Vaginitis case file

Vaginitis Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 22

A 25-year-old woman presents to the office with a 1-week history of vaginal discharge. She describes the discharge as being green-yellow in color with a bad odor. She has never had this type of discharge in the past. She complains of increased vaginal soreness and discharge after she has intercourse. She denies any itching, abdominal pain, nausea, vomiting, fever, chills, or sweats. She is currently sexually active and is using an intrauterine device (IUD) as her contraceptive method. She has been with one male partner for the past 3 months and he has no symptoms. She does state that she first had intercourse at age 15 and has had multiple sexual partners. She had a chlamydia! infection 2 years ago that was treated with oral antibiotics. Her last menstrual period was 2 weeks ago and was normal. She also denies any recent antibiotic treatment. On examination, she is afebrile, has normal vital signs, and appears to be in no acute distress. Her general physical examination is normal. On pelvic examination, she has normal external genitalia. She has a small amount of frothy, homogenous green-gray discharge at the introitus. The cervix has a "strawberry"-red appearance with a slight amount of discharge noted in the os. The IUD string is in place. Chlamydia and gonorrhea specimens are obtained from the os and a sample of the vaginal discharge is collected for microscopic evaluation. Bimanual examination shows no cervical motion tenderness, and a normal uterus and adnexa.

⯈ What organism is the most likely cause of her symptoms?

⯈ What would you expect to see on microscopic examination of the vaginal discharge?

⯈ What is the recommended treatment for this infection?

ANSWER TO CASE 22:

Vaginitis

Summary: A 25-year-old woman presents with a foul-smelling vaginal discharge. She has a greenish, frothy discharge and a "strawberry cervix" noted on examination.

• Organism most likely to cause this infection: Trichomonas vaginalis.
• Expected microscopic examination findings: Motile, flagellated trichomonads, and many white blood cells.
• Recommended treatment: Metronidazole 2 g by mouth in a single dose for both the patient and her sexual partner. Metronidazole 500 mg twice a day for a week is an alternate regimen.

ANALYSIS

Objectives

1. Be able to differentiate among common presentations of vaginitis on the basis of clinical information and laboratory testing.
2. Know the current guidelines for treatment of the various etiologies of vaginitis.

Considerations

Women with vaginitis may present with a variety of symptoms, including vaginal discharge, itching, odor, and dysuria. There are many potential causes of vaginitis, including sexually transmitted pathogens and overgrowth of organisms found in the normal vaginal flora. Common among the causes of vaginitis are Candida albicans, T vaginalis, and polymicrobial (Gardnerella vaginalis predominant) mix of bacterial vaginosis.

Certain historical information may lead a clinician to suspect a specific cause of vaginitis in a given patient. For example, a history of recent antibiotic use may predispose to a Candida vaginitis, as the antibiotic may alter the normal vaginal flora and allow the overgrowth of a fungal organism. Women with diabetes mellitus are also more predisposed to developing yeast infections. A history of multiple sexual partners may raise the likelihood of a sexually transmitted infection, such as trichomoniasis.

The patient's symptoms and signs may also suggest a specific organism as the cause of her vaginitis. Fungal infections tend to have thick discharge and cause significant pruritus. The discharge of bacterial vaginosis is often thinner and patients complain of a "fishy" odor. Trichomonas produces a discharge that is usually frothy and the patient's cervix is frequently very erythematous.

The key test to determining the cause of vaginal discharge, which guides the specific treatment, is microscopic examination of the discharge. A sample of the discharge is examined both as a "wet mount" (ie, mixed with a small amount of normal saline) and as a "KOH prep" (ie, mixed with a small amount of 10% potassium hydroxide). On wet mount, the examiner can evaluate the normal epithelial cells and look for white blood cells, red blood cells, clue cells, and motile trichomonads. The hyphae or pseudohyphae of Candida are best seen on KOH prep.

Approach To:

Vaginal Infections

DEFINITIONS

BACTERIAL VAGINOSIS: Condition of excessive anaerobic bacteria in the vagina, leading to a discharge that is alkaline.

CANDIDA VULV OVAGINITIS: Vaginal and/or vulvar infection caused by Candida species, usually with heterogenous discharge and inflammation.

TRICHOMONAS VAGINITIS: Infection of the vagina caused by the protozoa T vaginalis, usually associated with a frothy green discharge and intense inflammatory response.

CLINICAL APPROACH

ETIOLOGIES

Vulvovaginal Candidiasis

This infection is typically caused by C albicans, although other species are occasionally identified. More than 75% of women have at least one episode during their lifetime. The presenting symptom is a thick, whitish discharge that has no odor and the patient complains of significant pruritus of the external and internal genitalia. On physical examination, the vaginal area can be edematous with erythema present. The discharge has a pH between 4.0 and 5.0. The diagnosis is confirmed by wet mount or KOH preparation showing budding yeast or pseudohyphae. Fungal cultures are not needed to confirm the diagnosis, but they are useful if the infection recurs or is unresponsive to treatment. Numerous treatment options are available for patients with vulvovaginal candidiasis, including over-the-counter and prescription medications. Uncomplicated candidiasis can be treated effectively with shortterm intravaginal preparations (creams or vaginal suppositories) or single-dose oral therapies (fluconazole 150 mg). Treatment of complicated or recurrent infection should begin with an intensive regimen for 10 to 14 days followed by 6 months of maintenance therapy to reduce the likelihood of recurrence. Treatment of sexual partners is not indicated unless symptomatic (eg, male partners with balanitis).

Trichomoniasis

This infection is caused by the protozoan T vaginalis and is classified as a sexually transmitted disease (STD). The incubation period is 3 to 21 days after exposure. Certain factors predispose to infection, such as multiple sexual partners, pregnancy, and menopause. The presenting complaint is copious amounts of a thin, frothy, green-yellow or gray malodorous vaginal discharge. Women can also have vaginal soreness or dyspareunia. Symptoms may start or be exacerbated during the time of their menses. Vaginal examination may reveal that the cervix has a "strawberry" appearance (red and inflamed with punctations) or that redness of the vagina and perineum is present. Microscopically, the wet mount preparation can demonstrate motile trichomonads and many white blood cells, although cultures may be necessary because of the significant number of false-negative results. The recommended treatment for trichomoniasis is oral metronidazole, given in a single, 2-g oral dose or 1-week regimen of 500 mg twice a day to both the patient and her sexual partner. It is important to screen for other STDs and to remember to treat the partner to ensure better cure rates.

Bacterial Vaginosis

Bacterial vaginosis (BV) arises when normal vaginal bacteria are replaced with an overgrowth of anaerobic bacteria and G vaginalis. Although not an STD, it is associated with having multiple sexual partners. Diagnosis can be based on the presence of three of four clinical criteria: (1) a thin, homogenous vaginal discharge; (2) a vaginal pH more than 4.5; (3) a positive KOH "whiff" test (a fishy odor present after the addition of 10% KOH to a sample of the discharge); and (4) the presence of clue cells in a wet mount preparation (Figure 22-1). Culture is generally not needed. Treatment options include both oral and topical vaginal preparations of metronidazole or clindamycin. There are no advantages to any of these regimens with regard to cure rates or recurrence, although patients do report more satisfaction with the vaginal preparations. Treatment of BV in asymptomatic pregnant women may reduce the incidence of preterm delivery. Treatment of sexual partners is not necessary and does not reduce the risk of recurrent infection.

Mucopurulent Cervicitis

This infection is characterized by purulent or mucopurulent discharge from the endocervix, which may be associated with vaginal discharge and/or cervical bleeding. The diagnostic evaluation should include testing for Chlamydia trachomatis and Neisseria gonorrhoeae, although the etiologic agent is not always found. Absence of symptoms should not prevent additional evaluation and treatment, as approximately 50% of gonococcal infections and 70% of chlamydia! infections are asymptomatic in women. The gold standard for establishing the diagnosis is a culture of the cervical discharge. Empiric treatment should be considered in areas of high prevalence of infection or if follow-up is unlikely. The first-line treatment recommendation for gonorrhea is ceftriaxone 125 mg intramuscularly. Because of the growing problem of antibiotic resistance, quinolone antibiotics (ciprofloxacin, ofloxacin) and oral cephalosporin antibiotics are no longer recommended for treatment of gonorrhea. The recommended treatment for Chlamydia infections is azithromycin in a single 1-g oral dose or doxycycline 100 mg orally twice daily for 7 days. Typical treatment regimens will cover for both gonorrhea and chlamydia and the treatment of sexual partners is advised.

Figure 22-1. Bacterial vaginosis. (A) "Clue cells". (B) Normal epithelium. (Reproduced, with pemission

from Kasper DL, Braunwald E, Fauci A, et aL Harrison's Principles of Internal Medicine. 16th ed. New Yorlc,

NY: McGraw-Hill; 2005:767.)

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is defined as inflammation of the upper genital tract, including pelvic peritonitis, endometritis, salpingitis, and tubo-ovarian abscess caused by infection with gonorrhea, Chlamydia, or vaginal and bowel flora. The presence of lower abdominal tenderness with both adnexal and cervical motion tenderness, without other explanation of illness, is enough to diagnose PID. Other 101°F, abnormal cervical or vaginal discharge, elevated sedimentation rate, elevated C-reactive protein, and cervical infection with gonorrhea or Chlamydia. Because of the clinical similarity between PID and ectopic pregnancy, a serum pregnancy test should be performed on all patients suspected of having PID.

Determination of appropriate treatment should consider pregnancy status, severity of illness, and compliance. Less-severe disease can generally be treated on an outpatient basis. Women who are pregnant, have HIV, or have severe disease

generally require inpatient therapy and treatment with parenteral antibiotics. Table 22-1 lists PID treatment regimens.

Patients who have PID need to be aware of potential complications, including the potential for recurrence of disease, the development of tubo-ovarian abscess, chronic abdominal pain, infertility, and the increased risk of ectopic pregnancy. It is important to discuss these potential problems with patients who are given a diagnosis of PID. All patients with STDs or who are at risk for developing STDs should be counseled on safer sexual practices, including abstinence, monogamy, and the use of latex condoms.

CASE CORRELATION

• See also Case 11 (Health Maintenance, Adult Female).

COMPREHENSION QUESTIONS

22.1 A 24-year-old nulliparous woman is noted to have a bothersome vaginal discharge. On examination, she is found to have a homogenous discharge with a fishy odor. Which of the following characteristics is likely to be noted on examination of the discharge?

A. Motile protozoa on wet mount

B. pH more than 4.5

C. Strawberry cervix on speculum examination

D. Budding hyphae on KOH examination

22.2 A 38-year-old woman complains of a new-onset vaginal discharge and irritation. She notes having had a urinary tract infection 10 days previously, with subsequent resolution of her symptoms following treatment. Which of the following is the best empiric therapy for her condition?

A. Oral metronidazole

B. Vaginal metronidazole

C. Oral fluconazole

D. Oral clindamycin

E. Oral estrogen and progestin therapy

22.3 A 24-year-old woman is noted to have lower abdominal tenderness, cervical motion tenderness, and a vaginal discharge. She has a low-grade fever of 100.5°F (38.0°C). Which of the following is the best therapy for her condition?

A. Ceftriaxone intramuscularly and doxycycline orally

B. Ampicillin orally and azithromycin orally

C. Metronidazole orally as a single dose

D. Ciprofloxacin orally as a single dose

ANSWERS

22.1 B. This discharge of homogenous and fishy odor is most likely bacterial vaginosis associated with an alkaline pH. Partner treatment is not necessary for bacterial vaginosis. Oral metronidazole is one treatment.

22.2 C. This patient most likely has Candida vulvovaginitis, since her discharge appeared after her cystitis, likely treated with antibiotics. A treatment for Candida vulvovaginitis includes fluconazole or topical azole agents such as miconazole.

22.3 A. An option for outpatient therapy of salpingitis (PID) is IM ceftriaxone and oral doxycycline. Oral metronidazole as a single dose is a treatment for Trichomonas vaginitis. Fluoroquinolones are not recommended in the United States for the treatment of gonorrhea or associated conditions, such as PID, due to increasing rates of resistance.

CLINICAL PEARLS

⯈ Remember to treat sexual partners when you diagnose a sexually transmitted infection and to test for other sexually transmitted infections that may initially be asymptomatic, such as HIV, hepatitis Band C, and syphilis.

⯈ Single-dose therapy is available for many types of infections, including Trichomonas, gonococcal and chlamydia! cervicitis, and Candida vaginitis. Providing single-dose therapy in your office will improve your patient's compliance, as well as rates of successful treatment.

REFERENCES

Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines. MMWR Morb Mortal Wkly Rep. 2010;59(RR-12):63-66. 

Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment 2010 guidelines: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep. 2012 August 10;61(31):590-594. 

Gradison M. Pelvic inflammatory disease. Am Fam Physician. 2012 Apr 15;85(8):791-796. 

Maier R, Katsufrakis PJ. Sexually transmitted diseases. In: South-Pau!JE, Matheny SC, Lewis EL, et al., eds. Current Diagnosis & Treatment: Family Medicine. 4th ed. New York, NY : McGraw-Hill; 2015. Available at: http://accessmedicine.mhmedical.com. Accessed May 25, 2015.

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