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Comparison of the Management of Vaginal Complaints in General Practice to a Protocol

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Comparison of the Management of Vaginal Complaints in General Practice to a Protocol Comparison of the management of vaginal complaints in general practice to a protocol Introduction of the cervix, which are often caused by sexually transmitted pathogens, are less In the 'Standards' program of the Dutch easy to diagnose . Both a 'broad' approach College of General Practitioners, Stand­ and a strategy based on microbiological L. WIGERSMA ards (sets of guidelines) for quality medi­ diagnosis appear to besuitable for general cal care are developed.I 2 The Standards practice. The patient 's choice may often be Wigersma L. Comparison of the manage­ project was preceded by a research pro­ decisive . Variations in every phase of the ment of vaginal complaints in general prac­ gram for assessment of the feasibility and process ofcare can be accounted for. tice to a protocol. Huisarts Wet 1993; utility in daily practice of protocols for In this article, the diagnostic and thera­ 36(Suppl): 25·30. common conditions (the Protocols Pro­ peutic approach of vaginal disease in ject).' Decisive elements in the process of general practices in Amsterdam, the Abstract A protocol was developed for the problem solving (prior probability, prog­ Netherlands, is described and compared to approach of vaginal complaints, common con­ nosis, the efficacy of diagnostic tests and the corresponding elements of the proto­ ditions in general practice (GP). The manage­ ment of vaginal complaints in general practices treatments, and the influence of contextual col. The comparison specifically deals in Amsterdam, the Netherlands, was studied. factors such as the relationship between with the use and efficacy of office labora­ The diagnostic and therapeutic approach is de­ doctor and patient) are included in proto­ tory tests, microbiological tests, presump­ scribed and compared to the protocol. In ac­ cols as well as in Standards." Different tive and specific treatments , education and cordance with the protocol, the GPs examined alternative approaches do justice to the the therapeutic approach in follow-up en­ practically all patients, and diagnosed common process and the context of care in general counters . Conclusions of the comparison vaginal infections by means of simple and ef­ practice.' are presented. fective tests. These infections were almost al­ As a part of the Protocols Project, a ways treated adequately . Microbiological tests protocol for the approach of vaginal com­ Patients and methods for sexually transmitted infections were per­ plaints was developed. The incidence of formed infrequently ; presumptive treatment was often administered. This proved inade­ vaginal complaints, defined as increased , In 13 general practices evenly distributed quate in quite a few cases. Education was rarely non-bloody discharge and/or vaginal pain, over Amsterdam, The Netherlands, with a offered, in spite of compelling arguments to the burning or itching, varies between 30 and total population of 23510 patients of contrary . Judged by the protocol, the manage­ 60 per 1000 female patients per year, with whom 11883 (50,5 per cent) are female, ment of vaginal complaints in general practice a peak incidence of 70-80 per 1000 be­ episodes following the presentation of a in Amsterdam appears to be satisfactory when tween 15 and 44 years.t" In 60 to 80 per new vaginal complaint were recorded dur­ it comes to diagnosing and treating new cases cent of cases presented to the general prac­ ing one year. An episode is a disease his­ of common vaginal infection. The diagnostic, titioner (GP), the complaints are caused by tory logically connected to a complaint, therapeutic and preventive management of sex­ a vaginal or cervical infection . Of these, which ends when the contact between pa­ ually transmitted infections can and should be 20-30 per cent is caused by candida albi­ tient and doctor about the complaint ends. improved according to the protocol. cans, 25-40 per cent by bacterial vaginosis Registration included the reason(s) for en­ and 15-20 per cent by sexually transmitted counter, diagnosis, diagnosis mutations in pathogens.t" Chlamydia trachomatis follow-up encounters, and interventions. Department of General Practice, University of Amsterdam, Meibergdreef 15, 1105 AZ causes about half of all sexually trans­ Directly after the first encounter, the GP Amsterdam. mitted infections, Neisseria gonorrhoea 10 and the patient completed a questionnaire L. Wigersma, MD, PhD, Professor of per cent, Trichomonas vaginalis 15 per regarding the actual complaint, the expec­ ambulatory AIDS care. cent, and other pathogens such as an­ tations the patient had of the GP's ap­ aerobes 25 per cent." 10 About 30 per cent proach and views on the results of the of vaginal complaints are of non-infec­ encounter. The obtained data were com­ tious origin, predominantly menopausal." pared to the protocol. The core of the protocol consists of two elements: well studied diagnostic and Results therapeutic approaches to infectious vagi­ nal complaints, and considerations regard­ It should be noted that new diagnoses are ing the choice between alternatives in based upon the GPs own findings. Table 1 general practice. These elements are shows the interventions connected with presented in the framework. The manage­ new diagnoses. Frequently a wet mount ment of common vaginal infections (can­ was made and examined, more often than didosis, trichomoniasis and bacterial vagi­ the pH-test. Gram stains were hardly nosis) is fairly uncomplicated. Infections made. Microbiological tests for gonor- HUISARTS EN WETENSCHAP 1993; 36(Suppl) 25 rhoea and chlamydial infection were ap­ that were corrected or newly administered treatment without specific microbiologi­ plied for in 50-70 per cent of cases where in the second encounter are shown in table cal assessment of the disease. The follow­ such infections were presumed. The pro­ 3. Treatment was administered in 59 per ing findings are in accordance with the visional diagnosis 'vaginal discharge' led cent of all cases (70 per cent of new diag­ protocol. Almost always a physical exam­ to a variety of microbiological tests. Blood noses, 54 per cent of old diagnoses) . The ination was performed. There is a clear tests and urine sediment examination were overall ratio between correct and incorrect correlation between the diagnoses of com­ rarely performed. Education was offered treatment was much higher in the first mon vaginal infections and the number of to 43 women (15,4 per cent), direct treat­ encounter, but this does not hold for sep­ times a wet mount was examined. Almost ment to 217 women (77,8 per cent). In arate diagnoses. Table 4 shows the sta­ no Gram stains were made. In most cases 65-100 per cent of (presumed) cases of bility of diagnoses in the course of epi­ treatment was administered after at least common vaginal infection and in 50-90 sodes. The overall percentage of muta­ some laboratory tests were performed, ex­ per cent of(presumed) cases of a sexually tions after the first encounter was 6,3 per cept in the case of presumed PID. This transmitted infection, direct treatment was cent, whereas it was IO per cent for bac­ condition, however, justifies immediate administered. Seven women (2,5 per cent) terial vaginosis and almost 30 per cent for presumptive treatment. Microbiological were referred, three of whom because of gonorrhoea. In the second encounter, 28 tests for gonorrhoea and chlamydiasis presumed Pelvic Inflammatory Disease per cent of diagnoses were new. were rarely applied for, except when the (PID). Results of the questionnaire survey GP thought they were indicated. showed that 40 per cent of the responding Comparison of the results to the proto­ Not or only partly in conformity with women expected to receive education dur­ col the protocol are the following results. The ing the encounter. Of these women, 75 per • Diagnostic approach . The prevalence number of pH investigations, a simple pro­ cent claimed to have received it. Another of the several conditions found in this cedure for discrimination between several IO per cent of respondents received edu­ population was in conformity with the infections, is relatively low. A higher per­ cation without having expected it. figures found in other morbidity surveys, centage of blood tests (ESR) might be Table 2 shows the treatments adminis­ except perhaps for the low percentage of expected in connection with the diagnosis tered in the first encounter and the assess­ Chlamydia infections we found . This may PID.? Culture for Trichomonas was regu­ ment of their correctness. The treatments be due to the fact that GPs often administer larly requested, whereas microscopic Table 1 Interventions correlated to new diagnoses ofvaginal complaints. Numbers Vaginal Fear Gonorrhoea Candidiasis Trichomoniasis PID Bacterial Chlamydiasis Vaginitis discharge o!STD vaginosis other n=25 n=9 n=7 n=114 n=32 n=17 n=45 n=11 n=19 Physical examination 23 2 6 113 30 16 39 9 17 pH test 3 36 21 4 18 5 9 Wet mount NaCI 12 5 3 79 23 5 31 4 13 Wet mount KOH 6 5 3 89 24 4 31 4 14 Gram stain 1 Test for GO 14 2 4 4 5 6 2 Test for Chlam . 8 2 3 3 8 4 Test for Trich . 10 2 1 1 3 1 Syphilis seral. 2 2 1 Other bloodtest 4 Urine sediment 2 2 1 5 Education 1 4 16 6 11 1 3 Medication 3 4 114 27 11 29 10 12 Referrals : STD-clinic 2 Dermatologist 1 Gynaecologist 3 26 HUISARTS EN WETENSCHAP 1993;36(Suppl) evaluation usually suffices. The fact that a infections, just like the protocol suggests. umed sexually transmitted infections and test for gonorrhoea was asked for more Treatment of candidiasis and trichomon­ PID in the first encounter were inadequate often than a test for Chlamydia probabl y iasis was correct in 96 and 89 per cent of or wrong in a substantial percentage of reflects incorrect assessment of the exist­ cases respecti vely, whereas bacterial vagi­ cases.
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