Vaginitis
Other STBBI and their partners: see Sexually transmitted infections. Atrophic vaginitis: see Menopause.
Don't miss
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Pregnancy, before a bimanual exam | Know where the placenta isSuspected loss of amniotic fluid: avoid the bimanual exam. |
| Reassess or investigate further | |
| Complicated infection | Lower abdominal pain, deep dyspareunia, or fever with a decline in general health.
These signs suggest pelvic inflammatory disease: see Sexually transmitted infections. INESSS protocol opens in a new tabINESSS syndromic GUO opens in a new tab |
| On bimanual exam | Lower abdominal, adnexal or cervical motion tenderness; A mass or another structural anomaly. |
| Anogenital lesions | New warts consistent with condylomas; Ulcerative, vesicular, erosive or pustular lesions. Genital ulcer: see Sexually transmitted infections. |
Diagnose
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| History | Ask about: Pregnancy, current or possible; Breastfeeding; Immunosuppression; Last menstrual period; Contraception; Sexual practices; STBBI history, last screen and results; Prior bacterial vaginosis or candidiasis; Antibiotics in the past 3 months. |
| Exam | Examine when possibleAlways examine if STBBI cannot be excluded after the risk assessment. |
| Bimanual exam | Indicated if:Pre- or post-menstrual spotting, or post-coital bleeding; Pelvic inflammatory disease risk factors; Purulent or mucopurulent endocervical exudate; Friable cervix (bleeds with a swab). |
| Pelvic inflammatory disease risk factors | Abortion or invasive gynecologic procedure in the past month; IUD insertion or removal in the past month; Chlamydia or gonorrhea in the past year; Prior pelvic inflammatory disease. |
| When to test for trichomonas | Test if: Signs compatible with trichomoniasis; An STBBI syndrome with negative chlamydia and gonorrhea tests after failed syndromic treatment, testing for M. genitalium too; Recent or regular sexual contact with a confirmed case. |
| Typical picture | |
| Bacterial vaginosis | Adherent, homogeneous, fluid, grey-white discharge; Fishy odour; No itch or mild itch; pH above 4.5; Amine odour with KOH. |
| Vulvovaginal candidiasis | Thick, curdy, white-yellow discharge; Moderate to severe itch; Erythema, oedema, fissures, excoriations; pH 4.5 or less, no amine odour; Recent antibiotics predispose. |
| Trichomoniasis | Frothy, yellow-green, malodorous discharge; Moderate to severe itch; Punctate haemorrhages on the genital mucosa (strawberry cervix); pH above 4.5. |
Investigate
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Discharge like bacterial vaginosis, candidiasis or trichomoniasis | Vaginal pH and KOH amine test, if feasible at the point of care; And/or a vaginal sample for microbiology. |
| Mucopurulent endocervical exudate | Vaginal or endocervical NAAT for chlamydia and gonorrhea; Plus an endocervical gonorrhea culture. |
| Pharyngeal or rectal symptoms | Swab that site for chlamydia and gonorrhea NAAT, plus a gonorrhea culture. |
| Other STBBI risk factors | Choose the other STBBI tests with the MSSS risk-factor tool. INESSS protocol opens in a new tabMSSS STBBI tool opens in a new tab |
| Cervicitis persisting after chlamydia and gonorrhea treatment | Test for M. genitalium, always; Test for trichomonas, if not done yet. |
| Pregnancy test | Possible pregnancy, pre- or post-menstrual spotting, or post-coital bleeding. |
| Gonorrhea found by NAAT only | Culture the infected sites for susceptibility, if this does not delay treatment. |
| Trichomonas, no exposure | Do not test a person with no symptoms and no sexual contact with a confirmed case. |
Treat
- INESSS Institut national d'excellence en santé et services sociaux
- SOGC Society of Obstetricians and Gynaecologists of Canada
| Decision | Guideline |
|---|---|
| Bacterial vaginosis | |
| When to treat | First visit, all 3 Amsel criteria: Homogeneous, milky discharge; Vaginal pH above 4.5; Amine odour with KOH; Clue cells on microscopy also count. After lab results: Compatible signs plus a Nugent score of 7 or more, or another compatible result. |
| Choosing a drug | Three options, with no stated orderMetronidazole allergy or intolerance: prefer clindamycin cream. Oral metronidazole not tolerated, no allergy: consider metronidazole gel. Clindamycin allergy or intolerance: prefer metronidazole. Adherence concern: metronidazole 2 g PO, 1 dose, may be considered. |
| Vulvovaginal candidiasis | |
| When to treat | Any one of: Compatible history: empiric treatment at the first visit, with no exam, pH, KOH test or swab; Compatible signs plus compatible pH and KOH criteria; After lab results: compatible signs plus yeast on wet mount or Gram stain, or another compatible result. |
| Limits of empiric treatment | Worse, persistent or back after treatment: examine and test before treating again. STBBI cannot be excluded: examine and test alongside the empiric treatment. |
| Recurrent VVC (4 or more episodes per year) | Induction: Fluconazole 150 mg, 3 doses 72 hours apart.
|
| Cervicitis | |
| When to treat | Before lab results for purulent or mucopurulent endocervical exudate. |
| First choice | Ceftriaxone 500 mg IM, 1 dose, plus Doxycycline 100 mg PO BID for 7 daysSecond choice and allergy: see the INESSS syndromic GUO and Sexually transmitted infections. |
| Drug cautions | |
| Condoms | Many topical and vaginal agents are oil-based. They can reduce the effectiveness of latex condoms and diaphragms, and of vaginal spermicides. |
| Metronidazole and alcohol | No alcohol during treatment and for at least 24 hours after, oral or gel. |
| Metronidazole and warfarin | Consider a lower warfarin dose from the start of metronidazole. Check the INR 4–5 days after the start and 4–5 days after the stop. |
| Clindamycin cream | Contraindicated with a history of inflammatory bowel disease or antibiotic-associated colitis. |
| Drug | Dose | Duration |
|---|---|---|
| Metronidazole | 500 mg PO BID | 7 days |
| Metronidazole 0.75% gel | 1 applicator (5 g) vaginally at bedtime | 5 days |
| Clindamycin 2% cream | 1 applicator (5 g) vaginally at bedtime | 7 days |
| Adherence concern | ||
| Metronidazole | 2 g PO | 1 dose |
| Drug | Dose | Duration | External cream, PRN, 7 days max |
|---|---|---|---|
| Oral, not in pregnancy or breastfeeding | |||
| Fluconazole | 150 mg PO | 1 dose | Clotrimazole 1% or miconazole 2%, DIE–BID |
| Vaginal, at bedtime | |||
| Clotrimazole 1% cream | 1 applicator (5 g) | 6 days | Clotrimazole 1%, DIE–BID |
| Miconazole 2% cream | 1 applicator (5 g) | 7 days | Miconazole 2%, DIE–BID |
| Drug | Dose | Duration |
|---|---|---|
| Vaginitis or cervicitis, first choice | ||
| Metronidazole | 500 mg PO BID | 7 days |
| Vaginitis or cervicitis, second choice | ||
| Metronidazole | 2 g PO | 1 dose |
| Most recent and regular partners, epidemiological treatment | ||
| Metronidazole | 500 mg PO BID or 2 g PO | 7 days or 1 dose |
Follow-up
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Test of cure, bacterial vaginosis or candidiasis | Not recommended |
| Test of cure, trichomonas | Not routine without persistent or recurrent symptomsPersistent or recurrent: repeat the NAAT at least 3 weeks after treatment ends.
Wet mount, culture or antigen test: may be sooner. INESSS protocol opens in a new tabINESSS Trichomonas GUO opens in a new tab |
| Test of cure, chlamydia or gonorrhea | When indicated, per the INESSS chlamydia and gonorrhea GUO: see Sexually transmitted infections. |
| Recurrent episodes | Reassess or investigate further after 4 or more episodes of bacterial vaginosis or candidiasis in 12 months, each assessed at the time. |
| During treatment or after results | Reassess or investigate further:
Drug intolerance;
Symptoms persist 48–72 hours after the start;
Still symptomatic and negative for the infection treated;
An STBBI other than chlamydia, gonorrhea, M. genitalium or trichomonas;
Chlamydia or gonorrhea at another site after cervicitis treatment;
Gonorrhea or M. genitalium resistant to the drug given;
Chlamydia with an LGV genotype;
Positive test of cure. INESSS protocol opens in a new tabINESSS syndromic GUO opens in a new tab |
| Confirm the treated infection | Still symptomatic: reassess if there is no improvement more than 3 days after the start. |
| Chlamydia, gonorrhea, M. genitalium or trichomonas found | Treat the infection found |
| Untreated bacterial vaginosis or candidiasis found | No symptoms now: give the result, start no new treatment. Same symptoms as at the first visit: treat the infection found. |
Pregnancy and breastfeeding
- INESSS Institut national d'excellence en santé et services sociaux
| Decision | Guideline |
|---|---|
| Bacterial vaginosis, pregnancy | Same options as outside pregnancy, but avoid metronidazole in the first trimester. |
| Bacterial vaginosis, breastfeeding | Prefer vaginal treatmentMetronidazole passes into breast milk. |
| Bacterial vaginosis found in pregnancy | Always treat, with or without symptoms when the result arrives.A bacterial vaginosis or M. genitalium result in pregnancy needs particular attention. |
| Vulvovaginal candidiasis | Vaginal treatment only, in pregnancy and breastfeeding.Pregnancy: prefer a longer course, at least 7 days. Breastfeeding: the usual durations can be used. |
| Trichomoniasis | Metronidazole 500 mg PO BID for 7 days, for the patient and for the most recent and regular partners. |
| Cervicitis, pregnancy | Ceftriaxone 500 mg IM or cefixime 800 mg PO, plus azithromycin 2 g PO 1 dose each. Start treatment, then consult an experienced colleague. |
| Doxycycline | Contraindicated in pregnancyCompatible with breastfeeding for a course under 3 weeks. |
| Fluconazole | Caution: Pregnancy or breastfeeding; QT prolongation; Severe liver impairment. |
Reviewed 17 October 2026 against the official sources below.
Sources
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