#215 Vaginitis in Nonpregnant Patients Flashcards
1
Q
Among patients with vaginal symptoms, what % are diagnosed with vaginal candidiasis?
A
17-39%
2
Q
Among patients with vaginal symptoms, what % are diagnosed with bacterial vaginosis?
A
22-50%
3
Q
Among patients with vaginal symptoms, what % are diagnosed with trichomoniasis?
A
4-35%
4
Q
How does the presence of estrogen affect vaginal epithelial cells on the molecular level?
A
Increase glycogen content (encourages colonization of vagina by lactobacilia)
5
Q
What is the normal vaginal pH of a reproductive-aged woman?
A
<4.5
6
Q
Is gardnerella vaginalis among the normal vaginal flora?
A
Yes
7
Q
Is Escherichia coli among normal vaginal flora?
A
Yes
8
Q
Is group B streptococci among normal vaginal flora?
A
Yes
9
Q
Is candida albicans among normal vaginal flora?
A
Yes
10
Q
Are any mycoplasma species among normal vaginal flora?
A
Yes
11
Q
What is the vaginal pH in prepubertal girls? In postmenopausal women?
A
Both >4.5
12
Q
Is bacterial vaginosis common among prepubertal girls? Postmenopausal women? Why?
A
Uncommon in both d/t estrogen-depleted environment
13
Q
Is vaginal candidiasis common among prepubertal girls? Postmenopausal women? Why?
A
Uncommon in both d/t estrogen-depleted environment
14
Q
Overgrowth of what type of bacteria cause bacterial vaginosis?
A
Facultative anaerobes (eg. G vaginalis, bacteroides species, peptostreptococcus, fusobacterium, prevotella, atopobium vaginae)
15
Q
What is the most common cause of abnormal vaginal discharge in reproductive aged patients?
A
Bacterial vaginosis
16
Q
Are certain race/ethnicities at higher risk for bacterial vaginosis?
A
Yes. higher prevalence in black, Hispanic, and Mexican American women
17
Q
What are risk factors for bacterial vaginosis?
A
Race and ethnicity (black, hispanic), age, douching, and sexual activity
18
Q
Does bacterial vaginosis occur in women who have not been sexually active?
A
Rarely
19
Q
Is bacterial vaginosis associated with sexual activity for heterosexual or lesbian couples?
A
Both
20
Q
What does bacterial vaginosis put nonpregnant patients at risk for?
A
Increased risk of various infections including PID, postprocedural gyn infections, increased susceptibility to STIs such as HIV and HSV2
21
Q
What symptoms present with bacterial vaginosis?
A
Many are asymptomatic. Abnormal vaginal discharge and a fishy odor, particularly after vaginal intercourse and menses
22
Q
What causes trichomoniasis?
A
Infection with protozoan parasite Trichomonas vaginalis
23
Q
What is the most common nonviral STI in the US?
A
Trichomoniasis
24
Q
What are risk factors for trichomoniasis?
A
African american, increased # sex partners, low socioeconomic status, douching
25
Has trichomoniasis been associated with PID?
Yes
26
Has trichomoniasis been associated with posthysterectomy cuff cellulitis?
yes
27
Is trichomoniasis associated with HIV and other STIs?
Yes
28
Is trichomonas typically symptomatic or asymptomatic?
More than 50% of patients are asymptomatic
29
What are the symptoms of trichomoniasis?
abnormal vaginal discharge, itching, burning, postcoital bleeding. (most commonly asymptomatic)
30
What is the most common cause of vaginitis?
Bacterial vaginosis
31
What is the second most common cause of vaginitis?
Vulvovaginal candidiasis
32
What are the symptoms of vulvovaginal candidiasis?
Asymptomatic colonization to severe vulvovaginal symptoms such as burning, itching, edema, dysuria, dyspareunia, and an abnormal discharge
33
In the workup of vaginitis, where should a swab for pH evaluation be collected?
From mid-portion of the vaginal side wall to avoid false elevations caused by cervical mucus, blood, semen, lubricants, or other substances
34
What is the pH level of normal physiologic discharge?
3.5-4.5
35
What is the pH level of bacterial vaginosis discharge?
>4.5
36
What is the pH level of trichomoniasis discharge?
>4.5
37
What is the pH level of vulvovaginal candidiasis discharge?
3.5-4.5
38
What are symptoms/discharge associated with normal physiologic discharge?
White and creamy or clear discharge
39
What are symptoms/discharge associated with bacterial vaginosis?
Increased thin, watery, white-gray vaginal discharge often with fishy odor. Most are asymptomatic
40
What are symptoms/discharge associated with trichomoniasis?
Yellow-to-green frothy vaginal discharge, abnormal vaginal odor, pruritus, irritation, and dysuria. More than half are asymptomatic
41
What are symptoms/discharge associated with vulvovaginal candidiasis?
Normal-appearing discharge or thick, white vaginal discharge, pruritus, burning, dyspareunia and dysuria
42
What are the gross examination findings with normal physiologic discharge?
White discharge in vaginal fornix and adherent to vaginal walls
43
What are the gross examination findings with bacterial vaginosis?
Thin, white-gray homogenous discharge
44
What are the gross examination findings with trichomoniasis?
Yellow, frothy vaginal discharge; vaginal or cervical-vaginal erythema with petechiae
45
What are the gross examination findings with vulvovaginal candidiasis?
Thick, white, curd-like vaginal discharge. In severe vulvovaginal candidiasis, erythema, edema, excoriations, and fissures may be present
46
What are the microscopy/KOH test results with normal physiologic discharge?
Mature squamous cells, rare PMH, background bacteria dominated by lactobacillus
47
What are the microscopy/KOH test results with bacterial vaginosis?
Clue cells (more than 20%), no PMNs, a positive KOH "whiff" test. Decreased or absent lactobacilli and increased cocci, and small curved rods
48
What are the microscopy/KOH test results with trichomoniasis?
Motile trichomonads, abundant PMNs, bacteria with both bacilus and cocci, variable KOH "whiff" test
49
What are the microscopy/KOH test results with vulvovaginal candidiasis?
Branching pseudohyphae, budding pseudohyphae (10x), or spores (40x) with 10% KOH. Mature squamous cells, rare PMNs, bacteria dominated by lactobacilus.
50
What diagnostic tests are recommended for bacterial vaginosis?
Recommended: Amsel criteria, Gram stain with Nugent scoring.
Alternative: FDA-approved commercial tests
51
What diagnostic tests are recommended for trichomoniasis?
Recommended: NAAT
Alternative: FDA-approved commercial tests, culture
52
What diagnostic tests are recommended for vulvovaginal candidiasis?
Recommended: microscopy, yeast culture
Alternative: FDA-approved commercial tests
53
Is bacterial culture recommended for the diagnosis of bacterial vaginosis?
No, because normal vaginal flora is heterogeneous, culture not specific for BV
54
What is Amsel Criteria? What is it used to diagnose? When is it positive?
BV can be diagnosed with 3/4:
1. homogenous thin white-gray discharge that smoothly coats vaginal walls
2. More than 20% clue cells
3. pH of vaginal fluid < 4.5
4. Positive KOH whiff test
55
What is the sensitivity and specificity of Amsel criteria for diagnosis of BV?
Sensitivity: 92%
Specificity: 77%
56
What is the reference standard for diagnosis of bacterial vaginosis?
Gram stain with Nugent scoring
57
How is a Nugent score performed (for bacterial vaginosis)?
Assigns a value to different bacterial morphotypes seen on gram stain of vaginal secretions
58
How is a Nugent score interpreted?
For diagnosis of BV:
0-3: normal flora
4-6: intermediate flora
7-10: BV flora
59
How do you diagnose BV is Nugent score is intermediate (4-6)?
Apply Amsel criteria
60
How does treatment of BV work?
Reduce the overgrowth of the patient's endogenous faculatative and anaerobic bacteria and enabling the lactobacilli to become dominant
61
True or false: people with BV should also be tested for other STIs?
Yes, per CDC recommendation
62
What treatment regimens are available for BV (drug name and route)?
Recommended: metronidazole PO or PV, Clindamycin cream PV
Alternative: Secnidazole PO, tinidazole PO, clindamycin PO, clindamycin ovules PV
63
What is the dosing of metronidazole to treat BV?
PO: 500mg PO BID for 7d.
PV: One applicator 0.75% gel (5g), qD for 5d
64
What is the dosing of clindamycin for treatment of BV?
PV#1: one applicator 2% cream (5g) qHS 7d
PO: 300mg BID for 7d
PV#2: 100mg ovules qHS for 3d
65
What is the dosing of Secnidazole for BV?
2g PO in a single dose
66
What is the dosing of tinidazole for treatment of BV?
2g PO daily for 2d OR 1g PO daily for 5d
67
What is the dosing of metronidazole for the treatment of uncomplicated trichomoniasis?
500mg BID for 7d (single dose has been preferred, but recent data from RCT show 7d course more effective)
68
What treatment options are available for trichomonas (drug name and route)?
Metronidazole PO
| Tinidazole PO
69
What is the dosing of tinidazole for treatment of trichomoniasis?
2g PO once
70
What over the counter agents are available to treat uncomplicated vulvovaginal candidiasis?
All intravaginal:
| Clotrimazole, miconazole, tioconazole
71
What prescription-only intravaginal and oral agents are available to treat uncomplicated vulvovaginal candidiasis?
Intravaginal: Butoconazole, terconazole
Oral: fluconazole
72
What is the dosing of fluconazole for uncomplicated vulvovaginal candidiasis?
150mg PO once
73
For how long after completion of oral metronidazole treatment should you avoid alcohol?
24 hours
74
For how long after completion of oral tinidazole should you avoid alcohol?
72 hours
75
True or false: Clindamycin ovules affect efficacy of condoms or diaphragms?
True. May weaken latex or rubber products up to 72 hours after treatment
76
True or false: patients should completely abstain from sexual activity during BV treatment?
False, they can if they use condoms
77
True or false: patients should use condoms for all sexual activity during BV treatment?
True
78
True or false: patients who are using intravaginal product to treat a vaginal infection should avoid use of tampons
True, generally recommended to ensure adequate dispersion of the medication
79
Do you need to perform a test of cure after BV treatment?
No, as long as symptoms have resolved
80
What % of patients will have BV recur within 3 months? Within 12 months?
30% within 3. 58% within 12.
81
What potential factors are associated with recurrent BV?
Douching, frequent sexual activity, previous hx of BV, persistence of pathogenic bacteria, or failure to reestablish a lactobacillus-predominant vaginal flora
82
What is the criteria for recurrent bacterial vaginosis?
At least three documented, separate episodes in 1 year
83
Do you offer some type of suppression to people with recurrent bacterial vaginosis?
Yes. Twice weekly suppressive metronidazole gel for 16 wks after treatment for the acute episode
84
What is the sensitivity of microscopy for diagnosis of trichomoniasis?
50-60%
85
How does the sensitivity of NAAT for trichomoniasis compare between urine and vaginal or cervical samples?
Equal sensitivity and specificity.
Sensitivity 95.3-100%
Specificity 95.2-100%
86
How long does a culture of trichomonas take to result?
At least 5 days
87
Does metronidazole or tinidazole have more gastrointestinal adverse effects?
Metronidazole
88
Is metronidazole gel or PO more effective in treating T vaginalis infections?
Oral. Metro gel is not effective.
89
Should patients with T vaginalis be retested after infection?
Yes, within 3 months because of high rates of infection recurrence
90
Can vulvovaginal candidiasis be reliable diagnosed based on clinical symptoms alone?
No
91
In a symptomatic patient, diagnosis of vulvovaginal candidiasis requires one of the follow two findings:
1. visualization of spores, pseudohyphae, or hyphae on wet-mount
2. vaginal fungal culture or commercial diagnostic test results positive for Candida species
92
What is the sensitivity of microscopy to detect yeast on a wet prep?
50-70%
93
When a patient with symptoms of yeast infection has a negative wet prep, what is the next step?
Culture
94
C albicans constitutes what % of all vulvovaginal Candida infections?
90%
95
Cultures may be positive for yeast in as many as what % of asymptomatic patients at any given time?
As many as 30%
96
What are pros and cons of using DNA probe test for diagnosis of yeast infection?
Pro: Results in hours. High sensitivity and specificity
Cons: cost, not FDA approved. Most tests don't distinguish between species (apart from newer probe that divides into 3 groups)
97
What is required to classify vulvovaginal candidiasis as uncomplicated?
ALL of the following:
1. sporadic or infrequent episodes
2. mild-to-mod symptoms or findings
3. C albicans infection (suspected or proven)
4. Non-immunocompromised patients
98
What classifies vulvovaginal candidiasis as complicated?
ANY of the following:
1. recurrent episodes (4 or more per year)
2. Severe symptoms or findings
3. Non- C albicans candidiasis (suspected or proven)
4. Diabetes, immunocompromising conditions, debilitation, or immunosuppressive therapy
99
What is recommended for treatment of uncomplicated vulvovaginal candidiasis?
Intravaginal azole therapy or oral fluconazole
100
What should you do if patient remains clinically symptomatic after treatment for vulvovaginal candidiasis?
Culture and susceptibility testing
101
What alteration should be made to treatment of vulvovaginal candidiasis in recurrent infections?
Extended antifungal treatment. Can give suppressive therapy with weekly doses of either an intravaginal or oral azole (eg 150mg weekly fluconazole for 6 months; or clotrimazole 500mg weekly or 200mg twice a week)
102
What are symptoms of severe vulvovaginal candidiasis?
Erythema, erosion, fissure, edema
103
What is recommended treatment for severe vulvovaginal candidiasis?
Prolonged course with a topical intravaginal azole for 10-14d or 2-3 doses of PO fluconazole q3 days
104
What is the second most common Candida species?
C galbrata
105
What is an effective treatment for C galbrata and other atypical Candida species?
Intravaginal boric acid (600mg daily for minimum of 14 days). Topical flucytosine 5g nightly for 2wks is another alternative, but it is expensive
106
What should you make sure to counsel patients about boric acid before prescribing it for candida infection?
Can be fatal if ingested orally, must be used intravaginally. Keep out of reach of children.
107
What % of users of over the counter treatment for yeast infection will get a contact dermatitis (presenting as localized burning and itching)?
Occur in approximately 5% of users
108
What is the appropriate management of findings c/w vulvovaginal candidiasis, bacterial vaginosis, or trichomoniasis on a cervical cytology report in an asymptomatic patient?
Pap tests are not reliable for diagnosis of vaginitis. Diagnostic confirmation is recommended.
109
Do asymptomatic patients with incidental candida or BV reported on a pap test require additional testing and/or treatment?
No and no
110
Do asymptomatic patients with incidentally found trichomonas on pap require additional testing and/or treatment?
Yes, should do confirmatory diagnostic testing and treat if confirmed
111
Are probiotics or nonmedical approaches effective for treatment or prevention of vaginitis?
Not recommended
112
How long after the last dose of therapy for trichomonas should a patient abstain from sexual activity?
Full 7 days since taking last antibiotic dose. As long as asymptomatic
113
Do partners of patients with BV need to be treated?
Data do not support that treatment of sex partners affects rates of relapse or remission
114
Do partners of patients with uncomplicated vulvovaginal candidiasis need to be treated?
No
