Updated: 1/28/2019

Vaginitis

Topic
Review Topic
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0
Questions
8
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Evidence
6
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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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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.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? Review Topic

QID: 109992
1

Anaerobic bacteria overgrowth within the vagina

0%

(0/0)

2

Inflammatory bacterial infection

0%

(0/0)

3

Insufficiently treated urinary tract infection

0%

(0/0)

4

Physiologic discharge secondary to normal hormonal fluctuations

0%

(0/0)

5

Pregnancy within the uterine tubes

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M2.GN.4826) A 26-year-old female presents to her gynecologist complaining of increased vaginal discharge for several days. She notes that the discharge is whitish and smells “weird,” and she also endorses mild burning with urination. She also feels like her groin has been slightly itchy. Review of systems is otherwise negative. The patient has a past medical history of type I diabetes and is on insulin. She has had three sexual partners total and has been with her most recent partner for one month. She has been using condoms intermittently with this partner. She last tested negative for HIV six months ago. Three years ago, she had an episode of chlamydia, which was treated and resolved. During this office visit, the patient’s temperature is 98.5°F (36.9°C), pulse is 71/min, blood pressure is 121/76 mmHg, and respirations are 13/min. Pelvic exam reveals no vulvar irritation but moderate amounts of discharge, shown in Figure A. Microscopic examination of the discharge reveals findings shown in Figure B. The patient is prescribed medication for her condition. Which of the following instructions should be given to the patient at this time? Review Topic

QID: 109436
FIGURES:
1

Avoid wearing panty liners

6%

(7/126)

2

Avoid alcohol consumption

37%

(47/126)

3

Schedule testing for HIV

13%

(16/126)

4

Perform routine douching

8%

(10/126)

5

Schedule her partner for treatment

36%

(45/126)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.GN.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? Review Topic

QID: 108567
FIGURES:
1

Congenital anomaly in the child

7%

(4/58)

2

Neonatal sepsis in the child

5%

(3/58)

3

Pyelonephritis

17%

(10/58)

4

Preterm delivery

59%

(34/58)

5

No increased risks

9%

(5/58)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M2.GN.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? Review Topic

QID: 108584
FIGURES:
1

Inquire about her husband's sexual history

0%

(0/15)

2

Prescribe the treatment to her husband

13%

(2/15)

3

Drink a 8 oz of water with the medication

7%

(1/15)

4

Avoid grapefruit juice when taking the medication

0%

(0/15)

5

Avoid alcohol when taking the medication

80%

(12/15)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(M2.GN.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?
Review Topic

QID: 103320
FIGURES:
1

IM ceftriaxone

0%

(0/0)

2

Oral fluconazole

0%

(0/0)

3

Oral metronidazole (patient only)

0%

(0/0)

4

Oral metronidazole (patient and partner)

0%

(0/0)

5

IM ceftriaxone and oral azithromycin

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.GN.207) A 25-year-old nulligravid female 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 most appropriate treatment plan? Review Topic

QID: 106222
1

Oral clindamycin for the patient and her partner

0%

(0/21)

2

Oral clindamycin for the patient

0%

(0/21)

3

Oral fluconazole for the patient and her partner

0%

(0/21)

4

Oral fluconazole for the patient

95%

(20/21)

5

Topical metronidazole

0%

(0/21)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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Topic COMMENTS (19)
Private Note