Gynecological Infections: Vaginitis and PID

Vaginitis Overview

Landscape view organization:

  • Column 1: General aspects
  • Column 2: Trichomonas Vaginitis
  • Column 3: Candidiasis
  • Column 4: Bacterial Vaginosis

Trichomonas Vaginitis

  • Organism: Trichomonas vaginalis (flagellated protozoa).
  • Chief Complaint:
    • Foul-smelling, frothy discharge (main).
    • Dysuria (painful urination).
    • Dyspareunia (painful intercourse).
    • Pruritus (itching).
  • Discharge Characteristics:
    • Yellowish-green.
    • Frothy.
    • Foul-smelling.
  • pH: Greater than 4.5 (pH > 4.5).
  • Speculum Examination: Strawberry cervix (red, inflamed).
  • Sexually Transmitted: Yes; partner treatment essential.
  • Investigation of Choice: Saline microscopy (motile flagellated organisms).
  • Pap Smear: Organism size equals the size of the nucleus of epithelial cells.
  • Gold Standard Investigation: Culture.
  • Whiff Test: May or may not be positive.
  • Treatment:
    • Metronidazole 500 mg BD for 7 days, or 2 grams stat.
    • Safe in pregnancy.

Candidiasis

  • Organism: Candida albicans (fungus).
  • Chief Complaint:
    • Itching/pruritus (main complaint).
    • Scanty discharge.
    • Splash dysuria (scratching vulva, leading to dysuria).
  • Discharge Characteristics:
    • Curdy white or cottage cheese-like.
    • Scanty.
  • pH: Less than 4.5 (pH < 4.5) (between 4 and 4.5).
  • Sexually Transmitted: Generally not; treat male partner only if symptomatic.
  • Investigation of Choice: Saline microscopy (hyphae, pseudohyphae, spores), KOH staining.
  • Pap Smear:
    • Hyphae (red thread-like structures).
    • Spores (smaller than the nucleus of epithelial cells).
    • Shish kebab appearance (epithelial cells stuck to hyphae).
  • Gold Standard Investigation: Culture.
  • Whiff Test: Negative.
  • Treatment:
    • Fluconazole 150 mg oral stat.
    • In pregnancy, use topical antifungals (miconazole or clotrimazole cream); oral antifungals contraindicated.
  • Recurrent Candidiasis:
    • More than or equal to 4 episodes a year (≥4\geq 4).
    • Treatment: Fluconazole 150 mg on days 1, 4, and 7, then weekly for 6 months.

Bacterial Vaginosis

  • Organisms:
    • Replacement of normal lactobacilli (Döderlein bacilli) by:
      • Gardnerella vaginalis (most important).
      • Mycoplasma.
      • Ureaplasma.
      • Peptostreptococcus.
      • Mobiluncus.
  • Note: Called vaginosis because there is no inflammation.
  • Chief Complaint:
    • Foul-smelling discharge (main).
    • No pruritus, dysuria, or dyspareunia.
  • Discharge Characteristics:
    • Off-white/gray.
    • Foul-smelling.
    • Profuse.
  • pH: Greater than 4.5 (pH > 4.5).
  • Sexually Transmitted: Never; no partner treatment needed.
  • Investigation of Choice: Saline microscopy (clue cells – vaginal epithelial cells with bacteria adhered).
  • Pap Smear: Clue cells.
  • Gold Standard Investigation: None; Gram staining with Nugent score (7-10 indicates BV) if other methods are inconclusive.
  • Whiff Test: Always positive (characteristic).
  • Amsel's Criteria (3 out of 4 for diagnosis):
    1. Off-white/gray discharge.
    2. pH > 4.5.
    3. Clue cells ≥\geq 20% of epithelial cells.
    4. Positive whiff test.
  • Treatment:
    • Metronidazole 500 mg BD for 7 days, or Clindamycin 300 mg BD for 7 days.
    • Treatment remains the same in pregnancy.
  • Important Points:
    • Most common cause of vaginal discharge in reproductive-age females.
    • In pregnant females, can lead to preterm labor.
    • Ratio of polymorphonuclear neutrophils to epithelial cells less than 1 (due to no inflammation).