Introduction
Mixed
vaginitis is caused by
the
simultaneous presence of at least two vaginal pathogens, contributing to
an abnormal vaginal milieu and leading to the development of vaginal
symptoms and signs(1).
Nevertheless, simply identifying the presence of at least two vaginal
pathogens in situ does not establish a cause–effect relationship with
clinical symptoms and signs. For
example, in patients with simple vaginitis, “vulvar pruritis” and
“thick curdy discharge” are more likely to be reported by women with
vulvovaginal candidiasis (VVC), while “thin white discharge” and
“odor” are more commonly reported in women with bacterial vaginitis
(BV)(2). Individual signs and
symptoms have only limited value in the recognition of vaginitis.
“Abnormal vaginal discharge,” “dyspareunia,” and “vaginal
soreness” can occur with any kind of vaginitis. In addition, the
presentation of mixed vaginitis can be atypical. Both pathogens require
specific therapies for complete
eradication(3). Therefore, in its
simplest form, mixed vaginitis refers to the simultaneous presence of
two or more potential pathogens in the lower genital tract,
regardless of the clinical
significance of the individual pathogens.
Today, approximately 20 lower genital tract-related infections have been
recognized, such infections are caused by bacteria, fungi, protozoa,
mycoplasma, and viruses(4). The majority of infections in the female
reproductive tract (FRT) occur in the vagina and cervix. Numerous
microorganisms are often linked to cervical infection, leading to
cervicitis, including herpes simplex virus-2 (HSV-2), Chlamydia
trachomatis (CT), Neisseria gonorrhoeae (NG), Mycoplasma, and
human papilloma virus (HPV)(5). The
most common forms of vaginal infection include bacterial vaginosis (BV),
trichomonas vaginalis (TV), vulvovaginal candidiasis (VVC), and
aerobic
vaginitis (AV). Mixed vaginitis in
this review encompasses these 4 common types of vaginitis.
The signs and symptoms of mixed
vaginitis are often atypical,
diagnosis cannot always be established,
treatment is complicated and the
vaginal microbiota is more likely to be perturbed in contrast to
single-type vaginitis. Moreover, mixed vaginitis can induce long-term
symptoms with intermittent exacerbations, and recurrence after treatment
is common, leading to repeat visits to physicians and higher healthcare
costs. Therefore, the major goal of this review is to help improve
clinicians’ understanding of mixed vaginitis and discuss the therapeutic
standard to reduce the disease burden and prevent associated
complications.