Vaginitis Management

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					Vaginitis & Management


    Dr Mimi FUNG
    Associate Consultant
    O&G PMH
Physiological vaginal discharge
Bacterial flora
    Lactobacillus acidophilus
    Diphtheroids
    Candida albicans
    Gardnerella vaginalis
    E. coli
    Group B streptcocci
    Genital mycoplasmatales
Physiological vaginal discharge
 Bacterial flora
 Water, electrolytes
 Cervical & vaginal epithelium
 pH 4.0
 White, flocculant, odorless
 Dependent areas of vagina
Vaginitis
 Pruritis
 Discharge
 Odour
 Pain
 Dyspareunia
 Dysuria
Commonest Causes
 Bacterial vaginosis
 Candidiasis
 Trichomoniasis
Bacterial Vaginosis
 Commonest cause
 Not vaginitis. No single infectious agent
 A shift in composition of normal vaginal flora
 ↑ anaerobes (10x)
 Gardnerella vaginalis, Mobiluncus, Mycoplasma,
 Ureaplasma, Gram negative rods / cocci,
 Steptococcus agalactiae (GBS)
 ↓ Lactobacilli
 Not sexually transmitted
Bacterial Vaginosis
Risk factors
  Foreign bodies (tampons, caps etc)
  Douching
  Sex toys, multiple partners
  Smoking
  OC Pills
  Antibiotics
Bacterial Vaginosis
Signs & symptoms
  Vaginal wetness
  Discharge with odour
  Thin, homogenous, grey white
  Fishy odour
  Copious, adherent to vaginal walls
  Pruritis & vaginal erythema rare
Bacterial Vaginosis: Clinical diagnosis
3 out of 4 Amsel’s criteria:
1) Abnormal grey discharge
2) Vaginal pH >4.5
3) Positive “Whiff” test ( fishy odour on addition
    of 10% KOH)
4) >20% vaginal epithelial cells being clue cells on
    Gram stain (borders obscured by adherent
    coccobacilli)
Sensitivity 92% specificity 77%
Bacterial Vaginosis: Clinical diagnosis
Nugent Gram stain scoring system
   Evaluates the no. of Lactobacilli,
   Gardnerella & Mobiluncus per oil
   immersion field
   0–3          Normal flora
   4–6          Intermediate flora
   7 – 10       BV flora
Bacterial Vaginosis: Association
Non-pregnant women
    PID
    post-procedural gynaecologic infections
    (surgical abortions, hysterectomy)
Pregnant women
    Preterm labour
    Low birth weight
    Premature rupture of membranes
Bacterial Vaginosis: Treatment
   Nitroimidazoles (Metronidazole)
   400mg tds po x 7 days
   500mg BD po x 7 days
   2g po as one dose
   not recommended in 1st trimester of pregnancy
   Macrolides (Clindamycin)
   300mg BD x 7 days
Bacterial Vaginosis: Recurrence
   Up to 30% women recur within 3 months
   Persistence of pathogenic bacteria
   Reinfection from exogenous source
   Enquire into patient’s personal / sexual life
   Treatment of partner – no benefit
   Lactobacillus supplement – no benefit
   ?prolonged antibiotic therapy??
Candidal vaginitis
   Normal vaginal habitant
   Estrogen dependent
   Candida albicans: 80-95%
   Candida glabrata
   Candida tropicalis
   Immunosuppression, hormonal changes,
   antibiotic therapy, obesity
Candidal vaginitis
   Pruritis
   Vaginal irritation
   Dysuria
   White, curd like, odourless
   Vaginal erythema with adherent plaques
Candidal vaginitis
   Wet smear with KOH: hyphae & buds
   Culture
Sobel (1998)
    Uncomplicated          Complicated

       Sporadic             Recurrent

   Mild to moderate          Severe

      C. albicans          Non albicans
                            candidiasis
Non immunocompromised     Uncontrolled DM
       women            Immunocompromised
Treatment
 Uncomplicated Candidiasis
 Local Azoles
   Miconazole
   Clotrimazole
   Fluconazole
Treatment
Complicated / recurrent Candidiasis
   Fluconazole 150mg then a repeat dose 3 days
   apart
   +/- 150mg pulses weekly
   Ketoconazole 100mg QD x 6 months
   Itraconazole 50-100mg QD x 6 months
   Nystatin vaginal pessaries x 2 weeks
   Boric acid 600mg vaginally QD x 2 weeks
Trichomonasis
 Lower genital tract infection by Trichomonas
 vaginalis
 Asymptomatic to acute PID
 Vaginal discharge
 Malodorous
 Frothy
 Grey, or yellow green
 Vulvovaginitis, dysuria, dyspareunia, post coital
 bleeding
Trichomonasis
 Vaginal erythema ++
 “strawberry cervix”
 +ve amine test
 Wet mount: motile protozoans
 Pap smear
 Sensitivity 98% specificity 96%
 Diamond’s medium for culture
Trichomonasis
Metronidazole
  2 grams po single dose
  500mg BD x 7 days
  400mg tds x 7 days
Tinidazole
  2 grams singe dose
∗Treat male partner
Cervicitis
Mucopruluent cervicitis
 Chlamydia trachomatis
 Neisseria gonorrhoea
Chlamydia trachomatis
 Asymptomatic 30-50%
 Vaginal discharge / spotting
 Post coital bleeding
 Friable eroded cervix
 Yellow green pruluent discharge
 Endocervical swab for culture / antigen
 testing
Chlamydia trachomatis
Treatment
  Azithromycin 1g PO x 1 dose
  Doxycycline 100mg BD PO x 7 days
  Erythromycin 500mg QID PO x 7 days
  Ofloxacin 300mg BD PO x 7 days
Treat partner
Gonorrhoea
  Asymptomatic
  Vaginal discharge
  Dysuria
  Abnormal uterine bleeding
  Endocervical swab for culture
  Gram stain for diplococci
  Co-infection with Chlamydia
Gonorrhoea
Treatment
   Ceftriaxone 250mg IM x 1 dose
   Ciprofloxacin 500mg PO x 1 dose

Co-infection with Chlamydia
   Azithromycin 2g PO x 1 dose
Treat partner
Other causes of vaginitis
  Local irritation
    Soaps, bubble baths, perfumed toilet papers,
    pads, powder, contraceptive agents, hygiene
    products, underwear
  Foreign bodies
    Tampons, condoms, tissue
  Sexual abuse
Other causes of vaginitis
  Atrophic vaginitis
    Inflammation of vagina secondary to lack of
    estrogen
    Localized burning, dryness, soreness,
    dyspareunia, spotting
    Dry and thin vaginal walls with little / no
    rugations
    Inflammation, petechiae, exudate
Treatment
  Local estrogen cream if no history of
  vaginal bleeding
  With history of vaginal bleeding,
  investigate before treatment
Diagnostic accuracy
Useful History
  Discharge characteristics
  Itchiness
  Irritative symptoms
  Odour
Less useful
  Dyspareunia, bleeding
Diagnostic accuracy
Useful signs:
 Thick flocculent curdy discharge
 Moderate to profuse, malodorous, yellowish
 discharge
 Vaginal erythema
Diagnostic accuracy
Office laboratory tests:
 Vaginal pH
 Microscopy
    Yeasts
    Bacilli with corkscrew motility
    Trichomonads
    Clue cells
  Whiff test
Empirical treatment
Carr et al
             J Gen Intern Med 2005;20:793-799



  Vaginal pH < 4.9        Vaginal pH > 4.9
  Fluconazole             Metronidazole +/-
                          Fluconazole
Problems

   Self treat
   Empirical treatment
Complementary / Alternative Rx
 Lactobacilli
 Yogurt
 Garlic
 Tea tree oil
 Douching
 Diet adjustment
 Hormonal manipulation
Vaginal discharge: Questions to ask
Discharge             Associated symptoms
  Onset                 Itching
  Duration              Soreness
  Amount                Dysuria
  Colour                Intermenstrual /
  Blood staining        postcoital bleed
  Consistency           Abdominal/ pelvic
  Odour                 pain
  Previous episodes     Dyspareunia
Thank you

				
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posted:12/29/2011
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