Vaginitis: Diagnosis, Treatment, Recurrence

Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

Vaginitis: Diagnosis, Treatment, Recurrence

Yvonne Piper, FNP San Francisco City Clinic California Prevention Training Center

10/1/2019

QUIZ!

? What is the most common cause of vaginitis?

? Bacterial vaginosis (BV) ? Chlamydia ? Trichomoniasis ? Yeast Infection

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Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

Vaginitis: Burden

? Vaginal discharge is one of the most common GYN complaints ? 90% due to 3 causes:

? BV is most common: 40-50% of vaginal complaints are BV 1, 2 ? Vulvovaginal yeast is 2nd most common: about 30% of vaginal complaints

? True prevalence may be obscured by use of OTC antifungals

? Trich

? About 15-20% of vaginitis cases, about 3 million cases/yr in US

? Other causes (remaining 10%)

? Atrophy ? Lichen Planus ? Contact derm (allergic or irritant) ? Other (e.g., DIV)

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Terminology

? Vaginitis: inflammation of vagina (due to infection, allergy, etc.) ? Vaginosis: abnormal or diseased condition of vagina ? Vulvitis: inflammation of vulva ? Vulvovaginitis: inflammation of both vulva & vagina ? Cervicitis: inflammation of cervix, may cause change to vaginal discharge

? Persistent: symptoms continue despite treatment and no re-exposure/re- infection

? No symptom-free interval

? Recurrent (reinfection): symptoms originally resolve, then come back after treatment

? Symptom-free interval between infections

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Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

Differential Diagnosis

? Infectious

? Non sexually transmitted

? Candida ? Bacterial Vaginosis

? Sexually transmitted

? GC/CT/trich

? Non-infectious

? Physiologic leukorrhea ? Atrophic (age, testosterone,

lactation) ? Lichen planus ? Contact dermatitis

(allergen/irritant) ? Desquamative Inflammatory

Vaginitis ? Foreign body

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NORMAL

YEAST

DDx chart here? SUBJECTIVE

May report

Itch, burn,

"discharge" but no dyspareunia

remarkable features

BV

Bad odor, potentially worse after sex, bathing, or menses

TRICH

Bad odor, potentially worse after sex or bathing

GC/CT

Can be asymptomatic; may have dyspareunia, postcoital spotting

APPEARANCE

ODOR/WHIFF TEST PH MICROSCOPY

Color & consistency can change with menses; thinner near ovulation

White, curd-like, adherent, maybe increased

Thin, homogenous, gray to white, fishy odor, maybe increased

Negative

Negative

Positive

< 4.5

Clue cells: Absent Lactobacilli: present WBCs: few Trichomonads: absent Pseudohyphae: Absent

Usually < 4.5, maybe slightly elevated

Clue cells: Absent Lactobacilli: present WBCs: increased Trichomonads: absent Pseudohyphae: Usually present

Over 4.5

Clue cells: Present Lactobacilli: Decreased WBCs: few Trichomonads: absent Pseudohyphae: Absent

Thin, frothy, yellow to green, maybe blood-tinged, increased

Positive OR negative Usually over 4.5

May be increased amount, can have cervical friability and/or discharge from os Negative

< 4.5

Clue cells: Absent Lactobacilli: present WBCs: increased Trichomonads: Present Pseudohyphae: Absent

Clue cells: Absent Lactobacilli: present WBCs: increased Trichomonads: absent Pseudohyphae: Absent

Materials Folder Link: 3

Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

10/1/2019

Get a good history!

? Precipitating factors (activity,

? Sexual practices

clothing, sex, bathing, menses, etc.)

? Associated sx (spotting, dysuria, dyspareunia)

? At-home treatments tried

? Recent antibiotic use

? Past hx of similar sx

? Self-diagnosis notoriously inaccurate! 3 ? In one study, self-reported yeast was:

? 33.7% yeast ? 18.9% BV ? Mixed vaginitis 21.1% ? Normal discharge 13.7% ? Other diagnoses 10.5% ? Trichomoniasis 2.1%

Testing

? Point of care

? Wet mount microscopy

? pH ? Saline ? 10% KOH

? Rapid tests (Affirm, OSOM)

? Send to lab

? May be able to check for STDs, yeast & BV all on one sample

? Depends on your local lab

? SureSwab?, NuSwab? ? BV/vaginitis panel ? Fungal culture

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Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

10/1/2019

Amsel Criteria 4

? Criteria for the diagnosis of BV, done by wet mount ? Need 3 of the following 4 criteria to be present

? Discharge: increased, homogenous, thin ? pH: over 4.5 on litmus paper ? Whiff test: positive amine odor after addition of 10% KOH ? Clue cells: present on at least 20% of epithelial cells (viewed on 40x power)

? Cell margins obscured by bacteria

Normal Vaginal Discharge

? Normal vaginal flora, primarily Lactobacilli, combined with cervical secretions, epithelial cells, vaginal transudate

? Subjective

? May change with menstrual cycle ? Patient may report change to odor, quantity, color

? Objective

? Appearance: usually white or transparent, thick or thin ? Odor ("whiff test"): negative ? pH: under 4.5 ? Wet mount

? Clue cells: absent ? Lactobacilli: present

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Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

10/1/2019

Yeast

? Usually caused by Candida sp., albicans (80-92%) 5 or otherwise (e.g., glabrata) ? Subjective:

? Itch, burn, soreness, dyspareunia

? Objective

? Appearance: discharge MAY BE white, clumpy, adherent; skin may be erythematous, fissured ? Odor ("whiff test"): negative upon addition of 10% KOH ? pH: under 4.5 ? Wet mount

? Clue cells: absent ? Lactobacilli: present ? WBCs: may be increased

? Wet mount not great at identifying organisms

? Found in saline about 40% and in KOH about 70% of the time ? Fungal organisms can be normal flora (10-20% of vaginas) 6, 7

? If wet mount WNL and no fungal culture available but signs/sx consistent, consider empiric tx (per CDC tx guidelines)

BV

? Caused by shift in vaginal flora: fewer lactobacilli, more anaerobes; often polymicrobial

? Subjective

? Malodorous discharge, may be increased. Worse after sex/menses ? Usually no dyspareunia

? Objective

? Appearance: thin, white to gray discharge, may be copious ? Odor ("whiff test"): positive amine odor with addition of 10% KOH ? pH: over 4.5 ? Wet mount:

? Clue cells: present, at least 20% of epithelial cells affected ? Lactobacilli: absent or decreased

Materials Folder Link: 6

Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

10/1/2019

Trichomoniasis

? Caused by protozoan Trichomonas vaginalis

? Subjective:

? Malodor, irritation, postcoital spotting, dyspareunia, dysuria

? Objective

? Appearance: thin discharge, often yellow, green, or gray, frothy/foamy

? Cervix may have "strawberry" appearance due to petechiae

? Odor ("whiff test"): often positive (but not always!) ? pH: often over 4.5 (but not always!) ? Wet Mount

? Clue cells: absent ? Lactobacilli: may be unaffected ? WBCs: often increased ? Motile organisms may be present

? Wet mount not great at identifying organisms (sensitivity 51-65%) 8, 9

? Send NAAT to lab, if available

Images:

GC/CT

? Can cause dysuria and/or changes to vaginal discharge

? Always possible to have more than one infection!

? Recommended to test for these in any complaint of unusual vaginal discharge

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Clinical Updates on Tuberculosis and STDs September 30 ? October 1, 2019 Las Vegas, NV

10/1/2019

Yeast

Images:

Classification of Yeast Infections

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