Sexually Transmitted Infections and Vulvovaginitis - handout



Vulvovaginitis and Cervicitis: Pathogenesis, Diagnosis and Treatment

Questions to be answered this lecture:

1. What are common symptoms of vaginitis?

2. What is the difference between vaginitis and cervicitis?

3. What are the top 3 causes of vaginitis?

4. How are the causes of vaginitis diagnosed and treated?

5. What are the top causes of cervicitis and how are they diagnosed and treated?

Case 1: Bacterial Vaginosis

A 22 y/o Caucasian female c/o 1 week of vaginal itching and irritation. She has not noted any vaginal discharge, abdominal pain or fevers. She is currently sexually active with one partner, believes she is in a monogamous relationship and uses oral contraceptives only for contraception. You believe she is complaining of symptoms of vaginitis.

1. What are the common sx of vaginitis?

a. discharge, pruritis, irritation, soreness, odor. Less commonly: dyspareunia, bleeding and dysuria.

b. Abdominal pain suggests PID

c. Suprapubic pain suggests cystitis

2. What is the difference between vaginitis and cervicitis?

a. Location of inflammation and cause

b. Cervicitis often presents with a vaginal discharge that can be confused with vaginitis

You perform a pelvic exam that reveals a thin white discharge, normal vulvar and vaginal mucosa, and a normal appearing cervix. She has no cervical motion tenderness or adnexal tenderness. You perform a routine pap smear, as well as test for the top causes of vaginitis and cervicitis.

1. What are the 3 main causes of vaginitis?

a. Bacterial vaginosis (40-50%)

b. Candidiasis (20-25%)

c. Trichomoniasis (15-20%)

d. Note, 2 of the top 3 are not typically considered sexually transmitted.

2. What are the 2 main causes of cervicitis?

a. Nisseria gonorrhea

b. Chlamydia trachomatis

3. What clinical scenarios make one diagnosis more likely than others?

a. Recent antibiotics – candida

b. New partner – gonorrhea, chlamydia or trichomonas

c. Symptoms begin premenstrually – candida

d. Symptoms postmenstrual - trichomonas

You perform cultures for GC and chlamydia and prepare slides for examination.

1. What characteristics of the top 3 causes of vaginitis will you see on your exam and your slides?

1. BV – (3 of 4 must be present) Homogeneous grey white discharge, Vaginal pH >4.5, Fishy odor with KOH, Clue cells on saline wet mount – single most reliable predictor (epithelial cells covered with coccobacilli.)

2. Candida – +/- clumpy white discharge, budding hyphae, vaginal pH4-4.5

3. Trichomonas – motile trichomonads on NS, possible + pap.

Your patient has clue cells on her saline wet mount, a fishy odor with KOH and a grayish discharge on exam. You diagnose her with bacterial vaginosis. She is immediately angry when you tell her, and is ready to storm out of the room to confront her boyfriend.

1. What can you tell her about the transmission and risk factors for BV? Is it sexually transmitted?

a. Pathogenesis: Change in vaginal flora: Reduction in lactobacilli. Increase in Gardnerella vaginalis, mobiluncus, mycoplasma hominis anaerobic gram negative rods and peptostreptococcus (all produce amines).

b. Risk factors: multiple or new sexual partners, early age of coitus, douching, cigarette smoking, IUD.

c. Can occur in women who have never had sexual intercourse

2. What is the treatment for BV?

a. Flagyl 500 mg po bid x 7 days (70-90% cure). Can also use a one time dose of 2G po, but have a higher treatment failure. Topical clindamycin is an alternative treatment, but may be less effective than flagyl. May cause more resistance, more low lactobacillus counts posttreatment, and there is a risk of pseudomembranous colitis.

3. Does her sexual partner need to be treated?

a. NO

You prescribe her a course of flagyl. Her symptoms initially resolve, but she returns 1 month later with recurrent symptoms. You examine her again and diagnose recurrent BV.

1. How do you treat recurrent infections?

a. You can retreat with a 10-14 day course of flagyl

b. Recurrent cases often benefit from suppressive therapy with twice weekly metronidazole gel for 3-6 months.

Other important points about BV:

1. No need to treat asymptomatic patients

2. Resolves spontaneously in 1/3 of women

3. Treat even if asx prior to abortion or hysterectomy – decreases post op infection rate

4. May increase risk of preterm delivery in pregnant women – controversial. Screening of pregnant women only at high risk for preterm delivery – no evidence that universal screening/tx decreases preterm deliv.

5. If treating a symptomatic pregnant woman or a woman trying to conceive, prefer to use clindamycin (2% vaginal cream x 7 nights or 300 mg po bid for 7 days) due to teratogenicity of flagyl.

Case 2: Candida vulvovaginitis

A 35 year old woman with type II dm and HTN comes to your office complaining of a week of vaginal pruritis and dysuria. She denies any discharge. Urinalysis shows 6-10 wbc, urine culture is negative. You perform a pelvic exam, send off cultures and prepare slides for examination. Wet mount has increased numbers of WBCs. KOH reveals budding hyphae.

2. What is the diagnosis? Candida vaginitis

3. What is the pathogenesis and risk factors for candida vaginitis?

- causes 1/3 of vaginitis (but epidemiologic data incomplete due to self reported histories and OTC medication use)

- 75% of women report at least 1 episode

- Risk factors: sporadic, dm, antibiotic use – esp with metronidazole used for bv. Lactobacillus administration during and after abx use does not decrease incidence., OCPs (esp with high levels of estrogen), vaginal sponge, diaphragm and IUD, pregnancy, immunosuppression (steroids, HIV)

- Not generally considered a sexual dz, but may be transmitted sexually – you see an increase in incidence at the time women begin having sexual intercourse.

4. How is candida diagnosed?

a. Clinically – vulvar pruritis, dysuria, soreness, irritation, dysparunia. Erythema of vaginal mucosa, D/C may be cottage cheese like, but can also be scant and thin like other infections.

b. Vaginal pH 4-4.5

c. May see on wet mount (50%). KOH increases sensitivity to 70%. Culture patients in whom you have a high suspicion and negative microscopy if symptomatic. Alternative = empiric therapy.

5. Do you need to treat asymptomatic women?

a. 10-20% of women are asymptomatic.

b. No – you do not need to treat if asx.

6. How do you treat candida vaginitis?

a. Patient preference is key. No improvement in cure rate with oral vs. intravaginal preparations.

b. Oral agents more convenient. Only oral fluconazole 150 mg x1 is approved by the USDA. Drug is at therapeutic levels for 72 hours after administration.

c. Oral azoles contraindicated in pregnancy.

7. In what situations might you consider a longer course of therapy? (14 days intravag, 2 doses 3 days apart of fluconazole)

a. Uncontrolled dm, immunosuppression, recurrent candida.

b. C. glabrata may be resistant to azoles – often have to use intravaginal boric acid (600 mg capsule qd x 14 days) or flucytosine (5 G qhs x 14d)

8. Do sexual partners need to be treated?

a. Most experts say no

9. Not assoc with poor pregnancy outcomes

10. How do you define recurrent candida vaginitis?

a. > 4 episodes/year

b. Occurs in 5-8% of women (may be due to immunosuppression or genetic susceptibility

c. Administration of lactobacillus as a means of decreasing recurrence has never been proven effective.

d. No benefit proven in treating sexual partners

e. May consider even giving fluconazole 150 mg q72 hours until patient asx, followed by weekly dosing, tapering to q2 weeks, q3 weeks, etc as long as patient remains asx. Redosing once a month prior to menses may be effective as this is when flares occur.

Case 3: Trichomonas

A 24 y/o woman comes into your office for a routine gynecological exam. She currently has no new complaints. She does note that she has a vaginal discharge that has been present and unchanged for 2-3 years. She has a new sexual partner as of 2 months ago. You examine her, perform a pap smear and cultures and send her on her way. The pap smear reports is that trichomonas is present.

1. What is the sensitivity of a pap smear for trichomonas? 60% PPV is low – so NEED to confirm with a wet mount or culture. However, PPV of liquid based cytology is much greater (sensitivity 96%, specificity 99%), so it is reasonable to start treatment based off of thin prep pap alone.

2. What percentage of people do not have MOTILE trichomonads seen on wt mount? 30-50%

3. What is the treatment for trich? Oral metronidazole (2 G po x1 or 250 mg po x 7d (often better tolerated) (intravaginal will not get the trich in the periurethral glands (bartholins and skene’s)

4. What about pregnant women ? Usually only treat symptomatic women until after the 1st trimester due to possible teratogenicity of metronidazole. Don’t treat asx women as will increase risk of preterm labor.

5. Treatment failure: make sure partner treated and retreat with 2G po flagyl qd x 3-5 days. If resistant trich on culture, treat with metronidazole 500 mg qid for 5-14 days

Other points about trichomonas:

Vaginal pH >4.5 (helps distinguish from candidiasis)

Spermicides reduce transmission

Complications: tubal inflammation/infertility, cervical neoplasia, facilitates HIV infxn, premature birth.

Case 4: STI screening and treatment

A 55 y/o recently divorced woman comes to you for care of her HTN and asthma. She tells you that she recently started a new relationship, and, since she has already gone through menopause, is not using condoms for birth control. She complains of slight vaginal discharge, but no irritation or pruritis. She asks you to perform her yearly pelvic exam. You do so and wonder if you should test her for STIs.

1. Who do you screen for STI’s? USPSTF recommends screening all sexually active women under age 25 and those over age 25 at risk.

You screen her for gonorrohea and chlamydia. Her chlamydia culture comes back from the lab as positive.

1. What percentage of women with chlamydia are asymptomatic? 70%

2. What are the clinical syndromes chlamydia is responsible for?

a. Urethritis, cervicitis, PID, epididymitis, neonatal infxn, lymphogranuloma verereum, Fitz-Hugh-Curtis syndrome, Reiters syndrome (spondyloarthropathy)

3. How many women with chlamydia develop salpingitis/PID? Unknown, but 20-60% of cases of salpingitis are caused by chlamydia.

4. What is the treatment?

a. Doxy 100 bid x7d or

b. Azithro 1G x1 or

c. Oflox 300 bid x7d or

d. Erythromycin 500qid x7d (preg women)

5. Treatment failure – usually caused by medical noncompliance.

What is the treatment of gonorrhea?

1. Ceftriaxone 125 mg IM x1 or

2. Ciprofloxacin 500 mg po x1 or

3. Ofloxacin 400 mg po x1 or

4. Levofloxacin 250 mg po x1

** need to be careful with the use of quinolones to treat gonorrhea due to rising quinolone resistance, particularly in Hawaii and California.

What viruses can cause cervicitis?

1. HSV

2. CMV

You diagose a 28 year old woman with isolated gonorrhea on a routine pelvic exam with culture. You give her a single dose of IM ceftriaxone. What other STIs do you need to now screen her for?

1. Chlamydia if not already done..

2. HIV

3. Hepatitis B and C

4. HSV

5. Syphillis

Case # 5

Atrophic vaginitis

63 y/o postmenopausal woman comes in to see you complaining of postcoital burning and a watery vaginal discharge. She denies dyspareunia. Urinalysis is normal. Vaginal mucosa on physical exam is smooth and light pink with few vaginal folds present. There is scant serosanguinous discharge. Wet mount reveals increased WBCs and is otherwise negative for pathology.

1. What is the diagnosis? Atrophic vaginitis

2. What are the typical sx of atrophic vaginitis?

a. Watery discharge

b. Dry feeling, despite discharge, even if not sexually active

c. Vaginal bleeding

d. Pruritis, burning, irritation, dyspareunia

3. What is the treatment? Topical vaginal estrogen. Usually nightly use for 1-2 weeks will relieve sx. May need to retreat periodically with 1 gram intravag. 1-2x.week

4. If estrogen contraindicated, can try lubricant like astroglide.

Vulvar disorders:

Squamous cell hyperplasia

Pathogenesis: unknown

Sx: pruritis, soreness, dysparuenia

Dx: Thickened vulva, red or white in color. Fissures may be present. Diagnosis made by biopsy, because need to rule out dysplasia/malignancy.

Treatment: Fluorinated corticosteroid, i.e. valisone 0.1% bid topically 4-6 weeks.

Lichen sclerosis

Sx: pruritis, dysparuenia, may be asx

Dx: white maculopapules, fissures, and loss of labial folds. Biopsy necessary for dx.

Treatment: fluorinated steroid: clobetasol 0.05% cream bid x 4 wks. Can be used in conjunction with testosterone 2% topically tid for 4 weeks then bid for 4 weeks then weekly for maintenance. If no improvement, biopsy.

Note: any persistent vulvar lesion needs a biopsy to rule out vulvar dysplasia!

What if, after history, physical, and microscopy, you still don’t have a diagnosis?

One study found that only 2/3 to ¾ of patients with vaginitis sx can be given a specific diagnosis. In most patients, an empiric course of therapy for presumed most likely diagnosis is less expensive and has less morbidity than additional testing with biopsy. Attempt to identify potential irritants – douching, spermicides, intravaginal preparations, pantyliners, soaps, perfumes, latex condoms. Always think about other STIs – GC and Chlamydia. Noninfectious vaginitis can sometimes be relieved with sodium bicarbonate sitz baths and/or topical vegetable oils. Topical corticosteroids should not be used unless a definite lesion is seen as above b/c they may lead to local burning

Summary of Treatments for Common causes of Vaginitis and Cervicitis:

|Organism |Symptoms |Vaginal pH |Diagnosis |Treatment |Resistance/ |

| | | | | |Recurrance |

|Bacterial Vaginosis |Vaginitis |>4.5 |Clue Cells, grey |Metronidazole 2 g x 1|Flagyl: 10-14 days |

| | | |d/c, fishy |or 500 qd x 7 d if |Twice weekly metronidazole gel|

| | | | |symptoms |for 3-6 months. |

|Candidiasis |vaginitis |4.5 |Motile on saline |Metronidazole |Make sure partner treated. |

| | | |prep, thin prep |2 G po x1 or 250 mg |Re-treat with 2G po flagyl qd |

| | | |pap, culture |po x 7d |x 3-5 days |

|N. gonorrhoeae |Cervicitis/PID/ | |Culture |Ceftriaxone IM or po | |

| |Disseminated | | |quinolone. | |

|C. trachomatis |Cervicitis/PID | |Culture |Doxy 100 bid x7d | |

| | | | |Azithro 1G x1 | |

| | | | |Oflox 300 bid x7d | |

| | | | |Erythromycin 500qid | |

| | | | |x7d (preg women) | |

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