Objectives

1. Be able to differentiate among common presentations of vaginitis on the basis of clinical information and laboratory testing.

2. Know the current guidelines for treatment of the various etiologies of vaginitis.

Considerations

Women with vaginitis may present with a variety of symptoms, including vaginal discharge, itching, odor, and dysuria. There are many potential causes of vaginitis, including sexually transmitted pathogens and overgrowth of organisms found in the normal vaginal flora. Common among the causes of vaginitis are Candida albicans, Trichomonas vaginalis, and Gardnerella vaginalis.

Certain historical information may lead a clinician to suspect a specific cause of vaginitis in a given patient. For example, a history of recent antibiotic use may predispose to a Candida vaginitis, as the antibiotic may alter the normal vaginal flora and allow the overgrowth of a fungal organism. Women with diabetes mellitus are also more predisposed to developing yeast infections. A history of multiple sexual partners may raise the likelihood of a sexually transmitted infection, such as trichomoniasis.

The patient's symptoms and signs may also suggest a specific organism as the cause of her vaginitis. Fungal infections tend to have thick discharge and cause significant pruritus. The discharge of bacterial vaginosis is often thinner and patients complain of a "fishy" odor. Trichomonas produces a discharge that is usually frothy and the patient's cervix is frequently very erythematous.

The key test to determining the cause of vaginal discharge, which guides the specific treatment, is microscopic examination of the discharge. A sample of the discharge is examined both as a "wet mount" (i.e.. mixed with a small amount of normal saline) and as a "KOH prep" (i.e., mixed with a small amount of 10% potassium hydroxide). On wet mount, the examiner can evaluate the normal epithelial cells and look lor white blood cells, red blood cells, clue cells, and motile trichomonads. The hyphae or pseudohyphae of Candida are best seen on KOH prep.

Etiologies

Vulvovaginal Candidiasis

This infection is typically caused by C. albicans, although other species are occasionally identified. More than 75% of women have at least one episode during their lifetime. The presenting symptom is a thick, whitish discharge that has no odor and the patient complains of significant pruritus of the external and internal genitalia. On physical examination, the vaginal area can be edematous with erythema present. The discharge has a pH between 4.0 and 5.0. The diagnosis is confirmed by wet mount or KOH preparation showing budding yeast or pseudohyphae. Fungal cultures are not needed to confirm the diagnosis, but they are useful if the infection recurs or is unresponsive to treatment. Numerous treatment options are available for patients with vulvovaginal candidiasis, including over-the-counter and prescription medications. Uncomplicated candidiasis can be treated effectively with short-term intravaginal preparations (creams or vaginal suppositories) or single-dose oral therapies (fluconazole 150 mg). Treatment of complicated or recurrent infection should begin with an intensive regimen for 10-14 days followed by 6 months of maintenance therapy to reduce the likelihood of recurrence. Treatment of sexual partners is not indicated unless symptomatic (e.g.. male partners with balanitis).

Trichomoniasis

This infection is caused by the protozoan T. vaginalis and is classified as a sexually transmitted disease. The incubation period is 3-21 days after exposure. Certain factors predispose to infection, such as multiple sexual partners, pregnancy, and menopause. The presenting complaint is copious amounts of a thin, frothy, green-yellow or gray malodorous vaginal discharge. Women can also have vaginal soreness or dyspareunia. Symptoms may start or be exacerbated during the time of their menses. Vaginal examination may reveal that the cervix has a "strawberry" appearance (red and inflamed with punctuations) or that redness of the vagina and perineum is present. Microscopically, the wet mount preparation can demonstrate motile trichomonads, although cultures may be necessary because of the significant number of false-negative results. The recommended treatment for trichomoniasis is oral metronidazole, given in a single, 2-g oral dose or 1-week regimen of 500 mg BID to both the patient and her sexual partner. It is important to screen for other sexually transmitted diseases (STDs) and to remember to treat the partner to ensure better cure rates.

Bacterial Vaginosis

Bacterial vaginosis (BV) arises when normal vaginal bacteria are replaced with an overgrowth of anaerobic bacteria and G. vaginalis. Although not an STD, it is associated with having multiple sexual partners. Diagnosis can be based on the presence of three of four clinical criteria: (a) a thin, homogenous vaginal discharge; (b) a vaginal pH >4.5: (c) a positive KOH "whiff' test (a fishy odor present after the addition of 10% KOH to a sample of the discharge): and (d) the presence of clue cells in a wet mount preparation (Fig. 22-1). Culture is generally not needed. Treatment options include both oral and topical vaginal preparations of metronidazole or clindamycin. There are no advantages to any of these regimens with regard to cure rates or recurrence, although patients do

Figure 22-1. Bacterial vaginosis. (A) "Clue cells." (B) Normal epithelium.

(.Reproduced with permission from Kasper DL. Braunwauld E, Fauci A, et al. Harrison's principles of internal medicine. 16tli ed. New York: McGraw-Hill, 2005:767.)

report more satisfaction with the vaginal preparations. Treatment of BV in asymptomatic pregnant women may reduce the incidence of preterm delivery. Treatment of sexual partners is not necessary and does not reduce the risk of recurrent infection.

Mucopurulent Cervicitis

This infection is characterized by purulent or mucopurulent discharge from the endocervix, which may be associated with vaginal discharge and/or cervical bleeding. The diagnostic evaluation should include testing for Chlamydia trachomatis and Neisseria gonorrhoeae, although the etiologic agent is not always found. Absence of symptoms should not prevent additional evaluation and treatment, as approximately 50% of gonococcal infections and 70% of chlamydial infections are asymptomatic in women. The gold standard for establishing the diagnosis is a culture of the cervical discharge. Empiric treatment should be considered in areas of high prevalence of infection or if follow -up is unlikely. The treatment recommendation for gonorrhea is ceftriaxone 125 mg intramuscularly; alternative therapies are ciprofloxacin 500 mg or ofloxacin 400 mg in a single oral dose. The recommended treatment for Chlamydia infections is doxycycline 100 mg orally twice daily for 7 days or azithromycin in a single 1-g oral dose when compliance is a concern. Typical treatment regimens will cover for both gonorrhea and chlamydia and the treatment of sexual partners is advised.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is defined as inflammation of the upper genital tract, including pelvic peritonitis, endometritis, salpingitis, and tuboovarian abscess caused by infection with gonorrhea. Chlamydia, or vaginal and bowel flora. Lower abdominal tenderness with both adnexal and cervical motion tenderness without other explanation of illness is enough to diagnose PII). Other criteria that enhance the specificity of the diagnosis include temperature > 101 °F. abnormal cervical or vaginal discharge, elevated sedimentation rate, elevated C-reactive protein, and cervical infection with gonorrhea or Chlamydia. Definitive diagnosis rests on techniques that are not generally used or readily available to make the diagnosis, such as laparoscopic findings consistent with PID. endometrial biopsy showing endometritis, and ultrasound examination findings showing thickened fluid-filled tubes with or without free pelvic fluid or tuboovarian complex. Because of the clinical similarity between PII) and ectopic pregnancy, a serum pregnancy test should be performed on all patients suspected of having PID.

Determination of appropriate treatment should consider pregnancy status, severity of illness, and compliance. Less-severe disease can generally be treated on an outpatient basis. Women who are pregnant, have HIV, or have severe disease generally require inpatient therapy and treatment with parenteral antibiotics. Table 22-1 lists PID treatment regimens.

Table 22-1

TREATMENT REGIMENS FOR PID

Oral

Ofloxacin 400 mg PO BID for 14 days or Levofloxacin 500 mg PO BID for 14 days

With or without metronidazole 500 mg PO BID for 14 days Ceftriaxone 250 mg IM single dose or

Cefoxitin 2 g IM and probenecid I g PO given concurrently plus doxycycline 100 mg PO BID for 14 days With or without metronidazole 500 mg PO BID for 14 days Parenteral Cefotetan 2 g IV of 12 h or

Cefoxitin 2 g IV of 12 h plus doxycycline 100 mg PO or IV of 12 h Clindamycin 900 mg IV of 8 h plus gentamicin 2 mg/kg loading dose followed by 1.5 mg/kg IV of 8 h

Ofloxacin 400 mg IV of 12 h or levofloxacin 500 mg IV daily

With or without metronidazole 500 mg IV of 8 h Ampicillin/sulbactam 3 g IV of 6 h plus doxycycline 100 mg PO or IV of 2 h

Patients who have PID need to be aware of potential complications, including the potential for recurrence of disease, the development of tuboovarian abscess, chronic abdominal pain, infertility, and the increased risk of ectopic pregnancy. It is important to discuss these potential problems with patients who are given a diagnosis of PID. All patients with STDs or who are at risk for developing STDs should be counseled on safer sexual practices, including abstinence, monogamy, and the use of latex condoms.

Comprehension Questions

[22.1] Which of the following vaginitis infections does not require treatment in the sexual partner to prevent recurrence of infection in the patient?

A. Vaginal candidiasis

B. Bacterial vaginosis

C. Gonococcal cervicitis

D. Trichomoniasis

[22.2] Which of the following factors predisposes females to vulvovaginal candidiasis infections?

A. Recent antibiotic use

B. Hypothyroidism

C. Condom use

D. Menopause

[22.3] Which of the following treatments regimens for PID is correct?

A. Ceftriaxone 125 mg IM plus azithromycin 1 g PO

B. Cefoxitin 2 g IV q 12 h plus doxycycline 100 mg PO BID

C. Ceftriaxone 250 mg IM plus doxycycline 100 mg PO BID for 7 days

D. Ciprofloxacin 500 mg PO single dose plus doxycycline 100 mg PO BID for 7 days

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