Updated: 5/20/2018

Vaginitis

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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. (Bacterial vaginosis)
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
  • 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 women
      • on 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
Clue
cells (vaginal epithelial cells covered with
Gardnerella) have stippled appearance along
outer margin (arrow in A ).
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RP.75) A 24-year-old woman presents complaining of a new onset vaginal odor. She reports that she is sexually active in a monogamous relationship with the same partner for two years. You perform a KOH prep, and notice an abnormal smell. On microscopy in your office, you observe the findings in figure A.

What is the most likely causative organism? Review Topic

QID: 106728
FIGURES:
1

Trichomonas vaginalis

13%

(13/97)

2

Candida albicans

4%

(4/97)

3

Escherichia coli

0%

(0/97)

4

Gardnerella vaginalis

78%

(76/97)

5

Neisseria gonorrhoeae

1%

(1/97)

M1

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