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Snapshot
  • A 25-year-old woman presents to her primary care physician due to malodorous vaginal discharge. She says the discharge has a greenish hue and her symptom is accompanied by postcoital bleeding and a burning sensation in her vaginal area. She describes practicing unprotected sex with her new partner. On speculum examination, there is a "strawberry cervix." Vaginal pH is 5.5. Saline microscopy demonstrates motile trichomonads. She is started on metronidazole and she is told that her partner must be started on the same medication. 
Introduction
  • Clinical definition
    • vaginal disorder secondary to
      • infection
        • in very rare cases, it may be caused by Enterobius vermicularis 
      • inflammation
      • changes in normal vaginal flora
  • Epidemiology
    • risk factors
      • bacterial vaginosis
        • multiple sexual partners
        • antibiotic use
        • intrauterine contraceptive device
      • trichomoniasis
        • multiple sexual partners
        • history of sexually transmitted infections
      • vulvovaginal candidiasis
        • immunosuppression (e.g., transplant patients and HIV infection)
        • uncontrolled diabetes
  • Etiology
    • the most common infections include
      • bacterial vaginosis
      • Candida vulvovaginitis
      • trichomoniasis
  • Pathobiology
    • normal biology
      • in premenopausal women, the vaginal nonkeratinized stratified squamous epithelium contains a large amount of glycogen
        • lactobacilli use this glycogen from sloughed cells to produce lactic acid creating an acidic vaginal environment (pH 4-4.5) that prevents the growth of pathogenic organisms
          • acidic environment normally maintains normal vaginal flora
    • pathogenesis
      • disruption of this acidic environment results in vaginitis
        • disruptive causes include
          • menstruation
          • sexual activity
          • pregnancy
          • foreign bodies
          • sexually transmitted disease
          • hygienic products
          • antibiotics
          • hypoestrogenic states (e.g., menopause)
  • Prognosis
    • bacterial vaginosis
      • infection may recur in 30% of women
    • trichomoniasis
      •  infection may recur in 5-31% of cases
    • vulvovaginal candidiasis
      • infection may recur in ~ 50% of initially infected women
Presentation
 
Vaginitis
Vaginitis Etiology Clinical Presentation
Bacterial vaginosis 
  • Gardnerella vaginalis
  • Symptoms
    • malodorous ("fishy" odor) vaginal discharge
    • nonpainful
  • Physical exam
    • off-white or gray and thin vaginal discharge
    • normal vulva
Vulvovaginal candidiasis

  • Candida albicans
  • Symptoms
    • pruritus and soreness
    • dyspareunia
  • Physical exam
    • thick, white, odorless, and curd-like vaginal discharge
    • vulvar erythema and edema
Trichomoniasis
  • Trichomonas vaginalis
  • Symptoms
    • malodorous greenish discharge
    • burning
    • dyspareunia and dysuria
    • postcoital bleeding
  • Physical exam
    • malodorous discharge
    • "strawberry" cervix
    • vulvovaginal erythema
  • Important note
    • sexually transmitted; therefore, the partner must also be treated
 
Studies
  • Management approach
    • a definitive diagnosis can be obtained by examining the vaginal discharge for
      • pH
      • fishy amine odor
      • microscopy
  • Speculum exam
    • indication
      • to evaluate for underlying causes of vaginitis
        • foreign body (e.g., retained tampon) leading to vaginitis
  • Vaginal pH
    • normal findings
      • pH of 4-4.5
    • bacterial vaginosis
      • pH of > 4.5
    • vulvovaginal candidiasis
      • pH of 4-4.5
    • trichomoniasis
      • pH of 5-6
  • Saline microscopy (wet mount)
    • bacterial vaginosis
      • clue cells found in epithelial cells  
    • vulvovaginal candidiasis
      • pseudohyphae
    • trichomoniasis
      • motile trichomonads 
  • Potassium hydroxide (KOH) wet mount
    • vulvovaginal candidiasis
      • pseudohyphae
  • Amine test ("whiff" test)
    • positive in ~70-80% of patients with bacterial vaginosis
Differential
  • Atrophic vaginitis
    • distinguishing factors
      • typically seen in menopausal women
      • on physical exam there is
        • thinning of the vaginal epithelium
        • loss of rugae
        • cervicovaginal friability
Treatment
  • Medical
    • metronidazole
      • indications
        • first-line agent for both pregnant and nonpregnant women with bacterial vaginosis 
          • clindamycin is an alternative
          • partners do not require treatment as this is not a sexually transmitted infection    
        • first-line agent pregnant and nonpregnant women with trichomoniasis
          • tinidazole is another option
          • sexual partner must be treated and sex must be avoided until treatment is complete and the patients are asymptomatic 
      • side -effects
        • disulfiram-like reaction 
    • -azole   
      • indication
        • first-line treatment option for women with vulvovaginal candidiasis
          • topical -azoles are preferred in pregnancy
      • medications include
        • fluconazole
        • clotrimazole
        • miconazole 
Complications
  • Bacterial vaginosis
    • miscarriage and spontaneous abortion
    • maternal infection
    • postpartum endometritis
    • neonatal complications include
      • low birth weight
      • prematurity
  • Trichomoniasis
    • prematurity 
    • premature rupture of membranes 
    • preterm premature rupture of membranes
  • Vulvovaginal candidiasis
    • premature rupture of membranes
    • preterm labor
    • cerebral candidiasis in the neonate
    • neonatal death
Clue
cells (vaginal epithelial cells covered with
Gardnerella) have stippled appearance along
outer margin (arrow in A ).
 

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