Vaginal Infections
In the United States, vaginal infections are one of the most common reasons women see their doctor, accounting for more than 10 million visits each year. Usually, vaginal infections cause only discomfort, although the discomfort may be substantial. However, these infections occasionally are or become serious.
Vaginal infections are a type of vaginitis, or inflammation of the lining (mucosa) of the vagina. Inflammation may result from chemical or mechanical irritants, such as hygiene products, bubble bath, laundry detergents, contraceptive foams and jellies, and synthetic underwear, as well as from bacterial, yeast, and viral infections.
In women, anything that reduces the acidity (increases the pH) of the vagina increases the likelihood of infection. Acidity may be reduced by hormonal changes shortly before and during menstrual periods or during pregnancy. Frequent douching, use of spermicides, and semen can also reduce acidity.
Many bacteria normally reside in the vagina. One type, called lactobacilli, normally maintains the acidity of the vagina. By doing so, lactobacilli help keep the lining of the vagina healthy and prevent the growth of bacteria or yeasts that cause infections. Bacterial vaginosis, the most common vaginal infection, results when the number of protective lactobacilli decreases and the number of other normally occurring bacteria (such as Gardnerella and Peptostreptococcus) increases. The reason for these changes is unknown. Bacterial vaginosis is more common among women who have a sexually transmitted disease, who have several sex partners, or who use an intrauterine device (IUD). But it is not a sexually transmitted disease. It can also occur in sexually inexperienced, lesbian, or monogamous women.
In women, yeast infections due to the fungus Candida albicans (candidiasis) are particularly common. Candida albicans normally resides on the skin or in the intestines. From these areas, the organism can spread to the vagina. Yeast infections are not transmitted sexually. They are common among pregnant women, obese women, and women who have diabetes. Yeast infections are more likely to occur during menstrual periods. Yeast infections are also more likely to develop if the immune system is suppressed by drugs (such as corticosteroids or chemotherapy drugs) or impaired by a disorder (such as AIDS). Antibiotics taken by mouth tend to kill the bacteria in the vagina that normally suppress the growth of yeast. Thus, the use of antibiotics increases the risk of developing vaginal infections. After menopause, women who take hormone replacement therapy are more likely to develop yeast infections.
Some vaginal infections are sexually transmitted (see Section 17, Chapter 200). Sexually transmitted diseases that can affect the vagina include chlamydial infections, genital herpes (see Section 17, Chapter 198), gonorrhea, syphilis, and trichomoniasis (a protozoan infection). Genital warts usually develop on the vulva but can develop in the vagina or on the cervix.
In children, vaginal infections are most commonly due to an object (such as a toy) inserted in the vagina and to bacteria. Yeast infections are less common. Children may develop a sexually transmitted vaginal infection as a result of sexual abuse.
Tight, nonabsorbent underclothing may irritate the genital area and trap moisture, making infection by bacteria or yeast more likely. Not keeping the genital area clean (for example, inadequately or improperly cleaning it after urinating or defecating) and fingering the genital area (which young girls may do) may make infection more likely.
 See the table Some Vaginal Infections.
 See the sidebar Nearby Infections: Vulvitis and Bartholinitis.
Symptoms and Diagnosis
Typically, vaginal infections produce a vaginal discharge and irritation in the genital area. The appearance and amount of the discharge vary depending on the cause. Soreness and swelling are less common. Some infections can make sexual intercourse painful and make urination painful and more frequent. Rarely, the folds of skin around the vaginal and urethral openings become stuck together. However, vaginal infections sometimes produce minimal or no symptoms. Some vaginal infections, if untreated, may lead to complications that are sometimes serious.
Because a vaginal discharge, itching, and odor may have different causes, children or women who have such symptoms should see a doctor. Information about a vaginal discharge, if present, can help the doctor determine the cause. The doctor may ask about possible causes of the discharge, such as lotions or creams used to try to relieve the symptoms (including home remedies), as well as hygiene. Other questions include when the discharge began, whether it is accompanied by itching, burning, pain, or a sore in the genital area, when it occurs in relation to the menstrual period, whether the discharge comes and goes or is always present, and, if the woman has had an abnormal discharge before, how it responded to treatment. The woman may be asked about her past and current use of birth control, pain after sexual intercourse, previous vaginal infections, and the possibility of sexually transmitted diseases. The doctor also asks whether the sex partner has symptoms and whether anyone else in the household has itching in the genital area. This information helps the doctor identify the cause of the woman's symptoms and determine whether other people require treatment.
A pelvic examination is performed. While examining the vagina, the doctor takes a sample of the discharge, if present, with a cotton-tipped swab. The sample is examined under a microscope or cultured to identify bacteria or other organisms. To determine whether the infection has spread outside the vagina, the doctor checks the uterus and ovaries by inserting the index and middle fingers of one gloved hand into the vagina and pressing on the outside of the lower abdomen with the other hand. If this maneuver causes substantial pain or if a fever is present, the infection may have spread.
Prevention
Keeping the genital area clean and dry can help prevent infections. Washing every day with a mild soap (such as glycerin soap) and rinsing and drying thoroughly are recommended. Wiping front to back after urinating or defecating prevents bacteria from the anus from being moved to the vagina. Children should be taught proper hygiene.
Wearing loose, absorbent clothing, such as cotton or cotton-lined underpants, allows air to circulate and helps keep the genital area dry. Douching frequently and using medicated douches are discouraged. These measures can reduce the acidity of the vagina, making infections, including pelvic inflammatory disease, more likely. Practicing sex safe and limiting the number of sex partners are important preventive measures.
Treatment
Treatment varies according to the cause.
Bacterial vaginosis is treated with an antibiotic taken by mouth or applied as a vaginal gel or cream. Bacterial vaginosis usually resolves in a few days but commonly recurs. If it recurs often, antibiotics may have to be taken for a long time. Propionic acid jelly may be used to make the vaginal secretions more acidic and thus discourage the growth of bacteria. For sexually transmitted diseases, both sex partners are treated at the same time to prevent reinfection.
Yeast infections are treated with antifungal drugs applied as a cream to the affected area, inserted into the vagina as a suppository, or taken by mouth. Several antifungal creams and suppositories are available without a prescription. A single dose of an antifungal drug taken by mouth is usually as effective as vaginal creams and suppositories. However, if infections recur often, several doses may be needed.
For trichomoniasis, a single dose of metronidazole cures up to 95% of women. However, a single dose is more likely to cause nausea and vomiting than treatment with several smaller doses. During sexual intercourse, condoms should be used until the infection resolves.
To relieve symptoms, a woman can use a premeasured vinegar-and-water douche, but only for a brief time. Occasionally, placing ice packs against the genital area, applying cool compresses, or sitting in a cool sitz bath may reduce soreness and itching. A sitz bath is taken in the sitting position with the water covering only the genital and rectal area. Flushing the genital area with lukewarm water squeezed from a water bottle may also provide relief.
Women who are at high risk of a yeast infection, such as those who have an impaired immune system, who have diabetes, or who are taking antibiotics for a long time (as for a urinary tract infection), may need to take an antifungal drug to prevent other infections from developing.
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