Vaginitis: Colpitis, Causes and Treatment

Vaginitis, also known as colpitis, is an inflammation of the vagina characterized by changes in discharge, itching, burning, discomfort, and sometimes pain during intercourse or urination. The most common infectious causes are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis; non-infectious causes include peri- and postmenopausal atrophic vaginitis and desquamative inflammatory vaginitis. Because the symptoms of the different forms overlap, accurate diagnosis requires laboratory confirmation, and treatment should be etiotropic and take into account risk factors for recurrence. [1]

A modern approach combines clinical assessment with nucleic acid amplification tests for trichomonas infection, molecular panels for bacterial vaginosis and candidiasis, as well as pH assessment and microscopy when indicated. New point-of-care rapid tests provide results within an hour and initiate treatment at the first visit, reducing loss to follow-up and lowering the risk of complications. If untreated, inflammation can spread to the cervix and upper uterine tract, increasing the risk of pelvic inflammatory disease. [2]

Code according to ICD-10 and ICD-11

In the International Classification of Diseases, Tenth Revision, the basic category for vaginitis is N76, "Other inflammatory diseases of the vagina and vulva." Specifically, it includes N76.0, "Acute vaginitis," as well as related entries for chronic and complicated forms; if the infectious nature is established, an additional pathogen code from the range B95-B97 is added. In certain clinical situations, code N77.1 is used for vaginitis associated with other diseases, such as systemic dermatoses. Correct coding is important for statistics and routing. [3]

In the eleventh version of the ICD-11 classification of diseases, vaginitis is classified under section GA02 with the subcategories of acute, inflammatory, subacute, or chronic vaginitis, as well as unspecified vaginitis. When referring to a patient with the complaint "vaginal discharge," the symptom category MF3A "Vaginal discharge" may be additionally used when the etiology has not yet been established. This classification allows for a more accurate reflection of the clinical situation and the stage of diagnosis. [4]

Table 1. Examples of codes for vaginitis according to ICD

System	Code	Name	When to use
ICD-10	N76.0	Acute vaginitis	Acute inflammatory manifestations without specifying the pathogen
ICD-10	N76	Other inflammatory diseases of the vagina and vulva	General category, requires clarification of subtype for payment
ICD-10	N77.1	Vaginitis associated with other diseases	In case of secondary inflammation
ICD-11	GA02.0-GA02.2	Acute, inflammatory, subacute or chronic vaginitis	For a more precise clinical form
ICD-11	MF3A	Vaginal discharge	At the stage of the primary complaint before the cause is established

Epidemiology

Vaginitis is one of the most common reasons for visits by women of reproductive age. Globally, hundreds of millions of new curable sexually transmitted infections are reported annually, often presenting with complaints of discharge and discomfort. In 2020, the World Health Organization estimated 374 million new cases of four curable infections in adults aged 15-49, of which 156 million were due to trichomoniasis, which can cause vaginitis. These estimates highlight the scale of the problem for primary care. [5]

Registries in countries with high testing coverage show consistently high rates of chlamydia and gonorrhea infections, often associated with vaginal symptoms. According to the Centers for Disease Control and Prevention in the United States, over 2.2 million cases of chlamydia, gonorrhea, and syphilis will be reported in 2024, with a significant proportion of young women affected. These statistics help inform screening and prevention planning. [6]

The incidence of bacterial vaginosis and vulvovaginal candidiasis varies across populations, reaching tens of percent among women of reproductive age in some studies. Recurrent forms of candidiasis constitute an important clinical subgroup and require long-term maintenance therapy, as reflected in European guidelines. [7]

In postmenopause, the incidence of atrophic vaginitis increases due to estrogen deficiency, as well as the desquamative inflammatory variant. These forms are often underestimated, as symptoms can be mild, but they impact quality of life and sexual health and require targeted treatment. [8]

Reasons

Infectious causes include bacterial vaginosis with a predominance of anaerobic flora and a decrease in lactobacilli, vulvovaginal candidiasis involving Candida albicans and non-albicans species, and trichomoniasis caused by the protozoan Trichomonas vaginalis. These conditions can coexist, and the clinical presentation often does not allow reliable differentiation without laboratory testing.[9]

Non-infectious causes include atrophic vaginitis due to estrogen deficiency and desquamative inflammatory vaginitis, a presumed immune-inflammatory variant with severe mucosal inflammation. Chemical irritants, allergic reactions, vulvar dermatoses, and microbiota imbalances following antibacterial therapy also contribute. A comprehensive assessment of these factors helps avoid excessive antibiotic therapy. [10]

Trichomoniasis often goes undiagnosed using microscopy alone, as sensitivity is low when parasite counts are low. In such cases, nucleic acid amplification tests significantly increase detection rates, changing treatment strategies and preventing transmission to partners. [11]

Concomitant cervical and urethral infections, as well as behavioral and social factors that influence the risk of infection and access to medical care, play an additional role. Therefore, management strategies include not only treatment but also safe sex counseling and partner testing for confirmed infections. [12]

Risk factors

Risk factors for infectious forms include unprotected sexual intercourse, multiple partners, a history of sexually transmitted infections, and youth, which is characterized by behavioral characteristics and a higher risk of exposure. Disturbances in the vaginal microbiota after antibacterial courses are also important. These factors must be considered when planning diagnostics and prevention. [13]

Microbiota changes, hormonal shifts, and the use of irritating intimate hygiene products are significant factors for bacterial vaginosis and candidiasis. Smoking and some contraceptive methods can affect the vaginal environment, which are discussed in guidelines as potential modifiable factors. Lifestyle considerations are part of a relapse prevention strategy. [14]

Atrophic vaginitis is associated with estrogen deficiency in peri- and postmenopause, and the risk is higher in those with contraindications to systemic hormone therapy or its absence. The desquamative inflammatory variant is more common in middle-aged and older women, may be associated with autoimmune conditions, and requires a personalized approach. [15]

Immunodeficiency states, including human immunodeficiency virus infection, increase the likelihood of symptomatic and recurrent forms and require more active diagnosis and monitoring of cure, particularly for trichomoniasis. This is taken into account in national and international guidelines. [16]

Pathogenesis

Bacterial vaginosis is characterized by a shift in the microbial community toward anaerobes and a decrease in the proportion of lactobacilli, which increases pH and disrupts the mucosal defense mechanisms. Biofilm formation promotes persistence and recurrence, which explains the limited effectiveness of short courses in some patients. Restoring the microbiota is becoming an important management goal. [17]

Vulvovaginal candidiasis is associated with yeast overgrowth due to local or systemic imbalances in the immune response and microbiota. Non-albicans species have different sensitivities to azoles, requiring adjustments to treatment regimens in the event of relapses or ineffective standard therapy. Maintenance regimens reduce the frequency of exacerbations. [18]

Trichomonas adhere to the epithelium, causing local inflammation and cell destruction, increasing neutrophil influx, and increasing the risk of coinfection. The infection is often asymptomatic but can exacerbate cervical inflammation and increase susceptibility to other pathogens, warranting active testing. [19]

In atrophic vaginitis, decreased estrogen levels thin the epithelium and reduce glycogen levels, depriving lactobacilli of a nutrient medium and raising the pH. This leads to dryness, microcracks, and inflammation even without an infectious agent. Correcting the hormonal deficiency restores protective mechanisms and reduces symptoms. [20]

Symptoms

Typical symptoms include changes in the amount and nature of vaginal discharge, itching, burning, vaginal discomfort, an unpleasant odor, and pain during intercourse or urination. With bacterial vaginosis, the discharge is often uniform, with a "fishy" odor; with candidiasis, it is thick and cheesy; with trichomoniasis, it is foamy and yellowish-greenish. However, clinical examination alone cannot be relied upon. [21]

Vulvar pain, irritation, and swelling are often associated with candidiasis and other dermatological conditions. The unpleasant odor associated with bacterial vaginosis often worsens after sexual intercourse. Overlapping symptoms require laboratory verification, especially in cases of recurrence or failure of empirical treatment. [22]

Atrophic vaginitis presents with dryness, burning, and microbleeding, often aggravated by sexual intercourse. The desquamative inflammatory variant produces severe inflammation, yellowish-bloody discharge, and sometimes erosions, which can mimic infection and require the exclusion of neoplasia and dermatoses. [23]

Systemic symptoms such as fever and severe pelvic pain are uncommon in uncomplicated vaginitis and suggest pelvic inflammatory disease or concomitant cervicitis. In such cases, the diagnostic workup is expanded. [24]

Forms and stages

Clinically, infectious forms are distinguished: bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis, as well as non-infectious forms – atrophic and desquamative inflammatory vaginitis. Mixed forms are possible, for example, a combination of bacterial vaginosis and candidiasis, which explains the unusual symptoms and variable response to therapy. [25]

Depending on the course of the disease, a distinction is made between acute episodes with severe symptoms and recurrent forms, particularly characteristic of candidiasis and bacterial vaginosis. Recurrent episodes of candidiasis are considered to be four or more episodes per year, requiring an induction course followed by maintenance treatment for several months. [26]

Severity is determined by the severity of symptoms, the presence of complications, pregnancy-associated risks, and comorbidities. This stratification influences the choice of medications, the duration of treatment, and the need for follow-up monitoring. [27]

For atrophic vaginitis, the stage reflects the degree of estrogen deficiency and the severity of mucosal atrophy. Treatment is aimed at restoring nutrition and reducing symptoms, rather than eradicating the pathogen. [28]

Complications and consequences

Untreated trichomoniasis is associated with an increased risk of sexually transmitted infections, cervical inflammation, and adverse pregnancy outcomes. Bacterial vaginosis is associated with an increased risk of pelvic inflammatory disease and postoperative infectious complications. These risks are reduced with prompt diagnosis and treatment. [29]

Repeated relapses of candidiasis impair quality of life, disrupt sleep and sexual function, and require long-term maintenance regimens and evaluation for non-albicans species. Incorrectly chosen regimens increase the risk of resistance and prolong the course of the disease. [30]

In pregnant women, bacterial vaginosis and trichomoniasis are associated with preterm birth and low birth weight, although the strength of the association and treatment response depend on timing and context. Treatment choices should consider fetal safety. [31]

Untreated atrophic and desquamative inflammatory vaginitis contribute to chronic pain, dyspareunia, and an increased risk of microtrauma and secondary infection. This justifies the active identification and correction of hormonal and immunoinflammatory factors. [32]

When to see a doctor

You should consult a doctor if you experience new or unusual discharge, an unpleasant odor, itching, burning, or pain during intercourse or urination. Other common causes include intermenstrual bleeding, especially postmenopausal, and lower abdominal pain. Early diagnosis speeds diagnosis and reduces the risk of complications. [33]

Immediate consultation is necessary in cases of severe pelvic pain, fever, vomiting, or severe weakness, as these symptoms are not typical of uncomplicated vaginitis and may indicate pelvic inflammatory disease or other acute conditions. An in-person examination is preferred. [34]

If symptoms persist after self-treatment or recur, laboratory verification is required, including nucleic acid amplification tests for trichomonas infection and molecular panels for bacterial vaginosis and candidiasis. This will allow for the selection of an etiotropic regimen and prevent chronicity. [35]

In cases of known exposure to a partner diagnosed with a sexually transmitted infection, testing and treatment are indicated, regardless of the presence of symptoms. Certain groups, including pregnant women and women with immunodeficiency, require priority routing. [36]

Diagnostics

The algorithm begins with a clinical assessment and basic point-of-care testing: vaginal pH measurement, an amine test, and microscopy of a native specimen, as indicated. However, clinical and microscopic methods have limited ability to differentiate mixed forms and have variable sensitivity, so they are supplemented by molecular panels. This approach improves accuracy and accelerates the initiation of therapy. [37]

Nucleic acid amplification tests for Trichomonas vaginalis are recommended due to their high sensitivity compared to microscopy. Post-treatment retesting in women with human immunodeficiency virus infection is recommended after 3 months, as the risk of reinfection is higher. These recommendations are reflected in national guidelines. [38]

Modern molecular panels for vaginitis include markers for bacterial vaginosis, yeast, and trichomonas. Rapid tests with results in less than an hour have become available, making them particularly useful in primary care and emergency departments. Panel selection depends on availability and the clinical need. [39]

In cases of atypical progression and exclusion of common causes, atrophic and desquamative inflammatory vaginitis are considered, for which colposcopy and targeted sampling, cytological and histological evaluation, as indicated, are indicated. In complex cases, interdisciplinary discussion is helpful. [40]

Table 2. Diagnostic tests for vaginitis

Method	Target	Advantages	Restrictions
pH measurement and the amine test	Screening for bacterial vaginosis	Fast and cheap	Low specificity in mixed forms
Microscopy of a native drug	Detection of "key" cells, pseudomycelium, trichomonas	Available at the aid station	Depends on experience, low sensitivity with a small number of pathogens
Nucleic acid amplification tests for Trichomonas vaginalis	Confirmation of trichomoniasis	High sensitivity and specificity	Cost, availability
Molecular panels for vaginitis	Simultaneous assessment of bacterial vaginosis, candidiasis and trichomoniasis	Fast results, convenience	Different analytical validity among different systems
Express panels at the aid station	Reducing time to treatment	Results in less than an hour	Requires implementation and quality control

Differential diagnosis

Vaginitis must be distinguished from cervicitis and urethritis. Cervicitis is more often characterized by mucopurulent endocervical discharge and contact bleeding, while vaginitis is characterized by localized vaginal symptoms, itching, and changes in pH. However, these conditions often coexist, so if sexually transmitted infections are suspected, extensive testing is indicated. [41]

Dermatological diseases of the vulva, such as lichen sclerosus, contact dermatitis, and psoriasis, as well as traumatic and chemical injuries, should be excluded. In cases of bloody discharge, especially postmenopausal, atrophic processes and neoplastic changes are considered, requiring colposcopy and targeted biopsies. This approach prevents delayed diagnosis of serious conditions. [42]

The list of differential diagnoses also includes foreign bodies, drug side effects, adverse reactions to intimate hygiene products, and, in the case of severe pain and fever, pelvic inflammatory disease. During pregnancy, the scope of diagnosis and treatment is discussed with an obstetrician-gynecologist. [43]

Table 3. Distinguishing features of the three main infectious causes

Sign	Bacterial vaginosis	Candidiasis	Trichomoniasis
Discharge	Homogeneous, grey-white, odor	Thick, curdy	Foamy, yellowish-greenish
pH	Increased	Usually normal	Increased
Microscopy	Key cells	Pseudomycelium or spores	Motile trichomonads
Recommended test	Molecular panel or criteria A msel	Sowing in case of relapse, panel	Nucleic acid amplification test

Treatment

Treatment is based on the etiology, severity, pregnancy, and risk of recurrence. For bacterial vaginosis, metronidazole or clindamycin are used in various forms, according to current recommendations, taking into account local availability and patient preference. For some women with recurrences, extended courses and strategies to prevent recurrence are considered. Sexual behavior counseling reduces the risk of recurrent dysbiosis in the microbiota. [44]

For mild to moderate vulvovaginal candidiasis, topical treatment with azoles is effective; in recurrent cases, an induction course followed by a maintenance regimen of at least 6 months is recommended. For non-albicans species, alternative medications and regimens are used. This approach improves symptom control and reduces the frequency of exacerbations. [45]

Trichomoniasis is treated with nitroimidazole medications. For women with human immunodeficiency virus infection, follow-up testing is recommended after 3 months to rule out reinfection. Nucleic acid amplification tests can confirm cure and detect persistence, allowing for adjustment of therapy. Partners should be examined and treated. [46]

Atrophic vaginitis is treated with topical estrogens or other agents aimed at restoring mucosal trophism after assessing contraindications. Desquamative inflammatory vaginitis may require anti-inflammatory and antibacterial regimens based on the clinical presentation. For mixed forms, stepwise therapy with symptom monitoring and laboratory verification of the effect is advisable. [47]

Table 4. Examples of etiotropic therapy

State	First line	Alternatives and notes
Bacterial vaginosis	Metronidazole or clindamycin preparations as recommended	Extended or repeated courses in case of relapses
Episodic candidiasis	Local azoles for a short course	In severe cases, systemic azoles are used as indicated.
Recurrent candidiasis	Induction for 3 days with azole, then maintenance for 6 months	Correction for non-albicans species
Trichomoniasis	Nitroimidazoles according to guidelines	Monitoring of cure according to indications, treatment of partners
Atrophic vaginitis	Local estrogens	Non-hormonal moisturizers for contraindications

Table 5. Support and organizational measures

Measure	Target	Comments
Abstinence until completion of the course	Reducing the risk of reinfection and failure	Especially important for trichomoniasis
Testing and treatment of partners	Breaking the chain of transmission	Recommended for confirmed infections
Behavioral counseling	Reducing the risk of new episodes	Discussion of barrier protection and hygiene
Using express panels at the point of assistance	Accelerating the onset of treatment	The result in less than an hour makes it easier to manage
Observation plan	Reducing relapses	Retesting as indicated, especially in high-risk groups

Prevention

Primary prevention includes barrier methods of protection, limiting the number of partners, regular screening in at-risk groups, and avoiding irritating intimate hygiene products. Education and access to timely diagnosis are key components in reducing the burden of disease in the population. [48]

Secondary prevention is aimed at early detection and treatment, as well as preventing relapses. For recurrent candidiasis, maintenance regimens are effective, while for bacterial vaginosis, extended courses and microbiota correction strategies are considered. Individualizing prevention increases its effectiveness. [49]

Tertiary prevention focuses on preventing complications, including pelvic inflammatory disease and adverse pregnancy outcomes. This includes timely referral to specialists, monitoring of recovery, and interdisciplinary management of complex cases. [50]

Forecast

With timely etiotropic therapy, the prognosis is favorable: most patients achieve clinical improvement within a few days or weeks. The prognosis worsens with recurrent candidiasis and bacterial vaginosis, as well as with untreated trichomoniasis, which emphasizes the importance of maintenance regimens and monitoring. [51]

The presence of concomitant risk factors, immunodeficiency conditions, and pregnancy require more careful monitoring and selection of safe regimens. The use of molecular panels and rapid assays increases accuracy and accelerates treatment, improving long-term outcomes. [52]

FAQ

Is it possible to differentiate the type of vaginitis based only on symptoms and type of discharge?

Not always. Clinical features overlap, so laboratory tests, including molecular panels and nucleic acid amplification tests for trichomonas infection, are needed for an accurate diagnosis. [53]

Should sexual partners be treated?

Yes, for confirmed sexually transmitted infections, especially trichomoniasis. Treatment of partners reduces the risk of reinfection and transmission of infection and improves treatment outcomes. [54]

What to do if candidiasis recurrences frequently?

An induction course of azole followed by maintenance for at least six months and a review of the etiology, including exclusion of non-albicans species, is recommended. This regimen reduces the frequency of exacerbations and improves symptom control. [55]

Is there any point in point-of-care rapid testing?

Yes. New point-of-care panels allow results to be obtained in less than an hour and treatment to be started on the first visit, which is particularly useful in primary care and emergency care. [56]

Is vaginitis dangerous during pregnancy?

Some forms, such as bacterial vaginosis and trichomoniasis, are associated with adverse obstetric outcomes. Treatment is selected based on gestational age and fetal safety, and monitoring is more thorough. [57]