Welcome back to the Doctor Rich channel! Have you ever had a vaginal infection? Well, 90% of women have — and it’s the most common reason (other than an annual exam) that women will go to see their OB/GYN. Stick around to the end to find out about the rare but treatable causes of recurrent vaginitis.
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Hi, I’m Doctor Rich — board-certified urogynecologist. Today, we’re gonna talk about vaginal infections, what causes them, how to diagnose them, and what you can do if it keeps coming back.
So vaginal infections are most commonly caused by bacterial vaginosis, yeast, and trichomonas. In fact, these three causes make up 90% of all vaginal infections. It’s important to keep in mind though — there is a normal vaginal discharge that can happen. It’s characterized by a thick or thin, white or clear discharge — approximately one to four milliliters per day.
This is a process where the vagina, the bacteria (the lactobacillus, which are the normal bacteria in the vagina), and the skin cells shed. The cervical mucus comes down, and all this comes out of the body as a vaginal discharge. This is part of a normal process.
So how do we distinguish this normal discharge from a vaginal infection? Why do vaginal infections happen in the first place?
The vaginal flora is made up of a bacteria called lactobacillus. Lactobacillus converts glucose into lactic acid, and this creates a very acidic environment in the vagina. This actually creates a protective pH range of about 3.8 to 4.2 — where only this lactobacillus can grow. Other bad bacteria and infections can’t survive in that environment. So when this balance is offset — and the vaginal pH actually starts to rise and become more acidic — these other opportunistic organisms like bacterial vaginosis and yeast can grow.
So what about BV (or bacterial vaginosis)?
This is typically a white or gray, odorous discharge. It can be thicker or thin and is diagnosed in the office with a swab and can be treated with a simple antibiotic. It’s important to remember this is not a sexual infection. It just represents the growth of abnormal bacteria in the vagina. Yeast — most commonly candida — can also grow in the vagina when the pH balance is off. This is also tested for in the office and treated with a simple antifungal medicine (either a cream or a pill). Typically the symptoms here are white, curd-like discharge that typically does not have an odor and causes itching.
Now neither of the first two are sexually transmitted infections, but triconomas vaginalis, on the other hand, IS a sexually transmitted infection. It can cause an odorous discharge, sexual pain, and urinary frequency or burning — and is typically included in the same swab that we use to detect the other two organisms. It is also treated quite easily with an antibiotic. Keep in mind though — your partner would also have to get treated (as it is a sexual infection), and then you would have to abstain from sex for two weeks after both partners have been treated.
And that’s it! That takes care of 90% of vaginal discharges.
What do you do though if the diagnosis of these organisms isn’t made or if you continue to have infections? It’s important to see your physician when the symptoms are occurring. You have to collect points of data every time that the infection is there to determine a pattern and to see if it’s the same infection or a different type of infection.
Gonorrhea and chlamydia can also cause a discharge. Typically, it has a color (either a yellow or greenish discharge) and can also result in bleeding after sex. So if any of these abnormal findings happen, make sure you go to see your doctor. And if the gonorrhea and chlamydia are not treated immediately, it can result in severe infections sometimes requiring surgery — so the diagnosis should not be delayed, and treatment should be done immediately.
Other less common sexually transmitted infections — mycoplasma and ureaplasma — are going to be tested (not as the initial visit but for recurrent infections or refractory infections) as either uncommon causes of recurrent discharge and vaginitis. When recurrent infections occur, oftentimes prolonged treatment courses are needed, and a workup for other systemic conditions can be required. So anything that affects the immune system — like diabetes and lupus and conditions like rheumatoid arthritis and HIV — can all make infections more likely or cause a primary discharge.
There are often overlooked causes of vaginal discharge, such as retained items — like retained tampons and retained condoms. We’ve seen that in the office, where vaginal discharge persists for months — and on exam, we find there’s a foreign body.
Often simple hygiene issues can come up. There are allergic reactions to soaps, lotions, scented sanitary napkins. In general, you want to avoid any of these things if you’re having a recurrent discharge. You’ll only want to use a hypoallergenic soap — we’ll put that down below.
And then there are several other possible causes including a fistula — which is actually a defect (or a hole) that forms between the vagina and an adjacent organ like the bladder or the bowel. If there’s a persistent fluid leak (particularly in the context of a recent prior pelvic surgery like a hysterectomy), this is one of the causes that has to be considered. Another cause to be considered is a rectovaginal fistula, where there can be gas or a brown discharge coming vaginally.
But another alarming cause of vaginal discharge is pelvic cancer, such as cervical cancer. So if you’re not up to date on your pap testing, this is one of the possibilities — and can be found on a simple Pap test in pelvic exam.
Talking about Pap awareness, please check out our “Dudes talk about Paps” video here.
And finally, we come to group B strep (or GBS), which is actually a colonizer in up to 20% of women. Only after all the other diagnoses have been ruled out, I think it’s reasonable to treat with an antibiotic for group B strep or GBS — if that’s identified on the swab.
Last but not least, there are a number of ulcerative conditions of infectious causes (like herpes) and vulvar skin conditions (like lichen and hidradenitis suppurativa) which can cause chronic discharge as well. All of these things should be evaluated immediately. And if a diagnosis can’t be reached — then referral to a specialist is recommended.
*Hypoallergenic Body Wash and Lotion:
Dove body wash: https://amzn.to/3IVYLwN
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Neutrogena body lotion: https://amzn.to/3PkwJgZ