Vaginitis

Kamala Jain, MD R1 Immersion Block Summer 2012

Symptoms- vaginal discharge, often causes itching or odor, may cause dysuria and dyspareunia

Vaginitis

Vaginitis Differential

• Bacterial Vaginosis ( BV) • Candida vulvovaginitis • Trichomonal Vaginitis • Atrophic Vaginitis • Chemical Vaginitis

Vaginitis Diagnosis • History

– Detailed history – Characteristic of discharge

• Odor, quantity, pruritis

• Examination of the vulva, vagina and the discharge and upon microscopic evaluation of the vaginal discharge and determination of its pH.

Vaginitis Diagnosis

History alone is NOT enough to make the

specific diagnosis, a pelvic examination and vaginal pH and microscopy testing must also be performed.

Case #1

A 23 y.o. GoPo presents to your office complaining of a vaginal discharge and odor. What further questions do you want to ask her?

History & Vaginitis • Risk Factors for Bacterial Vaginosis ( BV)

– Douching, prior history of BV • Candida vulvovaginitis

– HIV, diabetes, recent antibiotics, steroid use, any immunosupresive agents

• Trichomonal Vaginitis – Sexual history

pH Testing and Microscopy • Obtain vaginal pH

– Normal vaginal pH 3.8-4.2 • Perform Whiff Test • Perform Microscopy

– Saline wet Prep – KOH testing

Factors Falsely Affecting pH • Saline falsely elevates pH • Endocervical secretions have a higher pH

than vaginal secretions • Menstrual secretions, blood, increase pH • Sperm increases pH

– Ask when last sexual intercourse occurred

Microscopy At the VA

ONLY USE IN CLINIC FOR TEACHING PURPOSES, Do not document what you see under the microscope in CPRS note.

We must also send a vaginal in pouch specimen

to the VA Lab for diagnosis. Be certain to obtain this specimen at the same time you collect the specimen to view in the lab.

Differential: elevated vaginal pH • Bacterial Vaginosis • Trichomonas Vaginitis • Atrophic vaginitis • Menstrual secretions, blood, increase pH • Sperm increases pH

– Ask when last sexual intercourse occurred

Diagnosis of Bacterial Vaginosis

• the presence of homogeneous discharge • pH > 4.5 • positive KOH whiff test • Presence of clue cells on microscopic

assessment of a saline smear

Clinical Diagnosis of BV is defined by three out of four of the following:

Treatment of Bacterial Vaginosis • Metronidazole 500 mg bid x 7 days • No need to treat partner

– Not considered a STI • If douching, counsel to stop

Diagnosis Candidiasis • Vaginal ph 4 • Microscopy

– Pseudohyphae on saline wet prep – Microfilaments on KOH – May be some WBCs

• Perform culture only for refractory cases or non-responsive to standard therapy.

Treatment of Candidiasis • Intravaginal azoles • Fluconzole 150 mg po now then 150 mg

again if no response in 72 hours • Perform culture only for refractory cases or

non-responsive to standard therapy.

Diagnosis Trichomonas • Vaginal ph 5, amine odor • Microscopy

– Motile Trich on saline wet prep – Increase in WBCs

Treatment Metronidzole 500 mg bid x 7 days or one

time dose 2 grams *** must treat partner too, STI

Diagnosis of Atrophic Vaginitis • Characteristic vaginal symptoms and

appearance on physical exam • Vaginal ph 5 • Microscopy

– Parabasal cells ( cuboidal) – May be some WBCs

Treatment: Topical estrogen or estring

Examination of Vaginal Wet Preps: Training