Comprehensive Approach to Vaginitis Management: Diagnostic Strategies and Treatment Guidelines

1. Vaginitis & Pelvic Inflammatory Disease Denver Prevention Training Center Denver Public Health 2016

2. Grace Alfonsi, MD, has no paidprofessional relationships to disclose Disclosures Source:

3. Be able to identify epidemiology, symptomatology, diagnosis, and treatment modalities for vaginal infections. Objectives Source:

4. Vaginal Environment Bacterial colony-forming units

5. Clinical manifestations of vaginitis

6. Which of the following types of vaginitis occurs most frequently? • Bacterial vaginosis • Candidiasis • Trichomoniasis • Atrophic vaginitis

7. Which of the following types of vaginitis occurs most frequently? 1. Bacterial vaginosis 2. Candidiasis 3. Trichomoniasis 4. Atrophic vaginitis

8. Vaginitis Etiologies “Other” includes atrophic, irritant/chemical, Desquamative interstitial vaginitis, erosive lichen planus

9. Case study Sara • 22-year old female • Partners: 1 new partner in the past month, 3 partners in the past 4 months, only has sex with men • Practices: only had vaginal sex in the past 4 months • Protection from STDs: Reports 75% condom use in past 4 months • Past STDs: GC twice in lifetime (both over 1 year ago), CT and Trich positive within last year, HIV negative one year ago • Complaint: discharge with odor for 3 weeks

10. Diagnosis of Vaginitis

11. Source: DMHC

12. Laboratory • What laboratory tests should be ordered? • Tests to diagnose vaginosis: • Wet prep • Whiff • pH • Additional STD testing: • GC/CT NAAT • HIV

13. Lab Results • HIV: nonreactive • GC/CT NAAT: pending • Wet prep: positive clue cells, negative yeast and trichomonads • Whiff: positive • pH: > 5.5

14. Lactobacilli Lactobacilli Artifact NOT a clue cell Saline: 40X objective Source: Seattle STD/HIV Prevention Training Center

15. NOT a clue cell Clue cells Saline: 40X objective NOT a clue cell Source: Seattle STD/HIV Prevention Training Center

17. Bacterial Vaginosis has been associated with which of the following? • PID • Premature rupture of membranes • Acquisition of HIV • All of the above

18. Bacterial Vaginosis has been associated with which of the following? 1. PID 2. Premature rupture of membranes 3. Acquisition of HIV 4. All of the above

20. Treatment Source: CDC 2015 STD Treatment Guidelines

21. Treatment Source: CDC 2015 STD Treatment Guidelines

22. Screening and Treatment in Asymptomatic Patients

23. BV Recurrence

24. Risk factors for Developing BV • Sexual activity – new and multiple male and female partners • Douching • Cigarette Smoking (women) Potentially protective • Estrogen containing contraceptives • Condom use

25. Case study Tanya • 24-year-old single female • Partners: 2 sex partners during the past year • Protection from STDs: no condoms with recent partners • Past history: Trichomoniasis 1 year ago at last check-up • Protection from pregnancy: oral contraceptives • Complaint: Smelly, yellow vaginal discharge and slight dysuria for 1 week; no vulvar itching, pelvic pain, or fever

26. Physical Exam • External genitalia: Normal with a few excoriations near the introitus, but no other lesions • Speculum exam: Moderate amount of frothy, yellowish, malodorous discharge, without visible cervical mucopus or easily induced cervical bleeding • Bimanual examination: Normal without uterine or adnexal tenderness

27. Source: UCHSC STD Library

28. Strawberry Cervix Source: Seattle STD/HIV Prevention Training Center

29. Based on history and exam, what tests should we do now? Vaginal Ph Whiff test Wet Prep

30. What do you see?

31. Lab Results • Vaginal pH = 6.0 • Wet prep • Numerous motile trichomonads • No clue cells • No yeast • Whiff test = positive

33. T. Vaginalis in Men • Found in 13-17 % men with NGU • Found in 11 – 14% of asymptomatic men • Most infected men are asymptomatic • Diagnostic test seldom available • Men treated usually through partner diagnosis Source: Sexually Transmitted Diseases, 4th ed. Sex Transm Infect 2000; 76: 355. J Infect Dis 2003; 188: 465-8.

34. Treatment 24 hrs 72 hrs 24 hrs Source: CDC 2015 STD Treatment Guidelines

35. First sexual contact: 2 months ago Last sexual contact: 2 days ago Twice a week, vaginal sex Partner Management Treat Treat? Jamie Calvin • First sexual contact: 7 months ago • Last sexual contact: 6 months ago • 3 times a week, vaginal and oral sex How should Tanya’s partners be managed?

36. Follow-up • Prescription: metronidazole 2 g orally, instructed to abstain from sexual intercourse until her partner is treated. • 2 weeks later: persistent vaginal discharge that has not subsided with treatment. Reported taking medication and maintaining abstinence (partner moved out of area). • Labs: CT and GC negative. Vaginal wet mount positive for motile trichomonads.

37. Why could Tanya still have Trichomonas? • She has trichomonas resistant to metronidazole • She had sex with her partner before he was successfully treated • Both of the above • Neither of the above

38. Why could Tanya still have Trichomonas? • She has trichomonas resistant to metronidazole • She had sex with her partner before he was successfully treated • Both of the above • Neither of the above

39. Treatment Failure

40. Case study Alexa • 24 year old female • Partners: one partner in last year; no partner in last 3 months, male partners only • Protection from STDs: occasional condom use • Past history: + CT 4 years ago • Protection from pregnancy: oral contraceptives • Complaint: vaginal discharge for 1 week with vulvar irritation and itching; dyspareunia and dysuria

41. Source: UCHSC STD Library Source: CDC

42. Source: CDC

43. Source:

44. Case Summary • Diagnosis: vulvo-vaginal candidiasis (VVC) • Treatment: You recommend an OTC cream preparation, but patient requests the fluconazole pill

45. Does fluconazole have better efficacy than topical azoles when treating Candida vaginitis? • Yes • No

46. Does fluconazole have better efficacy than topical azoles when treating Candida vaginitis? • Yes • No

47. Recommended Regimens *See STD Treatment Guidelines for specific regimen options. Source: CDC 2015 STD Treatment Guidelines

49. Complicated VVC Treatment Source: CDC 2015 STD Treatment Guidelines

50. Case study Megan • 17 year old female • Partners: 1 new partner starting 2 months ago • Complaint: Pelvic pain and some vaginal bleeding (not when cycle is due) • Exam: Bimanual exam reveals cervical motion tenderness (CMT), midline and left adnexal tenderness to palpation What else do we need to know?