Evaluation of Vaginitis

1. Evaluation of Vaginitis • Baylor College of Medicine • Anoop Agrawal, M.D.

2. Background • Vaginitis is among the most common conditions for women to seek medical care. • Vaginal discharge accounts for approximately 6 million to 10 million office visits per year. • Vaginitis can be infectious or non-infectious • Infectious is limited to three principle diseases: bacterial vaginosis, candidiasis and trichomoniasis • Non-infectious:atrophic vaginitis, chemical irritation, lichen planus, allergic vaginitis

3. Review of normal vaginal flora • Lactobacilli are the predominant bacteria and regulate the vaginal environment. • The bacteria make lactic acid which maintains a vaginal pH of 3.8 to 4.5. • This inhibits adherence of bacteria to vaginal wall. • Some lactobacilli (60%) also produce hydrogen peroxide which has shown to destroy HIV in vitro.

4. Exam findings • Examine external genitalia, vaginal sidewalls, and cervix, quality of discharge. • Fissures/excoriations are signs of candidal infections. • ‘strawberry’ cervix assoc. with trich seen in only 2-5% of cases • The microscopic evaluation of vaginal discharge is the mainstay in diagnosis of infectious vaginitis. • Samples for pH testing should be taken by touching swab to the sidewall of vagina

5. Case One • You perform an annual pap/pelvic exam on a sexually acitve 23 yo female. The results of the pap and GC/Chlam are negative. However, the pap smear report cites the presence of clue cells. According to the chart, the patient denied any symptoms and scant vaginal discharge was noted on your exam. • Do you treat this woman for bacterial vaginosis? • If she is asymptomatic, then no treatment is required.Other bacteria such as Gardnerella vaginalis, strep species, anaerobes are also present as part of the normal flora.

6. Wet Mount Preparation • Place small amount of discharge on two slides. Add one drop of NaCl on one, and KOH on the other. • First, view the saline slide. • Let KOH slide sit for 1 to 2 minutes to allow the solution to dissolve the cell membranes. • Start at low power (10x); optimal viewing usually at 40x, may try 100x

7. Normal Wet Mount • Epithelial cell borders will be clear, with recognizable contents and sharp distinct cell borders. • On saline mount you should see predominantly lactobacilli - which can vary in size but typically are large gram positive rods. • May also see WBCs, but should be less in number than vaginal epi’s. Likely lactobacilli adherent to epithelial cell

8. Bacterial Vaginosis • B.V. accounts for 10 to 50% of infectious vaginitis cases in women of childbearing age. • What is the change in the vaginal flora? • A shift from lactobacilli-dominant to a mixed flora that can include Gardnerella vaginalis, Mycoplasma hominis, anaerobes • The characteristic discharge is thin, milky, homogeneous, and fishy-smelling.

9. Bacterial Vaginosis: Diagnosis • Diagnosis cannot be reliably made on patient’s history alone. Studies have demonstrated poor correlation between symptoms and final diagnosis. • Options for diagnosis: • Wet mount evaluation • culture of the vagina • DNA probe • What are the criteria for diagnosis?

10. Bacterial Vaginosis: Diagnosis • The Amsel criteria is the standard used in making a clinical diagnosis of B.V.Three of the four criteria must be met: • vaginal pH greater than 4.5 • thin, watery discharge • wet mount showing more than 20% clue cells • positive ‘whiff’ test (amine odor)

11. Differentiating Vaginitis

12. Bacterial Vaginosis - Wet Mount • Search for “clue cells” - which are vaginal epithelial cells with indistinct borders because of large numbers of adherent bacteria. Need more than 20% of cells to be “clue cells” for diagnosis of bacterial vaginosis. Lactobacilli can also adhere to cell border, so take note of morphology of organisms

13. Case Two • 30 yo female presents for her routine pap/pelvic exam. Her LMP was 8 weeks ago and her UPT is positive. She is asymptomatic and her exam is normal. Her wet mount reveals clue cells. Does she require treatment? • Though B.V. has been shown to be a risk factor for premature labor and perinatal infection, evidence supports treatment of high-risk women (prior h/o preterm birth). The benefits of treating asymptomatic, low risk pregnant women is less clear. • If treatment is planned, then oral therapy is recommended. Topicals should be avoided as it may increase risk of prematurity. (CDC)

14. Bacterial Vaginosis • USPSTF Guidelines gave a ‘D’ recommendation for screening of bacterial vaginosis in pregnancy - i.e., do not screen asymptomatic, low-risk women, supported by fair evidence. • BV is associated with increased risk of PID, endometritis following delivery, post-hysterectomy infections, acquisition of HIV and other STDs. • Hence, treatment is recommended for asymptomatic women scheduled to undergo certain gyn procedures to prevent postprocedure infection.

15. BV: Treatment • Oral: Metronidazole 500mg bid for 7 days • alternative: clindamycin 300mg bid for 7 days • Topical: Metrogel (0.75%) one 5 g application intravaginally for 5 days. • alternative: clindamycin cream 2% • Oral vs. Topical - equal efficacy; topical with fewer systemic side effects; patient preference • Recurrent BV infections: is common and requires longer treatment course with above agents, typically 10 to 14 days.

16. Case Three • A 40 yo female with diabetes (Hgb A1c 6.3) is complaining of vaginal itching and whitish discharge. She reports having had frequent yeast infections over the past year. She began having symptoms last week and has tried OTC therapies, but her symptoms have not improved. • How reliable are a patient’s self-diagnosis of yeast infections? • Should the patient have tried OTC therapy before coming to see you? • What are the options in managing this patient?

17. Vulvovaginal Candidiasis • Most commonly caused by C. albicans 80 to 90% of the time, though other species such as C. glabrata and C. tropicalis can be seen. • 10 to 20% of women have asymptomatic colonization with C. albicans • Symptoms include pruritis, dysuria, and thick curdy discharge. • Studies have shown candidiasis to have been confirmed in only 33% of women who self-diagnosed yeast infection.

18. Vulvovaginal Candidiasis: Diagnosis and Therapy • KOH wet mount is best means of diagnosis, specificity of 97%. • Oral and topical therapies have equal efficacy rates. Again patient preference guides choice. • Severe infections:two or three sequential doses of 150mg fluconazole each 72 hours apart or intravaginal therapy for 7 to 14 days. • Vaginal cultures: can be performed in patients with persistent or recurrent symptoms

19. Recurrent Candidiasis • Recurrent infection defined as four or more infections in one year. • If patient is not responding to therapy, then infection with candida species other than albicans - glabrata or tropicalis. • Non-albicans species are often resistant to azole therapy. • Therapies in such cases include intravaginal teraconazole or boric acid.

20. Trichomoniasis • Typical symptoms include pruritis, frothy, yellow discharge. • Wet mount has low sensitivity, but high specificity - i.e. 50% of wet mounts can be negative in culture proven trichomoniasis • Treatment is single dose of 2 grams oral metronidazole. Topical therapy is less efficacious. • Unlike asymptomatic BV and candidiasis, asymptomatic trichomoniasis should be treated.

21. Case Four • An 18 yo female reports pruritis and yellow discharge for past 3 days. She also states her LMP was 2 months ago. On examination of the wet mount you see trichomonads. • Is metronidazole safe to use in this scenario? • Yes, the CDC no longer discourages use during the first trimester. • What if the patient was asymptomatic and trichomonads were found on a pap smear? or wet mount? How would this change your management?

22. Case Four, cont. • Trichomoniasis in pregnancy: Studies have shown that treating asymptomatic infections in pregnancy can increase risk of preterm delivery. • Treat sexual partners. Reinfection of treated partners of untreated women can only be avoided by abstinence or use of condoms. • Trichomonas seen on pap smear: • Conventional cytology is not reliable (low sens/spec) • Liquid-based preps have low sensitivity (61%), but high specificity (99%), so it is reasonable to treat patient if trichomonas seen on pap.

26. References • Eckert, L.O. Acute Vulvovaginitis. New England Journal of Medicine, 355;12:1244-52. • Owen, M.K. Clenney, T.L. Management of Vaginitis. American Family Physician; 70:11; Dec 1, 2004. • Sobel, J.D. Bacterial Vaginosis. UpToDate ® 2007.