those with a laboratory-confirmed diagnosis (81 out of 170) received one or more inappropriate prescriptions [43]. Self-diagnosis and treatment can further complicate the diagnostic process as the patient may have a partially treated infection or a reaction to a previous treatment [44].

Secondary approach — Upon completion of the initial diagnostic evaluation above, some patients remain without an identified cause of their symptoms. For those in whom Candida vaginitis, bacterial vaginosis (BV), and trichomoniasis have been excluded, and no other source of vaginitis has been identified, we take the following approach:

●Repeat evaluation when symptoms are present – If the patient had minimal symptoms at the time of initial evaluation and the evaluation was nondiagnostic, we repeat the steps of the initial evaluation at a future visit when they are symptomatic. Repeating the steps at a time when symptoms are present is particularly important for individuals who have recently been treated with antimicrobials. When symptoms persist without a clear diagnosis, the author advises biopsy of the symptomatic site [20].

●Repeat vaginal pH – Repeat the vaginal pH, as it helps guide the differential diagnosis and diagnostic process (table 1):

•Increased – If pH is increased, consider noninfectious causes of vaginal symptoms, such as vaginal atrophy, atrophic vaginitis, erosive lichen planus, lichen sclerosus, desquamative inflammatory vaginitis, and pemphigoid syndromes. BV and trichomoniasis are commonly associated with increased vaginal pH and should be excluded, preferably with nucleic acid amplification testing (NAAT). (See 'Nucleic acid amplification tests (NAATs)' above.)

•Normal – If pH is normal, the vagina is likely to be normal with normal microbiome, so focus on the most common vulvar and external causes of vulvovaginal symptoms, such as contact or irritant dermatitis, seborrheic or eczematoid dermatitis, psoriasis, or vulvodynia. Candidiasis should be excluded with microscopy, NAAT, or culture. (See 'Test vaginal discharge' above.)

•Decreased – If the pH is decreased, some evaluate for cytolytic vaginosis. (See 'Pruritus' below.)

●Obtain additional history – Obtain additional information on the evolution of the patient's initial symptoms and whether any new or dominant finding has emerged. We pay particular attention to less common and non-infectious causes (table 3), duration of symptoms (acute versus chronic disease), site of symptoms (vulva versus vagina), and whether there has been a recent change in sexual partner or practices (eg, change in type of lubricant or condom), as this information is also helpful in forming a differential diagnosis.

●Refer to vulvovaginal specialist if available – Referral to a vulvovaginal specialist is reasonable if the evaluating clinician has not been educated in vulvovaginal disease. The evaluation of the patient continues as below. (See 'Detailed secondary history' below.)

Detailed secondary history — For individuals who remain without a diagnosis after the initial history and evaluation above, we obtain additional history in attempt to identify the cause of the patient's symptoms.

●Acuity and timing of symptoms – Are the symptoms acute, chronic, or recurrent? An acute process is likely to have an infectious etiology; a chronic process is more likely from inflammation unrelated to infection.

●Associated symptoms – Does the patient have pelvic pain or systemic symptoms (eg, fever, nausea)? Pelvic pain is suggestive of pelvic inflammatory disease (PID) and suprapubic pain is suggestive of cystitis, although both are rare with vaginitis. The common causes of vaginitis are not associated with systemic symptoms. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and "Acute simple cystitis in adult and adolescent females".)

●Sexual practices – For individuals with undiagnosed vaginitis, we obtain a detailed sexual history. Females who have sex with females and females who have sex with both females and males are at increased risk of BV [45]. Those with a new sexual partner have an increased risk of acquiring sexually transmitted infections (STIs) such as T. vaginalis or cervicitis related to N. gonorrhoeae or C. trachomatis. (See "Screening for sexually transmitted infections".)

●Medication history – What medications (prescription and nonprescription) are being used? Antibiotics predispose to candidal vulvovaginitis; estrogen-progestin contraceptives can increase physiologic discharge; pruritus and burning unresponsive to antifungal agents may be due to vulvovaginal dermatitis. (See "Vulvar dermatitis".)

●Hygienic practices – What are the patient's hygienic practices? Mechanical, chemical, or allergic irritation may cause vulvovaginal symptoms (pruritus, burning) mistakenly attributed to an infectious source. Vaginal symptoms can result from irritants (eg, scented panty liners, spermicides, povidone-iodine, soaps and perfumes, and some topical drugs) and allergens (eg, latex condoms, topical antifungal agents, seminal fluid, chemical preservatives) that produce acute and chronic hypersensitivity reactions, including contact dermatitis. We ask about vaginal practices using over-the-counter and traditional products and/or medicines as these can have adverse effects [46]. Patient symptom/contact diaries may be helpful. (See "Vulvar dermatitis".)

●Medical history – Does the patient have a history of an oral mucosal, ocular, cutaneous, or systemic disease that could affect the vulvovaginal area? As examples:

•Herpes simplex virus and Behçet's syndrome can cause vulvovaginal ulcers.

-(See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection".)

-(See "Clinical manifestations and diagnosis of Behçet syndrome", section on 'Urogenital lesions'.)

•Females with diabetes are prone to vulvovaginal candidiasis. (See "Susceptibility to infections in persons with diabetes mellitus".)

•Inflammatory bowel diseases, such as Crohn disease or ulcerative colitis, may present with vulvar swelling, fissure, and/or ulcers before the onset of gastrointestinal symptoms.

-(See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults".)

-(See "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)

•Individuals with HIV are prone to vaginal infections. (See "HIV and women", section on 'Gynecologic issues'.)

•After transplantation, graft versus host disease can cause vaginal irritation, discharge, ulceration, and stenosis [47,48]. (See "Clinical manifestations and diagnosis of chronic graft-versus-host disease", section on 'Genitalia'.)

•Lichen planus is often diagnosed in the mouth prior to being identified in the vulvovaginal mucosa. (See "Lichen planus".)

•Stevens-Johnson syndrome and toxic epidermal necrolysis have potentially severe vulvovaginal sequelae [49]. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis".)

●Surgical history – Has the patient had recent transvaginal surgery or repair of perineal lacerations from childbirth? Vaginal symptoms may be related to a foreign body, bacterial infection, granulation tissue, or vaginal fistula.

Continued evaluation by dominant symptom — The dominant symptom guides the next steps of the evaluation. The symptom or symptom collection guide the differential diagnosis (table 3).

Inflammation or irritation — Individuals whose vaginitis complaint is associated with significant irritation or inflammation are further evaluated for dermatitis and desquamative inflammatory vaginitis.

●Vulvar dermatitis – Vulvar dermatitis, an allergic or chemical-induced irritative dermatitis, is the most common noninfectious etiology of vulvovaginal itching, irritation, or burning associated with inflammatory changes. Vaginal pH is normal in these patients. Allergens/irritants include soaps, creams, microbicides, toilet paper, detergents, and sanitary pads. Diagnosis and management involves identifying and eliminating the offending agent by taking a thorough history and systematically removing potential irritants and allergens from the urogenital environment (table 4). Patient symptom/contact diaries may be helpful. (See "Vulvar dermatitis".)

Corticosteroid therapy is indicated to control inflammation and relieve symptoms. We use a medium potency fluorinated topical steroid two to three times per day, as needed, until symptoms resolve (table 5). (See "Irritant contact dermatitis in adults" and "Topical corticosteroids: Use and adverse effects".)

●Desquamative inflammatory vaginitis – Desquamative inflammatory vaginitis is an uncommon chronic clinical syndrome of unknown etiology that usually occurs in perimenopausal females. Patients present with purulent vaginal discharge, vulvovaginal burning or irritation, dyspareunia, and vulvar and vaginal erythema. (See "Desquamative inflammatory vaginitis (DIV)".)

The diagnosis requires all of the following criteria:

•At least one of the following symptoms: vaginal discharge, dyspareunia, pruritus, burning, irritation

•Vaginal inflammation (spotted ecchymotic rash, erythema, focal or linear erosion)

•Vaginal pH >4.5

•Saline microscopy showing increased parabasal and inflammatory cells (ie, leukocyte to epithelial cell ratio greater than 1:1)

Pruritus — Pruritus unrelated to infection can occur anywhere in the lower genital tract: the vagina, vestibule, vulva, perineum, or perianal area. It can be uni- or bilateral and may be difficult for the patient to localize. Infrequent, transient, mild vulvovaginal pruritus is relatively common and may be normal. Evaluation is indicated in individuals with persistent, chronic, or severe pruritus.

●Infectious etiologies – Candida is the most common infectious cause of vulvovaginal pruritus, followed by trichomoniasis and, uncommonly, BV.

●Non-infectious etiologies – Noninfectious etiologies of vaginal discharge associated with pruritus include vulvar dermatitis, other vulvar dermatoses, and cytolytic vaginitis. Rarely, vulvar or vaginal malignancy can present with pruritus as the main symptom.

●Evaluation – Evaluation of patients with pruritus involves taking a detailed history, which often takes a considerable amount of time, and performing a thorough physical examination, with laboratory tests guided by clinical findings. Tissue biopsy can be necessary to make the diagnosis.

●Treatment – Treatment often begins with a local "drug holiday" (ie, removing potential causes of pruritus from daily life). Empiric drug therapy should be avoided. Targeted drug therapy is administered when a specific cause is identified.

Specific causes of pruritus include:

●Vulvar dermatitis – Vulvar dermatitis, the most common vulvar dermatosis, can present as vaginitis with complaints of pain and/or itching as well as the finding of inflammation on physical examination. (See 'Inflammation or irritation' above.)

●Other vulvar dermatoses – Patients whose chief complaint is vaginitis associated with pruritus, without infection or vulvar dermatitis, are further evaluated for other disorders of the vulvar skin. Biopsy can be required to diagnose other vulvar conditions. (See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers" and "Vulvar lesions: Diagnostic evaluation".)

•Inflammatory vulvar dermatoses include lichen sclerosus, lichen planus, and lichen simplex chronicus. (See "Vulvar lichen sclerosus: Clinical manifestations and diagnosis" and "Vulvar lichen planus".)

•Other common skin conditions that may present with external pruritus include psoriasis, eczema, and seborrheic dermatitis. (See "Psoriasis: Epidemiology, clinical manifestations, and diagnosis" and "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis" and "Seborrheic dermatitis in adolescents and adults".)

●Malignancy – Although malignancy is uncommon in individuals presenting with vaginitis, vulvar pruritus is the most common complaint among symptomatic patients with vulvar intraepithelial neoplasia (VIN); other presentations include a visible lesion, a palpable abnormality, perineal pain or burning, or dysuria. Malignancy, while rare, is more likely in menopausal individuals. (See 'Unique populations' below.)

●Cytolytic vaginosis – Cytolytic vaginosis refers to a rare controversial syndrome of vaginal hyperacidity due to overgrowth of lactobacilli, although the existence of this entity is debated. It is characterized by pruritus, dyspareunia, vulvar dysuria, and cyclical increase in symptoms during the luteal phase [50,51]. The cyclic symptoms are thought to reflect the higher levels of lactobacilli that occur in the luteal phase.

Diagnostic criteria include presence of white vaginal discharge, pH between 3.5 and 4.5, Gram stain showing large numbers of lactobacilli, paucity of white blood cells, evidence of cytolysis (bare nuclei, shreds of cytoplasm), and most importantly exclusion of candidal infection by culture.

Sodium bicarbonate douches have been used for treatment. A solution of one rounded teaspoon of sodium bicarbonate in 600 mL of water is used for irrigating the vagina, once per day for 7 to 14 days. There are no data to support longer courses of therapy.

Pain

●Acute onset of purulent discharge and pain – Individuals who present with acute pelvic pain and purulent vaginal or cervical discharge are evaluated for PID and Group A Streptococcus.

•Pelvic inflammatory disease (PID) – (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

•Group A Streptococcus (Streptococcus pyogenes [GAS]) – Those whose evaluation is negative for PID may have Group A Streptococcus (Streptococcus pyogenes [GAS]), although this infection is more common in prepubertal females [52,53]. GAS can colonize and be transmitted from skin (especially in individuals with chronic dermatological conditions), nasopharynx, and the gastrointestinal tract (including the perianal area) [54]. (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Group A streptococcal infection'.)

Clinical features include acute onset of frankly purulent discharge accompanied by pruritus, soreness and irritation, erythema, labial edema, and possibly dysuria from burning of the skin with voiding. Vaginal pH can be normal or mildly increased. Microscopy of the discharge reveals a marked increase in polymorphonuclear leukocytes (PMNs) and Gram stain shows chains of gram-positive cocci.

Penicillin treatment after confirmation of the diagnosis by culture rapidly leads to cure. We use Penicillin VK 500 mg four times daily for 10 to 14 days or clindamycin cream 2% vaginally for 7 to 10 days.

●Serosanguinous discharge and pelvic pain – Individuals with serosanguinous discharge and pelvic symptoms (eg, pain and/or bloating) and a negative initial vaginitis evaluation are assessed for fallopian tube carcinoma. Fallopian tube carcinoma typically presents in the fifth or sixth decades with vague complaints, although the incidence of this cancer is very low. The so-called "classic" symptoms and signs associated with this malignancy include: serosanguinous vaginal discharge (50 to 60 percent), pelvic pain (30 to 50 percent), and a pelvic mass (12 to 61 percent); however, the full triad (Latzko triad) is noted in fewer than 15 percent of patients. Hydrops tubae profluens, which refers to intermittent discharge of clear or blood-tinged fluid spontaneously or on pressure followed by shrinkage of the adnexal mass, has been described as pathognomonic of the disease. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis", section on 'Subacute presentation'.)

●Chronic introital pain – Vestibulodynia refers to spontaneous or induced pain on penetration of the introitus and tenderness provoked by focal vestibular pressure. These symptoms should be present for at least three to six months and other causes of vestibular pain, such as infectious vaginitis, should be excluded before making the diagnosis. Vaginal discharge and vaginal inflammation are typical features of vaginitis but are not part of the clinical spectrum of vestibulodynia. Candidal vulvovaginitis may mimic localized, provoked vulvodynia and may also be an initial trigger for this condition. (See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

●Postcoital vulvovaginal pruritus and pain – Seminal plasma allergy or hypersensitivity is a rare disorder characterized by postcoital vulvovaginal itching, burning, edema, and erythema with or without systemic signs and symptoms. Vaginal discharge is not a typical feature. Complaints occur immediately or within one hour after contact with seminal plasma. Most affected persons are under age 40 years and have a family history of atopy.

The diagnosis is based on absence of symptoms with condom use and on positive skin testing with a pooled sample of seminal fluid. (See "Allergic reactions to seminal plasma".)

Vulvar lesions — While a wide variety of lesions can develop on the vulva, most are not associated with vaginitis in the absence of infection. Vulvar lesions can be grouped by appearance and then further evaluated with examination and biopsy, as indicated. The differential and diagnosis of vulvar lesions is presented in detail separately.

●(See "Vulvar lesions: Diagnostic evaluation".)

●(See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers".)

●(See "Vulvar lesions: Differential diagnosis of red lesions".)

●(See "Vulvar lesions: Differential diagnosis of white lesions".)

●(See "Vulvar lesions: Differential diagnosis of pigmented (black, brown, blue) lesions".)

●(See "Vulvar lesions: Differential diagnosis of yellow, skin-colored, and edematous lesions".)

Persistent genital malodor — The normal odor of vaginal secretions cannot be clearly defined but is probably slightly sour due to lactic acid and volatile sulfur compounds. Persistent genital malodor can seriously impair an individual's quality of life; the cause is difficult to identify after readily diagnosable causes have been excluded.

●Common etiologies – The common causes include [55]:

•Neglected foreign body (including retained tampon)

•BV

•Trichomoniasis

•Infectious ulcer/PID

•Pelvic fistula (rectovaginal, vesicovaginal, ureterovaginal)

•Hidradenitis suppurativa

•Chronic constipation

•Urinary incontinence

•Fecal incontinence

•Poor hygiene

•Malignant ulcer

•Excessive genital perspiration and local bacterial colonization related to obesity

Other potential causes of malodor include metabolic disorders (see "Inborn errors of metabolism: Epidemiology, pathogenesis, and clinical features", section on 'Abnormal odors'), olfactory reference syndrome [56], and olfactory hallucinations. (See "Nonepileptic paroxysmal disorders in adolescents and adults", section on 'Olfactory hallucinations'.)

●Management – Management depends on determining a cause, although an etiology is frequently not established. In the absence of poor hygiene, frequent washing and vaginal douching are not helpful and can be harmful. Excessive soaping of the genital area can cause a chemical vulvitis and douching (rinsing of the vagina with vinegar or an antiseptic with the aid of a douche bag) can increase the risk of vaginal and pelvic infection [57,58].

•Elevated vaginal pH or lack of lactobacilli – For individuals with an elevated vaginal pH or lack of lactobacilli on Gram stain of vaginal discharge, a single but not repeated trial of antibiotics for anaerobic infection is reasonable (eg, metronidazole 500 mg orally twice daily for seven days).

•No identifiable abnormality – For those with no identifiable abnormalities, use of a specific medical grade stainless steel douching device (Water Works Douching Device) can be helpful. A randomized trial including 140 women with perceived vaginal odor and no vaginal infection reported significant improvement after douching daily for four weeks with tap water using this device [59]. In the Water Works group, odor intensity scores fell from 7.3 to 1.8 (p <0.001), which was superior to that among women who used a conventional over-the-counter plastic douche bag, 7.2 to 3.4 (p <0.003).

Increased vaginal discharge (leukorrhea) — Leukorrhea is the thin, white, non-foul-smelling normal vaginal discharge that typically begins 6 to 12 months before menarche. (See 'Normal vaginal discharge' above.)

●Evaluation – Patients who present with complaints of excessive leukorrhea undergo the evaluation outlined above.

●Counseling – After exclusion of pathological causes of vaginal discharge, females with alterations in their normal vaginal discharge can be reassured that changes in the volume and character of vaginal discharge are normal. Causes can include changes in diet, sexual activity, medication, stress, etc.

●Interventions – If pathology has been excluded and the patient remains bothered by the discharge, progestin-only therapy, such as progestin-only contraceptive pills, depot medroxyprogesterone acetate injection every three months, or norethindrone acetate 5 mg orally daily, will decrease estrogen levels and thus may decrease physiological leukorrhea. However, supporting data are lacking and side effects of some progestin-only therapies may not be warranted for this indication alone.

Currently no dietary modifications are relevant in management of vaginitis with the exception of avoiding excessive refined sugars in some individuals prone to Candida vulvovaginitis. Similarly, probiotics available in the United States are not proven to be useful in prevention or control of vaginitis.

Other — The following diagnoses are listed because clinicians sometimes attempt to diagnose and treat patients for these conditions. We do not believe they are causes of vaginitis.

●Group B Streptococcus (GBS) – GBS commonly colonizes the vagina: Approximately 20 percent of women are colonized with GBS [52,60]. Whether GBS is a pathogen in vulvovaginitis is controversial. Some clinicians believe it has a pathogenic role in vulvovaginitis and report an ameliorative effect on vulvovaginal symptoms with antibiotic treatment (oral penicillin or clindamycin cream). We and most experts do not believe this organism has a pathogenic role in symptomatic vulvovaginitis and that positive culture results merely reflect colonization, which is facilitated by disruption of the normal vaginal bacterial environment [60]. Therefore, in individuals with vaginitis, both GBS culture and treatment of positive culture results should be avoided.

●Nonspecific bacterial vaginitis (BV) – The concept of nonspecific BV is no longer acceptable. In the past, many with BV were given the diagnosis of nonspecific vaginitis but this should no longer occur since clear diagnostic criteria for BV are now available. (See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation'.)

As discussed above, vaginal bacterial cultures are rarely indicated in patients with vaginal discharge and are frequently misleading, leading to unnecessary antibacterial therapy. Apart from GAS, a clear causal relationship between any bacteria and vaginitis has not been established.

Treatment of infectious causes of vulvovaginitis should be targeted to the causative organism. Sulfanilamide cream (eg, triple sulfa or AVC cream) has no role in the treatment of vulvovaginitis, as it is less effective than other therapies (eg, metronidazole for T. vaginalis and BV, fluconazole for Candida vulvovaginitis) [61,62].

●Mycoplasma hominis, Ureaplasma parvum, and Ureaplasma urealyticum – Molecular tests for these species are sometimes bundled with tests for more common causes of vaginitis. However, there are limited data to suggest that these organisms cause vaginitis independent of co-occurring bacterial vaginosis [63,64].

UNIQUE POPULATIONS

●Prepubertal children – The evaluation of vaginitis in prepubertal children is presented separately:

•(See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment".)

•(See "Gynecologic examination of the newborn and child".)

●Postmenopausal females – Postmenopausal individuals undergo the initial evaluation discussed above. In addition to performing the initial evaluation, the clinician should assess for vulvovaginal atrophy (ie, genitourinary syndrome of menopause) and genital neoplasia and/or malignancy.

•Vulvovaginal atrophy – Vulvovaginal atrophy is common in menopausal individuals and may be present in addition to other causes of vaginitis.

-Clinical presentation – Nonspecific signs and symptoms include a watery, white or yellow, malodorous discharge; vaginal burning or irritation; itching; dyspareunia; and urinary symptoms such as urgency, frequency, and/or leakage. Physical findings include thinning of the vaginal epithelium, loss of elasticity, loss of rugae, pH ≥5, vaginal erosions, and cervicovaginal friability. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Clinical manifestations and diagnosis".)

-Microscopy findings – The wet mount is nonspecific, as similar findings occur in other inflammatory vaginal conditions. It shows parabasal cells, many polymorphonuclear leukocytes (PMNs), and no lactobacilli, with or without background bacteria. Parabasal cells are immature squamous epithelial cells that are rounded and have a large nucleus-to-cytoplasm ratio; in contrast, mature squamous epithelial cells are larger, cuboidal, with a smaller nucleus-to-cytoplasm ratio, and sometimes folded. The presence of epithelial cells rather than parabasal cells and premenopausal status helps to distinguish bacterial vaginosis (BV) from atrophic vaginitis.

-Treatment – Symptomatic response to topical estrogen therapy, which restores the vaginal epithelium, supports the diagnosis. Antibiotics are not needed. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Vaginal estrogen therapy'.)

•Intraepithelial neoplasia and malignancy – Neoplasia and malignancy are unusual causes of vaginal discharge but are more common in menopausal individuals. Tissue biopsy, with or without colposcopy, is generally required for diagnosis.

-Vaginal intraepithelial neoplasia (VaIN) – VaIN can present with vaginal discharge and/or postcoital spotting, although patients are usually asymptomatic. (See "Vaginal intraepithelial neoplasia".)

-Vulvar intraepithelial neoplasia (VIN) – VIN may cause vulvar pruritus or burning. (See "Vulvar squamous intraepithelial lesions (vulvar intraepithelial neoplasia)".)

-Fallopian tube cancer – Fallopian tube cancer may present with a serosanguineous vaginal discharge and pelvic pain. (See 'Pain' above.)

●Tamoxifen users – Females taking tamoxifen are at increased risk of Candida vulvovaginitis. Individuals with recurrent candidal infections can be offered maintenance therapy with extended oral fluconazole. (See "Candida vulvovaginitis in adults: Recurrent infection", section on 'Initial drug treatment'.)

●Persons with recurrent or chronic symptoms – Individuals with continued vaginal symptoms are separated into those with recurrent symptoms (ie, symptoms improve at intervals) and those with chronic, ongoing symptoms.

•Recurrent symptoms after intervals of improvement – For those with recurrent vaginitis, we look at chart results of past testing. Frequently the wrong diagnosis is provided by false-positive tests for organisms (eg, Gardnerella vaginalis). We also inquire as to the type of therapy the patient received and the response to this therapy. We then perform microscopy and repeat testing, as indicated, for BV, candida, trichomonas, sexually transmitted infections (STIs), including herpes simplex virus, and, less commonly, group A streptococcus.

•Chronic or persistent symptoms – Patients who continue to exhibit symptoms and/or have positive tests for STIs after treatment are most likely to have been reinfected by their sexual partner(s) [65]. Thus, we advise repeating the approach outlined in the initial evaluation above, including repeat testing for STIs. While gonorrhoea and chlamydia are cervical pathogens, infection can result in abnormal discharge. However, neither infection is typically the cause of recurrent vulvovaginal symptoms in the absence of cervicitis. (See 'Diagnostic evaluation' above.)

POSTDIAGNOSTIC MANAGEMENT — Individuals with a confirmed diagnosis are treated as indicated. If the patient's symptoms resolve, no further evaluation or treatment is warranted. However, those diagnosed with sexually transmitted infections (STIs) presumably have an infected partner and are at increased risk of reinfection or acquiring other sexually transmitted diseases. Thus, sexual partners of individuals diagnosed with an STI should be referred for specific testing and treatment. Partner-delivered patient medication (PDPM), also known as expedited partner therapy (EPT), is an alternative if evaluation of the sexual partner is not possible or unlikely. (See "Screening for sexually transmitted infections" and "Treatment of Chlamydia trachomatis infection", section on 'Management of sex partners'.)

RESOURCES FOR PATIENTS AND CLINICIANS

●The International Society for the Study of Vulvovaginal Disease provides open access to patient handouts in multiple languages.

●The American College of Obstetricians and Gynecologists provides open access to Vaginitis: Frequently Asked Questions.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Bacterial vaginosis" and "Society guideline links: Gynecologic infectious diseases (non-sexually transmitted)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Vaginal discharge (The Basics)" and "Patient education: Vulvar itching (The Basics)")

●Beyond the Basics topics (see "Patient education: Vaginal discharge in adult women (Beyond the Basics)" and "Patient education: Vaginal yeast infection (Beyond the Basics)" and "Patient education: Bacterial vaginosis (Beyond the Basics)" and "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Normal vaginal discharge – In reproductive-aged females, normal vaginal discharge consists of 1 to 4 mL of fluid (per 24 hours), which is white or transparent, thick or thin, and mostly odorless. Estrogenized vaginal epithelium contains glycogen that is converted by lactobacilli into lactic acid, thereby resulting in an acidic vaginal environment (typically pH 4.0 to 4.5 as measured with pH paper). This acidity helps maintain the normal vaginal flora and inhibits growth of pathogenic organisms that are typically present. (See 'Normal vaginal discharge' above.)

●Common etiologies – Vaginitis can result from infectious and noninfectious causes. Infectious vaginitis is much more common and typically results from bacterial vaginosis (BV), Candida vulvovaginitis, and/or trichomoniasis. Noninfectious etiologies include vaginal atrophy/atrophic vaginitis in postmenopausal individuals, foreign body (eg, retained tampon or condom), irritants and allergens (eg, vaginal washes or douches (table 4)), dermatoses, and several rarer entities including some systemic medical disorders (eg, rheumatoid arthritis and systemic lupus). (See 'Abnormal discharge' above.)

●Presenting symptoms – Individuals with vaginitis typically present with one or more of the following: change in vaginal discharge, pruritus, burning, irritation, erythema, dyspareunia, spotting, and dysuria. (See 'Clinical features' above.)

●Initial diagnostic evaluation – Determining the etiology of vaginitis is mandatory before initiating therapy. The initial evaluation consists of a history, physical examination, tests for vaginal and cervical infections, and reassessment after targeted treatment (algorithm 1). (See 'Summary of approach' above.)

•Comparison of test approaches – Two main testing strategies include office-based testing of vaginal pH and microscopy or clinical laboratory testing, typically with nucleic acid amplification tests (NAATs) (figure 1 and table 2). In-office testing provide immediate results if trained providers and equipment are available and is less costly but, for most infections, is less sensitive and specific. Laboratory testing has higher sensitivity and specificity but takes more time and incurs higher cost. (See 'Test vaginal discharge' above.)

-Vaginal pH and microscopy – To measure vaginal pH, a pH test stick (or pH paper if available) is applied for a few seconds to the vaginal sidewall. A sample of the patient's vaginal discharge is obtained with a cotton swab, smeared onto a slide, and evaluated under a microscope with both saline and potassium hydroxide (figure 1). If pH and microscopy do not identify an infectious cause but the clinical suspicion is high, further diagnostic testing is performed with culture or NAATs, as indicated. (See 'pH and microscopy' above.)

-Clinical laboratory tests – Diagnostic laboratory tests (eg, rapid antigen and NAAT) can be used for primary diagnosis of BV, vaginal candidiasis, or trichomonas vaginitis or performed if pH testing and microscopy are not diagnostic. (See 'Nucleic acid amplification tests (NAATs)' above.)

•Testing for sexually transmitted infections (STIs) – The STIs Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis must always be considered in sexually active individuals with vaginitis since those with STIs may go on to develop pelvic inflammatory disease (PID) and its potential complications. Individuals presenting for an STI evaluation or at risk for HIV acquisition are offered HIV testing as well. (See 'Perform tests for STI' above.)

●Alarm findings – Findings that warrant a change in the diagnostic evaluation include an obvious vulvar, vaginal, or cervical cancer; probable PID; vulvovaginal ulceration; and vaginal fistulae. These patients should be immediately referred for specialty evaluation and care. (See 'Alarm findings' above.)

●Lack of diagnosis after initial evaluation – Approximately 25 to 40 percent of patients with vaginitis symptoms do not have a specific cause identified on initial diagnostic evaluation. These patients undergo secondary evaluation, preferably at a time when symptoms are present. (See 'No diagnosis after initial evaluation' above.)

●Special populations – Special populations that require different evaluation or treatment include prepubertal children, menopausal individuals, those receiving tamoxifen therapy, and persons with recurrent symptoms. (See 'Unique populations' above.)