Vaginitis
Differential Diagnosis — Comparative Table
| Characteristic | Vaginal candidiasis | Bacterial vaginosis | Trichomoniasis |
|---|---|---|---|
| Leukorrhea | White + thick + clumpy + cottage cheese-like appearance + scant | Gray or white + homogeneous + fluid + adhere to walls + abundant | Yellow-green + foamy + malodorous + abundant |
| Odor | Absent or slightly yeasty | Fishy odor ++ (volatile amines — trimethylamine) — worse after intercourse and menses | Unpleasant + foul odor |
| Vaginal pH | Normal (< 4.5) — acidic | High (≥ 4.5) — basic | High (≥ 4.5–6.0) |
| Itching / burning | Intense itching ++ + burning + vulvar erythema + edema + fissures | Absent or mild pruritus | Itching + burning + painful urination |
| Whiff test (KOH 10 %) | Negative | Positive +++ (fishy smell upon addition of KOH) | Sometimes positive |
| Microscopy | Pseudo-hyphes + budding yeast (yeast) + numerous polymorphonuclear leukocytes | Clue cells (vaginal cells covered with bacteria—a pathognomonic sign + >20 % epithelial cells) + few PNN | Trichomonas mobiles (motile flagellate protozoan) |
| Diagnostic criteria | Clinique + KOH + culture if recurrent | Amsel Criteria (3 out of 4) or Nugent Score | NAAT (PCR) + or microscopy (less sensitive) |
Amsel Criteria — Bacterial Vaginosis (3 out of 4 criteria)
- Criterion 1: homogeneous grey or white leucorrhoea + adherent to vaginal walls
- Criterion 2: Vaginal pH ≥ 4.5 (measured with pH paper on vaginal secretions)
- Criterion 3: Positive whiff test - fishy odor when KOH 10 % is added to secretions (release of volatile amines by anaerobic bacteria)
- Criterion 4: clue cells ≥ 20 % of vaginal epithelial cells on microscopic examination (cells covered with cocobacilli - ground-glass cell appearance)
- Diagnosis if ≥ 3 criteria out of 4: sensitivity 70-92 % + specificity 94-98 %
Treatment
- Uncomplicated vaginal candidiasis (single episode + presumed Candida albicans): fluconazole 150 mg per os single dose (reference treatment - very effective + convenient + cure rate 90 %) + or clotrimazole vaginal cream + ova (7 days) + or miconazole 1,200 mg ova single dose + or econazole + azole topical treatments are all effective and well tolerated.
- Recurrent vaginal candidiasis (≥ 4 episodes/year): fluconazole 150 mg D1 + D4 + D7 (induction treatment) → then fluconazole 150 mg/week × 6 months (maintenance treatment) → look for and treat favouring factors (diabetes + antibiotic therapy + immunodepression + untreated partner) + culture with antifungus (C. glabrata + C. tropicalis - fluconazole-resistant species)
- Bacterial vaginosis metronidazole 500 mg × 2/d per os × 7 days (reference treatment) + or metronidazole vaginal gel 0.75 % × 5 days + or clindamycin vaginal cream 2 % × 7 days → pregnancy: metronidazole 500 mg × 2/d × 7 days (recommended systemic treatment) + or clindamycin 300 mg × 2/d × 7 days + DO NOT treat asymptomatic male partner (no proven benefit)
- Trichomoniasis : metronidazole 2 g po single dose (or 500 mg × 2/d × 7 days - better tolerated) + simultaneous treatment of partner mandatory + avoid alcohol 24 h after + tinidazole 2 g single dose if allergic or resistant to metronidazole + MADO in Quebec (to be declared if trichomoniasis confirmed according to local guidelines)
- Atrophic vaginitis (menopause genitourinary syndrome): low-dose topical vaginal estrogens (cream + ring + ova) → mucosal restoration + pH normalization + symptom relief + very low systemic absorption → no major contraindications (except hormone-sensitive breast cancer) + or ospemifene per os (SERM - selective estrogen receptor modulator)
See a doctor if abnormal vaginal discharge persists despite self-prescribed treatment, or if it is accompanied by fever, pelvic pain, or bleeding – these signs may indicate pelvic infection (salpingitis) requiring urgent care. Any vaginitis during pregnancy must be evaluated and treated by a doctor. For the diagnosis of vaginitis (pH, microscopy, NAAT) and appropriate treatment, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's physicians and nurse practitioners (NPs) diagnose vaginitis through a complete clinical examination (vaginal pH + Whiff test + microscopy + NAAT as indicated), prescribe treatment suitable for each etiology (fluconazole for candidiasis + metronidazole for vaginosis and trichomoniasis), manage recurrent candidiasis with maintenance treatment, treat atrophic vaginitis with topical estrogens, and ensure partner management in cases of trichomoniasis. Consultations are available at several service locations in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not substitute for medical or gynecological advice. Trichomoniasis is an STD that requires simultaneous treatment of the partner. Bacterial vaginosis during pregnancy must be treated by a doctor due to the risk of premature birth.
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