Vaginitis and vaginal discharge are common complaints prompting women to visit their health care providers. The differential diagnosis is extensive and should include physiologic discharge, chemical or irritant vaginitis, atrophic vaginitis, and vaginitis due to the infectious agents discussed in the following sections. Many over-the-counter products, such as topical antifungals, are widely available and allow women to self treat, often inappropriately. This makes diagnosis even more difficult and confusing when patients present with partially treated disease.
Patients with vaginitis should undergo a speculum examination with careful examination of the cervix for discharge and acquisition of cultures (2). If no cervical discharge is present, then the vaginal mucosa should be inspected and material obtained for pH as well as microscopic examination with normal saline and potassium hydroxide solutions. These simple bedside procedures should aid in determining whether or not a patient has an infectious etiology for vaginitis and guide further evaluation.
Signs and symptoms of bacterial vaginosis (BV) include a foul smelling, homogeneous, white, adherent vaginal discharge. Vulvovaginal pruritis, burning, and dys-parenuria may be associated (52). Diagnosis is usually based on clinical criteria which generally include any three of the following: (1) homogeneous, uniformly adherent discharge with little evidence of inflammation on examination; (2) vaginal fluid pH >4.5; (3) amine "fishy" odor after addition of 10% potassium hydroxide (KOH) solution to vaginal fluid; (4) presence of "clue" cells (epithelial cells with coarse granulation and bacterial studding along cell membrane) (2).
Despite being the most common cause of vaginal discharge, the pathogenesis and mode of acquisition of BV are poorly understood. There is ample evidence that it is at least in part an STD. Risk factors for BV include multiple sexual partners, a new sexual partner, douching, and intrauterine device (IUD) as contraceptive method (52). Carriage rates are higher among sexually active women than in sexually inexperienced women (52). There appears to be no counterpart infection in men and there is no evidence that treatment of sexual partners is beneficial (52).
BV probably represents a disturbance of the balance of vaginal flora more than an actual infection (52). It arises when the normal flora, especially Lactobacillus species, are replaced by bacteria such as Garderella vaginalis, Mycoplasma hominis, Prevotella species, and anaerobes such as Bacteroides sp. (52).
Table 6 lists the recommended and alternative treatments of BV. Although the cure rates of the three regimens vary from 71% to 82% at 4 wk after treatment, all three are considered equally effective (2). Metronidazole, 750 mg p.o. q.d. for 7 d, has been approved for treatment of BV, but there are no data at this time comparing its efficacy to the regimens described previously (2,52). Recurrent BV is not uncommmon and the etiology of recurrences is yet to be determined (52). There are no reports of resistance at this time.
In the pregnant patient, BV is associated with adverse outcomes such as preterm labor, preterm birth, premature rupture of membranes, and chorioamnionitis (52). A recent randomized controlled trial has shown that pregnant women with BV had lower rates of preterm delivery when treated with metronidazole and erythromycin (53). The CDC recommends that women at risk for preterm delivery be screened for BV early in the second trimester and treated if positive (even if asymptomatic) (Table 6) (2). Treatment of low-risk asymptomatic women is controversial. Intravaginal clindamycin cream should be avoided in pregnancy because of evidence of increased risk of preterm delivery (2).
Trichomoniasis is caused by the protozoan Trichomonas vaginalis. Classically, infection is associated with a thin, greenish-yellow vaginal discharge, dysparenia, vaginal irritation, and sometimes dysuria (54). On examination, a thin vaginal discharge along with punctate cervical hemorrhages (strawberry cervix) is characteristic. Men are frequently asymptomatic although trichomoniasis may cause prostatitis and epididymi-tis (54).
Although clinical examination alone is not usually sufficient to establish a diagnosis, motile trichomonads seen on a wet mount are considered diagnostic. Unfortunately, sensitivity of wet mount examination is only about 60% in women and 50-90% in men (54). Although culture remains the gold standard of diagnosis, recent studies show that detection by PCR is very sensitive (97%) and specific (98%) (55).
T. vaginalis infection is the most common nonviral STD in the United States (16). Although trichomonads can survive for up to 45 min outside the human body, the consensus view is that T. vaginalis is transmitted sexually (54). Risk factors for trichomo-niasis include multiple sexual contacts and low socioeconomic status (54). Trichomoniasis has been associated with vaginal cuff cellulitis after abdominal hys-
Treatment of Vaginitis
Metronidazole vaginal gel OR
Clindamycin vaginal cream
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