8.03 Vaginitis
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agk's Library of Common Simple Emergencies

Presentation
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A woman complains of itching and irritation of
the labia and vagina, perhaps with vaginal
discharge or odor, vague low abdominal
discomfort, or dysuria. (Suprapubic discomfort
and urinary urgency and frequency suggest
cystitis.) Abdominal examination is benign but
examination of the introitus may reveal
erythema of the vulva and edema of the labia
(especially with Candida). Speculum examination
may disclose a diffusely red, inflamed vaginal
mucosa, with vaginal discharge either copious,
thin, and foul-smelling (characteristic of
Trichomonas or anaerobic overgrowth) or thick,
white, and cheesy (characteristic of Candida
and associated with more intense vulvar
pruritis). Bimanual examination should show a
non-tender cervix and uterus, without adnexal
tenderness or masses or pain on cervical
motion.

What to do:
-----------

- Take a brief sexual history. Ask if partners
   are experiencing related symptoms.
- Perform speculum and bimanual pelvic exam.
   Collect urine for possible culture and
   pregnancy tests which may influence
   treatment. Swab the cervix or urethra to
   culture for N. gonorrheae and swab the
   endocervix to test for Chlamydia. Touch pH
   indicator paper to the vaginal mucus (a
   pH>4.5 suggests anaerobic vaginosis, but
   this is only useful if there is no blood or
   semen to buffer vaginal secretions).
- Dab a drop of vaginal mucus on a slide, add a
   drop of 0.9% saline and a cover slip, and
   examine under 400x for swimming protozoa
   (Trichomonas vaginalis), epithelial cells
   covered by adherent bacilli ("clue cells"
   of Gardnerella vaginalis and other
   anaerobes), or pseudohyphae and spores
   ("spaghetti and meatballs" appearance of
   Candida albicans).
- If epithelial cells obscure the view of
   yeast, add a drop of 10% KOH, smell whether
   this liberates the odor of stale fish
   (characteristic of Gardnerella, Trichomonas
   and semen) and look again under the
   microscope.
- Gram stain a second specimen. This is an even
   more sensitive method for detecting Candida
   and clue cells, as well as a means to
   assess the general vaginal flora, which is
   normally mixed, with occasional
   predominance of gram-positive rods. Many
   white cells and an overabundance of
   pleomorphic gram-negative rods suggests
   Gardnerella infection. Gram-negative
   diplococci inside white cells suggests
   gonorrhea.
- If Trichomonas vaginalis is the etiology,
   discuss with the patient the options of
   metronidazole (Flagyl) 500mg bid x 7d, or
   2000mg once. The latter has practically as
   good a cure rate, but obviously better
   compliance, and shortens the time she must
   abstain from alcohol for 24 hours after the
   last dose because of metronidazole's
   disulfiram-like activity. Sexual partners
   should receive the same treatment. In the
   first trimester of pregnancy, substitute
   intravaginal clotrimazole 100mg vaginal
   suppository qhs x7d, which is less
   effective, but safer than metronidazole
   vaginal gel. Metronidazole is
   contraindicated in the first trimester and
   controversial thereafter. Treatment of
   asymptomatic patients can be be delayed
   until after delivery.
- If Candida albicans is the etiology,
   prescribe miconazole (Monistat) or
   clotrimazole (Gyne-Lotrimin) 200mg vaginal
   suppositories to be inserted qhs x 3d.
   These treatments are available without
   prescription. Prescription alternatives for
   recurrences, which is active against fungi
   other than Candida, are butoconazole
   (Femstat) and terconazole (Terazol) one 5
   gram applicator of cream qhs for three days
   and seven days, respectively. Use of cream
   also allows its soothing application on
   irritated mucosa. A single oral dose of
   fluconazole (Diflucan) 150mg po is at least
   as effective as intravaginal treatment of
   vulvovaginal candidiasis, and many patients
   seem to prefer it. Gastrointestinal side
   effects are fairly common and serious side
   effects can occur. In pregnancy, halve the
   dose and double the course of topical
   clotrimazole, (the same as the regimen for
   Trichomonas above).
- If the diagnosis is bacterial vaginosis,
   which is an overgrowth of Gardnerella
   vaginalis or other anaerobes, the strongest
   treatment is metronidazole 500mg bid or
   clindamycin 300mg bid x 7d. Metronidazole
   vaginal gel 0.75% 5 grams bid x 7d is an
   alternative which is more expensive but
   carries fewer gastrointestinal side effects
   than the oral form. Sex partners need not
   be treated unless they have balinitis.
- To prevent rebound Candida vaginitis after
   antibiotics decimate the normal vaginal
   flora, or for treatment of mild vaginitis,
   consider douching with 1% acetic acid
   (half-strength vinegar) to maintain a
   normal low pH ecology.
- Remember that any given patient may harbor
   more than one infection.
- Arrange for followup and instruct the patient
   in prevention of vaginitis.

What not to do:
---------------

- Do not prescribe sulfa creams for non-
   specific vaginitis. The treatments above
   are more effective.
- Do not miss underlying pelvic inflammatory
   disease, pregnancy, or diabetes, all of
   which can potentiate vaginitis.
- Do not miss candidiasis because the vaginal
   secretions appear essentially normal in
   consistency, color, volume and odor.
   Non-pregnant patients may not develop
   thrush patches, curds or caseous discharge.

Discussion
----------

Both Candida albicans and Gardnerella vaginalis
(previously known as Hemophilus vaginalis or
Corynebacterium vaginale), are part of the
normal vaginal flora. A number of anaerobes
share the blame in bacterial vaginosis. An
alternate therapy uses active-culture yogurt
douches to repopulate the vagina with lacto-
bacilli. Candida vaginitis is more common in
the summer, under tight or nonporous clothing
(jeans, synthetic underwear, wet bathing
suits), and in users of antibiotics and
contraceptives (which alter vaginal mucus), as
well as in diabetes mellitus, steroid-induced
immuinosupression and use of broad-spectrum
antibiotics. Trichomonas can be passed back and
forth between sexual partners, a cycle that can
be broken by treating both. Ask patients with
vulvar pruritis, erythema and edema, but with
otherwise normal saline, KOH and Gram stain
microscopy, about the use of hygene sprays or
douches, bubble baths or scented toilet tissue.
Contact vulvovaginitis may result from an
allergic or chemical reaction to any one of
these or similar products and can be treated by
removing the offending substance and prescrib-
ing a short course of a topical or systemic
corticosteroid.

References:
-----------

- Abbott J: Clinical and microscopic diagnosis
   of vaginal yeast infection: a prospective
   analysis. *Ann Emerg Med* 1995;25:587-591.
- Swedberg J, Steiner JF, Deiss F, et al:
   Comparison of a single-dose vs one-week
   course of metronidazole for symptomatic
   bacterial vaginosis. *J Am Med Assoc*
   1985;254:1046-1049.
- Martin DH, Mroczkowski TF, Dalu ZA et al: A
   controlled trial of a single dose of
   azithromycin for the treatment of
   chlamydial urethritis and cervicitis. *N
   Eng J Med* 1992;327:921-925.

Illustration
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