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Vaginitis

Vaginitis is the most common gynecologic problem encountered by primary care physicians. It may result from bacterial infections, fungal infection, protozoan infection, contact dermatitis, atrophic vaginitis, or allergic reaction.

Pathophysiology

Vaginitis results from alterations in the vaginal ecosystem, either by the introduction of an organism or by a disturbance that allows normally present pathogens to proliferate.

Antibiotics may cause the overgrowth of yeast or they may cause pathogenic strains to dominate, giving rise to bacterial vaginosis. Douching may alter the pH level or selectively suppress the growth of endogenous bacteria.

Clinical Evaluation of Vaginal Symptoms

The type and extent of symptoms, such as itching, discharge, odor, or pelvic pain should be determined.

A change in sexual partners or sexual activity, changes in contraception method, medications (antibiotics), and history of prior genital infections should be sought.

Evaluation of the vagina begins with close inspection of the external genitalia for excoriations, ulcerations, blisters, papillary structures, erythema, edema, mucosal thinning, or mucosal pallor.

The color, texture, and odor of vaginal or cervical discharge should be noted.

The pH level can be determined by placing pH paper on the lateral vaginal wall or immersing the pH paper in the vaginal discharge.

A pH level greater than 4.5 often indicates the presence of bacterial vaginosis. It may also indicate the presence of Trichomonas vaginalis.

Saline Wet Mount

One swab should be used to obtain a sample from the posterior vaginal fornix, obtaining a "clump" of discharge. Place the sample on a slide, add one drop of normal saline, and apply a coverslip.

Coccoid bacteria and clue cells (bacteria-coated, stippled, epithelial cells) are characteristic of bacterial vaginosis.

Trichomoniasis is confirmed by identification of trichomonads--mobile, oval flagellates. White blood cells are prevalent.

Potassium Hydroxide (KOH) Preparation

Place a second sample on a slide. Apply one drop of 10% potassium hydroxide (KOH) and a coverslip. A pungent, fishy odor upon addition of KOH--a positive whiff test--strongly indicates bacterial vaginosis.

The KOH prep may reveal Candida in the form of thread-like hyphae and budding yeast.

Cultures are not routinely indicated in the initial evaluation of vaginitis.

Screening for STDs. Testing for gonorrhea and chlamydial infection should be completed for women with a new sexual partner, purulent cervical discharge, or cervical motion tenderness.

Differential Diagnosis

The most common cause of vaginitis is bacterial vaginosis, followed by Candida albicans. The prevalence of trichomoniasis has declined in recent years.

Common nonvaginal etiologies include contact dermatitis from spermicidal creams, latex in condoms, or douching. Any STD can produce vaginal discharge.

Bacterial Vaginosis

Bacterial vaginosis develops when a shift in the normal vaginal ecosystem causes replacement of the usually predominant lactobacilli with mixed bacterial flora. Bacterial vaginosis is the most common type of vaginitis.

Bacterial vaginosis has been found in 10-25% of patients in gynecologic clinics and in up to 64% of patients visiting STD clinics. Among women with bacterial vaginosis, 50% are asymptomatic.

pH > 4.0

Clue cells

Positive KOH whiff test

Homogeneous discharge.

Treatment regimens

Topical (intravaginal) regimens

Metronidazole gel ( MetroGel) 0.75%, one

Oral metronidazole ( Flagyl)

Candida is the second most common diagnosis associated with vaginal symptoms. It is found in 25% of asymptomatic women. Fungal infections account for 33% of all vaginal infections.

Patients with diabetes mellitus or immunosuppressive conditions such as infection with the human immunodeficiency virus (HIV) are at increased risk for candidal vaginitis. Candidal vaginitis occurs in 25-70% of women after antibiotic therapy.

Symptoms. The most common symptom is pruritus. Vulvar burning may be noted, and this can be exacerbated with micturition or sexual intercourse. Also common is an increase or change in consistency of the vaginal discharge.

Physical examination

Candidal vaginitis most often causes a nonmalodorous, thick, adherent, white vaginal discharge that appears "cottage cheese-like."

The vagina is usually hyperemic and edematous. Vulvar erythema and excoriations may be present due to scratching or contact irritation.

The normal pH level is not usually altered with uncomplicated candidal vaginitis. Microscopic examination of vaginal discharge diluted with saline (wet-mount) and 10% KOH preparations will reveal hyphal forms or budding yeast cells in 50-70% of individuals with yeast infections. Some yeast infections are not detected by direct microscopy because there are relatively few numbers of organisms.

Confirmation of candidal vaginitis by culture is not recommended. Candida on Pap smear is not a sensitive finding because the yeast is a constituent of the normal vaginal flora.

Treatment of candida vulvovaginitis

Trichomonas vaginalis

Trichomonas, a flagellated anaerobic protozoan, is a sexually transmitted disease with a high transmission rate. Non-sexual transmission is possible because the organism can survive for a few hours in a moist environment.

Symptomatic women most often have a copious, yellow-gray or green homogeneous discharge. They may also describe a foul odor, vulvovaginal irritation, and, occasionally, dysuria. The pH level is usually greater than 4.5. Frothy discharge is present in less than 35% of infected patients, and punctate lesions, or "strawberry cervix," are seen in 25%.

The diagnosis of trichomonal infection is made by examining a fresh wet-mount preparation for mobile, flagellated organisms. An abundance of leukocytes usually is also seen.

Occasionally the diagnosis is reported on a Pap test. Treatment should be given.

Treatment of Trichomonas vaginitis

Metronidazole ( Flagyl), 2 g PO in a single dose for both the patient and sexual partner, or 500 mg PO bid for 7 days. Ten percent of patients experience nausea and vomiting with the 2-g dose.

Topical therapy with commercially available, topical metronidazole is not recommended because the organism may persist in the urethra and Skene's glands after local therapy.

Screening for coexisting sexually transmitted diseases should be completed.

Recurrent or recalcitrant infections

If patients are compliant but develop recurrent infections, treatment of their sexual partners should be confirmed.

Cultures should be performed. In patients with documented persistent infection despite compliance with treatment by the patient and her partner(s), a resistant trichomonad strain may require high dosages of metronidazole (more than 2.5 g/d), often combined with intravaginal metronidazole suppositories prepared by a pharmacist (500 mg once or twice daily) for at least 10 days. Commercial preparations of metronidazole gel are not effective.

Pregnancy. Metronidazole is contraindicated during the first trimester. Patients may be treated after the first trimester with metronidazole. Clotrimazole, 100 mg vaginally qhs x 7-14 d, is 48% effective.

Other diagnoses causing vaginal symptoms

One-third of patients with vaginal symptoms will not have laboratory evidence of bacterial vaginosis, Candida, or Trichomonas.

Other causes of the vaginal symptoms include cervicitis, allergic reactions, and vulvodynia.

Atrophic vaginitis should be considered in postmenopausal patients if the mucosa appears pale and thin and wet-mount findings are negative.

Oral estrogen (Premarin) 0.625 mg qd should provide relief.

Estradiol vaginal cream 0.01% may be effective as 2-4 g daily for 1-2 weeks, then decreasing by 50% for 1-2 weeks; maintenance dosage is 1 g one to three times weekly.

Conjugated estrogen vaginal cream may be effective as 2-4 g daily (3 weeks on, 1 week off) for 3-6 months.

Allergy and chemical irritation

Patients with a short history of vulvar irritation should be questioned about use of substances that cause allergic or chemical irritation, such as deodorant soaps, laundry detergent, vaginal contraceptives, bath oils, perfumed or dyed toilet paper, hot tub or swimming pool chemicals, and synthetic clothing.

Topical steroids and systemic antihistamines can help alleviate the symptoms until the irritant can be identified.