Managing Common Vulvovaginal Diseases

Frederick J. Fleury, MD Springfield, Illinois

A relatively small number of vulvovaginal disorders occur commonly severe proven mondial vulvovaginitis in the office practice of the family physician, and they may present or the very acute symptomatic patient who is miserable. In resistant cases, oral challenging problems in management. Knowledge of the differential contraceptives should be discontinued diagnosis, diagnostic procedures, and methods of therapy is essential or the dosage reduced, if possible. in dealing with these common problems. This paper presents an Since reusable douching equipment updated perspective of the diagnosis and management of the more harbors monilia and other organisms, the practice of douching may be the common vulvovaginal diseases which can be effectively managed by cause of reinfection. In patients who the family physician. will not stop douching, a compromise might be a disposable douching prod­ Complaints referable to the effective than nystatin preparations1 '4 uct. Weight reduction and screening and are an important part of (Mycostatin, Nilstat) in the treatment for are occasionally helpful. the office practice of the family physi­ of monilia. A new vaginal tablet has Labial and penile smegma should be cian and the gynecologist. Since this been recently released which need be kept in mind as a reservoir for rein­ area is not emphasized sufficiently in used only once daily for seven days, fection, and tub bathing is preferable most training programs, the practi­ clotrimazole (Gyne-Lotrimen), for the to showers to remove this focus. tioner must learn about vulvovaginal treatment of monilia. Studies compar­ diseases and develop a diagnostic ing its effectiveness to present medi­ cations are in progress. approach on his own. Trichomoniasis is a venereal disease Time is saved when the proper although it may be infrequently con­ diagnostic tools and reagents (Table 1) tacted otherwise.5 When suspected, are in the examination room or close Monilia this must be confirmed with at hand. Treatment is simplified with a Monilia is responsible for about one wet smears showing the motile proto- working of the third to one half of all vaginal infec­ zoon (Figure 2). Wet smears without more common conditions, a planned tions. , oral contraceptives, apparent trichomonads but with many diagnostic approach, and a proven , and diabetes are important white blood cells could still be tricho­ effective therapeutic regimen (Table predisposing factors. The diagnosis can moniasis, but it is more likely to be a 2). Because of the innumerable be made on wet smear examination or of some other creams, ointments, and suppositories (Figure 1) in most cases, but occa­ cause. Cultures may be helpful in these available, it is helpful to select one or sionally cultures are necessary when cases. two to keep in mind. Substitutions can wet smears are negative. This is es­ (Flagyl) is the drug be made with time when newer medi­ pecially true when the patient has of choice in symptomatic cases of cations are proven more effective. douched, worn a to the office, trichomoniasis, and treatment must Such is the case with the new medica­ or recently finished a vaginal medica­ include all sexual contacts. The need tion miconazole nitrate (Monistat), tion. Wet smears will also be negative for treatment of asymptomatic pa­ which was recently shown to be more with Torulopsis glabrata which shows tients, for example those discovered no hyphae on wet smear but is a incidentally on Pap smears, is debat­ “monilia species” on culture, and able. In a recent chart review of 351 accounts for up to nine percent of patients found to have Trichomonas From the Department of Obstetrics and monilia . Treatment is out­ vaginalis on their Pap smears, only 52 Gynecology, Southern Illinois University, percent were symptomatic (FJ School of Medicine, Springfield, Illinois. Re­ lined in Table 2. quests fo r reprints should be addressed to One percent gentian violet, though Fleury: study in progress). The small Dr. Frederick J. Fleury, Department of number of asymptomatic patients in Obstetrics and Gynecology, Southern Illi­ messy, is helpful in treatment failures, nois University, School of Medicine, P.O. whom the diagnosis was missed be- Box 3926, S p rin g fie ld , III 62708. and occasionally in the patient with

487 THE JO URNAL OF FAM ILY PRACTICE, VOL. 3, NO. 5, 1976 cause of negative wet smears, were telephoned and treated along with their contacts. Initially asymptomatic Table 1. Diagnostic Equipment patients were also called, but nearly all still had no symptoms and the notifi­ Instruments for Biopsy cation resulted in more anxiety and Keys biopsy punch (4mm) confusion than benefit. Although Small, sharp scissors some authors feel asymptomatic car­ Pickups without teeth riers will inevitably become symp­ tomatic, this has not been our exper­ ience. Disposables for Biopsy Clinical and laboratory studies sug­ 1% lidocaine hydrochloride gest the traditional ten-day and even (Xylocaine) with adrenalin the five-day metronidazole (Flagyl) Oxidized cellulose (Oxycel) cotton treatment schedules are much more 3cc syringes drug than is necessary. Dykers6 recent­ 25 or 27 gauge needles ly reviewed the literature of single­ 1% toluidine blue dose programs, and treated 31 patients 1% acetic acid with 2 gm (eight tablets) of metronida­ zole taken all at once. This “single Silver nitrate sticks Figure 1. Wet Smear for Monilia shot” therapy appears as effective as Disposables for Wet Smears the longer programs. In our own on­ going study using 2 gm stat, 95 per­ Standard microscopic slides cent of the first 220 patients returning Cover slips for follow-up have been cured (FJ 10% KOH in eyedropper bottle Fleury: study in progress). Studies with Physiologic saline in eyedropper similar and even smaller doses are bottle underway. The April-May 1976 FDA drug bulletin has recommended only Equipm ent seven days of treatment for men and Microscope women, and the same dose for each. That is, one tablet t.i.d. It is quite likely that the FDA recommendation will change again to a still lower dosage in the near future. treatment of trichomonal vaginitis.”10 Treatment failures may be due to The FDA further stated “. . .available excessive numbers of certain evidence indicates that the total dose in the vagina that can inactivate metro­ of Flagyl presently given to patients, nidazole.7,8 This occurs most com­ when compared to the life span doses monly when there is a severe con­ given to rodents, is very low.” The comitant bacterial infection or in a great fortune in the discovery of postoperative patient, such as after metronidazole and the prior failure of Figure 2. Wet Smear for Trichomoniasis , conization, or cautery. all other measures is recounted in an Successful eradication of tricho- interesting article entitled “History of monads in these cases requires con­ the Treatment of Trichomoniasis.”11 comitant therapy of the bacterial infection or retreatment at a later Hemophilus Vaginalis postoperative date. Hemophilus vaginalis is the most A recent medical publication en­ common cause of malodorous dis­ titled “Is Flagyl Dangerous?” has charge and probably the most com­ caused a great deal of concern.9 The mon venereal disease. Most cases of statements therein parallel those of the “nonspecific vaginitis” are actually Health Research Group (HRG) of Hemophilus vaginalis and not “non­ Washington, DC, founded by Ralph specific” at all. This term has en­ Nader, and suggest “tub baths twice couraged physicians to make casual daily,” “biweekly with. . .vin­ visual diagnoses and should be aban­ egar,” and “avoidance of pantyhose doned. Its pungent odor and frequent and other tight clothing” for symp­ bubbles can lead to the erroneous visual tomatic trichomoniasis. These are un­ diagnosis of trichomoniasis. The wet proven and unlikely remedies, and the smears, however, show “clue cells” Food and Drug Administration in a (Figure 3) and very few white blood subsequent publication stated that the cells since Hemophilus vaginalis does HRG position is “denied” and “Flagyl not infect the tissue but simply thrives Figure 3. "Clue Cells" for Hemo­ should continue to be available for the in the vaginal secretions. philus Vaginalis

488 THE JO URNAL OF FAM ILY PRACTICE, VOL. 3, NO. 5, 1976 Figure 4. Worrisome Lesions and White

489 THE JO URNAL OF FAM ILY PRACTICE, VOL. 3, NO. 5, 1976 Table 2. Diagnosis and Treatment (continued)

Differential Diagnosis Diagnostic Procedure Treatm ent

Worrisome Lesions and Collins stain followed by office biopsy See below White Vulvas (Table 3)

Lichen sclerosus et atrophicus Collins stain entire vulva 1. Topical 2% testosterone propionate in and related atrophic vulvas Biopsy shows: (Figure 4, g) atrophic petrolatum rubbed vigorously into epithelium plus other features of lichen affected skin t.i.d. sclerosus et atrophicus depending upon 2. Correct cause of chronic severity 3. Careful local hygiene thin epithelium 4. Steroids and , though affording loss of retepegs symptomatic relief, will not cure this homogenous zone in severe cases condition and may make it worse (more atrophic) 5. Vulvectomy is n o t indicated because up to 90% of cases will reoccur

Hypertrophic dystrophy Collins stain entire vulva 1. Topical steroids t.i.d. (neurodermatitis. Biopsy shows: (Figure 4, d) thick 2. Correct cause of chronic irritation "benign ") epithelium excluding the keratin layer 3. Careful local hygiene acanthosis 4. Vulvectomy is n ot indicated when elongated retepegs cellular histology is benign

Atypical or dysplastic Collins stain 1. Wide local excision when moderate or lesions Biopsy shows histological atypia that is not severe simply due to 2. Simple vulvectomy with extensive (Figure 4, e) lesions

Carcinoma in situ Collins stain entire vulva 1. Wide local excision of small lesions Biopsy shows full thickness skin 2. Collins stain to rule out otherwise inapparent lesions 3. Simple vulvectomy with extensive lesions

Invasive lesions Collins stain entire vulva 1. Radical vulvectomy plus groin dissection Biopsy shows cancer has broken through 2. Oncological consultation basement membrane

“ continue Rx through “ “ see comments in text

492 THE JO URNAL OF FAM ILY PRACTICE, VOL. 3, NO. 5, 1976 It is important to treat also the Urinary Incontinence (Figure 4,b) (burning) is vulvar or urinary male consorts, or patients will “keep Urinary incontinence is a frequent tract (urethral, lower abdominal). getting it back.” Ampicillin, 500 mg cause of chronic vulvar inflammation. Management of acute primary qid. for five days or tetracycline 250 In most cases corrective surgery al­ herpes includes oral , such as mg q.i.d. for five days, is sufficient for leviates the problem, but great care codeine preparations, careful perineal both men and women. Triple sulfa must be taken in the preoperative hygiene to prevent superinfection, (Sultrin) vaginal cream has been shown evaluation of the urinary incontinence. voiding into bath water if vulvar effective in lieu of oral therapy in Operations on patients with atonic dysuria is severe or having the patient women. Good studies are needed to bladders with overflow incontinence pour water over the vulva while void­ test the effectiveness of all vaginal will give the patient even higher resid­ ing. Povidone-iodine (Betadine) is not creams and suppositories for Hemo­ ual volumes. Operations on patients only helpful in preventing bacterial philus vaginalis. with “spastic” bladders are also superinfection, but is virucidal12 in doomed to failure. Chronic vitro and effective clinically.13 One is found in about one half of the percent neutral red dye or 0.1 percent patients with incontinence and re­ proflavine applied to open vesicles and sponds to dilatation. exposed to light is effective in shorten­ ing the course of infection and re­ ducing the number of recurrences. Cervicitis w ith Leuko rrh e a This phototherapy is thought to dis­ Infection of the is a common rupt the viral DNA replication. Similar source of purulent mucoid “vaginal” to Flagyl, phototherapy is surrounded Tinea discharge. Wet smears show many by controversy. This mode has been white blood cells but no specific path­ Tinea infection or “jock rash” shown to transform hamster embryo ogen. These cervical infections fre­ should be suspected if the scaly derma­ fibroblasts in tissue culture into malig­ quently respond to 10 to 14 days of titis extends to the mons or crural nant cells.14 However, phototherapy, oral ampicillin or sulfa preparations. folds. Scrapings of the scales mixed though in use for nearly 1 5 years, has Refractory infections may require with 10 to 20 percent KOH and not been associated with neoplasia in cryocautery followed by another heated will show hyphae on high humans. course of oral antibiotics. Vaginal power microscopic examination (Fig­ creams (sulfa) are apparently effective ure 5). Many dermatologists prefer as well, but controlled studies are oral griseofulvin, 500 mg once or twice needed. daily for three to six weeks, rather than topical medication (Table 2). Poor Hygiene Many patients prefer showers to tubs for bathing and consequently is more common in the former. It is truly unusual to see a patient with Herpes Cervical Eversion with Mucorrhea vulvitis who is practicing careful vulvar Herpes vulvitis has been quite com­ hygiene regardless of the quantity of Many patients complain of a clear mon in the past two to three years and vaginal discharge and are found to vaginal discharge, urinary inconti­ is causing a great deal of patient nence, or rectal discharge. Proper have a large area of healthy everted anxiety and discomfort. The first endocervical mucosa. The clear mucus vulvar hygiene includes careful cleans­ (primary) infection is characteristically ing of the interlabial folds which are is nonirritating, has no odor, and need more severe with its greater numbers not be aggressively managed. Promis­ often neglected. The accumulated of vesicles and ulcers than in the smegma is a reservoir for repeated cuous use of the cryocautery in these recurrent or secondary infections. This cases is a “cure worse than the dis­ vaginal and urinary infections as well patient frequently has inguinal ade­ as a cause of vulvitis. ease.” Management consists simply of nopathy, malaise, and low grade fever reducing the content in oral as well. Herpes antibodies are usually contraceptives, careful perineal hy­ negative with this first infection; how­ giene, and reassurance. ever, a second antibody titer a month later will show a rise in serum anti­ Contact bodies to herpes. The diagnosis can be made by viral culture of the vessicle Perfumed sprays, soaps, and toilet fluid and Pap smear is positive for tissue can be irritating to some pa­ inclusion bodies in almost 60 percent tients and should be avoided. Bor­ of patients. rowed or prescribed medications can Vulvar Inflammation The patients frequently complain cause chemical irritation or allergic Vaginal Discharge of dysuria and unless questioned fur­ reaction in a small number of patients. Treatment includes withdrawal of the Vaginal discharges are one of the ther, the correct diagnosis may be offending agent, topical steroids and most common causes of vulvar inflam­ delayed. All phone calls for dysuria or frequent sitz baths in warm, soapy mation, as outlined in the foregoing “bladder infection” should include water. discussion. questions to determine whether the

493 THE JO URNAL OF FAM ILY PRACTICE, VOL. 3, NO. 5, 1976 not think this entity is a premalignant lesion. Table 3. Biopsy Procedure

Collins stain

Paint entire vulva with 1% Hypertrophic Dystrophy toluidine blue on cotton-tipped applicators Chronic severe inflammatory le­ sions (Figure 4,c,d) may be micro­ Wash off stain after 1 minute with scopically worrisome to the untrained 1% acetic acid and cotton eye at first glance, but the treatment is balls or gauze pads not surgical. Topical steroids plus great care in correcting the cause of the Areas holding the stain are suspect chronic will rapidly resolve for atypia (excoriations will most lesions. When moderate to severe also hold stain, however) dysplasia (Figure 4,e) or carcinoma in Infiltrate each biopsy site with 1-2 cc situ is also present, then and only then of 1% Xylocaine with adrenalin is vulvectomy or wide local excision indicated. Twist 4 mm keys punch into skin to depth of about 5 mm

Remove biopsy with pickups and scissors

Atypical or Dysplastic Lesions Pack biopsy site firmly with Oxycel Mild degrees of atypia can be ob­ cotton, or cauterize biopsy site served closely while treating the under­ with silver nitrate sticks Worrisome Lesions and White Vulvas lying vulvitis, if present. Moderate or (Figure 4) severe atypia in any focus should be Suture is rarely if ever needed Management begins with biopsy locally excised. Diffuse moderate or (Table 3). Areas selected for biopsy severe atypia requires wide local exci­ References may be more obvious after Collins sion or simple vulvectomy. These pa­ 1. Davis JE, Frudenjeld JH, Goddard tients should be followed closely for JL : Comparative evaluation of Monistatand Stain (Table 3) which stains superficial Mycostatin in the treatment of vulvovaginal nuclei that are not normally present. recurrence and are at greater risk to . Obstet Gynecol 44:403-406 developing similar disease on the cer­ 1974 One of the major pitfalls is treatment 2. Culbertson C: Monistat: A new without histological diagnosis. An­ vix and vagina. fungicide for treatment of vulvovaginal candidiasis. Am J Obstet Gynecol 120: other pitfall is vulvectomy for histo­ 973-976, 1974 3. Qualey JR, Cooper C: Monistat logically benign disease because the Creme (miconazole nitrate) a new agent for pathology report contained some the treatment ot vulvovaginal candidiasis. J Reprod Med 15:123-125, 1975 reference to “leukoplakia.” The term 4. Schuster E, Giulian KD: A new drug “leukoplakia” is a cause of much Carcinoma in situ for vulvovaginal candidiasis in pregnancy. OB/GYN Digest (original article), Septem­ confusion and should be abandoned. Patients with carcinoma in situ or ber, 1975, p1 3-1 5 Operation should be reserved for “Bowens disease” should have wide 5. Santler R, Thurner J: Contagious­ ness of . Wien Klin moderate or severe dysplasia or more local excision of their lesions or simple Wochenscher 86:46-49, 1974 6. Dykers JR : Single-dose metronida­ advanced lesions. vulvectomy when the lesions are dif­ zole for Trichomonal vaginitis. N Engl J fuse. Conservative surgery should be Med 293:23-24, 1975 7. Nicol CS, Evans A J, McFadzean JA, reserved for reliable patients, and et al: Inactivation of metronidazole. Lancet aggressive management is wise in those 2:441, 1966 8. McFadzean JA, Pugh IM, Aquires patients less likely to consent to long­ S L , et al: F u rth e r o bservations on strain term follow-up. sensitivity of Trichomonas vaginalis to metronidazole. Br J Vener Dis 45:161-162, 1969 Lichen Sclerosus et Atrophicus 9. Is Flagyl Dangerous? The Medical Letter on Drugs & Therapeutics 17:53-54, Lichen sclerosus (Figure 4,f,g) heals 1975 slowly but progressively with topical 10. FDA Talk Paper: Flagyl position denied. T75-73, October 29, 1975 testosterone two percent in petrola­ Invasive Lesions 11. Forgan R: History of the treatment of trichomoniasis. Br J Vener Dis tum. Topical steroids, estrogens, or Microinvasive and frankly invasive 48:522-524, 1972 petrolatum alone will give symp­ lesions require total vulvectomy and 12. Amstey MS, Metcalf S: Effect of povidone — iodine on herpes type 2, in tomatic relief but not histological bilateral groin dissection. Wide local vitro. Obstet Gynecol 46:528-529, 1975 cure. The cause of the chronic vulvar 13. Friedrich EG, Masukawa T: Effect excision and unilateral groin dissection of povidone — iodine on herpes genitalis. irritation must be eliminated. These are contraindicated because of the rich Obstet Gynecol 45:337-339, 1975 lesions may rarely be found to coexist 14. Lei JH, Jerkofsky MA, Rapp F: crosslymphatic drainage of the vulva. Demonstration of oncogenic potential of with malignancy or dysplasia on the Consultation is mandatory and is wide­ mammalian cells transformed by DNA — containing following photodynamic same vulva, but most authorities do ly available. inactivation. Int J Cancer 15:190-202, 1975

494 THE JO URNAL OF FAM ILY PRACTICE, VOL. 3, NO. 5, 1976