Vaginitis

pathophysiology etiology diagnosis treatment

Pauls boat

The dynamic vagina

vaginal secretions, exfoliated cells, cervical mucosa lactobacillus acidophilus estrogen glycogen vaginal pH metabolic byproducts of flora and pathogens

Causes of vaginitis
antibiotics contraceptives sexual intercourse douching stress hormones allergies and chemical irritation

Bacterial vaginosis
proliferation of Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus species most common cause 1/3 to 2/3 asymptomatic 15 to 19% of all women 10 to 30% pregnant women

BV misc.
role of sexual transmission unclear risk for preterm labor and PROM increased frequency of abnl PAPs, PID, endometritis Sxs: profuse malodorous discharge Exam: thin grayish discharge, seldom vaginal or vulvar irritation

Risks associated with BV

Early sexual debut new or multiple sex partners IUD (50% contract it over 2y) OCP Lesbians/receptive oral sex no RCTs but association with douche, csection and around time of menses

Amsels criteria
thin, homogenous discharge positive whiff test clue cells present on microscopy vaginal pH > 4.5

BV treatment
metronidazole 500 mg metronidazole 250 mg BID x 7 days TID x 7 days clindamycin 2% cream metronidazole 2 g po qhs x 7 days single dose metrogel 0.75% BID x metrogel (no previous 5 day (vs. QD) PTL)

Vulvovaginal Candidiasis
second most common in U.S. Candida albicans predominates increasing frequency of non-albicans species (C. glabrata) Risks: OCPs, diaphragm, IUD, early intercourse, >4X/month, receptive oral sex, diabetes, recent antibiotics. endogenous vaginal flora in 50% women

Vaginal candidiasis
not sexually transmitted nor related to number of sexual partners treatment of male partner of no benefit c/o pruritis, vaginal irritation, dysuria vulvovaginal itching not normal in healthy women (lichen sclerosis, vulvar cancer) exam: thick white discharge, no odor, normal pH vulvar and vaginal erythema

diagnostics
pH normal (< 4.5) pseudohyphae, budding yeast cells negative whiff test GS and culture in select cases

non c. albicans
multiple budding yeast absence of pseudohyphae

vulvovaginal candidiasis Rx
topical antifungals (clotrimazole, miconazole, terconazole) fluconazole (Diflucan) 150 mg single dose Boric acid 600 mg in size 0 gelatin capsules, IV, daily x 7 to 14 d 14 day oral azole, plus 6 months maintenance with: nizoral 100 mg daily, sporanox 100 mg daily, fluconazole 150 BIW or clotrimazole vag supp 500 mg weekly boric acid

Trichomoniasis
third most common (10-25%) protozoan Trichomonas vaginalis sexually transmitted (treat partner) Risks: IUD, smoking, multiple partners 20 to 50% asymptomatic a/w PROM and PTL

 c/o copious, malodorous, discharge, pruritis, vaginal irritation exam: edema/erythema, strawberry cervix, frothy, purulent discharge pH > 4.5 motile pear-shaped with flagella, many polys may be whiff positive

Evaluation

Trich treatment
metronidazole 2 g single dose (not recommended in 1st trimester) metronidazole 500 mg bid x 7 days treat the partner do not treat asymptomatic pregnant patients if it recurs, 2-4 g metronidazole QD x 10-14 days, send a culture/sensitivity.

Atrophic Vaginitis
Due to decreased estrogen, decreased glycogen, less lactic acid production and then a rise in pH Symptoms: soreness, postcoital burning, dyspareunia, occasional spotting Exam: thin, erythematous mucosa, few folds, may have petechiae pH 5-7, smear with polys, G- rods

Atrophic vaginitis
Treatment: topical estrogen QHS x 1-2 weeks

Other considerations
Dermatitis of the vulva: consider dermatoses such as contact dermatitis, eczema, psoriasis as well as lichen planus and lichen sclerosis. Biopsy if unsure stop the itch/scratch cycle with topical steroids

Others...
Address clothing, allergens, etc. symptoms improved with BID warm soaks add an anti-histamine