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Updated: May 11 2020

Vaginitis

Images
https://upload.medbullets.com/topic/114061/images/bacterial_vaginosis_001.jpg
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  • Snapshot
    • A 26-year-old woman presents to her primary care physician due to a foul smelling vaginal discharge. She reports that this is the first time this occurred. She describes the discharge as off-white with a "fish-like" odor. She denies any pain during sexual intercourse, post-coital bleeding, burning, or pruritus. She has a new sexual partner where she consistently uses condoms. She reports to recently practicing vaginal douching. On physical exam, the vulva appears normal. Speculum examination demonstrates an off-white to gray vaginal discharge and a normal cervix. Vaginal pH is 5.5. An amine test is positive. Saline microscopy demonstrates clue cells within the vaginal epithelium.
  • Introduction
    • Clinical definition
      • vaginal disorder secondary to
        • infection
        • inflammation
        • changes in normal vaginal flora
    • Epidemiology
      • risk factors
        • bacterial vaginosis
          • multiple sexual partners
          • antibiotic use
          • intrauterine contraceptive device
        • trichomoniasis
          • multiple sexual partners
          • history of sexually transmitted infections
        • vulvovaginal candidiasis
          • immunosuppression (e.g., transplant patients and HIV infection)
          • uncontrolled diabetes
          • antibiotic use
    • Etiology
      • the most common infections include
        • bacterial vaginosis
        • Candida vulvovaginitis
        • trichomoniasis
    • Pathobiology
      • normal biology
        • in premenopausal women, the vaginal nonkeratinized stratified squamous epithelium contains a large amount of glycogen
          • lactobacilli use this glycogen from sloughed cells to produce lactic acid creating an acidic vaginal environment (pH 4-4.5) that prevents the growth of pathogenic organisms
            • acidic enviroment normally maintains normal vaginal flora
      • pathogenesis
        • disruption of this acidic environment results in vaginitis
          • disruptive causes include
            • menstruation
            • sexual activity
            • pregnancy
            • foreign bodies
            • sexually transmitted disease
            • hygienic products
            • antibiotics
            • hypoestrogenic states (e.g., menopause)
    • Prognosis
      • bacterial vaginosis
        • infection may recur in 30% of women
      • trichomoniasis
        • infection may recur in 5-31% of cases
      • vulvovaginal candidiasis
        • infection may recur in ~ 50% of initially infected women
  • Presentation
      • Vaginitis
      • Vaginitis
      • Etiology
      • Clinical Presentation
      • Bacterial vaginosis
      • Gardnerella vaginalis
      • Symptoms
        • malodorous ("fishy" odor) vaginal discharge
        • nonpainful
      • Physical exam 
      • off-white or gray and thin vaginal discharge
      • normal vulva
      • Vulvovaginal candidiasis
      • Candida albicans
      • Symptoms
        • pruritus and soreness
        • dyspareunia
      • Physical exam
        • thick, white, odorless, and curd-like vaginal discharge
        • vulvar erythema and edema
      • Trichomoniasis
      • Trichomonas vaginalis
      • Symptoms
        • malodorous
        • greenish discharge
        • burning dyspareunia and dysuria
        • postcoital bleeding
      • Physical exam
        • malodorous discharge
        • "strawberry" cervix
        • vulvovaginal erythema
      • Important note 
        • sexually transmitted; therefore, the partner must also be treated
  • Studies
    • Management approach
      • a definitive diagnosis can be obtained by examining the vaginal discharge for
        • pH
        • fishy amine odor
        • microscopy
    • Speculum exam
      • indication
        • to evaluate for underlying causes of vaginitis
          • foreign body (e.g., retained tampon) leading to vaginitis
      • Vaginal pH
        • normal findings
          • pH of 4-4.5
        • bacterial vaginosis
          • pH of > 4.5
        • vulvovaginal candidiasis
          • pH of 4-4.5
        • trichomoniasis
          • pH of 5-6
      • Saline microscopy (wet mount)
        • bacterial vaginosis
          • clue cells found in epithelial cells
        • vulvovaginal candidiasis
          • pseudohyphae
        • trichomoniasis
          • motile trichomonads
        • Potassium hydroxide (KOH) wet mount
          • vulvovaginal candidiasis
            • pseudohyphae
        • Amine test ("whiff" test)
          • positive in ~70-80% of patients with bacterial vaginosis
  • Differential
    • Atrophic vaginitis
      • distinguishing factors
        • typically seen in menopausal womenon
        • physical exam there is
          • thinning of the vaginal epithelium
          • loss of rugae
          • cervicovaginal friability
  • Treatment
    • Medical 
      • metronidazole
        • indications
          • first-line agent for both pregnant and nonpregnant women with bacterial vaginosis
            • clindamycin is an alternative
          • first-line agent pregnant and nonpregnant women with trichomoniasis
            • tinidazole is another option
          • sexual partner must be treated and sex must be avoided until treatment is complete and the patients are asymptomatic
      • -azole 
        • indication
          • first-line treatment option for women with vulvovaginal candidiasis
            • topical -azoles are preferred in pregnancy
        • medications include
          • fluconazole
          • clotrimazole
          • miconazole
  • Complications
    • Bacterial vaginosis
      • miscarriage and spontaneous abortion
      • maternal infection
      • postpartum endometritis
      • neonatal complications include
        • low birth weight
        • prematurity
    • Trichomoniasis
      • premature rupture of membranes
      • preterm premature rupture of membranes
    • Vulvovaginal candidiasis
      • premature rupture of membranes
      • preterm labor
      • cerebral candidiasis in the neonate
      • neonatal death
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