vaginitis

infectious vaginitis causes

infectious vaginitis causes

bacterial vaginosis

vulvovaginal candidiasis

trichomoniasis

non infectious vaginitis causes

atrophy- (decreased estrogen in menopause, hormone irregularities, med causes like steroids)

allergic

irritant (douching, scented products)

inflammatory

normal bacteria involved in vagina

lactobacilli

Gardnerella vaginalis, Escherichia coli, group B strep, genital Mycoplasma sp, Candida albicans

bacterial vaginosis bacteria involved

G vaginalis

bacteroides sp, peptostreptococcus sp, fusobacterium sp, prevotella sp, atopbium vaginae

vulvovaginal candidiasis organism involved

Candida albicans, other candida sp

bacteria involved in trichomoniasis

Trichomonas vaginalis

signs + symptoms of BV

fishy odor

thin homogenous discharge (worsens post coitus) ± pelvic discomfort

no inflammation

signs + symptoms of vulvovaginal candidiasis

white, thick cheesy or curdy discharge

vulvar itching or burning

dysparunia

dysuria

no odor

vulvar erythema and edema

signs + symptoms of trichomoniasis

green or yellow frothy discharge, foul order, vaginal pain or soreness

inflammation- strawberry cervic

BV pH

>4.5

vulvovaginal candidiasis pH

3.5-4.5

trichomoniasis pH

>4.5

2 options for diagnostic testing of vaginitis

microscopy + vaginal pH + amine (whiff test)

or NAAT

normal vagina pH (premenopause vs premenarchal or postmenopausal)

premenopausal 4-4.5

>4.5 pre menarchal or post menopausal

normal cells under microscope of vagina

squamous epithelial cells

parabasal cells (predominant in premenarchal and postmenopausal pts)

diagnosis for BV (2 criteria/scoring systems)

amsel clinical criteria or gram stain with nugent scoring

amsel diagnostic criteria for BV

thin homogenous discharge

positive whiff test

clue cells present on microscopy (squamous epithelial cells studded with many coccobacilli)

vag pH >4.5

**3/4 of criteria met

initial BV treatment

metronidazole 500mg po bid x 7 days

metronidazole 0.75% vagina gel 1 applicatorful (5g) PV daily x 5 days

clindamycin 2% vaginal cream 1 applicatorful (5g) PV daily x 7 days

alternative treatment regimen for BV

clindamycin 300mg po vid x 7 days

pregnancy BV Tx

metronidazole 500mg po bid x 7 days

metronidazole 250mg po TID x 7 days (if cant tolerate 500mg dose)

clindamycin 300mg po BID x 7 days

what to do for treatment of BV recurrence

first recurrence- retrial of same regimen or trial of diff initial regimen

do you treat sexual partners for BV

not recommended

when to treat BV

only if Sx

OR asymptomatic and:

• prior to IUD insertion

• prior to gynecologic surgery

• prior to therapeutic abortion

• prior to upper genital tract instrumentation

• high risk pregnancy

reccurent BV is considered how many documented separate cases

>/= 3 per year

BV suppresive therapy

after initial therapy for acute episode- start metro 0.75% vaginal gel 1 applicatorful twice weekly x 4-6mo

changing abx or extending abx may also be an option

trichomoniasis recommended diagnosis method

NAAT recommended

when to test for reinfection of trich

2wks-3mo after Tx

trich initial Tx options

metro 2g po x single dose

metro 500mg po bid x 7 days

**some say 7 day regimen recommended for women

trich pregnancy Tx

metro 2g po x single dose

do you treat sexual partners with trich

yes

how to treat trich recurrence

differentiate between recurrence or persistent infection

if one regimen fails use the alternate initial tx

otherwise consider susceptibiltiy testing

oral metronidazole counselling points

AE’s: GI upset, metallic taste, urethral burning, dark or reddish brown discoloration of urine

avoid alcohol during treatment and for up to 72hr following completion

topical metronidazole counselling points

AE; vaginal discharge, yeast infection, vulva/vaginal irritation, pain and discomfort

avoid using tampons

clindamycin (topical) counselling points

AEs: vaginal itch

delay Tx until completion of menstrual period

contains mineral oil- may decrease effectiveness of condoms and diaphragms for atleast 5 days after use

trich NAAT result

often positive

do you treat asymptomatic vulvovaginal candidiasis

no

risk factors for vulvovaginal candidiasis

recent abx use

pregnancy

uncontrolled diabetes

aids

steroid use

immunosuppresion

when to refer vulvovaginal candidiasis when minor ailment prescribing

pt is pre pubertal

1st time

underlying illness like diabetes (if uncontrolled)

pregnant

recurrence of vulvovaginal candidiasis within 2mo of last episode

immunosuppressed

is at risk of an STI (history of unprotected sex, multiple partners, casual sexual encounter)

vulvovaginal candidiasis initial treatment

topical azole therapy (clotrimazole, miconazole)

fluconazole 150mg po as single dose

terconazole 0.4% or 0.8% vaginal cream 1 applicatorful (5g) PV qhs x 7 days

pregnancy vulvovaginal candidiasis Tx

topical azole therapy PV x 7-14 days

vulvovaginal candidiasis recurrence tx (not necessarily for reccurent VVC just like one recurrence)

topical azole Tx x 7-14 days

fluconazole 150mg po x 3/7 × 3 doses

do you treat partners for vulvovaginal candidiasis

only if symptomatic

duration of therapy for topical azole Tx for candidiasis

1-3 days , or 6-7 days

when shiuld you see results with topical azole therapy

within 7 days of beginning treatment (results are not achieved more quickly with a shorter Tx)

do topical or oral azoles have more efficacy for candidiasis

equal

when to use topical azoles (what time)

at bed time

can you use topical azoles during mesnses

yes

oral fluconazole ae’s

nausea, abdominal discomfort, headache

what is complicated VVC

ANY of the following criteria:

recurrent episodes (4+ per year)

severe symptoms or findings

non C albicans candidiasis (suspected or proven)

diabetes, immunocomprimising conditions, debilitation or immunosuppresive Tx (corticosteroids)

treatment of severe VVC

give second dose of flucanazole PO 3 days after first dose

treatment of recurrent VVC caused by C albicans (induction treatments, maintenance treatments, + alternatives)

fluconazole 150mg po q 3/7 for 3 doses (induction) then q weekly x 6 months (maintenance)

alternative induciton Tx: topical azole PV x 10-14 days or boric acid 300-600mg gel caps PV daily x 14 days

alternative maintenance Tx: ketoconazole 100mg po once daily, clotrimazole 500mg PV once a month, boric acid 300mg capsule PV x 5 days each month beginning first day of menstrual cycle

if someone has non albicans VVC what is likely causative organism

C glabrata

who likely gets non albicans VVC

uncontrolled diabetics or immunocomprimesed/receiving steroids

most common Tx for non albicans VVC

boric acid 600mg PV daily x 14 days (CI in pregnancy so must just try topical azole for 2-3wks)

atrophic vaginits risk factors

menopause, lactation, oophorectomy, chemo/radiation, immunological disorders, premature ovarian failure, endocrine disorders, antiestrogen meds

irritant vaginitis Risk factors

soaps, tampons, contraceptive devices (condoms, diaphragms), sex toys, pessaries, topical products, douching, medications, clothing

allergic vaginitis risk factors

sperm, douching, latex condoms or diaphragms, tampons, topical products, meds, clothing, atopic history