Review Question - QID 103320

This patient has candidal vulvovaginitis, or a yeast infection, and should be treated with oral fluconazole.

Candidal vulvovaginitis is due to overgrowth of Candida albicans in the vaginal canal. Patients present with irritation, itchiness, erythema, dysuria, and cottage-cheese like discharge. KOH microscopy is characterized by pseudohyphae. Vaginal pH is normal (<4.5). Although candidal vulvovaginitis is not sexually transmitted, sex increases the risk of infection. Other risk factors include diabetes, antibiotic use, pregnancy, and immune dysfunction such as HIV infection.

Hainer et al. discuss the diagnosis and treatment of vaginitis. Vaginitis is typically divided into three different types of infections: vulvovaginal candidiasis, bacterial vaginosis, and trichomoniasis. Bacterial vaginosis is caused by the overgrowth of anaerobic bacteria and can be diagnosed utilizing the Amsel criteria: milky vaginal discharge, clue cells on microscopy, pH > 4.5, and a positive whiff test. Trichomoniasis often is often diagnosed by microscopy, which reveals trichomonads with corkscrew motility. Other signs of infection with Trichomonas vaginalis includes pH > 4.5, positive whiff test, frothy discharge, and high leukocyte count on wet-mount microscopy.

Sobel describes the treatment strategies for recurrent vulvovaginal candidiasis. The occurrence of vulvovaginal candidiasis is typically limited to pre-menopausal women, however, it is becoming more common in post-menopausal women due to the increased use of hormone replacement therapy. The preferred treatment of recurrent vulvovaginal candidiasis is fluconazole maintenance suppressive therapy, however, there has been increasing drug resistance.

Figure A shows a wet mount with the characteristic pseudohyphae of Candida albicans among normal vaginal epithelial cells. Illustration A shows characteristic clue cells seen in bacterial vaginosis. Illustration B demonstrates Trichomonas vaginalis on the right upper corner of the image among squamous cells.

Incorrect Answers:
Answer 1: IM ceftriaxone is used to treat cervicitis due to gonorrhea. It should not be used in the treatment of Candidal vulvovaginitis.
Answer 3: Oral metronidazole can be used to treat bacterial vaginosis. As it is not a sexually transmitted infection, it is not necessary to treat the partner.
Answer 4: Oral metronidazole can be used to treat Trichomonas vaginalis infection. It is sexually transmitted, and thus the partner should also be treated.
Answer 5: IM ceftriaxone and oral azithromycin should be used in the treatment of either gonorrhea or chlamydia. Since there is a high incidence of co-infection, treatment for both is recommended.