The healthy vagina is protected by lactobacilli, which produce lactic acid and keep the pH at about 3.8–4.5. Anything that disturbs this flora or raises pH — antibiotics, douching, semen, menstrual blood, low estrogen, high glucose — allows overgrowth of other organisms. Vaginitis causes discharge, odor, itching, or irritation; the three most common causes are bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis.

Risk factors

• BV: new or multiple sex partners, douching, lack of lactobacilli, smoking
• VVC: antibiotic use, diabetes (poor control), pregnancy, high-estrogen states, corticosteroids, immunosuppression, tight nonbreathable clothing. Condoms are not a risk factor
• Trichomoniasis: unprotected sex, multiple partners, other STIs; often asymptomatic, especially in men

Vulvar conditions (covered briefly)

• Bartholin cyst/abscess — see benign gynecologic tumors
• Genital herpes (painful vesicles and ulcers) and genital warts (condylomata acuminata from HPV types 6 and 11) — see sexually transmitted infections
• Contact or irritant dermatitis from soaps, pads, sprays; lichen sclerosus (white, thin, itchy skin; small increased risk of vulvar cancer — treated with potent topical corticosteroid and long-term follow-up)

Subjective

• Discharge — color, consistency, odor, timing (after intercourse, menses)
• Itching, burning, external dysuria, dyspareunia
• Recent antibiotics, diabetes, pregnancy, corticosteroids, contraceptive method, douching and hygiene products
• Sexual history: new or multiple partners, partner symptoms, condom use — risk for STIs
• Last menstrual period and possibility of pregnancy

Objective

• Vulvar redness, swelling, excoriations, fissures (VVC)
• Discharge characteristics on speculum exam; cervical appearance (strawberry cervix, mucopurulent discharge suggesting cervicitis)
• Lesions: vesicles, ulcers, warty growths, white plaques
• Pelvic or abdominal pain, cervical motion tenderness, or fever suggest PID rather than simple vaginitis — a higher-priority problem

• Vaginal pH (pH paper) — > 4.5 suggests BV or trichomoniasis; normal pH with symptoms suggests candidiasis
• Saline wet mount — clue cells (BV), motile trichomonads
• 10% KOH prep — pseudohyphae/budding yeast (VVC); whiff test (amine odor = BV)
• BV diagnosis — Amsel criteria (3 of 4): thin homogeneous discharge, pH > 4.5, clue cells > 20% of epithelial cells, positive whiff test; Gram stain (Nugent score) is the laboratory reference; molecular tests are available
• Trichomonas: nucleic acid amplification test (NAAT) is the most sensitive — wet mount misses many cases
• Yeast culture for recurrent or complicated VVC (non-albicans species resist azoles)
• Test for other STIs with trichomoniasis — chlamydia, gonorrhea, syphilis, HIV
• Blood glucose/A1C with recurrent candidiasis

Bacterial vaginosis (CDC 2021) — treat symptomatic women (including pregnant women)

• Metronidazole 500 mg orally twice daily for 7 days, or metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days
• Alternatives: oral clindamycin, clindamycin ovules, secnidazole, tinidazole
• Pregnancy: metronidazole and clindamycin are both acceptable. Symptomatic BV in pregnancy is linked to preterm labor, premature rupture of membranes, chorioamnionitis, and postpartum endometritis
• Partners: CDC does not recommend routine treatment of partners; a 2025 trial found that treating male partners with oral and topical antibiotics reduced recurrence, so guidance may change — follow current protocol
• Recurrence is common (about half within a year); suppressive metronidazole gel may be used

Vulvovaginal candidiasis

• Uncomplicated: topical azole (clotrimazole, miconazole — many over the counter) for 1–7 days, or fluconazole 150 mg orally once
• Severe or immunocompromised: longer courses (e.g., fluconazole every 72 hours for 2–3 doses)
• Recurrent VVC (3 or more episodes in 12 months): induction therapy then weekly fluconazole for 6 months; oteseconazole is an option for people not of reproductive potential
• Pregnancy: topical azole for 7 days — avoid oral fluconazole
• Sex partners do not need treatment

Trichomoniasis

• Women: metronidazole 500 mg orally twice daily for 7 days; men: metronidazole 2 g orally once; tinidazole is an alternative
• All sex partners are treated at the same time (expedited partner therapy where legal); abstain until both are treated and symptoms resolve
• Retest women within 3 months (high reinfection rates)
• Pregnancy: metronidazole is used; infection is linked to preterm birth and low birth weight

Atrophic vaginitis — vaginal moisturizers and lubricants; low-dose vaginal estrogen (see menopause).

Drug safety

Listed in priority order.

1. Rule out higher-priority problems — pregnancy (LMP, hCG), PID (pelvic pain, fever, cervical motion tenderness), and other STIs; refer promptly
2. Collect specimens correctly — before starting treatment; avoid lubricant on the speculum except water; label and transport promptly
3. Administer treatment and check interactions and contraindications — warfarin, QT-prolonging drugs, pregnancy, allergies
4. Symptom relief — cool compresses or cool/lukewarm sitz baths (plain water or baking soda soaks) for itching and burning; loose cotton clothing; avoid scratching. These comfort measures are independent nursing actions; medications need a prescription
5. Partner management and STI counseling for trichomoniasis — confidential, nonjudgmental communication
6. Glucose control and review of antibiotic or steroid use in recurrent candidiasis
7. Follow-up — retesting for trichomoniasis within 3 months; return if symptoms persist

• Do not douche — it removes protective lactobacilli and increases BV, PID, and other infections
• Avoid scented soaps, bubble baths, feminine sprays, and scented pads; wash the vulva with water or mild unscented soap; wipe front to back
• Breathable cotton underwear, avoid tight synthetic clothing; change out of wet swimsuits or exercise clothes promptly
• Complete the full course of medication even if symptoms improve
• Vaginal medications: insert at bedtime lying down; wear a pad; continue through menses if instructed (avoid tampons during vaginal therapy)
• Condoms: use consistently; oil-based vaginal creams can weaken latex condoms — use another method or abstain during treatment and for several days after
• Trichomoniasis: partners must be treated; no intercourse until both are treated and symptom-free; get retested within 3 months
• Candidiasis: unnecessary antibiotics increase risk; people with diabetes should keep glucose controlled; seek care rather than repeated self-treatment if symptoms recur (to confirm the diagnosis)
• Pregnancy: report abnormal discharge — some infections increase the risk of preterm birth; do not use oral fluconazole unless prescribed
• Return promptly for fever, pelvic pain, sores, or symptoms that persist after treatment

• Normal vaginal pH 3.8–4.5, maintained by lactobacilli
• BV: thin gray discharge, fishy odor, pH > 4.5, clue cells, positive whiff test → metronidazole; routine partner treatment not recommended
• VVC: thick white curd-like discharge, intense itching, normal pH, pseudohyphae → azole; risk after antibiotics, diabetes, pregnancy
• Trichomoniasis: frothy yellow-green discharge, strawberry cervix, motile protozoa → metronidazole and treat all partners; retest within 3 months
• Atrophic vaginitis: estrogen loss → dryness, dyspareunia → vaginal estrogen, moisturizers
• Amsel criteria: 3 of 4
• Pregnancy VVC: topical azole 7 days, not oral fluconazole
• No douching; cotton underwear; avoid scented products
• Clindamycin cream weakens latex condoms
• Metronidazole: metallic taste; no alcohol during therapy and for 72 hours after; raises INR with warfarin
• Cool compresses and sitz baths are independent nursing comfort measures