grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present
grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli.
grade 0: No bacteria present
grade 4 Gram positive cocci predomina
Amsel’s criteria
At least three of the four criteria are present for the diagnosis to be confirmed:
Thin, white, homogeneous discharge
Clue cells on microscopy of wet mount
pH of vaginal fluid >4.5
Release of a fishy odour on adding alkali (10% KOH)
Bacterial Vaginosis: Management
General advice
Avoid vaginal douching
Avoid use of shower gel
Avoid use of antiseptic agents or shampoo in the bath etc
Treatment indicated:
Symptomatic women
Women undergoing some surgical procedures
Women who do not volunteer symptoms may elect to take treatment if offered
Bacterial Vaginosis: Treatment
Metronidazole 400mg twice daily for 5-7 days
Metronidazole 2 g single dose
Intravaginal metronidazole gel (0.75%) once daily for 5 days
Intravaginal clindamycin cream (2%) once daily for 7 days
Alternative regimens
Tinidazole 2G single dose
Or
Clindamycin 300 mg twice daily for 7 days
TOC not indicated
PN not indicated
Case 2: Trichomonas Vaginalis
25 yr old Female
1/52 Vaginal soreness
Profuse offensive discharge
Dysuria
Discomfort during SI
LSI 2/52
CMP ONS UPSI
4 SP in last 3/12 – P/UPSI
On implant for contraception
PMhx – NAD
Trichomonas Vaginalis
Flagellated protozoon.
Found in
the vagina,
urethra (90% )
paraurethral glands.
Infection can only follow intravaginal or intraurethral inoculation of the organism.
Trichomonas Vaginalis: Symptoms
10-50% are asymptomatic.
Commonest symptoms are:
vaginal discharge
vulval itching
dysuria
offensive odour (+/-)low abdo pain
(+/-) vulval ulceration.
Trichomonas Vaginalis: Signs
Up to 70% have vaginal discharge, from thin and scanty to profuse and thick.
Classical frothy yellow discharge occurs in 10-30%.
Other signs include vulvitis, vaginitis and 2% of patients have strawberry cervix.
Trichomonas Vaginalis: Complications
Associated with preterm delivery and low birth weight in pregnancy
May predispose to maternal postpartum sepsis
May enhance HIV transmission
Trichomonas Vaginalis: Diagnosis
TV testing should be done in women complaining of vaginal discharge or vulvitis, or found to have evidence of vulvitis, and/or vaginitis on examination
Swab taken from posterior fornix during speculum examination
Self-taken swabs are likely to give equivalent results
Nucleic acid amplification tests (NAAT) if available.
Trichomonas Vaginalis: Diagnosis
Microscopy
Detection of motile trichomonads by light-field microscopy.
The wet preparation should be read within 10 minutes of collection.
Culture
Culture has a higher sensitivity compared to microscopy and can detect TV in men.
Point of care tests
OSOM Trichomonas Rapid Test (Genzyme Diagnostics, USA) has demonstrated a high sensitivity and specificity
Molecular detection
NAATs offer the highest sensitivity. They should be the test of choice where resources allow and are becoming the current ‘gold standard’.
Trichomonas Vaginalis: Management
General Advice
Full explanation of diagnosis with written information.
Screening for other STIs
Recommended Regimens
Metronidazole 400-500mg twice daily for 5-7 days
Alternative Regimens
Tinidazole 2g orally in a single dose
TOC is recommended in 1/52 for symptomatic patient
PN: partners should be treated
Case 3: Vulvovaginal Candidiasis
19 yr Female
3/7 Severe vulval soreness
Itching
Cuts on vulval skin
Burns when PU
Clumpy white discharge
Not sexually active
Normally fit and well
Recent chest infection Rx with abx
No contraception
Periods normale 5/28
Vulvovaginal Candidiasis
An acute inflammatory dermatitis of the vulva and vagina caused by mucosal invasion of commensal yeast species, caused in 80-92% by Candida albicans
Non-albicans species e.g. C. glabrata, C. tropicalis, C. krusei, C.parapsilosis, and Saccharomyces cerevisiae
Vulvovaginal Candidiasis: Symptoms:
Vulval itch
Vulval soreness
Vaginal discharge
Superficial dyspareunia
External dysuria
Vulvovaginal Candidiasis: Signs:
Erythema
Fissuring
Discharge, typically curdy but may be thin. Non-offensive.