Updated: 4/16/2022

Vaginitis

0%
Topic
Review Topic
0
0
N/A
N/A
Questions
11
0
0
0%
0%
Evidence
10
0
0
Topic
  • 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.
  • summary
    • Clinical definition
      • vaginal disorder secondary to
        • infection
          • in very rare cases, it may be caused by Enterobius vermicularis
            • typically causes perianal itching
        • 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)
  • Presentation
    • Vaginitis
      VaginitisEtiologyClinical 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
        • malodorousgreenishdischarge
        • 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
      • Physiologic leukorrhea (normal vaginal discharge)
        • odorless, white or yellowish discharge
        • no other symptoms or exam abnormalities
      • Atrophic vaginitis
        • distinguishing factors
          • typically seen in menopausal women
          • on physical exam there is
            • thinning of the vaginal epithelium
            • loss of rugae
            • cervicovaginal friability
      • Vaginal foreign body
        • distinguishing factors
          • most common cause of foul-smelling discharge and spotting or vaginal bleeding in children
      Treatment
      • Medical
        • metronidazole
          • indications
            • first-line agent for both pregnant and nonpregnant women withbacterial 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 withtrichomoniasis
              • 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 ).
    • Vaginitis
      VaginitisEtiologyClinical 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
        • malodorousgreenishdischarge
        • 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
  • 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
Flashcards (0)
Cards
1 of 0
Questions (11)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.GN.17.4725) A 24-year-old G1P0 at 20 weeks gestation presents for a routine obstetric visit and complains of vaginal discharge for one week. She describes the discharge as watery and yellow, and she has had an associated burning sensation on urination. She otherwise feels well and has no complaints. Two weeks ago, the patient was found to have asymptomatic bacteriuria on routine urinalysis and completed a 10-day course of nitrofurantoin. Her pregnancy has otherwise been uncomplicated. She denies new sexual partners or previous history of sexually transmitted diseases. On pelvic exam, there is a foul odor. Her cervix is shown in Figure A. This patient is at most increased risk for which of the following?

QID: 108567
FIGURES:

Congenital anomaly in the child

9%

(6/69)

Neonatal sepsis in the child

6%

(4/69)

Pyelonephritis

14%

(10/69)

Preterm delivery

59%

(41/69)

No increased risks

9%

(6/69)

M 8 D

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.GN.17.4727) A 32-year-old woman presents to her gynecologist’s office complaining of increased vaginal discharge for one week. She describes the discharge as watery yellowish with a “bad smell.” She denies new sexual partners but reports inconsistent use of condoms with her husband. Pelvic exam is normal aside from foul-smelling discharge in the vaginal canal and some external irritation of the labial skin. Wet mount of a vaginal swabbing is shown in Figure A. Which of the following instructions should be given to the patient when prescribing the first-line treatment for this condition?

QID: 108584
FIGURES:

Inquire about her husband's sexual history

3%

(1/34)

Prescribe the treatment to her husband

18%

(6/34)

Drink a 8 oz of water with the medication

3%

(1/34)

Avoid grapefruit juice when taking the medication

0%

(0/34)

Avoid alcohol when taking the medication

76%

(26/34)

M 7 D

Select Answer to see Preferred Response

(M2.GN.17.4874) A 24-year-old woman calls her gynecologist complaining of vaginal odor and vaginal discharge. She had an intrauterine device placed last year and does not use condoms with her boyfriend. She has a past medical history of constipation and depression. She recently was successfully treated for a urinary tract infection with a 2-day course of antibiotics. Physical exam demonstrates an off-white vaginal discharge and a strong odor. Pelvic exam demonstrates an absence of cervical motion tenderness and no adnexal tenderness. Which of the following is the most likely diagnosis?

QID: 109992

Anaerobic bacteria overgrowth within the vagina

50%

(4/8)

Inflammatory bacterial infection

38%

(3/8)

Insufficiently treated urinary tract infection

12%

(1/8)

Physiologic discharge secondary to normal hormonal fluctuations

0%

(0/8)

Pregnancy within the uterine tubes

0%

(0/8)

M 6 D

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(M2.GN.16.29) A 28-year-old woman with a history of type 2 diabetes mellitus presents to her gynecologist complaining of 4 days of vaginal itching and burning. Gynecological exam reveals vulvar and vaginal erythema as well as vaginal discharge that resembles cottage cheese. Vaginal wet-mount with KOH prep is shown in Figure A. What treatment should this patient receive?

QID: 103320
FIGURES:

IM ceftriaxone

0%

(0/4)

Oral fluconazole

100%

(4/4)

Oral metronidazole (patient only)

0%

(0/4)

Oral metronidazole (patient and partner)

0%

(0/4)

IM ceftriaxone and oral azithromycin

0%

(0/4)

M 7 C

Select Answer to see Preferred Response

(M2.GN.15.207) A 25-year-old nulligravid woman presents to clinic complaining of abnormal vaginal discharge and vaginal pruritis. The patient's past medical history is unremarkable, and she does not take any medications. She is sexually active with 3 male partners and does not use condoms. Pelvic examination is notable for a thick, odorless, white discharge. There is marked erythema and edema of the vulva. Vaginal pH is normal. Microscopic viewing of the discharge shows pseudohyphae and white blood cells. Which of the following is the best next step in treatment?

QID: 106222

Oral clindamycin for the patient and her partner

0%

(0/29)

Oral clindamycin for the patient

3%

(1/29)

Oral fluconazole for the patient and her partner

0%

(0/29)

Oral fluconazole for the patient

93%

(27/29)

Topical metronidazole

0%

(0/29)

M 7 D

Select Answer to see Preferred Response

(M2.GN.15.47) A 9-year-old girl is brought to the pediatrician by her mother who reports that the girl has been complaining of genital itching over the past few days. She states she has noticed her daughter scratching her buttocks and anus for the past week; however, now she is scratching her groin quite frequently as well. The mother notices that symptoms seem to be worse at night. The girl is otherwise healthy, is up to date on her vaccinations, and feels well. She was recently treated with amoxicillin for a middle ear infection. The child also had a recent bout of diarrhea that was profuse and watery that seems to be improving. Her temperature is 98.5°F (36.9°C), blood pressure is 111/70 mmHg, pulse is 83/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable for excoriations over the girl's anus and near her vagina. Which of the following is the most likely infectious etiology?

QID: 105445

Candida albicans

9%

(1/11)

Enterobius vermicularis

18%

(2/11)

Gardnerella vaginalis

0%

(0/11)

Giardia lamblia

55%

(6/11)

Herpes simplex virus

18%

(2/11)

M 6 E

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Evidence (10)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (21)
Private Note