Evaluation of Vaginitis (PowerPoint)

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					Evaluation of Vaginitis
    Baylor College of Medicine
      Anoop Agrawal, M.D.
Vaginitis is among the most common
conditions for women to seek medical care.

Vaginal discharge accounts for
approximately 6 million to 10 million office
visits per year.

Vaginitis can be infectious or non-infectious

  Infectious is limited to three principle
  diseases: bacterial vaginosis, candidiasis
  and trichomoniasis

  Non-infectious: atrophic vaginitis,
  chemical irritation, lichen planus, allergic
 Review of normal
   vaginal flora
Lactobacilli are the predominant bacteria
and regulate the vaginal environment.

The bacteria make lactic acid which
maintains a vaginal pH of 3.8 to 4.5.

  This inhibits adherence of bacteria to
  vaginal wall.

Some lactobacilli (60%) also produce
hydrogen peroxide which has shown to
destroy HIV in vitro.
      Exam findings
Examine external genitalia, vaginal sidewalls,
and cervix, quality of discharge.

  Fissures/excoriations are signs of candidal

  ‘strawberry’ cervix assoc. with trich seen
  in only 2-5% of cases

The microscopic evaluation of vaginal
discharge is the mainstay in diagnosis of
infectious vaginitis.

Samples for pH testing should be taken by
touching swab to the sidewall of vagina
           Case One exam on a
You perform an annual pap/pelvic
sexually acitve 23 yo female. The results of
the pap and GC/Chlam are negative. However,
the pap smear report cites the presence of
clue cells. According to the chart, the patient
denied any symptoms and scant vaginal
discharge was noted on your exam.

Do you treat this woman for bacterial

  If she is asymptomatic, then no treatment is
  required. Other bacteria such as
  Gardnerella vaginalis, strep species,
  anaerobes are also present as part of the
  normal flora.
Wet Mount Preparation
Place small amount of
discharge on two slides.
Add one drop of NaCl on
one, and KOH on the

First, view the saline

Let KOH slide sit for 1 to
2 minutes to allow the
solution to dissolve the
cell membranes.

Start at low power (10x);
optimal viewing usually
at 40x, may try 100x
         Normal Wet Mount
Epithelial cell borders
will be clear, with
recognizable contents
and sharp distinct cell

On saline mount you
should see
lactobacilli - which can
vary in size but typically
are large gram positive
                               Likely lactobacilli
May also see WBCs, but       adherent to epithelial
should be less in number              cell
Bacterial Vaginosis
B.V. accounts for 10 to 50% of infectious
vaginitis cases in women of childbearing

What is the change in the vaginal flora?

  A shift from lactobacilli-dominant to a
  mixed flora that can include Gardnerella
  vaginalis, Mycoplasma hominis,

The characteristic discharge is thin, milky,
homogeneous, and fishy-smelling.
 Bacterial Vaginosis:
Diagnosis cannot be reliably made on patient’s
history alone. Studies have demonstrated
poor correlation between symptoms and final

Options for diagnosis:

  Wet mount evaluation

  culture of the vagina

  DNA probe

What are the criteria for diagnosis?
Bacterial Vaginosis:
The Amsel criteria is the standard used in
making a clinical diagnosis of B.V. Three
of the four criteria must be met:

  vaginal pH greater than 4.5

  thin, watery discharge

  wet mount showing more than 20% clue

  positive ‘whiff’ test (amine odor)
Differentiating Vaginitis
       Bacterial Vaginosis -
            Wet Mount
   Search for “clue cells” -
which are vaginal epithelial
cells with indistinct borders
because of large numbers of
adherent bacteria.

Need more than 20% of cells to
be “clue cells” for diagnosis of
bacterial vaginosis.

Lactobacilli can also adhere to
cell border, so take note of
morphology of organisms
             Case Two
30 yo female presents for her routine pap/pelvic
exam. Her LMP was 8 weeks ago and her UPT is
positive. She is asymptomatic and her exam is
normal. Her wet mount reveals clue cells. Does she
require treatment?

Though B.V. has been shown to be a risk factor for
premature labor and perinatal infection, evidence
supports treatment of high-risk women (prior h/o
preterm birth). The benefits of treating
asymptomatic, low risk pregnant women is less

If treatment is planned, then oral therapy is
recommended. Topicals should be avoided as it may
increase risk of prematurity. (CDC)
  Bacterial Vaginosis
USPSTF Guidelines gave a ‘D’
recommendation for screening of bacterial
vaginosis in pregnancy - i.e., do not screen
asymptomatic, low-risk women, supported by
fair evidence.

BV is associated with increased risk of PID,
endometritis following delivery, post-
hysterectomy infections, acquisition of HIV
and other STDs.

Hence, treatment is recommended for
asymptomatic women scheduled to undergo
certain gyn procedures to prevent
postprocedure infection.
        BV: Treatment
Oral: Metronidazole 500mg bid for 7 days

  alternative: clindamycin 300mg bid for 7 days

Topical: Metrogel (0.75%) one 5 g application
intravaginally for 5 days.

  alternative: clindamycin cream 2%

Oral vs. Topical - equal efficacy; topical with
fewer systemic side effects; patient preference

Recurrent BV infections: is common and requires
longer treatment course with above agents,
typically 10 to 14 days.
          Case Three
A 40 yo female with diabetes (Hgb A1c 6.3) is
complaining of vaginal itching and whitish
discharge. She reports having had frequent
yeast infections over the past year. She began
having symptoms last week and has tried OTC
therapies, but her symptoms have not

How reliable are a patient’s self-diagnosis of
yeast infections?

Should the patient have tried OTC therapy
before coming to see you?

What are the options in managing this patient?
Most commonly caused by C. albicans 80 to
90% of the time, though other species such
as C. glabrata and C. tropicalis can be seen.

10 to 20% of women have asymptomatic
colonization with C. albicans

Symptoms include pruritis, dysuria, and
thick curdy discharge.

Studies have shown candidiasis to have
been confirmed in only 33% of women who
self-diagnosed yeast infection.
Candidiasis: Diagnosis and
KOH wet mountTherapy
                 is best means of diagnosis,
specificity of 97%.

Oral and topical therapies have equal efficacy
rates. Again patient preference guides

Severe infections: two or three sequential
doses of 150mg fluconazole each 72 hours
apart or intravaginal therapy for 7 to 14 days.

Vaginal cultures: can be performed in patients
with persistent or recurrent symptoms
Recurrent Candidiasis
 Recurrent infection defined as four or
 more infections in one year.

 If patient is not responding to therapy,
 then infection with candida species other
 than albicans - glabrata or tropicalis.

   Non-albicans species are often
   resistant to azole therapy.

   Therapies in such cases include
   intravaginal teraconazole or boric acid.
Typical symptoms include pruritis, frothy,
yellow discharge.

Wet mount has low sensitivity, but high
specificity - i.e. 50% of wet mounts can be
negative in culture proven trichomoniasis

Treatment is single dose of 2 grams oral
metronidazole. Topical therapy is less

Unlike asymptomatic BV and candidiasis,
asymptomatic trichomoniasis should be
          Case Four
An 18 yo female reports pruritis and yellow
discharge for past 3 days. She also states
her LMP was 2 months ago. On examination
of the wet mount you see trichomonads.

Is metronidazole safe to use in this scenario?

  Yes, the CDC no longer discourages use
  during the first trimester.

What if the patient was asymptomatic and
trichomonads were found on a pap smear? or
wet mount? How would this change your
       Case Four, cont.
Trichomoniasis in pregnancy: Studies have shown
that treating asymptomatic infections in pregnancy
can increase risk of preterm delivery.

  Treat sexual partners. Reinfection of treated
  partners of untreated women can only be avoided
  by abstinence or use of condoms.

Trichomonas seen on pap smear:

  Conventional cytology is not reliable (low

  Liquid-based preps have low sensitivity (61%),
  but high specificity (99%), so it is reasonable to
  treat patient if trichomonas seen on pap.

Eckert, L.O. Acute Vulvovaginitis. New
England Journal of Medicine,

Owen, M.K. Clenney, T.L. Management
of Vaginitis. American Family Physician;
70:11; Dec 1, 2004.

Sobel, J.D. Bacterial Vaginosis.
UpToDate ® 2007.

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