Vaginal itching, discharge, and odor are among the most common complaints in gynecologic and primary care offices.1 Women often call their practitioners after self-treating at home. Self-diagnosis has been shown to be correct less than one-third of the time, leading to millions of dollars wasted on treating the wrong entity.2 Diagnosis by phone has also been shown to be only marginally better than chance. The symptoms of an infectious vaginitis are often confused and/or complicated by irritation, allergy, or other systemic diseases. Contact dermatitis and atrophy are similar in prevalence to candidiasis among patients referred for chronic vaginitis.3
Recognition and tailoring treatment to the correct disease process is paramount when managing patients with recurrent vulvovaginal symptoms. This involves seeing a patient, making a correct diagnosis, and treating any other conditions that may affect the success of the treatment chosen.
The natural defense of the vagina relies on protective organisms, intact epithelial cells, and often estrogen. Lactobacillus is the cornerstone of this protection, lowering the vaginal pH to create an environment unsuited to the growth of bacteria.4 It also inhibits bacterial adherence to epithelial cells and competes with them for nutrients. The vaginal equilibrium is affected by semen, arousal, tampons, menstrual blood, douching, antibiotics, and other contact irritants (Table 1).
Damage to the epithelial cells in the vagina due to trauma, bacterial overgrowth, or loss of estrogen can lead to difficulty in eliminating unwanted bacteria and increased sensitivity to the many irritants that come in contact with vulvovaginal tissue.5 Contact dermatitis can compound an otherwise “simple” infection and predispose women to recurrence due to a breakdown of their natural defenses.
Many cases of acute vaginitis can be easily treated when correctly diagnosed, however, some women will have persistent or recurrent disease. This article focuses on the more common causes of recurrent infectious vaginitis: Candidiasis and bacterial vaginosis (BV) and the methods used for their treatment and prevention.