Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs



Sexuality - Sexually Transmitted Infections - Vaginitis (B3)

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Epipithelial cell
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Another major symptom complex are those females presenting with a vaginal discharge. The three most common vaginal infections in adolescents are Trichomonas Vaginalis vaginitis, bacterial vaginosis and candidal infections.

The above slide is an example of a smear - gram stained from a female with normal vaginal secretions. It shows an epithelial cell, no white cells and normal lactobacillus organisms.

White Cell
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Above is a wet mount from a woman with an abnormal discharge. She has multiple white cells. One would expect less than 5 white cells per high power field or less than one white cell for every epithelial cell in the field in a wet mount from normal vaginal secretions..

Trichomonas Vaginalis Vaginitis

One common infection is trichomonas vaginalis. The picture below shows a common discharge from a "trich" infection. It is yellowish or can be whitish or greenish.

Discharge from "trich" infection
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One can also see petechial lesions on the cervix with trichomonas infections. These are sometimes known as a "strawberry cervix".

"Strawberry Cervix"
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The easiest diagnostic tool is the wet mount. Below is a wet mount from vaginal secretions from a teen with a trichomonas infection. One can see both numerous white cells and the ovoid trichomonas organisms. In a wet mount they can be seen moving around with their flagellae arising from one end. It is sometimes helpful to look at low power to find one of the moving organisms. However, since the wet mount only has 60% -80% sensitivity, one may have to treat on clinical grounds if the organism cannot be seen on wet mount.

Wet Mount with Trichomonas Organism
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Treatment for this infection is outlined in the CDC recommendations. However, in general:

  • Both metronidazole 2 g PO in a single dose and metronidazole 500 mg PO b.i.d X 7 days are 95% effective.
  • Local creams not proven effective
  • Follow-up is not needed if the teen is asymptomatic
  • For those who fail treatment, it is best to retreat with a 7 day course.
  • Partners should be treated and advised to avoid sex until both partners are cured.
  • Metronidazole is safe in pregnancy

Bacterial Vaginosis

Another common vaginal infection is a bacterial vaginosis. This infection is characterized by a clear grayish, foul-smelling (fishy odor) discharge. It is usually not associated with much erythema or irritation. There is usually no associated dysuria. The infection is best considered a sexually-associated infection . While it can be sexually transmitted, the infection can also occur in virginal females. There is also little evidence that treatment of sexual partners alters the course.

Bacterial Vaginosis
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The infection is usually associated with an overgrowth of multiple vaginal organisms including both gram-negative and gram positive organisms (especially G. vaginalis and Mycoplasma hominis) and anaerobic bacteria (particularly Bacteroides sp and Mobiluncus sp ). There is a loss of the normal lactobacillus organisms found in the normal gram stain seen previously. Below is a gram stain from a discharge with a woman having bacterial vaginosis.

gram stain from a discharge with a woman having bacterial vaginosis
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It demonstrates the loss of lactobacillus organisms and the appearance of multiple gram positive and gram negative organisms. Below are examples of wet mounts from normal vaginal secretions and those from a female infected with bacterial vaginosis. Note on the left the clear central area of the epithelial cells and the sharp border. This is in distinction to the abnormal wet mount on the right which shows a hazy border and ground glass appearance of the epithelial cell ("clue cell").

Normal epithelial cell

Normal Epithelial Cell
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"Clue cell"

Clue Cell
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The CDC-suggests the Amsel criteria for the diagnosis of the syndrome of bacterial vaginosis which depends upon the presence of 3 of 4 of the following clinical symptoms and signs (CDC, 1998):

  • The presence of a homogeneous, white, noninflammatory discharge that smoothly coats the vaginal walls ;
  • The presence of clue cells on microscopic examination (see above) In general, clue cells should comprise at least 20% of the cells examined.
  • The vaginal pH is > 4.5 .
  • The vaginal discharge has a fishy odor before or after the addition of 10% KOH, known as the “whiff test”.

Gram stain is also sometimes use as diagnostic tool. In the gram stain there is replacement of the normal flora with small, pleomorphic, coccobacilli as seen above. Culture is currently not recommended as a diagnostic test.

Treatment is outlined in the CDC guidelines but includes either:

  • Metronidazole 500 mg PO b.i.d X 7 days (95% effective)
  • Clindamycin cream 2%, one applicator qhs X 7 d
  • Metronidazole gel, one applicator bid X 5 d

Candida Vaginitis

The last infection in the common three to be discussed is shown below - Candida vaginitis

Candida Vaginitis
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While vulvovaginal candidiasis is a common form of vaginitis in females, it is often a problem determining true infection from nonpathogenic colonization. Candida albicans causes about 85% of infections. The infection can also be sexually associated as sexual intercourse or contact is not necessary for an infection. Predisposing factors include diabetes mellitus, pregnancy, oral contraceptives, oral steroid use, broad-spectrum antibiotics and immunocompromising diseases. In addition, some women probably have a mild Candida antigen-specific immunologic deficiency.

click for full-size image

Candida vaginitis is associated with intense burning, pruritus and erythema. The discharge is often similar to that above which is a thick, curdy, cottage-cheese appearance. On wet mount or KOH smear, one can visualize budding yeast and pseudohyphae as seen below. The KOH prep has a sensitivity of about 40% to 80%. Rapid diagnostic tests are becoming available but have not been well studied. Culture is expensive and time consuming.

Treatment can be done either through one of the many topical agents or oral therapy as outlined in CDC guidelines. It is important to remember that:

  • Single dose interventions should be reserved only for mild/moderate cases
  • In recurrent severe infections, oral agents may need to be used for a more extended period of time.
  • Follow-up is only needed if symptoms persist.
  • Treatment of partners does not effect the course.
  • The topical agents are ok to use in pregnancy.
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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.