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Vaginitis and pelvic inflammatory disease (PID)
The three vaginal infections are told apart by the discharge, the pH and microscopy; PID is a clinical diagnosis — lower abdominal pain with cervical motion, uterine or adnexal tenderness — and is treated at once, without waiting for results.
Why it matters in the exam
Vaginitis questions describe a discharge and ask for the diagnosis and treatment. Bacterial vaginosis: thin grey discharge with a fishy smell, pH above 4.5 and clue cells; treatment is metronidazole, and the partner is not treated. Candida: thick white discharge and itching, normal pH, and hyphae on microscopy; treatment is a single oral dose of fluconazole, and in pregnancy topical azoles. Trichomonas: frothy yellow-green discharge, a "strawberry cervix", high pH and motile organisms; treatment is metronidazole for both partners.
Pelvic inflammatory disease is caused mainly by chlamydia and gonococcus and by vaginal bacteria. The threshold for treatment is low: a young woman with lower abdominal pain and tenderness on examination is treated empirically, because delay raises the risk of infertility, ectopic pregnancy and chronic pain. Ectopic pregnancy and appendicitis are excluded first. Admission is needed with a tubo-ovarian abscess, pregnancy, severe illness, vomiting or failure of oral treatment after 72 hours. An intrauterine device does not need removing. Fitz-Hugh–Curtis syndrome is perihepatitis with right upper quadrant pain.
Key points
- Vaginosis: high pH, fishy smell, clue cells → metronidazole.
- Candida: normal pH, itching, hyphae → fluconazole.
- Trichomonas: high pH, froth, strawberry cervix → metronidazole for both partners.
- PID: clinical diagnosis and immediate empirical treatment.
- Admission: abscess, pregnancy, severe illness, failure after 72 hours.
Summary table
| Condition | Discharge and pH | Microscopy or test | Treatment |
|---|---|---|---|
| Bacterial vaginosis | Thin, grey, fishy smell; pH above 4.5 | Clue cells, positive whiff test | Metronidazole 500 mg twice daily for 7 days; partner not treated |
| Candida | White, thick, itching; pH up to 4.5 | Hyphae on KOH | Fluconazole 150 mg orally, single dose; in pregnancy — topical azole for 7 days |
| Trichomonas | Frothy, yellow-green; pH above 4.5; strawberry cervix | Motile trichomonads or NAAT | Metronidazole 500 mg twice daily for 7 days; treat the partner |
| PID — outpatient treatment | Lower abdominal pain and tenderness on examination | NAAT for chlamydia and gonococcus; pregnancy test | Ceftriaxone 500 mg IM, plus doxycycline and metronidazole for 14 days |
| PID — admission | Tubo-ovarian abscess, pregnancy, severe illness, failure after 72 hours | Ultrasound | IV antibiotics; drain an abscess that does not respond |
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Sources
- CDC Sexually Transmitted Infections Treatment Guidelines, 2021 — Bacterial vaginosis; trichomoniasis; vulvovaginal candidiasis; pelvic inflammatory disease
- ACOG Practice Bulletin No. 215, 2020 — Vaginitis in Nonpregnant Patients
- Berek and Novak's Gynecology, 16th edition (2019) — Genitourinary Infections and Sexually Transmitted Diseases
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.