Vaginitis definition
Vaginitis is defined as inflammation or infection of the vagina
Vaginitis symptoms
vulvovaginal itching, burning, irritation, dyspareunia, “fishy” vaginal odor, and abnormal vaginal discharge
Etiology for vaginitis?
- vulvovaginal candidiasis (17–39%)
- bacterial vaginosis (22–50%)
- trichomoniasis (4–35%)
- undiagnosed (7–72%)
- vulvar skin diseases, desquamative inflammatory vaginitis, and genitourinary syndrome of menopause
What are some members of normal vaginal flora?
Gardnerella vaginalis, Escherichia coli, group B streptococci, genital Mycoplasma species, and Candida albicans
- What’s the normal vaginal pH?
2. What about for prepubertal girls and postmenopausal women?
- Estrogen increases glycogen content in vaginal epithelial cells, which in turn encourages colonization of the vagina by lactobacilli. Lactobacilli produces lactic acid and keeps vaginal pH less than 4.5.
- The pH of the vagina is elevated (higher than 4.5) because lactic acid-producing lactobacilli are sparse. Prepubertal girls and postmenopausal women (not using estrogen) uncommonly have bacterial vaginosis or vaginal candidiasis
- Is Bacterial Vaginosis an infection or inflammatory state?
- What kind of bacteria are overgrowing?
- List risk factors for BV
- BV increase your risk of what?
- Bacterial vaginosis is not a true infectious or inflammatory state.
- An overgrowth of facultative anaerobic organisms (eg, G vaginalis, Bacteroides species, Peptostreptococcus species, Fusobacterium species, Prevotella species, and Atopobium vaginae) and a lack of hydrogen peroxide-producing lactobacilli.
- Race and ethnicity (black, Hispanic, and Mexican American women), age, douching, and sexual activity
- PID, postprocedural gynecologic infections, and increased susceptibility to STIs such as HIV and HSV2
- What population is Trichomonas vaginalis more prevalent in?
- What other risk factors increase your risks for Trichomonas vaginalis?
- What disease does Trichomonas vaginalis associate with?
- Symptoms of Trichomonas?
- Does a recent diagnosis of trichomoniasis mean recent acquisition?
- What physical exam findings for trichomoniasis?
- pH?
- What will you see on microscopy?
- How do you diagnose trichomoniasis?
- Treatment for trichomoniasis
- What if patient is allergic to nitroimidazoles?
- Organism resistant to metronidazole?
- How long should you avoid alcohol if you are taking metronidazole?
- African American women are 10 times more commonly affected compared with non-Hispanic white women.
- Increased number of sex partners, low socioeconomic status, and douching.
- PID, posthysterectomy cuff cellulitis, HIV, and other STIs.
- Asymptomatic or have minimal symptoms; however, symptomatic patients with trichomoniasis may report an abnormal (frothy yellow-green) vaginal discharge, itching, burning, postcoital bleeding, abnormal vaginal odor, dysuria
- No, because asymptomatic carriage can occur for prolonged periods in men and women
- “Strawberry cervix”
- pH >4.5.
- Motile trichomonads on microscopy, abundant PMNs, bacilli and cocci
- Nucleic acid amplification testing (NAAT) can be performed on vaginal, cervical, or urine specimens with equal sensitivity (95.3–100%) and specificity (95.2–100%).
- Not microscopy because of poor sensitivity (50-60%).
- DNA probe testing inferior to NAAT. Sensitivity 98%, specificity 46.3%
- Multiplex PCR combines DNA probe and amplification. Can also test for other pathogens. Sensitivity 93%, specificity 99%
- Antigen-detection testing (“rapid test”) can be performed at point-of-care in 10 min. Sensitivity 88.3%, specificity 98.8% - Oral metronidazole 500mg BID for 7 days
- Alternative:
–tinidazole 2g once
More expensive, fewer GI side effects
–Dot not use Metronidazole gel because it’s not effective
- If patient is allergic to nitroimidazoles, should be referred for desensitization
- Resistance to metronidazole unlikely
- Exclude nonadherence or reinfection
- If treatment unsuccessful, consider alternative regimen
–Tinidazole 500mg QID x14d (90% effective in case series of 33 patients)
–Tinidazole 500mg TID x7d (effective in case series of 3 patients)
– Consider sending susceptibility culture if treatment fails and adherence assured
Intravaginal paromycin + either high-dose tinidazole or intravaginal boric acid anecdotally effective - Avoid alcohol during treatment, 24h after metronidazole or 72h after tinidazole
- Symptoms for Vulvovaginal Candidiasis?
- What’s the pH?
- What would you see on microscopy?
- How do you diagnose vulvovaginal candidiasis?
- Ranges from asymptomatic colonization to severe vulvovaginal symptoms
Edema
Normal to thick white “cottage cheese” discharge
Vulvovaginal burning/itching
Dysuria
Dyspareunia
Edema/excoriations in severe cases - Normal pH
- Yeast forms on microscopy, mature squamous cells, rare PMNs, mostly lactobacilli
- Diagnosis requires symptomatic patient plus either:
- Visualization of spores, pseudohyphae, or hyphae on wet-mount microscopy
- Vaginal fungal culture or commercial diagnostic test result positive for Candida species
–Yeast culture preferred if microscopy negative in symptomatic patients.
–PCR testing quick, high-performance, but more expensive and not FDA-approved
Sensitivity 97.7%, specificity 93.2%
May not report speciation
What is the recommended initial evaluation for patients with symptoms of vaginitis?
- Complete medical history
- location of symptoms (vulva, vagina, anus), description of symptoms, and duration of symptoms
- sexual history (including number and gender identification of sex partners and specific sexual practices, barrier usage)
- self-treatment with over-the-counter medications or prescription medications
- vulvovaginal hygiene practices (eg, shaving, douching)
- underlying medical conditions (eg, diabetes, HIV status, inflammatory bowel disease)
- relation of symptoms to the menstrual cycle - physical examination of the vulva and vagina
- a thorough evaluation of the vulva and skin surrounding the anus. - clinical testing of vaginal discharge (ie, pH testing, a potassium hydroxide [KOH] “whiff test,” and microscopy)
What findings on physical exam will suggest chronic inflammation?
erythema, hypopigmentation, papules and plaques, melanosis, edema, or architectural changes
What vulvar findings would you have for BV?
Bacterial vaginosis does not affect the vulva and is not an inflammatory condition.
What vulvar findings would you have for candidiasis and trichomoniasis?
Vulvar erythema and edema in addition to vaginal findings.
Fissures may be present in severe vulvovaginal candidiasis
Where should you swab for pH?
The swab for pH evaluations be obtained from the mid-portion of the vaginal side wall to avoid false elevations in pH results caused by cervical mucus, blood, semen, lubricants, or other substances.
What is the Amsel criteria? What’s the sensitivity and specificity?
Bacterial vaginosis can be diagnosed based on the presence of 3 of the following four Amsel criteria:
- Homogeneous, thin, white-gray discharge that smoothly coats the vaginal walls
- More than 20% clue cells (eg, vaginal squamous cells studded with adherent coccobacilli) on saline microscopy
- A pH of vaginal fluid greater than 4.5
- Positive KOH whiff test result (ie, detection of an amine or fishy odor before or after a sample of vaginal discharge is mixed with the addition of 10% KOH).
sensitivity of 92% and a specificity of 77%
Gram Stain With Nugent Scoring
- Scores 0–3 means what?
- Scores 4-6 means what?
- Scores 7-10 means what?
Gold standard to diagnose BV
Scores assigned to bacterial morphotypes seen on microscopy
Scores 0–3 are interpreted as normal flora;
scores reported as 4–6 are intermediate flora;
scores valued 7–10 are interpreted as bacterial vaginosis flora.
If an intermediate score is obtained, then Amsel criteria are assigned to dispute or accept the diagnosis of bacterial vaginosis
Treatment for uncomplicated BV
The following have comparable safety and efficacy profiles. The choice of therapy should be individualized based on factors such as patient preference, cost, convenience, adherence, ease of use, and history of response or adverse reactions to previous treatments.
- Oral metronidazole 500mg BID x7 days
- or Vaginal Metronidazole gel 0.75%, 5g daily x5 days
- or Vaginal Clindamycin cream 2%, 5g HS x7 days
Alternative treatment
- or Oral Secnidazole 2g once
- or oral Tinidazole 2g daily x2 days
- or oral Tinidazole 1g daily x5 days
- or Oral Clindamycin 300mg BID x7 days
- or Vaginal Clindamycin ovules 100mg HS x3 days
Abstaining from alcohol use
- during treatment with oral nitroimidazoles
- for 24 hours after completion of metronidazole
- for 72 hours after treatment with tinidazole
Abstain from sexual activity (condoms if abstinence not possible)
Avoid tampons if using intravaginal treatment
Consider testing for HIV and other STIs
No re-screening necessary if symptoms resolve
- How frequent does BV recur?
- What’s the definition of recurrent BV?
- What are some Risk factors for recurrence?
- How to treat recurrent BV?
- Following treatment, bacterial vaginosis may recur in up to 30% of patients within 3 months and 58% within 12 months
- “Recurrent BV” is ≥3 separate, documented episodes within one year
- Douching, frequent sexual activity, a previous history of bacterial vaginosis, persistence of pathogenic bacteria, or failure to reestablish a lactobacillus-predominant vaginal flora
- Can offer suppressive therapy
- Intravaginal 0.75% metronidazole gel twice weekly for 16w after acute treatment
- Oral metronidazole 2g + fluconazole 150mg once monthly
Can also try extending course or switching antibiotic
Follow oral metronidazole with intravaginal boric acid 600mg daily x21d, then suppression
What’s the most common non viral STI?
Trichomoniasis
- Defined uncomplicated vulvovaginal candidiasis?
2. Define complicated vulvovaginal candidiasis?
- Must have all:
- Sporadic/infrequent episodes
- Mild to moderate symptoms/findings
- Candida albicans infection (suspected or proven)
- Individual is not immunocompromised - Any of these:
- Recurrent episodes (≥4 per year)
- Severe symptoms/findings
- Non-C albicans species (suspected or proven)
- Diabetes or other immunocompromising conditions (HIV, debilitation, corticosteroid use, etc)
How do you treat Uncomplicated Vulvovaginal Candidiasis?
- Symptomatic relief and mycologic cure >90% with any recommended regimen. Base treatment choice on patient preference/adherence, cost, convenience, history of response/adverse reactions
Oral agent: fluconazole 150mg once
Topical:
- OTC:
– clotrimazole cream 5g, 1% (7-14 days), 2% (3 days)
– Miconazole 5g 2% (7 days), 4% (3 days)
- Prescription
– Butoconazole cream 5g, 2% once
– Terconazole cream 5 g, 0.4% x 7 days; 0.8% x 3 days
– Terconazole 80mg vaginal suppository daily x3 days
Most common side effects:
Topical treatment: local burning/irritation in ~5% of patients
Oral treatment: GI effects, headache, LFT elevations (all usually mild and self-limited)
Allergic reactions to oral fluconazole are rare
How do you treat Complicated Vulvovaginal Candidiasis?
Oral fluconazole 150mg one time recommended as first-line treatment
- Consider culture with susceptibility testing if:
Patient is clinically symptomatic after treatment
OR non-Candida albicans isolated (often intrinsically resistant to azoles)
How do you treat RECURRENT VULVOVAGINAL CANDIDIASIS?
Suppressive therapy improves cure rate, decreases recurrence
- Oral fluconazole 150mg weekly x6mo
- Clotrimazole 500mg weekly or 200mg twice weekly
Confirm with yeast culture if fluconazole resistance is suspected
- What are the symptoms of severe vulvovaginal candidiasis?
2. How do you treat severe vulvovaginal candidiasis ?
- Vulva erythema, erosion, fissure, and edema
- Prolonged course with a intravaginal azole for 10-14 days OR oral fluconazole q72h for 2-3 doses
Suppressive weekly doses are not necessary in this population of patients
What do you use to treat Non-C albicans infection?
- 10% of infections, typically C glabrata
- Confirmed with yeast culture
Intravaginal boric acid 600mg daily for ≥14 days
Can be FATAL if orally ingested, place out of reach of children/pets and use reliable contraception
Alternative treatment:
Topical flucytosine 5g nightly for 2w
Usually cost-prohibitive
