Vaginitis


Patients with vulvovaginal symptoms should be seen and examined.

Note: Refer to the original guideline document for dosing information for all of the drugs listed below.
Candida

History: Vulvar itching, ± discharge, dysuria, dyspareunia

Discharge/Physical Exam: White, "cottage cheese"; pH 3.5 to 4.5; vulvar erythema

Odor: None

Testing the Discharge: On potassium hydroxide (KOH) preparation, the presence of hyphae
Treatment:
Miconazole (e.g., Monistat®)
Clotrimazole (e.g., Gyne-Lotrimin®, Femcare®, Mycelex®)
Butoconazole cream or suppositories (e.g., Femstat®)
Fluconazole (e.g., Diflucan®)
Terconazole (e.g., Terazol®)
The topical boric acid capsule may be necessary in refractory cases of recurrent disease
Comments:
One-third of all cases of vaginitis
Recent use of antibiotics associated with candidal vaginitis
Recurrent candidiasis (>4 episodes/year) occurs in 5% of women, and occur in immunocompromised hosts or patients with diabetes
Over the counter preparations are acceptable
Yogurt (which contains acidophilus) ingestion may decrease recurrence in healthy subjects
Should be treated during pregnancy
Longer treatment courses are more effective but lower compliance
Longer treatment and/or prophylaxis may be necessary in some cases
Shorter course treatment may be associated with more hypersensitivity reactions
Consider treatment with Terazol® if a recurrent infection
Boric acid needs to be specifically compounded and is usually not available the same day

Trichomonas

History: Burning, itching discharge. Dysuria, dyspareunia. Discharge/Physical Exam: Thin, grayish green; punctate hemorrhages on vagina and cervix. Odor: Malodorous Testing the Discharge: Many white blood cells, flagellated ovoid protozoa, but organisms are only seen in 50-70% of culture-confirmed cases. pH>5.0
Treatment:
Oral metronidazole
Comments:
Sexually transmitted
Male carriers are asymptomatic
Often seen on Pap smears, but many false positives. Should not treat unless the diagnosis is confirmed clinically.
Partner must also be treated simultaneously
Metronidazole is associated with an Antabuse-like interaction with alcohol or vinegar
Other important side effects of metronidazole include a metallic taste in the mouth (<10% of patients); interaction with warfarin and transient leukopenia
Association with premature rupture of membranes and prematurity is controversial. During pregnancy, common practice is to consider deferring treatment until after the first trimester, although the Centers for Disease Control and Prevention (CDC) recommends pregnant women can be treated even in the first trimester. Treatment of asymptomatic pregnant women does not prevent preterm labor. 

Bacterial Vaginosis (BV)

History: Discharge, foul smell, inflammatory symptoms absent Discharge/Physical Exam: Grayish thin, homogeneous discharge; pH>4.5. Culture has no role in diagnosis. Treat only if symptomatic. Odor: Whiff test positive Testing the Discharge: Must have 3 of the following 4 findings:
clue cells
pH>4.5
positive whiff test
homogeneous discharge
Treatment:
Oral metronidazole
Topical clindamycin
Metronidazole Gel
Comments:
Most common cause of vaginitis in women of childbearing age
Some studies suggest an association of bacterial vaginosis with preterm birth and treatment in women with previous premature birth associated with a reduction in preterm birth
Also associated with posthysterectomy, postpartum and postabortion infection
No role for vaginal culture
Metronidazole side effects (see above)
Do not need to treat a partner, since this is not a sexually transmitted disease (STD)

Atrophic vaginitis

History: Soreness, burning, dyspareunia; scant discharge Discharge/Physical Exam: Very little or watery discharge seen; thin vaginal mucosa with loss of normal contours Odor: None Testing the Discharge: Small rounded, parabasal cells, few squamous cells: increased leukocytes. pH 5-7
Treatment:
Oral estrogen (e.g. Premarin®, Estrace®)
Topical estrogen (e.g. Estroderm®)
Vaginal preparations of estrogen (e.g. Premarin® Estring)
Comments:
Occurs in prepubescent and postmenopausal women
May occur in breastfeeding women or amenorrheic women with low body fat
Oral estrogen regimens should be accompanied by progestin administration in women with an intact uterus.
Estring® associated with lower systemic absorption of estrogen.
Contact vulvovaginitisHistory: Exposure to irritants; burning, itching Discharge/Physical Exam: None Odor: None Testing the Discharge: Numerous white blood cells. Maybe normal
Treatment:
Avoidance of irritant
Comments:
Soaps, perfumes, tampons, panty liners, spermicides, latex condoms, antibacterial and antimycotic vaginal preparations can be precipitants.
Condoms are potential irritants.
Women may assume this is a yeast infection and self-treat with over the counter antifungals.

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