Vaginitis

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Vaginitis

• Whats Really Going on Down There?

2
Objectives

• To understand the most common forms of vaginitis
• To be able to distinguish between and to
  diagnosis the causes of vaginitis
• To select the most appropriate treatment for
  various forms of vaginitis.

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Vaginitis

• Vaginal discharge is the most common symptom
  complaint in gynecology
• Prompts about 10million visits a year
• Variety of causes, but most common are infection
  and atrophy
• three main types of infection are bacterial
  vaginosis accounts for 50 of cases. Trichomonas
  and Candidal are 25 each.
• Atrophy universally associated with menopause

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Causes of Vaginitis

• Type of Vaginitis
• Allergic
• Atrophy
• Chemical irritation
• Foreign Body with or w/o infection or trauma
• Lichen planus
• Bacterial Vaginosis
• Trichomoniasis
• Vulvovaginal candidiasis

• Etiology/comments
• Latex, sperm, douching, hygiene products
• Estrogen deficiency
• Soaps, Hygiene products
• Tampons, pessary or other contraceptive device
• Associated with skin or oral lesions
• Gardnerella, bacteroides, mycoplasma hominis
• Tricamonas Vaginalis
• C. albicans, glabrate, tropicalis

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Bacterial Vaginosis

• Replacement of normal Lactobacillus sp. in the
  vagina with high concentrations of anaerobic
  bacteria
• Cause of microbial alteration is not fully
  understood.
• Associated with multiple sex partners, douching,
  and lack of lactobacilli.
• Up to 50 of women with BV may not report any
  symptoms.

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Bacterial Vaginosis

• Thin, homogeneous, white discharge that coats the
  vaginal walls
• Presence of clue cells on micro examination
• pH of vaginal fluid 4.5
• A fishy odor of vaginal discharge before or after
  treatment with KOH solution (whiff test)

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BV Treatment regimens

• Recommended regimens
• Metronidazole 500mg po twice a day for 7 days.
• Metronidazole gel 0.75 one full applicator
  intravaginally for 5 days
• Clindamycin cream 2 one full applicator
  intravaginally for 7 days
• Alternative regimens
• Metronidazole 2g orally single dose.
• Clindamycin 300mg orally twice a day for 7 days
• Clindamycin ovules 100mg intravaginally for 3
  days
• Routine treatment of sexual partners not
  recommended

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BV in Pregnancy

• Associated with adverse pregnancy outcomes to
  include PROM, preterm birth, preterm labor and
  postpartum endometritis.
• All symptomatic pregnant women should be
  evaluated and treated.
• Recommended regimens
• Metronidazole 250mg orally three times a day for
  7 days
• Clindamycin 300mg orally twice a day for 7 days.

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Candida Vaginitis

• Produced by a ubiquitous airborne gram-positive
  fungus
• 75 of cases are caused by Candida Albicans
• 5-20 are produced by C. glabrata and C.
  tropicalis. The percentage of infections from
  these two organisms have increased in the past
  few years.
• Candida species are part of the normal flora of
  _at_25 of women. Prevalence greater in the rectal
  and oral mucosa. When the ecosystem of the vagina
  is disturbed, candida becomes an opportunistic
  pathogen.
• Lactobacilli inhibit the growth of fungi in the
  vagina however, when the relative concentration
  of lactobacilli declines, the rapid overgrowth of
  Candida occurs.

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Candida Vaginitis

• Primarily a disease of child bearing years.
• Approximately 3 out of four women will have a
  least one infection during their lifetime
• Rarely found mixed with Trichomonas or bacterial
  vaginosis.
• Not associated with other sexually transmitted
  diseases.
• 10 of male partners may have concomitant penile
  infection. However, treatment of partners does
  not reduce the recurrence rate
• No direct relationship to the number of organisms
  and patient signs/symptoms

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Causes of Candida Vaginitis

• C. albicans is not usually a pathogenic organism.
  Overgrowth in vagina is caused by host factors
  that establish growth
• Hormonal factors changes associated with both
  pregnancy and menses. ? High estrogen levels
• Depressed cell immunity exogenous
  corticosteriods, AIDS etc
• Antibiotic use broad spectrum that destroy
  lactobacilli

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Candidal Vaginitis

• Nonmalodorous thick white discharge that adheres
  to vaginal walls.
• Hyphal forms or budding yeast cells on
  microscopic evaluation
• Pruritus
• pH level

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Treatment

• Topical application of imidazoles- miconazole,
  clotrimazole, butoconazole or tioconazole.
• Equal effectiveness between the traditional 7 day
  therapy and 3 day.
• Exert action by changing the permeability of the
  surface membrane of the fungus.
• Cure rates exceed 90
• Most women prefer oral therapy with single dose
  Diflucan 150mg which produces therapeutic
  concentrations in vaginal secretions for a
  minimum of 72hr

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Recurrent Infections

• Defined as 4 or more episodes of symptomatic
  vaginal infections during 12month time period
• Women are 3X more likely to be asymptomatic
  carriers of C.albicans
• ? Drug sensitivity
• Culture of vaginal discharge to identify fungus
  species
• Potential therapy includes gentian violet, boric
  acid, povidone-iodine douching or dietary changes.

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Treatment of Recurrent Infections

• Acute Episodes
• Clotrimazole 100mg intravaginally X 7 days
• Diflucan 150mg po X1
• Ketoconazole 200mg po daily X14days
• Boric Acid 600mg vaginal suppository bid X14 days
• Prophylaxis
• Clotrimazole 100mg 2 tabs intravaginally twice
  weekly for 6 months
• Ketoconazole 100mg po daily for 6 months
• Diflucan 150mg po qmonth
• Boric Acid 600mg vaginal suppository daily during
  menstruation

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Trichomonas Vaginalis

• Unicellular flagellated protozoan that inhabits
  the vagina and lower urinary tract.
• Estimated 2.5 to 3 million cases in the U.S. each
  year.
• Most common non-viral and non-chlamydial sexually
  transmitted disease.
• Incubation period 4-28 days and can survive up to
  24hrs on wet surface.

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Trichomonas Vaginitis

• Copious amounts of yellow-gray to green frothy
  malodorous discharge
• pH level 4.5
• Mobile, flagellated organisms and leukocytes on
  wet-mount.
• Vulvovaginal irritation and dysuria

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Trichomonas Treatment options

• Initial measures (including asymptomatic
  patients)
• Flagyl 2gm po x1 or
• Flagyl 500mg po bid x 7days
• Treat male sexual partners
• Treatment failures
• Re-culture patient
• Retreat with Flagyl 2gm po followed by trial of
  Flagyl 2gm po daily X 5 days if patient still
  infected after second treatment.

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Atrophic Vaginitis

• Estimated 10 to 40 of postmenopausal women have
  symptoms of atrophic vaginitis.
• In pre-menopausal women, the vaginal epithelium
  is rugated and rich in glycogen stores.
  Lactobacilli depend on glycogen for from sloughed
  vaginal cells. Lactic acid produced by these
  cells lowers vaginal pH to 3.5- 4.5. This is
  essential for the bodys natural defense against
  infection
• Menopause is the leading cause of decreased
  circulating levels of estrogen
• After menopause, the endometrium is thinned and
  the increased vaginal pH predisposes the vagina
  and urinary tract to infection and mechanical
  weakness.

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Symptoms

• Decrease in vaginal lubrication
• Dryness
• Dyspareunia
• Vulvar pruritus
• Yellow malodorous discharge
• Urethral discomfort
• Sexual dysfunction

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Diagnosis

• History exogenous agents that may cause or
  aggravate symptoms.
• Perfumes, powders, soaps, panty liners.
  Tight-fitting clothing and use of synthetic
  materials can worsen symptoms.
• Exam atrophic epithelium appears pale smooth and
  shiny.
• Inflammation and easy friability. External
  genitalia may also have diminished elasticity,
  sparsity of pubic hair, vulvar lesions
• Lab findings
• serum hormone levels, cytologic examination of
  smears and ultrasound of endometrial thickness.
  Elevated pH level (5).

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Treatment Options

• Estrogen replacement
• Most effective in the restoration of anatomy and
  resolution of symptoms.
• Replacement therapy restores the normal pH levels
  and thickens and revascularizes the normal
  epithelium
• Systemic therapy
• may not eliminate the symptoms in 10-25 of
  patients.
• Usually needed for 24months to eradicate dryness
  but some may not respond to this length of
  treatment
• Transvaginal therapy
• effective in relieving symptoms without causing
  significant proliferation of the vaginal
  epithelium.
• Multiple delivery systems to include creams,
  pessaries or hormone releasing ring.
• Moisturizers and lubricants
• Help maintain natural secretions and coital
  comfort.
• May be used in conjunction with estrogen
  replacement therapy or as alternative therapy.
  Effectiveness is generally less then 24hr.

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Question 1

• A 31year old married white female complains of
  vaginal discharge, odor and itching. Speculum
  exam reveals a homogenous yellow discharge,
  vulvar and vaginal erythema and a strawberry
  cervix.
• The most likely diagnosis is
• A. Candidal Vaginitis
• B. Bacterial Vaginosis
• C. Trichomonal Vaginitis
• D. Chlamydial infection
• E. HSV type 2

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Answer 1

• C. Trichomonal Vaginitis

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Question 2

• 22yo female presents for recurrent vaginal
  discharge. She states that discharge is white in
  color and has slight odor. Occurs several times a
  year and she tries OTC antifungal meds to help
  resolve the issue. No itching or irritation.
  Denies douching or using perfumes or powders over
  area. Symptoms usually occur around menses. Has
  not had formal evaluation her PCM prescribed
  oral Diflucan based on her symptoms after she
  left a T-con.
• On PE no vulvar lesions. white discharge that
  pools in the posterior fornix. Normal appearing
  cervix. pHseveral gram positive rods. Based on these
  findings, you decide
• A. Treat her for extended period with oral
  antifungals while awaiting culture results
• B. Reassure patient that discharge is physiologic
  and review hygiene with her.
• C. Treat with Flagyl 500mg po bid for 7 days
• D. Recommend that patient return for evaluation
  after extended period off medications and
  re-evaluate

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Answer 3

• B. Reassure patient that discharge is physiologic
  and review hygiene with her.

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Question 3

• Which of the following statements are true?
• A. The USPSTF concludes that the evidence is
  insufficient to recommend for or against
  routinely screening high-risk pregnant women for
  bacterial vaginosis
• B. The USPSTF recommends against routinely
  screening average-risk asymptomatic pregnant
  women for bacterial vaginosis
• C. All of the above.
• D. None of the above

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Answer 3

• C. All of the above.
• The USPSTF found good-quality studies with
  conflicting results that screening and treatment
  of asymptomatic bacterial vaginosis in high-risk
  pregnant women reduce the incidence of preterm
  delivery. The magnitude of benefit exceeded risk
  in several studies, but the single largest study
  reported no benefit among high-risk pregnant
  women.
• There is good evidence that screening and
  treatment of bacterial vaginosis in asymptomatic
  women who are not at high risk do not improve
  outcomes such as preterm labor or preterm birth.

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Questions?
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References

• Stenchever Vaginitis. Comprehensive gynecology,
  4th ed. 2001.
• Centers for Disease Control and Prevention (CDC)
  Sexually Transmitted Diseases Treatment
  Guidelines 2002. MMWR, 200251(No. RR-6).
• Clenney T.L., Jorgenson S.K., Owen M. Vaginitis.
  Clinics in Family Medicine (2005) 71
• Bachmann G.A., Nvadunsky N.S. Diagnosis and
  Treatment of Atrophic Vaginitis. American Family
  Physician. (2000) 61

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Vaginitis

• Objectives
• Epidemiology
• Classifications
• Bacterial Vaginosis
• Presenting signs/symptoms
• Diagnostic evaluation
• Treatment
• Trichomonas
• Presenting signs/symptoms
• Diagnostic Evaluation
• Treatment
• Candidal
• Presenting signs and symptoms
• Diagnostic evaluation
• Treatment
• Atrophic
• Presentation
• Diagnostic Eval
• Treatment

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Fem-V

• New at-home test to help determine how to treat
  vaginal infections.
• Many women try to use anti-fungal meds first
• Diagnostic strip placed inside a panty liner that
  measures the pH and vaginal discharge.
• test if discharge is watery and higher then
  normal pH suggestive of bacterial infection
• Not reliable if used
• Within 48hr of intercourse
• Within 72hr of using contraceptive creams
• During menses for 1 day before and 5 days after
• Incorrectly indicates bacterial infection 20 and
  false negative 10

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Question 4

• Pruritis Vulvae
• A. Is effectively treated with local estrogen
• B. Is associated with thin vaginal epithelium
• C. Occurs as a part of normal menopause
• D. Can occur secondary to candidiasis or
  trichomoniasis

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Answer 4

• D. Can occur secondary to candidiasis or
  trichomoniasis