GUM - Non STIs

Question 1

What factors predispose to vaginal candidiasis?

Answer 1

Vaginal candidiasis is an extremely common condition which many diagnose and treat themselves

Predisposing factors
diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV, iatrogenic

Question 2

What are the features of vaginal candidiasis?

Answer 2

‘cottage cheese’, non-offensive discharge
vulvitis: dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

Question 3

How is vaginal candidiasis investigated?

Answer 3

A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis. The discharge tends to coat the sides of the vagina as seen on speculum examination.

Question 4

How is vaginal candidiasis managed?

Answer 4

options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Question 5

How should recurrent vaginal candidiasis be managed?

Answer 5

compliance with previous treatment should be checked
confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses such as lichen sclerosus
exclude predisposing factors (see above)
consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months

Question 6

What is bacterial vaginosis?

Answer 6

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.

Question 7

What are the features of BV?

Answer 7

vaginal discharge: ‘fishy’, offensive

asymptomatic in 50%

Question 8

What is Amsel’s criteria for diagnosing BV?

Answer 8

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present

1) thin, white homogenous discharge
2) clue cells on microscopy: stippled vaginal epithelial cells
3) vaginal pH > 4.5
4) positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 9

What is the Ison-Hay criteria for diagnosing BV?

Answer 9

The Hay/Ison criteria are defined as follows:
grade 1 (Normal): Lactobacillus morphotypes predominate
grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but
Gardnerella or Mobiluncus morphotypes also present
grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli.

Question 10

How is BV treated?

Answer 10

oral metronidazole for 5-7 days
70-80% initial cure rate
relapse rate > 50% within 3 months
the BNF suggests topical metronidazole or topical clindamycin as alternatives

Question 11

Why is BV a problem in pregnancy and how is it treated?

Answer 11

Bacterial vaginosis in pregnancy:

• results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
• it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes