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Management of Persistent Vaginitis

Nyirjesy, Paul MD

doi: 10.1097/AOG.0000000000000551
Contents: Clinical Expert Series
Expert Discussion
Spanish Translation

With vaginitis remaining a common condition that leads women to seek care, it is not surprising that some women develop chronic vulvovaginal problems that are difficult to diagnose and treat. With a differential diagnosis that encompasses vulvar disorders and infectious and noninfectious causes of vaginitis, accurate diagnosis is the cornerstone of choosing effective therapy. Evaluation should include a symptom-specific history, careful vulvar and vaginal examination, and office-based tests (vaginal pH, amine test, saline and 10% potassium hydroxide microscopy). Ancillary tests, especially yeast culture with speciation, are frequently crucial to obtaining a correct diagnosis. A heavy but normal physiologic discharge can be determined by excluding other causes. With vulvovaginal candidiasis, differentiating between Candida albicans and non-albicans Candida infection has important treatment ramifications. Most patients with C albicans infections can be successfully treated with maintenance antifungal therapy, usually with fluconazole. Although many non-albicans Candida, particularly Candida glabrata, may at times be innocent bystanders, vaginal boric acid therapy is an effective first choice for many true non-albicans Candida infections. Recurrent bacterial vaginosis, a difficult therapeutic challenge, can often be controlled with maintenance therapy. Multiple options, especially high-dose tinidazole, have been used for metronidazole-resistant trichomoniasis. With the aging of the U.S. population, atrophic vaginitis and desquamative inflammatory vaginitis, both associated with hypoestrogenism, are encountered frequently in women with persistent vaginitis.

Persistent vaginitis encompasses a broad range of conditions, most of which can be controlled with readily available therapies.Supplemental Digital Content is Available in the Text.

Department of Obstetrics and Gynecology, Drexel University School of Medicine, Philadelphia, Pennsylvania.

Corresponding author: Paul Nyirjesy, MD, 245 North 15th Street, New College Building, 16th Floor, Philadelphia, PA 19102; e-mail:

Continuing medical education for this article is available at

Financial Disclosure Dr. Nyirjesy has been a consultant for Novadigm, Viamet Pharmaceuticals, Symbiomix, Cepheid, and Hologics. He has received research grants from Novadigm, Viamet Pharmaceuticals, Symbiomix, and Becton–Dickinson.

© 2014 by The American College of Obstetricians and Gynecologists.