Vaginitis refers to a disruption in the vaginal ecosystem that can results in symptoms such as itching, burning, soreness, pain, increase in discharge, and a foul or fish-like odor. In addition, some patients cannot specifically describe their symptoms and describe the abnormality as a non-specific discomfort or soreness or they may describe a feeling like sand paper.
It is important for the patient to understand that the vagina is one of many ecosystems in and on the human body. The vaginal ecosystem is complex and consists of many constituents, e.g. chemical compounds such as carbohydrates (sugars), proteins, nucleic acids, yeasts, and bacteria. The resident vaginal bacteria consist of many different non-pathogenic and pathogenic bacteria.
Vaginitis is a non-specific term that is applied to abnormal conditions of the vaginal ecosystem, more specifically abnormalities in the resident and non-resident microbiology. Examples are conditions related to disruption in the resident bacteriology (namely aerobic vaginitis, bacterial vaginosis, and yeast vaginitis), acquisition of sexually transmitted micro-organisms, and conditions that are not due to changes in the resident microbiology but acquisition of bacteria from the environment.
Not all vulvar or vaginal itching is due to a yeast infection or yeast colonization. This assumption often leads the patient to purchase over-the-counter medications which, in some instances, provide transient relief. Patients who think they have a “bacterial vaginal infection” often purchase douching agents. The reason that these over-the-counter agents fail to resolve the condition is because (1) the diagnosis is incorrect, (2) the agent is not effective, and (3) the ecosystem is not restored to a healthy state.
The microbiology of the vagina can be described as follows:
- Consists of a variety of bacteria:
- Non-pathogenic bacteria
- Pathogenic bacteria
- A healthy or normal vaginal resident microbiology is characterized by certain species of Lactobacillus, specifically L. crispatus, L. gasseri, and L. jensenii.
- When these species of Lactobacillus are dominant, they are present in a concentration that is equal to or greater than 1,000,000 bacteria/ml of vaginal fluid.
- When Lactobacillus is dominant, the pathogens are present in concentrations that is equal or less than 1,000 bacteria/ml of vaginal fluid.
- The ratio of Lactobacillus to pathogenic bacteria is 1,000,000:1,000 or 1,000:1.
- When pathogenic bacteria are dominant, the ratio of Lactobacillus (non-pathogen) to pathogenic bacteria is 1:1,000.
A patient with recurrent or chronic vaginitis is often treated for yeast and administered an antifungal medication, most commonly diflucan. A patient with yeast vulvovaginitis must be properly evaluated and a correct diagnosis must be established. If the patient has been treated with various antifungal agents, it may be necessary to determine the resistance pattern to various antifungal agents to prescribe the correct antifungal agents.
Bacterial Vaginitis and Bacterial Vaginosis
Patients with bacterial vaginitis or bacterial vaginosis are often administered antibiotics, most commonly metronidazole (Flagyl) or clindamycin (Cleocin). However, these treatments can be met with failure resulting in repeated treatments with similar agents.
A patient presenting with a disruption in the vaginal bacteriology must be properly evaluated to determine whether the patient has bacterial vaginitis (aerobic vaginitis, AV) or bacterial vaginosis. The two conditions are distinctly different but may be similar in a basic deficiency. The basic similarly may be that the underlying problem, in both conditions, is that the patient is not colonized by the appropriate species of Lactobacillus. Therefore, the patient’s vaginal microbiology must be evaluated to determine if the appropriate species of lactobacilli are present, if the pathogens are present, the concentrations of each pathogen, and the ratio of lactobacilli to pathogens.
WHAT IS THE CORRECT PROCEDURE FOR A PATIENT WITH VAGINITIS?
The correct answer is to determine the cause or specific diagnosis. This can only be accomplished by seeing the patient, obtaining a detailed history, and performing a thorough abdominal/pelvic examination.
The abdominal/pelvic examination should be detailed and determine if there are any lesions or skin changes. If there are lesions and/or skin changes, a biopsy may be necessary. Characteristics of the vaginal discharge should be determined, e.g. the color of the vaginal discharge, is there an odor associated with the discharge, the pH of the vaginal discharge, and consistency of the vaginal discharge. A specimen of the vaginal discharge should be examined microscopically. This examination can provide the physician with significant information to assist in establishing a diagnosis.
The physician will obtain a specimen from the vagina to determine the microbiologic status of the vagina. The specific information that is required is; (a) which species of lactobacilli are present, (b) are there key bacteria representative of bacterial vaginitis and vaginosis present, (c) are yeast present, (d) if yeast are present, which species are present, and (e) what is the antibiotic and antifungal resistant pattern.
The patient’s history is important and the patient can be proactive by bringing a detailed medical history with her when seeing the physician. This not only increases the probability of determining the cause of her symptoms and it allows the physician to spend more time examining and discussing the findings with the patient. Completing the attached Vaginitis Questionnaire form and bringing it with you on your initial visit will provide information that will enable your physician to obtain more details regarding your risk factors for vaginitis and the possible risks for recurrent vaginitis. The answers you will provide will stimulate additional physician questions. This information is required, so that the physician can explain to the patient:
- The nature of the problem,
- Perhaps the cause or status of the problem,
- Which treatment has the greatest potential for success,
- If the patient will require long term therapy
Vaginitis is a complicated disruption in the patient’s vaginal microbial ecology. These conditions, specifically various types of vaginitis, are not infections in the true sense but changes in the vaginal microflora that usually do not respond to antibiotic therapy over the long term. Cases of vaginitis require re-establishment of a healthy vaginal microflora.
Therefore, the patient must develop an understanding of the problem, what treatments are available, and the goal of the treatment plan.
If you have been treated repeatedly for vaginitis and the problem has not been resolved call 713-383-9579 for consultation and evaluation.