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hours).
White or transparent, thick, and mostly odorless.
Is formed by mucoid endocervical secretions in combination
with sloughing epithelial cells, normal bacteria, and vaginal
transudate.
The discharge may become more noticeable ( during
pregnancy, use of estrogen-progestin contraceptives,
midmenstrual cycle close to the time of ovulation.
The pH of the normal vaginal secretions is 3.5 to 4.5.
Dozens of different bacterial isolates.
Lactobacillus
Diphtheroids
S. epidermidis
Causes of vaginitis
Infectious vaginitis :
Common causes
Bacterial vaginosis (40 to 50 percent of cases)
Vulvovaginal candidiasis (20 to 25 percent of cases)
Trichomoniasis (15 to 20 percent of cases)
Less common causes
Foreign body with secondary infection
Desquamative inflammatory vaginitis
Streptococcal vaginitis (group A)
Ulcerative vaginitis associated with Staphylococcus aureus
and toxic shock syndrome
Idiopathic vulvovaginal ulceration associated with HIV.
Causes of vaginitis
Noninfectious vaginitis :
Chemical or other irritant
Allergic, hypersensitivity, and contact dermatitis
(lichen simplex)
Traumatic vaginitis
Atrophic vaginitis
Postpuerperal atrophic vaginitis
Desquamative inflammatory vaginitis (steroidresponsive)
Erosive lichen planus
Collagen vascular disease, Behcet's syndrome,
Idiopathic vaginitis
dysurea
vaginosis.
Erythema, edema, or fissure formation suggest
candidiasis, trichomoniasis, or dermatitis.
Diagnostic studies
Vaginal pH:
Vaginal pH is the single most important finding.
A strip of pH paper is applied to the vaginal sidewall.
A pH above 4.5 in a premenopausal woman suggests
infections such as
bacterial vaginosis or trichomoniasis (pH 5 to 6)
helps to exclude candida vulvovaginitis (pH 4 to 4.5).
Vaginal pH may be altered (usually to a higher pH)
0.9 percent normal saline solution on a glass slide. Cover slips are
placed on the slides, which are examined under a microscope at
low and high power.
flagella, larger than a WBC but smaller than epithelial cells, that
are usually seen swimming or thrashing around in the wet prep.
Clue cells are epithelial cells that have bacteria adhered to their
Diagnostic studies
The KOH prep is made by adding a drop of 10 percent
potassium hydroxide KOH solution to a drop of saline
Diagnostic studies
Microscopy:
Candidal buds or hyphae
Motile Trichomonas
Epithelial cells studded with adherent coccobacilli
(clue cells)
Polymorphonuclear cells (PMNs).
The saline should be at room temperature and
microscopy should be performed within 10 to 20
minutes
Excess WBCs without evidence of yeast, trichomonads, or
Candida Albicans
Trichomonas
Diagnosis BV
BV can be clinically diagnosed by finding 3 of the
following 4 signs and symptoms:
1-A homogeneous, off-white creamy discharge that
adheres to the vaginal walls
2-clue cells
3-pH >4.5
4-fishy odor after the addition of 10% KOH (whiff test)
Vaginal culture:
For Candida or Trichomonas , if microscopy is negative
because microscopy is not sufficiently sensitive to exclude
these diagnoses in symptomatic patients.
Cervical culture:
For cervicitis, typically due to Neisseria gonorrhoeae or
Chlamydia trachomatis, if you see a purulent vaginal
discharge, fever, or lower abdominal pain (PID).
Sexual behaviors that result in STD-related vulvovaginitis
Diagnostic
Criteria
Normal
Bacterial
Vaginosis
Vaginal pH
3.8 - 4.2
> 4.5
Discharge
White,thin,
flocculent
Thin, white,
gray
Amine odor
"whiff" test
Absent
Fishy
Microscopic
Lactobacilli,
epithelial cells
Trichomonas
Candida
Vaginitis
Vulvovaginitis
4.5
Yellow, green,
White, curdy,
frothy
"cottage cheese"
Fishy
Absent
Clue cells,
Budding yeast,
Trichomonads,
adherent cocci,
hyphae,
WBCs >10/hpf
no WBCs
pseudohyphae
Treatment
Candida:
Butoconazole (Femstat)*
(Femstat)* 2 percent cream 5 g/day for 3 days or 1 day for sustained release
formulation
(Gynazole) 2 percent cream 5 g/day for a single dose
Clotrimazole (Gyne- lotrimin, Mycelex)* 1 percent cream 5 g/day for 7 to 14
days
100 mg vaginal tablet 1/day for 7 days
Miconazole (Monistat) 2 percent cream 5 g/day for 7 days
100 mg vaginal suppository 1/day for 7 days
200 mg vaginal suppository 1/day for 3 days
1200 mg vaginal suppository 1 suppository
Tioconazole (Vagistat) 6.5 percent cream 5 g in a single dose
Terconazole (Terazol) 0.4 percent cream 5 g/day for 7 days
80 mg vaginal suppository 1/day for 3 days
Nystatin (Mycostatin) 100,000 U vaginal tablet 1/day for 14 days
Fluconazole (Diflucan)
Trichomonas / BV
Metronidazole
PO 500 mg bid x 7 days OR 2 gms single dose.
PV
Clindamycin 300 mg po bid x 5 days for BV.
Atrophic vaginitis
Lubricating /moisturizing gel.
Low dose Estrogen :
- Systemic
- Local
PID
Pelvic inflammatory disease (PID) is a general term that refers
tract infection
including
infertility
ectopic pregnancy
abscess formation
and chronic pelvic pain.
risk)
being sexually active before age 20 (women)
current or past STDs
New sexual partner within 3 months
Non use of barrier contraceptives
douching more than once or twice a month
use of intrauterine device (IUD) contraceptionit may slightly increase the risk of PID
(this risk is lowered when women are tested and treated for
infections before getting an IUD)
Complications of PID
can be prevented with early treatment.
Without treatment, PID can cause infertility, ectopic
Complications of PID
The most serious complication of PID is the
present.
Temperature may be elevated but is normal in many
cases
In general, clinicians should err on the side of
overdiagnosing and treating milder cases.
Some women have chlamydial infection of the upper
genital tract without apparent clinical manifestations of
PID (i.e., silent salpingitis).
tenderness
along with WBCs seen on vaginal wet mount
Additional supportive criteria
to increase the specificity:
- Oral temperature higher than 101F (38.3C)
- Abnormal cervical or vaginal mucopurulent discharge
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level
- Laboratory documentation of cervical infection with
N gonorrhoeae or C trachomatis
PMNs/1000x field
and to look for intracellular Gram-negative diplococci)
2. Endocervical and rectal cultures for N.gonorrhoeae
3. Culture of endocervical swab or first void urine for C.
trachomatis
4. Wet prep for WBCs
5. If menses is late or if the patient is not using reliable
contraception
- check pulse and blood pressure (supine and seated);
- obtain serum or sensitive urine pregnancy test if ectopic
pregnancy is suspected.
Treatment PID
broad spectrum antimicrobial coverage should be
provided to cover gonorrhea, chlamydia, and anaerobes.
Patients should be advised to:
Rest for 1 to 3 days or until symptoms have resolved or
Diagnosis uncertain
Surgical emergency not R/O
Suspected pelvic abcess
Pregnancy
Adolescent or noncompliant
Unable to eat
Temperature > 38o C
Outpatient failure or cannot keep f/u
Regimen A
Either of the following:
- Ofloxacin 400 mg orally twice a day for 14 days
- Levofloxacin 500 mg orally once daily, with or without
Metronidazole
500 mg orally twice a day for 14 days.
Regimen B
Any of the following:
- Ceftriaxone 250 mg IM once,
- Cefoxitin or Cefotetan 2 g IM plus Probenecid, 1 g orally in a single
dose,
[Other parenteral third-generation cephalosporins (e.g., ceftizoxime
or cefotaxime),]
plus
- Doxycycline 100 mg orally twice a day for 14 days, with or without
Metronidazole 500 mg orally twice a day for 14 days
department
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