Vaginitis Flashcards
Differential diagnosis
- Candidiasis
- Bacterial vaginosis
- Trichomoniasis
- Atrophic vaginitis
- Vulvar dermatologic conditions
- Vulvodynia
- UTI
Prepubertal/postmenopausal vagina vs. reproductive-aged vagina
Thinned vaginal epithelium, pH of 4.7 or greater
Estrogenation of the vagina: increased glycogen content of vaginal epithelium, colonization of the vagina by lactobacilli
Normal vaginal flora
Gardernella vaginalis, E. coli, group B strep, genital mycoplasma, Candida albicans
Vaginitis HPI questions
- Change in discharge, odor, itching, irritation, burning, swelling, dyspareunia, dysuria
- Location of symptoms
- Duration
- Relationship to menses
- Response to prior treatment
- Self-treatment and douching
- Sexual history
Vaginitis PE and testing
Visual exam of vulva, speculum exam, vaginal pH, amine whiff test, wet mount, KOH microscopy
Optional vaginal cxs, PCR for yeast and Trich, enzyme tests for BV and Trich, DNA testing
Vulvovaginal candidiasis diagnosis
Either 1. Visualization of blastospores or pseudohyphae on saline or KOH microscopy or 2. + cxs in a symptomatic woman
Uncomplicated vulvovaginal candidiasis
sporadic or infrequent episodes, mild to moderate sxs, suspected Candida albicans, nonpregnant woman w/o medical problems
Complicated vulvovaginal candidiasis
4+ episodes/yr, severe sxs, suspected or proved non-Candida albicans, women with diabetes, severe medical illness, immunosuppression, or other vulvovaginal conditions, pregnancy
Side effects of oral antifungals
GI intolerance, headache, elevated liver tests
Treatment of vulvovaginal candidiasis
clotrimazole or fluconazole
For complicated cases of Candida albicans, intensive initial therapy for 7-14 days followed by prolonged treatment with 150 mg weekly for 6 months successfully controls 90% of cases and has a protective effect long-term for 50% of cases
Clotrimazole 500 mg weekly or 200 mg twice weekly is also an option
Vaginal boric acid (600 mg) can be used in azole failures
In pregnancy: high-dose fluconazole is associated with birth defects so topical imidazoles are used for 7 days
Bacterial vaginosis
Polymicrobial infection due to lack of lactobacilli with an overgrowth of facultative anaerobic organisms
Anaerobes found in BV
G vaginalis, Mycoplasma hominis, Bacteriodes, Peptosteptococcus, Fusobacterium, Prevotella, Atopobium vaginae
Diagnosis of BV
3/4 of Ansel’s criteria: 1) grayish discharge, 2) positive amine test, 3) pH >4.5, and 4) > than 20% clue cells
Nugent’s score is used in research settings
Treatment of BV
Oral metronidazole
- Should treat before hysterectomy or abortion
In pregnancy: same - no known teratogenic effects
Side effects of metronidazole
- GI sxs, disulfiram reactions (stay away from alcohol for 24 hr)
BV associations during pregnancy
low birth weight, PROM, and prematurity
-Should screen for in women with prior preterm deliveries
Symptoms of trichomoniasis
abnormal discharge, itching, burning, and postcoital bleeding
Diagnosis of trichomoniasis
visualization of motile trichomonads on saline microscopy (50-60% sensitivity), cxs (90%), OSOM Trichomonas rapid test (antigens)
Treatment of BV
metronidazole (desensitization for allergic women)
- Send resistant cases to labs for testing
Atrophic vaginitis diagnosis and treatment
elevated vaginal pH and parabasal and intermediate cells on microscopy
water based moisturizers and topical or systemic estrogen
Desquamative inflammatory vaginitis
occurs most often in peri/postmenopausal women
sxs: burning, dyspareunia, and green/yellow discharge
- common to find strep B, but not caused by this
- Possibly a vaginal erosive lichen planus
- similar to Trich, w/o motile organisms and negative cxs
Treatment of desquamative inflammatory vaginitis
clindamycin gel, but relapse is common
When should cultures be considered for vaginitis
Negative microscopy but symptoms of candidiasis or trich
- No use in BV
When is it appropriate to provide treatment for vaginitis w/o an exam
in known compliant patient with multiple confirmed prior diagnsoses with same sxs
How should patients be evaluated in the absence of a microscope?
check for elevated pH to test for BV and Trich
Tests: pH, amine, G vaginales proline aminopeptidase activity, and vaginal sialidases
How to manage BV or Trich on a cytology report
follow with culture
Causes of vaginitis in pediatric patients
dermatologic, group A strep and Haemophalus organisms, pinworms, STDs
- rarely Candadiasis
