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Vaginitis

It is estimated that somewhere between 10 and 13 million visits per year occur relating to complaints that turn out to be vaginitis or vaginal infection. One-third of women who attend sexually transmitted diseases clinics or adolescent health clinics will have some form of vaginitis or vaginosis if they are evaluated completely. While most of the causes of vaginitis that we'll talk about today can be easily diagnosed and effectively treated.

This slide shows you some of the pitfalls in the diagnosis and treatment of vaginitis that clinicians fall into. One of the pitfalls is the telephone diagnosis. Some woman calls, says that she thinks she has whatever and the health care provider calls in a prescription. That is really not a very accurate way to make a diagnosis. We have some good data now that show that seventy-five percent.

Gardnerella can be present in up to fifty percent of women if you look for it. Again, it is not the cause of bacterial vaginosis. It is sometimes a marker for it, but it is not a very sensitive marker for it.

Mycoplasma and ureaplasma can be part of the vaginal flora and we had a question on those two organisms earlier in the week. These data again suggest why it is very iffy whether or not these organisms are truly sexually transmitted diseases or not. Another thing that is important to recognize is that there is such a thing as a normal physiologic discharge.

The vaginal discharge can be affected by age, by place in the cycle, sexual arousal, the use of oral contraceptives, pregnancy and douching. It is not uncommon to see a woman who believes that she has an abnormality because now she has this heavier vaginal discharge than she ever had from the time she began menstruating.

Men also get trichomonas infections. It is not very common that they actually get a longstanding enough infection to come in for evaluation, but it is a very rare cause of urethritis in men - less than one percent of urethritis will be due to trichomoniasis. The reason for this is that because of the differences in anatomy, men do not allow the trichomoniasis parasite to adhere to the urethral epithelial cells for any duration of time. Because of urine flowing by, they sort of get washed out on a regular basis. In addition, prostatic fluid is actually trichomonacidal.

Therapy for trichomoniasis consists of metronidazole. This is the only drug available in the United states that we have to treat this particular infection. You can use any of the doses lasted. The 2 gram p.o. single dose is the one that we most commonly use. It has a slightly lower cure rate, although this difference is not statistically significant, but the single-dose therapy has the advantage of better compliance, lower total dose.

Metronidazole cannot be used in the first trimester of pregnancy but it can be used after the first trimester of pregnancy, so if a woman is identified in the first trimester who has trichomoniasis, you are left with trying to palliate her until you can get her into the second trimester and treat her with metronidazole. The palliative measures that have been used in the past include things like clotrimazole.

As I mentioned, bacterial vaginosis is the most prevalent of the vaginal infections. The name has been changed over time. It is now an 'osis' because it is an abnormal condition, but there is no inflammation or 'itis' associated with it.

Why do we care about bacterial vaginosis? Does a disturbance in the flora really mean anything? Do we really need to be looking for this? Is this important? There are some reasons why we should be looking for it and why we should be treating it. I like to divide those reasons into gynecologic and obstetrical reasons.

With respect to the gynecologic reasons, we know now that women who have untreated bacterial vaginosis and go on to have either elective or emergent gynecologic procedures, have an increased risk of endometritis, postoperative and post procedural infections, cuff cellulitis if they have had a total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic inflammatory disease.

The obstetrical reasons, I think, are even more important. In a woman who is pregnant and has bacterial vaginosis, we know now that there is an increased risk of both preterm labor and premature rupture of membranes; chorioamnionitis; post partum endometritis; and low birth weight infants, which is not listed on this slide, but which has been associated with it. Having said that, the most common symptom is nothing. Fifty-two percent of women are asymptomatic; the other forty-eight percent do have symptoms. When symptoms are present, the cardinal symptom is usually vaginal malodor.

The diagnostic criteria that are recommended for bacterial vaginosis diagnosis are listed here. You need three of four criteria in order to make the diagnosis: the presence of the discharge; a positive whiff test; an elevated pH; and the presence of clue cells. The pH is the most sensitive of the tests and the clue cells is the most specifi.

We have a couple of different options to use in the treatment of bacterial vaginosis. Metronidazole orally for seven days, 500 mg p.o. b.i.d. is one of the first-line regimens. You can also use metronidazole gel, one applicator intravaginally twice daily for five days, or clindamycin cream, one applicator intravaginally at bed-time for seven days. There has been a lot of marketing and competition between these two particular companies. They are both about equally efficacious. In fact, they are both considered first-line regimens. I will tell you that from a theoretical standpoint, I like metronidazole better than clindamycin. The reason for that is because clindamycin has activity against lactobacilli; it will kill off lactobacilli.

Recurrence after therapy is common. We need to expect that women will have recurrences; how often they get them is dependent on each individual patient. Treating recurrent infections can certainly be difficult to do. There are no guidelines yet on what to do with women who are frequent recurers with this disease.

Pregnant women should not be treated with clindamycin cream. If you have a pregnant woman, the recommended regimen is the 250 p.o. t.i.d. regimen of metronidazole for seven days. You can also use metronidazole gel. If a woman has bacterial vaginosis identified in the first trimester, you would not give the oral metronidazole.

Last but not least, I wanted to talk about yeast infections. There are no reliable numbers on the incidence of this, but it is thought that at least three-fourths of women will develop at least one yeast infection at some point during their reproductive years. Less than five percent of women have chronic or recurrent disease. Those women who do have chronic or recurrent disease can have a lot of morbidity associated with this.

Asymptomatic colonization of the vagina occurs in ten to twenty percent of women who will have C. albicans present at part of their normal vaginal flora. That is thought to be the entree of the organism going from colonizer to pathogen, although we don't understand why or how it does that. The things that we all think about as causing yeast infections are really just associated with an increased risk of yeast infections.

The symptoms and signs are itching, burning and soreness. Those are really the big three. The discharge is almost an after thought. That is one of the ways that you can differentiate these patients in the office. They are really going to be upset about itching, burning and soreness as opposed to discharge.

On physical examination, the external genitalia can often be abnormal with tender, erythematous, edematous external tissues.

As far as treatment, you don't want to treat over the phone, as I mentioned. There are a variety of topical agents you can use and a variety of distribution mechanisms. Nystatin and the azole derivatives are the two types of therapies that we have in topical treatment form. Nystatin is not as good as the azole derivatives. Among the azoles, however, no one is better than the other. The cure rate with the azoles is eighty-five to ninety percent and that is better than nystatin, which is, at best, somewhere around eighty percent. Over the last 10 years we have been treating with shorter courses.