STI-associated syndromes guide: Vaginitis

This guide provides an overview of the management and empiric treatment of sexually transmitted infection (STI) - associated vaginitis, which is an inflammation or infection of the vagina, characterized by discharge, itching or odour. While some information on bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC) has been included, they are not usually considered STIs and their management and treatment is beyond the scope of this guide.

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Public health importance

In primary care settings, vaginal discharge is among the most common reasons for gynecological consultation. Bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomoniasis are the most common infectious causes of vaginal discharge.

Trichomoniasis is sexually transmitted. It is associated with an increased risk of human immunodeficiency virus (HIV) acquisition and transmissionFootnote 1Footnote 2Footnote 3. Trichomoniasis in pregnancy may be associated with premature rupture of the membranes, preterm birth and low birth weightFootnote 4Footnote 5.

BV is the most common cause of vaginal discharge in people of reproductive age and is characterized by an overgrowth of genital tract organisms (e.g., Gardnerella vaginalis, Prevotella, Mobiluncus spp.) and a depletion of lactobacilli. BV is not sexually transmitted, however, it is associated with increased acquisition of HIV, human papilloma virus (HPV) and Chlamydia trachomatis (CT)Footnote 6Footnote 7.

VVC is not considered to be sexually transmitted. Approximately 75% of women will experience at least one episode of VVC during their lifetimes and 5%-10% will have more than one episode. Persistent Candida colonization and an increased incidence of VVC can occur in women with HIVFootnote 8Footnote 9Footnote 10Footnote 11.

Common STI-associated etiology

The most common STI-associated cause of vaginitis is trichomoniasis, caused by Trichomonas vaginalis, a protozoan.

Vaginal discharge may also be associated with cervicitis caused by Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT). Refer to the Gonococcal Infections and Chlamydial Infections (including LGV) guides, or the Cervicitis section of this guide, as appropriate.

Clinical manifestations

Symptoms and signs of trichomoniasis include:

In women, 10-50% of trichomoniasis infections are asymptomaticFootnote 12.

Most men with trichomoniasis are asymptomatic, but some may have mild urethritisFootnote 12.

Diagnostic testing

Recommended testing for trichomoniasis:

Vaginal infections can cause signs and symptoms that are similar to those of cervicitis. If cervicitis is suspected, refer to the Cervicitis section of this guide.

* Clue cells are epithelial cells covered in coccobacilli.

Empiric treatment and management

The decision to treat trichomoniasis empirically or to wait for test results should reflect the:

Empiric Treatment for trichomoniasis
Non-pregnant people

Metronidazole 2 g PO in a single dose [A-l]
or
Metronidazole 500 mg PO BID for 7 days [A-l]
Notes:

  • Efficacy is 82-88% for both regimens; increases to 95% if partner also treatedFootnote 17
  • Intravaginal metronidazole gel is not effective
  • Prevalence of metronidazole-resistant T. vaginalis is estimated at 5%; it usually responds to high-dose metronidazoleFootnote 18
Pregnant people

Metronidazole 2 g PO in a single dose for symptom relief [A-l].
Notes:

  • Metronidazole 500 mg PO BID for 7 days [A-l] is an alternate treatment in pregnancy.
  • It is not recommended that those who are asymptomatic during pregnancy be treated [D-l]Footnote 19.
  • It is not known whether treatment will improve pregnancy outcomesFootnote 4Footnote 5.

Treat current sexual partners with the same empiric treatment regimen as the index case.

Follow-up

No follow-up is necessary for trichomoniasis, unless symptoms persist or recur (usually due to reinfection).

In the case of suspected or confirmed gonorrhea or chlamydia (including LGV), consult etiology specific guides for treatment, follow-up and test of cure (TOC) recommendations.

Reporting and partner notification

Trichomoniasis is reportable in certain provinces and territories. Refer to the local public health authority for information on reporting requirements for trichomoniasis.

When treatment is indicated for other STIs: notify, evaluate, test and treat (as appropriate) sexual partners. Refer to the etiology-specific guide(s) for guidance on reporting and partner notification.

References

Footnote 1

Schwebke JR. Update of trichomoniasis. Sex Transm Infect 2002 Oct;78(5):378-379.

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Footnote 2

Sorvillo F, Smith L, Kerndt P, Ash L. Trichomonas vaginalis, HIV, and African-Americans. Emerg Infect Dis 2001 2001;7(6):927-932

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Footnote 3

Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999 Feb;75(1):3-17.

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Footnote 4

Kigozi GG, Brahmbhatt H, Wabwire-Mangen F, Wawer MJ, Serwadda D, Sewankambo N, et al. Treatment of Trichomonas in pregnancy and adverse outcomes of pregnancy: a subanalysis of a randomized trial in Rakai, Uganda. Am J Obstet Gynecol 2003;189(5):1398-1400.

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Footnote 5

Gülmezoglu AM. Interventions for trichomoniasis in pregnancy. Cochrane Database of Syst Rev 2002(3).

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Footnote 6

Bautista CT, Wurapa E, Sateren WB, Morris S, Hollingsworth B, Sanchez JL. Bacterial vaginosis: a synthesis of the literature on etiology, prevalence, risk factors, and relationship with chlamydia and gonorrhea infections. Mil Med Res 2016;3(1):4.

Return to footnote 6 referrer

Footnote 7

Atashili J, Poole C, Ndumbe PM, Adimora AA, Smith JS. Bacterial vaginosis and HIV acquisition: a meta-analysis of published studies. AIDS 2008 Jul 31;22(12):1493-1501.

Return to footnote 7 referrer

Footnote 8

McClelland RS, Lavreys L, Katingima C, Overbaugh J, Chohan V, Mandaliya K, et al. Contribution of HIV-1 infection to acquisition of sexually transmitted disease: a 10-year prospective study. J Infect Dis 2005;191(3):333-338.

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Footnote 9

Duerr A, Heilig CM, Meikle SF, Cu-Uvin S, Klein RS, Rompalo A, et al. Incident and persistent vulvovaginal candidiasis among human immunodeficiency virus-infected women: Risk factors and severity. Obstet Gynecol 2003;101(3):548-556.

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Footnote 10

Ohmit SE, Sobel JD, Schuman P, Duerr A, Mayer K, Rompalo A, et al. Longitudinal study of mucosal Candida species colonization and candidiasis among human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women. J Infect Dis 2003;188(1):118-127.

Return to footnote 10 referrer

Footnote 11

Schuman P, Sobel JD, Ohmit SE, Mayer KH, Carpenter CC, Rompalo A, et al. Mucosal candidal colonization and candidiasis in women with or at risk for human immunodeficiency virus infection. HIV Epidemiology Research Study (HERS) Group. Clin Infect Dis. 1998;27(5):1161-1167.

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Footnote 12

Sherrard J. How to diagnose and manage Trichomonas vaginalis. The Pharmaceutical Journal, PJ, October 2017, Vol 299, No 7906;299(7906):DOI:10.1211/PJ.2017.20203485.

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Footnote 13

Meites E., Gaydos C.A., Hobbs M.M., Kissinger P., Nyirjesy P., Schwebke J.R., et al. A Review of Evidence-Based Care of Symptomatic Trichomoniasis and Asymptomatic Trichomonas vaginalis Infections. Clin Infect Dis 2015;61(Suppl):S837-S848.

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Footnote 14

Van Der Pol B, Williams J, Taylor S, et al. Detection of Trichomonas vaginalis DNA by use of self-obtained vaginal swabs with the BD ProbeTec Qx assay on the BD Viper system. J Clin Microbiol 2014;52(3):885-889.

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Footnote 15

Schwebke J, Hobbs M, Taylor S, et a. Molecular testing for Trichomonas vaginalis in women: results from a prospective U.S. clinical trial. J Clin Microbiol 2011;49(12):4106-4111.

Return to footnote 15 referrer

Footnote 16

Elias J, Frosch M, Vogel U. Neisseria. In: Jorgensen J, Pfaller M, Carroll K, Funke G, Landry M, Richter S, et al, editors. Manual of clinical microbiology. 11th ed. Washington, DC: ASM Press; 2015. p. 635-651.

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Footnote 17

Forna F, Gülmezoglu AM. Interventions for treating trichomoniasis in women. Cochrane Database of Syst Rev. 2003(2).

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Footnote 18

Schmid G, Narcisi E, Mosure D, Secor WE, Higgins J, Moreno H. Prevalence of metronidazole-resistant Trichomonas vaginalis in a gynecology clinic. J Reprod Med 2001 Jun;46(6):545-549.

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Footnote 19

Klebanoff MA, Carey JC, Hauth JC, Hillier SL, Nugent RP, Thom EA, et al. Failure of metronidazole to prevent preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis infection. N Engl J Med 2001;345(7):487-493.

Return to footnote 19 referrer

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