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Vaginitis

Vaginitis. pathophysiology etiology diagnosis treatment Paul’s boat. The dynamic vagina. vaginal secretions, exfoliated cells, cervical mucosa lactobacillus acidophilus estrogen glycogen vaginal pH metabolic byproducts of flora and pathogens. Causes of vaginitis. antibiotics

addison-hickman
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Vaginitis

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  1. Vaginitis • pathophysiology • etiology • diagnosis • treatment • Paul’s boat

  2. The dynamic vagina • vaginal secretions, exfoliated cells, cervical mucosa • lactobacillus acidophilus • estrogen • glycogen • vaginal pH • metabolic byproducts of flora and pathogens

  3. Causes of vaginitis • antibiotics • contraceptives • sexual intercourse • douching • stress • hormones • allergies and chemical irritation

  4. Bacterial vaginosis • proliferation of Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus species • most common cause • 1/3 to 2/3 asymptomatic • 15 to 19% of all women • 10 to 30% pregnant women

  5. BV misc. • role of sexual transmission unclear • risk for preterm labor and PROM • increased frequency of abnl PAPs, PID, endometritis • Sxs: profuse malodorous discharge • Exam: thin grayish discharge, seldom vaginal or vulvar irritation

  6. Risks associated with BV • Early sexual ‘debut’ • new or multiple sex partners • IUD (50% contract it over 2y) • OCP • Lesbians/receptive oral sex • no RCT’s but association with douche, c-section and around time of menses

  7. Amsel’s criteria • thin, homogenous discharge • positive “whiff” test • “clue cells” present on microscopy • vaginal pH > 4.5

  8. metronidazole 500 mg BID x 7 days clindamycin 2% cream qhs x 7 days metrogel 0.75% BID x 5 day (vs. QD) metronidazole 250 mg TID x 7 days metronidazole 2 g po single dose metrogel (no previous PTL) BV treatment

  9. Vulvovaginal Candidiasis • second most common in U.S. • Candida albicans predominates • increasing frequency of non-albicans species (C. glabrata) • Risks: OCPs, diaphragm, IUD, early intercourse, >4X/month, receptive oral sex, diabetes, recent antibiotics. • endogenous vaginal flora in 50% women

  10. Vaginal candidiasis • not sexually transmitted nor related to number of sexual partners • treatment of male partner of no benefit • c/o pruritis, vaginal irritation, dysuria • vulvovaginal itching not normal in healthy women (lichen sclerosis, vulvar cancer) • exam: thick white discharge, no odor, normal pH • vulvar and vaginal erythema

  11. diagnostics • pH normal (< 4.5) • pseudohyphae, budding yeast cells • negative “whiff” test • GS and culture in select cases

  12. non c. albicans • multiple budding yeast • absence of pseudohyphae

  13. topical antifungals (clotrimazole, miconazole, terconazole) fluconazole (Diflucan) 150 mg single dose Boric acid 600 mg in size 0 gelatin capsules, IV, daily x 7 to 14 d 14 day oral azole, plus 6 months maintenance with: nizoral 100 mg daily, sporanox 100 mg daily, fluconazole 150 BIW or clotrimazole vag supp 500 mg weekly boric acid vulvovaginal candidiasis Rx

  14. Trichomoniasis • third most common (10-25%) • protozoan Trichomonas vaginalis • sexually transmitted (treat partner) • Risks: IUD, smoking, multiple partners • 20 to 50% asymptomatic • a/w PROM and PTL

  15. Evaluation • c/o copious, malodorous, discharge, pruritis, vaginal irritation • exam: edema/erythema, “strawberry” cervix, frothy, purulent discharge • pH > 4.5 • motile pear-shaped with flagella, many polys • may be whiff positive

  16. Trich treatment • metronidazole 2 g single dose (not recommended in 1st trimester) • metronidazole 500 mg bid x 7 days • treat the partner • do not treat asymptomatic pregnant patients • if it recurs, 2-4 g metronidazole QD x 10-14 days, send a culture/sensitivity.

  17. Atrophic Vaginitis • Due to decreased estrogen, decreased glycogen, less lactic acid production and then a rise in pH • Symptoms: soreness, postcoital burning, dyspareunia, occasional spotting • Exam: thin, erythematous mucosa, few folds, may have petechiae • pH 5-7, smear with poly’s, G- rods

  18. Atrophic vaginitis • Treatment: • topical estrogen QHS x 1-2 weeks

  19. Other considerations • Dermatitis of the vulva: consider dermatoses such as contact dermatitis, eczema, psoriasis as well as lichen planus and lichen sclerosis. • Biopsy if unsure • stop the itch/scratch cycle with topical steroids

  20. Others... • Address clothing, allergens, etc. • symptoms improved with BID warm soaks • add an anti-histamine

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