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Jennifer F. Wilson Science Writer: Sankey Williams,MD Christine Laine,MD,MPH Section Co-Editors: CME Questions Practice Improvement Treatment Diagnosis Screening Prevention and in theclinic © 2009AmericanCollegeofPhysicians judgment. The informationcontainedhereinshould neverbeusedasasubstituteforclinical tis andcervicitis. CME Objective:To gainknowledgeaboutthe managementofpatientswithvagini- resources referencedineachissueof primary resourcesformoredetailcanconsulthttp://pier.acponline.org andother MKSAP of sciencewritersandphysicianwriters.Editorialconsultantsfrom the ACP’s MedicalEducation andPublishingDivisionwiththeassistance editors develop Knowledge andSelf-AssessmentProgram). PIER education resourcesofthe The contentof (Physicians’ InformationandEducationResource) provide expertreviewofthecontent.Readerswhoareinterestedinthese In theClinic In theClinic American CollegeofPhysicians is drawnfromtheclinicalinformationand from theseprimarysourcesincollaborationwith In theClinic Annals ofInternalMedicine . MKSAP (ACP), including page ITC3-16 page ITC3-14 page ITC3-10 page ITC3-5 page ITC3-3 page ITC3-2 PIER (Medical and in the clinic he has a squamous and is susceptible to , , and candidiasis. Vaginitis may also result Tfrom irritants, allergic reactions, or postmenopausal atrophy. The endocervix has a columnar epithelium and is susceptible to with , trachomatis, or less commonly, herpes sim- plex . Vaginitis causes discomfort, but rarely has serious consequences except during and gynecologic . Cervicitis may be asymptomatic and if untreated, can lead to pelvic inflammatory disease (PID), which can damage the reproductive organs and lead to , , or chronic . Because vaginitis and cervicitis are common, clinicians should be familiar with their prevention, diagnosis, and treatment. Prevention What factors increase the can thin the vaginal lining and risk for vaginitis and cervicitis? cause vaginal itching and burning. Unprotected sex and multiple A review of the available published data sexual partners increase the risk found that douching was practiced by for vaginitis due to bacterial vagi- 15.5% of adolescent girls and young 1. Garnett GP, Anderson nosis or trichomoniasis and of women in the United States and that the RM. Sexually trans- cervicitis due to , practice was strongly associated with mitted diseases and sexual behavior: in- chlamydia, or more rarely, herpes increased risk for PID, bacterial vagi- sights from mathe- simplex virus. Transmission rates nosis, and ectopic pregnancy (4). matical models. J In- fect Dis. 1996;174 increase with repeated exposure Suppl 2:S150-61. How can patients decrease their (1). Gonorrhea, chlamydia, and [PMID: 8843245] risk for vaginitis and cervicitis? 2. Centers for Disease trichomoniasis are transmitted Control and Preven- Consistently using dur- tion. Sexually trans- exclusively through sexual contact mitted diseases treat- ing and limit- (2). Bacterial vaginosis, a syn- ment guidelines, ing the number of sexual partners 2006. MMWR drome characterized by alter- Recomm Rep. reduces the risk for some infec- 2006;55:1-94. ations in the vaginal flora, has [PMID: 16888612] tions that can cause vaginitis and 3. Larsson PG, never been proven to be a sexual- cervicitis. Latex condoms are less Bergström M, Forsum ly transmitted infection (STI) U, et al. Bacterial vagi- prone to breakage than other nosis. Transmission, (3). Sexual transmission has not role in genital tract types and are recommended for infection and preg- been shown to cause vulvovaginal STI prevention. However, if latex nancy outcome: an candidiasis. enigma. APMIS. prevents their use, poly- 2005;113:233-45. urethane condoms are an option. [PMID: 15865604] , uncontrolled 4. Merchant JS, Oh K, A woman should avoid sexual in- Klerman LV. Douch- diabetes, and other hormonal tercourse with a partner who has ing: a problem for changes may predispose patients adolescent girls and genital lesions or penile dis- young women. Arch to vaginal yeast . Pediatr Adolesc Med. charge. Treatment of patients 1999;153:834-7. Clothing that traps moisture may [PMID: 10437756] with STIs and their sexual part- 5. Laga M, Manoka A, also contribute to these infections ners can prevent recurrent vagini- Kivuvu M, et al. Non- or exacerbate symptoms. Vaginal ulcerative sexually tis and cervicitis. Good glycemic transmitted diseases contraceptives, damp or tight- control in women with diabetes as risk factors for HIV- 1 transmission in fitting clothing, scented deter- and avoidance of unnecessary an- women: results from gents and soaps, , a cohort study. AIDS. tibiotics may help to limit vagini- 1993;7:95-102. feminine sprays and deodorants, tis due to yeast. Avoidance of [PMID: 8442924] 6. Taha TE, Hoover DR, and poor hygiene can irritate potential causes of irritation, such Dallabetta GA, et al. the and vagina and, possi- Bacterial vaginosis as vaginal contraceptives, scented and disturbances of bly, increase susceptibility to soaps, feminine hygiene products, vaginal flora: associa- tion with increased infection. A drop in hormone and damp or tight-fitting cloth- acquisition of HIV. levels after natural ing, may also help to reduce the AIDS. 1998;12:1699- 706. [PMID: 9764791] or surgical removal of risk for some types of vaginitis.

© 2009 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 1 September 2009 Prevention... Unsafe sex increases the risk for some types of vaginitis and cervici- tis. Irritants, allergens, and low estrogen levels can cause vaginitis and may in- crease susceptibility to infection. Antibiotics, uncontrolled diabetes, hormonal changes, and clothing that traps moisture may lead to vaginal yeast infections. Infectious vaginitis and cervicitis can often be prevented by using condoms and limiting the number of sexual partners. Patients should stop using products that can irritate the vulva and vagina.

CLINICAL BOTTOM LINE

Screening Should clinicians screen asymptomatic and not having nonpregnant women for causes of gynecologic surgery should not be vaginitis and cervicitis? screened for bacterial vaginosis. No Screening at-risk women for prospective studies have document- asymptomatic infections can reduce ed the prevention of PID or HIV long-term complications of un- with treatment of bacterial vaginosis. treated infections. Untreated gon- orrhea and chlamydia can lead to Screening can be performed in PID and subsequent infertility, conjunction with the annual 7. Martin HL, Richardson Papanicolaou smear or preopera- BA, Nyange PM, et al. tubal pregnancy, and chronic pain. Vaginal lactobacilli, Prospective studies have shown that tively in women with indications microbial flora, and risk of human im- bacterial vaginosis and STIs, in- for screening. Table 1 lists tests munodeficiency virus that may be useful in screening type 1 and sexually cluding trichomoniasis, are risk transmitted disease factors for HIV (5–8). and diagnosis. For detection of acquisition. J Infect Dis. 1999;180:1863-8. gonorrhea, culture permits sus- [PMID: 10558942] In the United States, routine screening for ceptibility testing, but cultures 8. Kamwendo F, Forslin chlamydia was shown to prevent PID in 1 L, Bodin L, et al. De- should be plated at the bedside creasing incidences trial in which women aged 18 to 34 years and immediately placed into 3% of gonorrhea- and were randomly assigned to chlamydia chlamydia-associated carbon dioxide and incubated. acute pelvic inflam- screening or usual care. At the end of fol- Unamplified probe assays for matory disease. A 25- low-up, women in the screening group year study from an gonorrhea and chlamydia are urban area of central had fewer verified cases of PID than Sweden. Sex Transm women in the usual care group (9 vs. 33; inexpensive and automated, but Dis. 1996;23:384-91. sensitivity is suboptimal (90% for [PMID: 8885069] relative risk, 0.44 [95% CI, 0.20 to 0.90]) (9). 9. Scholes D, Stergachis gonorrhea; 78% for chlamydia) A, Heidrich FE, et al. Prevention of pelvic Clinicians should screen women (11). Inexpensive enzyme immuno- inflammatory disease who are at risk for sexually trans- assays are available for chlamydia, by screening for cer- vical chlamydial in- mitted causes of vaginitis and cer- but sensitivity is only 55% to fection. N Engl J Med. vicitis for gonorrhea, chlamydia, 70%. Amplified DNA testing by 1996;334:1362-6. [PMID: 8614421] and T. vaginalis infections. Candi- polymerase chain reaction (PCR) 10. Joesoef MR, Schmid GP, Hillier SL. Bacteri- dates for screening include women or ligase chain reaction (LCR) is al vaginosis: review with new or multiple sexual part- the “gold standard” for gonorrhea of treatment options and potential clinical ners, history of unprotected inter- and chlamydia. Although it is ex- indications for thera- py. Clin Infect Dis. course, or history of STIs. In pensive, it can be performed on 1999;28 Suppl 1:S57- addition, all sexually active women vaginal, cervical, or urinary speci- 65. [PMID: 10028110] 11. Clarke LM, Sierra MF, younger than 24 years should re- mens (12, 13, 14). The gold stan- Daidone BJ, et al. Comparison of the ceive annual chlamydia screening. dard test for T. vaginalis is culture Syva MicroTrak en- Clinicians should also screen (90% to 95% sensitivity and 100% zyme immunoassay and Gen-Probe PACE women who are about to undergo specificity). Other options for 2 with culture gynecologic surgery. Untreated bac- screening for trichomoniasis for diagnosis of cer- vical Chlamydia tra- terial vaginosis is associated with include direct microscopic exami- chomatis infection in a high-prevalence infectious complications of gyneco- nation of vaginal fluid (“wet female population. J logic and obstetric surgery (10). prep,” 60% sensitivity), an Clin Microbiol. 1993;31:968-71. Nonpregnant women who are enzyme-linked immunosorbent [PMID: 7681852]

1 September 2009 Annals of Internal Medicine In the Clinic ITC3-3 © 2009 American College of Physicians Table 1. Laboratory and Other Tests for Vaginitis and Cervicitis Test Sensitivity, % Specificity, % Notes Vaginal pH 89% for diagnosis 73% for diagnosis Normal pH is <4.5. Blood, semen, and cervical secretions may interfere with test. of bacterial of bacterial pH usually normal in candidiasis and >4.5 in bacterial vaginosis and sometimes vaginosis vaginosis trichomoniasis. “Whiff” test on 43% for diagnosis 91% for diagnosis Add 10% potassium hydroxide to vaginal secretions. Test results are positive if vaginal of bacterial of bacterial a fishy smell is present. Positive in bacterial vaginosis and sometimes in secretions vaginosis vaginosis trichomoniasis. Microscopic 65%–85% for 100% for yeast Mix secretions in a small amount of saline and observe using “high dry” 40× lens. examination yeast infection, infection with Note the presence of budding yeast and pseudohyphae, motile trichomonads, of vaginal fluid 60% for compatible clinical and clue cells (squamous epithelial cells covered with whose edges are trichomoniasis, findings, 100% for obscured). Observe number and type of bacteria: Moderate numbers of large 80% for bacterial trichomoniasis, 80% rods represent lactobacilli (normal flora); large numbers of coccobacilli or motile vaginosis for bacterial curved rods strongly suggest bacterial vaginosis. vaginosis Gram stain of 89% compared 83% compared with Nugent method is the most widely used. Determines quantities of 3 different vaginal secretions with Amsel criteria Amsel criteria bacterial morphotypes: large gram-positive rods (lactobacilli), small gram- for bacterial variable coccobacilli (Gardnerella, Prevotella), and curved rods (Mobiluncus). vaginosis Scores range from 1–10, with 0–3 = normal, 4–6 = intermediate, and 7–10 = bacterial vaginosis* Culture for yeast Not routinely indicated; may detect colonization as opposed to infection. or G. vaginalis InPouch TV 90%–95% 100% Commercially available culture media inoculated at bedside is currently the gold culture for standard. Compared with culture, direct microscopic examination of the vaginal Trichomonas fluid (“wet prep”) has sensitivity of 60%. Self-obtained specimens may be used vaginalis with culture in special settings. Vaginal specimen may be transported to laboratory on an Amies gel transport swab before inoculation into culture pouch. OSOM 80% (compared 99% ELISA strip test for vaginal samples. CLIA complexity moderate. Trichomonas with InPouch TV) Rapid Test Affirm DNA 94% for bacterial 81% for bacterial Semiautomated office-based test to distinguish between causes of vaginosis. hybridization vaginosis, 80% for vaginosis, 98% for trichomoniasis trichomoniasis FemExam pH/amine 87% 92% Rapid card test for pH and amines. If positive, further testing is needed to test card demonstrate bacterial vaginosis or trichomoniasis PIP test card 90% 97% Rapid card test for bacterial vaginosis. Detects proline iminopeptidase. Endocervical Gram 50%–60% 95% Determines whether intracellular gram-negative diplococci are present. Very stain for cervicitis helpful, but sensitivity is lacking. Accuracy is improved by obtaining endocervical specimen without vaginal contamination. Culture for 90% 99% Traditional culture method on Thayer-Martin agar. Ideally, should be plated at Neisseria bedside and immediately placed into 3% carbon dioxide and incubated, but an gonorrhoeae Amies gel transport swab may be used. Necessary to use culture if susceptibility for cervicitis testing or monitoring is desired. Gen-Probe 90% for gonorrhea, 96% for gonorrhea, Unamplified probe for gonorrhea and chlamydia. Automated and relatively (unamplified 78% for chlamydia 99% for chlamydia inexpensive with suboptimal sensitivity. probe assay) for cervicitis PCR or SDA for 99% 99% Amplified DNA testing for gonorrhea and chlamydia, gold standard. Expensive, cervicitis but can be performed on vaginal or urine specimens. Chlamydia culture 70%–90% 99% Not widely available, and sensitivity varies by laboratory. Requires specimen for cervicitis collection with Dacron-shafted swab into transport media. Wooden shafts are toxic to culture. Enzyme 55%–70% 98% Several commercially available. Inexpensive with suboptimal sensitivity. immunoassays for chlamydia Direct fluorescence 55%–70% 82%–100% Not suited for large volume. Sensitivity and specificity vary with skill of observer. antibody testing for chlamydia

CLIA = Clinical Laboratory Improvement Amendments; ELISA = enzyme-linked immunosorbent assay; PCR = polymerase chain reaction; PIP = proline iminopeptidase; SDA = strand displacement activation. * From Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993;168:1503-9. [PMID: 8498436].

© 2009 American College of Physicians ITC3-4 In the Clinic Annals of Internal Medicine 1 September 2009 assay–based rapid test (80% sen- and neonatal chlamydial pneumo- sitivity, 99% specificity), or a nia, but treatment may not prevent semiautomated office-based test preterm birth. The optimal time to (80% sensitivity, 98% specificity). screen for causes of vaginitis and cervicitis during pregnancy is not Should clinicians screen pregnant known. women for vaginitis and cervicitis? Clinicians should screen pregnant A randomized trial in pregnant women women for vaginitis and cervicitis. with bacterial vaginosis and a history of Whether transmitted sexually or previous preterm delivery compared the not, infectious vaginitis and cervici- effects of metronidazole and erythromy- tis can cause complications for cin at a mean of 22.7 weeks and at 27.6 weeks of gestation (n = 433) versus mother and baby. Both trichomoni- (n = 191). Premature delivery oc- asis and bacterial vaginosis have curred in 110 women assigned to been associated with preterm metronidazole and erythromycin (26%) birth, , and post- and 68 women in the placebo group partum . Gonorrhea (36%, P = 0.010), indicating that treat- 12. Smith KR, Ching S, and chlamydia during pregnancy are ment reduced rates of premature deliv- Lee H, et al. Evalua- tion of ligase chain causes of ophthalmia neonatorum ery in this population (15). reaction for use with urine for identifica- tion of Neisseria gonorrhoeae in fe- males attending a Screening... Clinicians should screen women who are at risk for sexually trans- sexually transmitted mitted causes of vaginitis and cervicitis for gonorrhea, chlamydia, and T. vaginalis disease clinic. J Clin infections. These include women with new or multiple sexual partners, history or Microbiol. 1995;33:455-7. current symptoms of STIs, or history of unprotected intercourse. These women [PMID: 7714206] should also receive an annual Papanicolaou test, and all sexually active women 13. Hook EW 3rd, Smith K, Mullen C, et al. Di- younger than 24 years should be screened for chlamydia annually. Clinicians agnosis of genitouri- should also screen for bacterial vaginosis in women who are about to undergo nary Chlamydia tra- gynecologic surgery. All pregnant women should receive screening for infectious chomatis infections by using the ligase causes of vaginitis and cervicitis. Trichomoniasis and bacterial vaginosis have chain reaction on been associated with preterm birth, chorioamnionitis, and postpartum endometri- patient-obtained vaginal swabs. J Clin tis. Gonorrhea and chlamydia during pregnancy are causes of ophthalmia neo - Microbiol. natorum and neonatal chlamydial pneumonia. 1997;35:2133-5. [PMID: 9230397] 14. Van Dyck E, Ieven M, Pattyn S, et al. De- CLINICAL BOTTOM LINE tection of and Neisseria gonor- rhoeae by enzyme immunoassay, cul- ture, and three nu- Diagnosis cleic acid amplifica- What is the role of the medical not cervical infection. Patient report of yel- tion tests. J Clin Microbiol. history and physical examination low predicted infection 2001;39:1751-6. [PMID: 11325985] in the diagnosis of vaginitis and with gonorrhea or chlamydia. C. albicans 15. Hauth JC, Golden- was strongly associated with the chief berg RL, Andrews cervicitis? WW, et al. Reduced The medical history is important symptom of vulvar pruritus (16). incidence of preterm delivery for determining the risk for STIs, with metronidazole Physical examination detects signs the symptoms that suggest specific and erythromycin in of vaginitis and cervicitis and can women with bacter- causes of vaginitis and cervicitis, ial vaginosis. N Engl provide clues to the cause. Clinicians J Med. and the presence or absence of 1995;333:1732-6. should perform a pelvic examina- [PMID: 7491136] upper genital tract infection. tion for vulvar or vaginal lesions or 16. Ryan CA, Courtois BN, Hawes SE, et al. erythema, vaginal discharge, cervi- Risk assessment, One prospective RCT studied the clinical cal motion or adnexal tenderness, symptoms, and manifestations and risk correlates of cervi- signs as predictors and endocervical mucus. However, of vulvovaginal and cal and vaginal infections in 779 women cervical infections in a normal examination does not rule an urban US STD seeking evaluation for a new problem at an clinic: implications out infection. for use of STD algo- STI clinic and found that patient report of rithms. Sex Transm only abnormal vaginal discharge predicted or cervical motion or abdom- Infect. 1998;74 Suppl 1:S59-76. trichomoniasis and bacterial vaginosis, but inal or adnexal tenderness should [PMID: 10023355]

1 September 2009 Annals of Internal Medicine In the Clinic ITC3-5 © 2009 American College of Physicians Table 2. of Vaginitis and Cervicitis Disease Characteristics Notes Bacterial vaginosis Homogenous vaginal discharge and odor Requires laboratory confirmation. Trichomoniasis “Frothy” vaginal discharge, pruritus Requires laboratory confirmation. Vaginal candidiasis “Cottage cheese” vaginal discharge, Laboratory confirmation should be sought; however, moderate-to-intense vulvovaginal pruritus empirical treatment may be appropriate for women with compatible clinical syndrome and no other identified infec- tion or with recurrent infections. Retained foreign body Discharge, foul odor Often a retained tampon. Physiologic vaginal discharge Minimal-to-moderate vaginal discharge, no Patients sometimes seek medical attention for physiologic laboratory evidence of infection discharge. Mucopurulent cervicitis Mucopus visible from endocervix, yellow May be caused by chlamydial infections, gonorrhea, or appearance on swab virus. Requires laboratory confirmation. Cause unknown in 50% of cases. Pelvic inflammatory disease Mucopurulent cervicitis may be present but Vaginal-probe ultrasonography may be helpful in the associated with fever; leukocytosis; and lower diagnosis by excluding pelvic mass. abdominal, adnexal, or cervical motion tenderness Vulvovaginal trauma Excoriations in unusual locations, recurring Consider domestic violence. pain,

raise concern about upper genital in pregnancy or during gynecologic tract involvement. Do not confuse surgery, rarely leads to serious con- the presence of cervical ectopy, sequences; however, cervicitis can which is common among young lead to infertility and other seri- women, with cervicitis. Mucopuru- ous complications if left untreat- lent discharge from the cervical os ed. Accurate diagnosis allows indicates the presence of the syn- appropriate therapy and decreases drome of mucopurulent cervicitis, the chances of ongoing or recur- which may be caused by gonorrhea ring symptoms. or chlamydia, or more rarely, by Cervicitis is generally classified as herpes simplex infection. The cause either chronic or acute. Chronic of mucopurulent cervicitis is un- cervicitis lasts for months or longer. known in approximately half of all Chronic cervicitis is often seen in cases, and its absence does not rule women after , during out the presence of gonorrhea or pregnancy, or with the use of oral chlamydia. Table 2 presents the dif- contraceptives. It may be due to an 17. Kahn JG, Walker CK, ferential diagnosis of vaginitis and Washington AE, et al. increased blood supply to the Diagnosing pelvic cervicitis. inflammatory dis- resulting from increased hormone ease. A comprehen- levels or an outward migration of sive analysis and How can clinicians distinguish considerations for vaginitis from cervicitis, and is the the squamocolumnar junction. Cer- developing a new vicitis may also be caused by sensi- model. JAMA. distinction important? 1991;266:2594-604. tivities to certain chemicals in [PMID: 1834868] Vaginitis refers to the symptoms spermicides, condoms, or feminine 18. Sellors J, Mahony J, produced when the normal vaginal Goldsmith C, et al. hygiene products, but this is less The accuracy of clin- environment becomes unbalanced ical findings and la- common than infection. paroscopy in pelvic because of hormonal changes, irri- inflammatory dis- ease. Am J Obstet tants, or changes in vaginal flora. How should clinicians evaluate for Gynecol. When an infection causes inflam- upper genital tract involvement in 1991;164:113-20. [PMID: 1824740] mation of the cervix, it is called cer- patients who have symptoms of 19. Hillis SD, Joesoef R, Marchbanks PA, et al. vicitis. Patients may have vaginitis vaginitis and cervicitis? Delayed care of and cervicitis simultaneously. It is Upper genital tract disease is dif- pelvic inflammatory disease as a risk fac- important to recognize the differ- ficult to diagnose, because presen- tor for impaired fer- tility. Am J Obstet ences in the presentation and cause tations, symptoms, and signs vary Gynecol. of vaginitis and cervicitis. Vaginitis widely, and because many women 1993;168:1503-9. [PMID: 8498436] is often uncomfortable but, except have subtle or mild symptoms.

© 2009 American College of Physicians ITC3-6 In the Clinic Annals of Internal Medicine 1 September 2009 The main concern is PID, which have a sensitivity of 65% when com- is caused by upward spread of pared with laparoscopic, histologic, or infectious microorganisms microbiological evidence of upper tract through the cervix to the , infection (20). fallopian tubes, ovaries, and peri- In a multicenter RCT designed to com- toneal cavity. Although multiple pare the effectiveness of outpatient and organisms can be responsible— inpatient therapy for PID and 1 of the and gonorrhea and chlamydia are largest PID studies in North America, in- common causes—the specific vestigators evaluated clinical predictors agent is often not identified. of endometritis in 651 women present- ing with of PID. The No diagnostic indicators have CDC minimal criteria were found to have been found to predict pelvic in- a sensitivity of 83% compared with 96% flammatory disease reliably (17). for adnexal tenderness (21). As many as 50% of PID episodes A follow-up involving the first 157 pa- go unrecognized (18). Early diag- tients in this study found that the pres- nosis and treatment are critical, ence of either mucopurulent discharge because missing upper tract infec- or vaginal leukocytes had a sensitivity of tion can result in acute and 89% for the diagnosis of histologic en- chronic sequelae, such as abscess dometritis in patients with pelvic pain formation, ectopic pregnancy, and tenderness (22). chronic infection and pain, and infertility. When evaluating patients for upper genital tract infection, per- One study demonstrated a 3-fold in- form a sensitive pregnancy test in creased risk for infertility or ectopic preg- women of reproductive age to nancy with delay of care. This associa- look for ectopic pregnancy and tion was strongest for women with spontaneous or septic . chlamydia; 17.8% (18 of 101) of those Consider other gynecologic and who delayed seeking care had impaired nongynecologic disorders, such as fertility, whereas none (0 of 13) of those ovarian cysts, , and who sought care promptly had known sequelae. The investigators noted that , that can cause lower the longer women with PID delay seek- in women who ing care, the greater the chance of im- are not pregnant. paired fertility (19). 20. Peipert JF, Boardman LA, Sung CJ. Per- formance of clinical The CDC recommends empirical and laparoscopic cri- teria for the diagno- treatment of PID in sexually ac- Centers for Disease Control and sis of upper genital tive women, if they are experienc- Prevention recommend empirical tract infection. Infect pelvic inflammatory disease Dis Obstet Gynecol. ing pelvic or lower abdominal 1997;5:291-6. treatment for women with lower pain, if no cause for the illness [PMID: 18476154] abdominal or pelvic pain, no 21. Peipert JF, Ness RB, other than PID can be identified, Blume J, et al; Pelvic evidence of alternative diagnosis, Inflammatory Dis- and at least one of the following and >1 of the following: ease Evaluation and Clinical Health Study is present on : • Uterine tenderness Investigators. Clinical cervical motion tenderness, uter- predictors of en- • Adnexal tenderness dometritis in ine tenderness, or adnexal tender- • Cervical motion tenderness women with symp- toms and signs of ness (2). In addition to 1 of the 3 The following supportive criteria pelvic inflammatory minimum criteria, signs of lower may increase the specificity of disease. Am J Obstet Gynecol. genital tract in- the diagnosis: 2001;184:856-63; dis- crease the specificity of diagnosis. • Oral temperature >38.3°C (>101°F) cussion 863-4. • Abnormal cervical or vaginal muco - [PMID: 11303192] Additional criteria may be used to 22. Peipert JF, Ness RB, purulent discharge Soper DE, et al. Asso- enhance the specificity of the • Presence of leukocytes on saline ciation of lower gen- minimum criteria (Box). ital tract inflamma- microscopy of vaginal secretions tion with objective • Laboratory documentation of cervical evidence of en- In a study of patients presenting with infection with N. gonorrhoeae or dometritis. Infect Dis signs of upper genital tract infection, the Obstet Gynecol. C. trachomatis 2000;8:83-7. CDC minimal criteria were found to [PMID: 10805362]

1 September 2009 Annals of Internal Medicine In the Clinic ITC3-7 © 2009 American College of Physicians What noninfectious conditions gonorrhea and chlamydia are should clinicians consider when pathogens of the columnar (not evaluating a patient for vaginitis squamous) epithelium, so a vagi- and cervicitis? nal sample without endocervical The most common noninfectious sampling would be inadequate. In causes for vaginitis and cervicitis women who have had a hysterec- are allergic reactions to laundry tomy, sample the urethra for gon- products, soaps, vaginal sprays, orrhea and chlamydia or use spermicidal products, or douches. urine for nucleic acid amplifica- Vaginal or cervical irritation or tion testing (23). Genital fluids complications may also be caused removed from the speculum may by a retained foreign body, such as be a mixture of vaginal and cervi- a tampon, or by vulvovaginal trau- cal secretions and should not be ma. Natural or surgical menopause used for vaginitis testing, espe- decreases hormone levels and can cially pH determination. The pH cause the vagina to become dry or of vaginal fluid may be increased atrophic, which can also result in by contamination with cervical vaginal itching and burning. secretions or semen. What is the role of laboratory Which organisms can cause testing in the diagnosis of vaginitis and cervicitis, and how vaginitis and cervicitis? can clinicians identify the If newer DNA-amplification etiologic organisms? tests are not affordable, presump- A microscopic examination of tive management is sometimes vaginal discharge with a drop of the only choice. Whenever possi- 0.9% saline solution (wet mount) ble, however, clinicians should can help to identify motile organ- perform laboratory testing to isms with flagella (trichomonads) confirm the diagnosis (Table 1). or epithelial cells covered with A specific diagnosis guides treat- bacteria obscuring the cell bor- ment, counseling, and partner ders (clue cells). Additional ex- notification. Laboratory testing amination of the secretions with can be particularly helpful when a drop of 10% potassium hydrox- multiple infections are present. ide is useful in identifying the For example, gonorrhea, chlamy- fishy odor of bacterial vaginosis dia, and bacterial vaginosis may (whiff test) or the filaments or coexist. Sensitivity and specificity spores of Candida species. Vaginal vary greatly among tests, and cli- cultures or rapid tests can help nicians should use the most sen- identify thecause when the diag- sitive and specific testing that is nosis remains uncertain after available and affordable. these office-based tests. What is the appropriate method Bacterial vaginosis for obtaining samples for The normally predominant vagi- laboratory investigation? nal organism is the Lactobacillus Clinicians should obtain samples genus, principally L. crispatus and from the vaginal walls and endo- L. jensenii. These organisms help cervix in all patients suspected of maintain the normal vaginal pH having vaginitis or cervicitis (16). less than 4.5, and lactobacilli that Sample the urethra for gonorrhea elaborate hydrogen peroxide pro- and chlamydia or use urine for vide some protection against nucleic acid amplification testing. pathogens. Bacterial vaginosis 23. Judson FN, Ruder Erroneous results and suboptimal occurs with the loss of such MA. Effect of hys- terectomy on genital sensitivity may occur with inade- lactobacilli and the resulting infections. Br J Vener quate sampling, because pathogens overgrowth of many species of Dis. 1979;55:434-8. [PMID: 43185] are site-specific. For example, bacteria, some of which cannot

© 2009 American College of Physicians ITC3-8 In the Clinic Annals of Internal Medicine 1 September 2009 be cultured and have been identi- and is one of the most common Consider the following tests in fied recently only by using nucle- STIs in the United States. A the diagnostic evaluation of ic acid amplification technology diffuse, malodorous, yellow-green vaginitis and cervicitis: (24). Although bacterial vaginosis vaginal discharge often contain- • Vaginal pH is usually found in sexually active ing bubbles is common in • “Whiff” test women, it is not considered an trichomoniasis. The sensitivity • Vaginal wet mount and potassium STI, women who have never had of identifying trichomonads hydroxide preparation sexual intercourse may be affect- (characterized by a jerky motility) • Endocervical specimen for gonor- ed, and recurrences are common on wet mount is approximately rhea and chlamydia even without reexposure. 60% to 70%, whereas the speci- • Test all women at risk for PID and who present with abdominal pain ficity is almost 100%. Cultures for N. gonorrhoeae and C. tracho - Symptoms of bacterial vaginosis for identifying T. vaginalis are matis by using DNA amplification include malodorous discharge more sensitive than wet-mount tests. without irritation or pain. On microscopy. • Perform a microscopic evaluation physical examination, clinical of the vaginal discharge to look Gonorrhea for evidence of trichomoniasis or criteria for bacterial vaginosis bacterial vaginosis. include a homogenous, white, Gonorrhea is caused by infection • Obtain a sensitive pregnancy test noninflammatory discharge that with the bacterium N. gonorrhoeae. in all women of reproductive age smoothly coats the vaginal walls; Most women with gonococcal presenting with signs or symp- presence of clue cells on micro- cervicitis are asymptomatic but toms of PID and before prescrib- ing therapy contraindicated in scopic examination; vaginal pH are still at risk for complications. pregnancy. greater than 4.5; and the presence Culture for N. gonorrhoeae re- • Consider blood leukocyte count if of a fishy odor to the vaginal dis- mains the gold standard of diag- PID is suspected. charge either before or after the nosis, but DNA amplification • Consider hepatic enzymes in addition of 10% potassium hy- assays, including PCR and LCR patients presenting with signs and symptoms of PID with right droxide. Symptomatic patients of an appropriate genital speci- upper quadrant pain. meeting at least 3 of these crite- men have proven both sensitive • Consider endometrial for ria should receive treatment. and specific. histologic evidence of en- dometriosis. Vaginal yeast infections Chlamydial infections • Consider in compli- Most yeast infections involve Infection with C. trachomatis is cated PID. C. albicans. Less common causes often asymptomatic. Findings on • Consider ultrasonography, com- physical examination may include puted tomography, or magnetic are C. glabrata, C. parapsilosis, resonance imaging to look for C. guilliermondii, and C. tropi- a yellow or cloudy mucoid dis- thickened, fluid-filled fallopian calis. Vaginal yeast infections charge from the cervical os, and tubes or tuboovarian abscess. may occur in any women, but the cervix may bleed easily when women who are pregnant, who swabbed or scraped during exam- are on antibiotics or cortico- ination. Some women with steroids, or who have diabetes are C. trachomatis infection develop at increased risk. Symptoms in- , with such symptoms as clude pruritus; external and inter- without frequency or nal erythema; and nonodorous, urgency. Chlamydia in the lower white, curd-like discharge. Be- genital tract does not cause cause vaginal yeast is found in vaginitis, but the infection may 10% to 20% of healthy women, cause cervicitis and PID. Symp- Candida found in asymptomatic toms range from absent to severe women does not require treat- abdominal pain with high fever ment. Microscopic examination and include prolonged menses, of vaginal fluid can be diagnostic. pain during sexual intercourse, Many women, even those with and bleeding between periods. profound symptoms, may not As with gonorrhea, culture is the 24. Fredricks DN, Fiedler gold standard for diagnosis, but TL, Marrazzo JM. Mo- reveal yeast on wet mount. lecular identification PCR and LCR assays of cervical of bacteria associat- ed with bacterial specimens, first-void urine speci- vaginosis. N Engl J Trichomoniasis is caused by mens, and genital fluids are Med. 2005;353:1899- 911. T. vaginalis, a protozoan parasite, highly sensitive and specific. [PMID: 16267321]

1 September 2009 Annals of Internal Medicine In the Clinic ITC3-9 © 2009 American College of Physicians Diagnosis... A range of noninfectious conditions and infectious organisms can cause vaginitis and cervicitis. The medical history is important for determining symptoms that suggest specific causes of vaginitis and cervicitis, the risk for STIs, and the presence or absence of symptoms of upper genital tract infection. Clini- cians should inquire about sexual history, particularly any recent new partner; any history of vaginitis; history of STIs in patient and partners; and vaginal dis- charge, odor, irritation, pruritus, or external dysuria. The physical examination should include inspection for vulvar or vaginal lesions, vaginal discharge, cervical motion or adnexal tenderness, and mucus from the endocervix. Laboratory testing is often warranted to confirm the cause of vaginitis or cervicitis. Upper genital tract disease can be difficult to diagnose, because presentation varies widely and because many women have subtle or mild symptoms. Because the long-term ef- fects of nontreatment can damage reproductive health, clinicians should have a relatively low threshold for making a diagnosis of PID.

CLINICAL BOTTOM LINE Treatment Which nondrug adjuvant measures response to alterations in the an- are helpful in the treatment of timicrobial susceptibility of the patients with vaginitis and organisms, so clinicians should cervicitis? consult the latest recommenda- Few if any published data support tions. Consider whether sexual nondrug therapy. Such therapies as partners need to be treated as well. povidone-iodine douches, yogurt, Table 3 summarizes drug therapy and vaginal acidification have not for vaginitis and cervicitis. been shown to be effective. Some evidence suggests that vaginal boric Yeast infections acid may be effective in the treat- Treatment for yeast infections in- ment of vulvovaginal candidiasis, cludes an imidazole in the form of particularly in patients infected 1- to 7-day intravaginal dosing or with strains relatively resistant to fluconazole in the form of a single the imidazoles (25). It has been oral dose. For patients with recur- documented that the lactobacilli in rent yeast infections, weekly oral yogurt adhere poorly to the vaginal fluconazole for 6 months reduces epithelium (26). Indeed, the lacto- the recurrence of candidal vaginitis bacilli in yogurt are not part of the during therapy. However, infections normal vaginal flora. Vaginal sup- are likely to recur after treatment is positories containing a human- discontinued. derived strain of an appropriate lactobacillus are being studied for Bacterial vaginosis effectiveness in reestablishing nor- Symptomatic patients who have at mal flora in women with bacterial least 3 of the diagnostic criteria vaginosis. Clinicians should discuss should receive treatment with 25. Sobel JD, Chaim W. Treatment of Toru- with all patients the lack of efficacy metronidazole or , ei- lopsis glabrata ther orally or vaginally. Oral tinida- vaginitis: retrospec- of these nondrug therapies in a tive review of boric nonjudgmental way. zole is an alternate treatment. acid therapy. Clin In- fect Dis. Vaginal clindamycin is not recom- 1997;24:649-52. How should clinicians decide mended for treatment in pregnancy, [PMID: 9145739] 26. Wood JR, Sweet RL, which drug to use to treat because it does not prevent the ges- Catena A, et al. In vaginitis and cervicitis? vitro adherence of tational complications. Lactobacillus species If a specific diagnosis of an STI to vaginal epithelial cells. Am J Obstet is made, follow CDC treatment Trichomoniasis Gynecol. guidelines (2). Optimal therapy Patients infected with T. vaginalis 1985;153:740-3. [PMID: 3934974] of STI may change rapidly in should receive treatment with a

© 2009 American College of Physicians ITC3-10 In the Clinic Annals of Internal Medicine 1 September 2009 Table 3. Drug Treatment for Vaginal and Cervical Infections Agent Dosage Benefits Side Effects and Notes Nystatin 1–7 d intravaginal dosing Effective and safe; some are Local irritation. For vaginal candidiasis. Yeast balanitis (cream and suppository) for candidiasis available over the counter may occur in male partners. Topical safe in pregnancy. Fluconazole 150 mg PO as a single dose 1 oral dose GI upset. Equal in price and efficacy to topical for vaginal candidiasis; for vaginal candidiasis. May be used 150 mg/wk PO to prevent prophylactically for recurrent candidiasis. recurrent infection Contraindicated in pregnancy. Cytochrome P450 inhibitor, so consider drug interactions. Metronidazole 500 mg PO bid for 7 d for Inexpensive GI upset, metallic taste, peripheral neuropathy, bacterial vaginosis; 2 g as a dizziness; disulfiram-like reaction is possible. Efficacy single dose for trichomoniasis is approximately 85% for bacterial vaginosis, but recurrences are common. Resistant strains of Trichomonas can occur and are usually cured with increased doses. Category B in pregnancy.* Metronidazole gel 1 applicator intravaginally bid Topical therapy with little Avoids the usual side effects of metronidazole; can every day for 5 d for bact- systemic absorption cause vaginal candidiasis. Efficacy same as oral erial vaginosis; longer therapy for bacterial vaginosis. Not effective for trichomoniasis. (10–14 d) may be helpful for Some data exist for twice-weekly prophylactic use of persistent bacterial vaginosis metronidazole gel for recurrent bacterial vaginosis. Clindamycin 300 mg PO bid for 7 d for Alternative to metronidazole Colitis. Expensive. Category B in pregnancy*. bacterial vaginosis for bacterial vaginosis Clindamycin 2% cream 1 applicator intravaginally Alternative to metronidazole, Vaginal yeast infections. Generic now available. Category qhs for 3–7 d for bacterial equal efficacy for bacterial B in pregnancy*. vaginosis vaginosis Clindamycin ovules 1 vaginal suppository per day Alternative to metronidazole Vaginal yeast infections. The FDA has recently for 3 d for bacterial vaginosis for bacterial vaginosis approved a single intravaginal dose for bacterial vaginosis. Category B in pregnancy*. Tinidazole 2 g as a single dose for Effective against some strains GI upset, but may be less than with metronidazole. uncomplicated trichomoniasis; of trichomonas that are Recently approved by the FDA. Both of these regimens longer duration for resistant resistant to metronidazole have been found to be effective. Contraindicated in first strains; 1–2 g/d for 2–5 d for trimester of pregnancy. bacterial vaginosis Ceftriaxone 125 mg IM for uncomplicated Effective for urogenital, rectal, Local pain at injection site, can dilute with lidocaine. gonorrhea; 250 mg IM for and pharyngeal gonorrhea Relatively expensive. No resistance seen to date. Category upper genital tract infection B in pregnancy*. Always combine with chlamydia treatment unless a DNA amplification test fails to detect chlamydia. Cefixime 400 mg PO as a single dose Effective oral No common side effects. Observe dosing if possible. Oral for gonorrhea equivalent to ceftriaxone. Category B in pregnancy*. Combine with chlamydia treatment. Spectinomycin 2 g IM Alternative for treatment of Local pain at injection site. Limited availability. Not gonorrhea for pregnant effective for pharyngeal gonorrhea. patients who are allergic to penicillin 100 mg PO bid for 7 d for First-line treatment for GI upset. Photosensitivity. Compliance may be a problem. chlamydia chlamydia in nonpregnant Contraindicated in pregnancy. patients Erythromycin 500 mg PO qid for 7 d Alternative for treatment GI upset. Compliance may be a problem. Category B in of chlamydia in pregnancy pregnancy*. Azithromycin 1 g PO as a single dose Single-dose therapy for None common; GI upset possible, including nausea, chlamydia with efficacy vomiting, abdominal pain, and diarrhea. Expensive. equal to that of doxycycline; Sachet package less costly than capsules. 2-g dose use 2 g PO single dose as licensed for treatment of gonorrhea but not recom- alternative for gonorrhea mended because of expense and side effects. Category B in pregnancy*. 2-g dose may be an option for pregnant women with gonorrhea who are receiving penicillin. Amoxicillin 500 mg PO tid for 7 d Alternative treatment for Second-line agent. Posttreatment testing may be useful chlamydia in pregnancy to confirm cure. Category B in pregnancy*.

bid = twice per day; FDA = U.S. Food and Drug Administration; GI = gastrointestinal; IM = intramuscular; PO = oral; qd = once per day; qhs = every night; qid = 4 times per day; tid = 3 times per day. * Category B means there is no evidence of risk in humans, but controlled studies are not available.

1 September 2009 Annals of Internal Medicine In the Clinic ITC3-11 © 2009 American College of Physicians single 2-g dose of metronidazole or bacterial vaginosis. Consider cost Quinolones should no tinidazole. In patients who do not and patient preference in deciding longer be used for the respond to this regimen, a 7-day whether to order topical or oral treatment course is appropriate. therapy. Intravaginal therapy treatment of gonorrhea avoids the systemic side effects of Gonorrhea oral therapy; however, some pa- Patients diagnosed with uncompli- tients prefer the ease of adminis- cated gonorrhea should be treated tration of oral therapy. Women with cefixime, 400 mg orally as a who use clindamycin cream or single dose, or ceftriaxone, 125 mg other topical creams and oint- intramuscularly as a single dose. ments that contain mineral or When upper genital tract infection is vegetable oil should be warned present, prescribe ceftriaxone, that they cannot use condoms or 250 mg intramuscularly, as part of diaphragms for contraception the therapy. Azithromycin, 2 g orally because the creams can weaken as a single dose, is a second-line latex. Topical clindamycin therapy therapy for gonorrhea but should be should not be used in pregnancy used with caution in the face of in- because it does not prevent gesta- creasing resistance. For pregnant pa- tional complications. tients who are allergic to penicillin, consider spectinomycin (2 g intra- Should clinicians recommend muscularly). treatment of the sexual partners of women with vaginitis and Quinolones should no longer be cervicitis? used for the treatment of gonor- With bacterial vaginosis and vagi- 27. Centers for Disease rhea, according to a 2007 update in Control and Preven- nal yeast infections, treatment of tion (CDC). Update treatment guidelines from the asymptomatic sex partners is un- to CDC’s sexually CDC (27). The recommendation transmitted diseases necessary. With STIs, however, treatment guide- was based on analysis of new data lines, 2006: fluoro- the partners of patients with from the agency’s Gonococcal Iso- quinolones no vaginitis or cervicitis should be longer recommend- late Surveillance Project, which ed for treatment of treated. This approach can signifi- gonococcal infec- showed that the proportion of fluo- tions. MMWR Morb cantly reduce the risk for reinfec- roquinolone-resistant gonorrhea Mortal Wkly Rep. tion in the index patient. Clini- 2007;56:332-6. cases in heterosexual men in the [PMID: 17431378] cians should ask patients with 28. Hogben M, McCree United States reached 6.7%. This DH, Golden MR. Pa- sexually transmitted vaginitis or was an 11-fold increase from 0.6% tient-delivered part- cervicitis to contact their sexual ner therapy for sexu- in 2001. ally transmitted partners, inform them of their risk diseases as practiced by U.S. physicians. Chlamydia for infection, and encourage them Sex Transm Dis. 2005;32:101-5. Doxycycline, 100 mg orally twice to seek medical care. It may be [PMID: 15668616] per day for 7 days, is a first-line helpful to provide patients with 29. Golden MR, Anukam U, Williams DH, et al. treatment for chlamydia in non- written information that they can The legal status of distribute to their partners. patient-delivered pregnant patients. Azithromycin, partner therapy for 1 g orally, is a single-dose option sexually transmitted Some clinicians give patients with infections in the for chlamydia with efficacy equal United States: a na- to that of doxycycline, but it is STIs prescriptions to tional survey of state offer to their partners. This medical and phar- more expensive. For pregnant pa- macy boards. Sex method is known as patient-deliv- Transm Dis. tients, prescribe azithromycin as 2005;32:112-4. described previously, oral erythro- ered partner treatment (PDPT), [PMID: 15668618] or expedited therapy. The PDPT 30. Packel LJ, Guerry S, mycin, 500 mg 4 times per day for Bauer HM, et al. Pa- method is gaining acceptance and tient-delivered part- 7 days, or oral amoxicillin, 500 mg ner therapy for 3 times per day for 7 days. is widely practiced, although it is chlamydial infec- not yet explicitly legal in many tions: attitudes and practices of Califor- When is topical treatment states. It has been proven effective nia physicians and nurse practitioners. appropriate? in a research setting, but some Sex Transm Dis. Topical therapeutic options are partners who receive PDPT forgo 2006;33:458-63. [PMID: 16794548] available for yeast infections and clinical evaluation, and this may

© 2009 American College of Physicians ITC3-12 In the Clinic Annals of Internal Medicine 1 September 2009 result in missed opportunities for not uncommon (35). Treatment the diagnosis and treatment of noncompliance or drug resistance comorbid conditions (28–30). should be considered. Reinfection by a sexual partner should also be A cross-sectional survey of 401 health care considered in recurrent cases of providers in New York City revealed that 20% frequently used provider referral, 49% had vaginitis or of cervicitis related to ever used PDPT, and 27% used PDPT fre- gonorrhea, chlamydia, or tri- quently. Providers who reported using PDPT chomoniasis. If infection is recal- were more likely to report frequent provider citrant despite treatment and referral than providers who had never used efforts to prevent reinfection, the PDPT (26.7% vs. 12.6%; P < 0.001) (31). patient may require consultation with a specialist for additional Research on women and men with testing and management. STIs suggests that giving them an- tibiotics for their partners is more Recurrence of bacterial vaginosis effective than simply asking them is very common. Although no to refer their partners for treatment firm recommendations exist, re- (32–34). Clinicians may want to currences may be prevented by the 31. Rogers ME, Opdyke consult with the local public health use of metronidazole gel, twice KM, Blank S, et al. Pa- STI program or clinic for guidance per week, and condoms. Routine tient-delivered part- ner treatment and on the management of potentially follow-up after treatment of bac- other partner man- infected sex partners. agement strategies terial vaginosis is not necessary, for sexually transmit- but recurrences of symptoms do ted diseases used by Short-term follow-up testing gener- New York City need reevaluation. Approximately healthcare providers. ally is not recommended. Consider 5% of women experience recurrent Sex Transm Dis. retesting for reinfection after longer 2007;34:88-92. vaginal yeast infections, and the [PMID: 16810120] intervals (for example, 3 months) 32. Stekler J, Bachmann risk is highest in women with im- L, Brotman RM, et al. and additional evaluation for vagini- mune system problems, poorly Concurrent sexually tis and cervicitis in high-risk patients transmitted infec- controlled diabetes, and pregnan- tions (STIs) in sex with refractory or recurrent disease. partners of patients Although recommended therapies cy. Resistance to azole anti-fungal with selected STIs: agents is increasingly common. implications for pa- for gonorrhea, chlamydia, and tri- tient-delivered part- Recurrent vaginal yeast infections ner therapy. Clin In- chomoniasis should result in a cure, fect Dis. patients can be reinfected by untreat- often involve non-C. albicans types 2005;40:787-93. of yeast, which are more resistant [PMID: 15736009] ed sexual partners. 33. Kissinger P, Mo- to the standard treatments. For hammed H, Richard- son-Alston G, et al. Do special considerations exist for patients with recurrent yeast in- Patient-delivered clinical care of patients with fections, weekly oral fluconazole partner treatment for male urethritis: a recurrent vaginitis and cervicitis? for 6 months reduces the recur- randomized, con- trolled trial. Clin In- Recurrences of STIs, bacterial rence of candidal vaginitis during fect Dis. vaginosis, and yeast infections are therapy. 2005;41:623-9. [PMID: 16080084] 34. Golden MR, Whit- tington WL, Hands- field HH, et al. Effect Treatment... Both topical and oral drug therapy options are available for yeast of expedited treat- ment of sex partners infections and bacterial vaginosis. Treatment for yeast infections includes imida- on recurrent or per- zoles or fluconazole. Treatment for bacterial vaginosis includes metronidazole, sistent gonorrhea or chlamydial infection. clindamycin, or tinidazole. If an STI (gonococcal, chlamydial, or trichomonal) is N Engl J Med. documented, follow the latest CDC treatment guidelines. Partners of patients 2005;352:676-85. with vaginitis or cervicitis due to these STIs should be treated to reduce the risk [PMID: 15716561] 35. Peterman TA, Tian for reinfection, prevent infection of other partners, and reduce the risk for com- LH, Metcalf CA, et al; plication in these patients themselves. Although patient-delivered partner treat- RESPECT-2 Study Group. High inci- ment is sometimes used, it is prohibited in some locales. High cure rates can be dence of new sexu- achieved if the recommended therapies are prescribed, if patients are compliant, ally transmitted in- and if reinfection is avoided. Recurrence of STIs, bacterial vaginosis, and yeast in- fections in the year following a sexually fections is common. transmitted infec- tion: a case for re- screening. Ann In- tern Med. CLINICAL BOTTOM LINE 2006;145:564-72. [PMID: 17043338]

1 September 2009 Annals of Internal Medicine In the Clinic ITC3-13 © 2009 American College of Physicians © 2009American Collegeof Physicians 39. U.S. Preventive Serv- DS,Halvor-38. Meyers 37. U.S. Preventive Serv- Na- 36. United Kingdom [PMID: 18838729] 2008;149:491-6, W95. Med. tern statement. AnnIn- recommendation TaskForceServices tions: U.S. Preventive transmitted infec- to prevent sexually havioral counseling ices Task Force. Be- 42. [PMID: 17576995] Med. 2007;147:135- Force. AnnIntern tive Services Task for theU.S. Preven- an evidenceupdate chlamydial infection: Screening for ices TaskForce. U.S. Preventive Serv- S; son H,Luckhaupt 34. [PMID: 17576996] Med. 2007;147:128- ment. AnnIntern ommendation state- ices Task Force rec- U.S. Preventive Serv- chlamydial infection: Screening for ices TaskForce. Health andHIV; 2005 sociation for Sexual As-England: British Disease. London, Pelvic Inflammatory of the Management tional Guidelinefor Cervicitis Vaginitis and Tool Kit in theclinic Improvement Practice Control andPrevention. diseasefrom theCentersforDisease inflammatory Access informationonpelvic www.cdc.gov/std/PID/STDFact-PID.htm Access informationonchlamydia from theCentersforDiseaseControl andPrevention. www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm Access informationongonorrheafrom Centers forDiseaseControl andPrevention. www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm vent Sexually Transmitted Diseases.” and Gynecologists’ brochure, CollegeofObstetricians Access theAmerican “How toPre- www.acog.org/publications/patient_education/bp009.cfm Causes and Treatment” and Gynecologists’ brochure, CollegeofObstetricians Access theAmerican “Vaginitis: www.acog.org/publications/patient_education/bp028.cfm infections. Health Association’s Social Access theAmerican transmitteddisease hotlineforsexually 1-800-227-8922 your patients onthefollowingAccess thepatientinformationlocated pagetodownload to anddistribute www.annals.org/intheclinic/toolkit-vaginitis.html Patient EducationResources and treatment inanelectronic formatdesignedforrapidaccessat thepointofcare. disease.tory PIER modulesprovide evidence-based, updatedinformationoncurrent diagnosis andthePIER inflamma- Access moduleonpelvic thePIER moduleonvaginitisandcervicitis pier.acponline.org PIER Modules ITC3-14 cervicitis? relevant tovaginitisand Are therepracticeguidelines 24 yearsoryounger shouldbe nonpregnant womenaged active, thatallsexually reported TaskServices Force (USPSTF) In 2007, theU.S. Preventive (36). of PID treatmentthreshold forempirical guideline recommends alow The UnitedKingdom’s national sistance problems (27). ofre- ment ofgonorrheabecause no longerbeusedforthetreat- mended thatquinolonesshould a 2007update, recom- theagency treatment forsuspectedPID. In recommendations, andempiric nostic evaluation, antimicrobial approachesprevention anddiag- 2006 (2). The guidelinesinclude in of patientswhohaveSTIs sive guidelinesforthetreatment released comprehen-The CDC treatment ofPID. andonthe vaginitis andcervicitis thatcause ofSTIs prevention onthe focusprimarily Guidelines In theClinic Annals of InternalMedicine laboratory forculture ifneeded. laboratory priate. Considerusingthestate whenappro- sexpartners notifying and have mechanismsforlocating ment. healthdepartments State infections tothehealthdepart- tient compliancewhenreporting andpa- notification with partner Clinicians shouldseekassistance inmanysettings. thereporting dle han- laboratories Microbiological isrequired reporting bylaw.ry partment. andlaborato- Physician tothestatehealthde- reported chlamydial infectionshouldbe ofgonorrheaand All cases departments? report tostatehealth Which STIsshouldclinicians (39). STIs for adultsatincreased for risk activeadolescentsand all sexually mended behavioralcounselingfor In 2008, theUSPSTFrecom- creased forinfection(37, risk 38). iftheyarescreened atin- only 25 yearsoroldershouldbe nonpregnant womenaged screened forchlamydia, whereas

1 September 2009 in theclinic WHAT YOU SHOULD In the Clinic Annals of Internal Medicine KNOW ABOUT VAGINITIS AND CERVICITIS

What are vaginitis and cervicitis? • Vaginitis is an inflammation of the vagina. Cervicitis is an inflammation of the cervix (the cervix connects the vagina and the uterus).

• Vaginitis can cause itching, irritation, discharge, or odor. Cervicitis may have no symptoms, or there may be abnor- mal bleeding, discharge, or pain, especially during sex.

• Vaginitis is not serious, except if you are pregnant or having gynecologic surgery.

• If cervicitis is not treated, it can lead to a serious infec- tion called pelvic inflammatory disease. This could cause problems, such as infertility and tubal pregnancy.

• Both vaginitis and cervicitis are common. • If you get treatment for an STI, ask your partner also. • Vaginitis can be caused by a yeast infection, bacteria, or trichomoniasis. An allergy to bath products, birth • To keep from getting yeast infections, don’t take an- control used in the vagina, damp or tight clothing, and tibiotics unless you really need them. If you are dia- not having enough estrogen are other causes. betic keep a good blood sugar level.

• Vaginitis can also occur because of overgrowth of bac- • To keep from getting vaginitis, don’t use douches or teria that are normally in the vagina. This is called bac- feminine sprays. terial vaginosis. What is the treatment for vaginitis or • Cervicitis is caused by chlamydia, gonorrhea, and her- pes simplex virus, which are all sexually transmitted cervicitis? infections (STIs). • These conditions are usually treated with an anti- biotic pill or a vaginal cream. Different antibiotics How can I prevent vaginitis and cervicitis? treat different types of infections. • Do not have too many sexual partners and use con- • Douches and treatments with a yogurt base or that doms every time you have sex. make the vagina more acidic do not work. For More Information Web Sites with Good Information on Vaginitis and Cervicitis www.acog.org/publications/patient_education/bp028.cfm American College of Obstetricians and Gynecologists’ brochure, “Vaginitis: Causes and Treatment” www.acog.org/publications/patient_education/bp009.cfm Access the American College of Obstetricians and Gynecologists’ brochure, “How to Prevent Sexually Transmitted Diseases.” www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm Access information on gonorrhea from Centers for Disease Control and Prevention. www.cdc.gov/std/Chlamydia/STDFact-Chlamydia.htm Access information on chlamydia from the Centers for Disease Control and Prevention. www.cdc.gov/std/PID/STDFact-PID.htm Access information on pelvic inflammatory disease from the Centers for Dis- ease Control and Prevention. Patient Information Patient CME Questions

1. A 30-year-old woman is evaluated for a A. Candidal vaginitis transmitted infections (STIs). She is in a 3-day history of vaginal discharge, itch- B. Trichomonas vaginalis long-term relationship with a man who ing, and irritation. During the past 12 C. Physiologic discharge has casual sexual encounters while months, she has had 5 similar episodes D. Bacterial vaginosis traveling for business and who does not and has treated her symptoms success- always use condoms for these contacts. fully with an over-the-counter vaginal 3. An otherwise healthy 25-year-old She had been using latex condoms and yeast cream. Three months ago, fasting woman is evaluated because of a white, nonoxynol-9 gel for contraception and plasma glucose measurement was nor- cheesy, and somewhat malodorous vagi- STI prevention. However, she has devel- mal. She is monogamous and has had 1 nal discharge. She has no dysuria or oped a latex allergy over the past year, male partner for the past 6 months. hematuria and no history of sexually manifest first by dermatitis to latex Vaginal examination during an office transmitted infections. The patient has gloves in her work as a dental hygienist, visit reveals inflammation of the exter- been sexually active with a single male then as vaginal irritation to latex nal genitalia and a nonodorous vaginal partner for more than 3 years. Her only condoms, and more recently with 2 discharge adherent to the vaginal walls. medication is an oral contraceptive. She episodes of wheezing when working On microscopic examination of the and her partner almost always use latex around (but not touching) latex at her vaginal discharge with potassium hy- condoms but occasionally have unpro- job. She plans to continue in this sexual droxide slide preparation, pseudohyphae tected sexual intercourse. relationship and wonders how best to and budding filaments are noted. A General physical examination is unre- protect herself against STIs. pregnancy test is negative. She would markable. Pelvic examination discloses a Which of the following approaches like to discuss what she can do to pre- moderately thick, malodorous, white would be most effective? vent recurrences. vaginal discharge. The cervix is normal, A. Continue using nonoxynol-9 and no ulcers are seen. The pH of the Which of the following is the most ap- B. Use polyurethane condoms vaginal secretions is 6.0. A wet prep propriate next step in management? C. Pretreat with a systemic shows no motile organisms, and cervical A. Ingest lactobacillus cultures every antihistamine specimens are sent for ligase chain re- day D. Use natural membrane condoms action testing for both gonorrhea and B. Begin weekly douching chlamydial infection. Stained specimens E. Begin , C. Avoid simple sugars of the vaginal material are shown and have the patient and partner D. Treat partner with antifungal (Figure A and B). get STI testing periodically cream E. Begin weekly oral fluconazole

2. A 25-year-old woman is evaluated for a 3-day history of malodorous vaginal dis- charge. She does not report any itching or irritation. She has been sexually active (A) (B) with the same partner for 6 months, us- ing condoms to avoid pregnancy. Her Which of the following is the most ap- medical history is unremarkable. propriate empiric therapy at this time? On physical examination, external geni- A. Single dose of azithromycin talia are normal. Internal vaginal exami- B. Single dose of ceftriaxone nation reveals a homogenous, white, C. Intravaginal clotrimazole cream malodorous discharge without the pres- D. Intravaginal clotrimazole cream ence of vaginal erythema. Bimanual ex- plus single dose of ciprofloxacin amination reveals no cervical motion E. Intravaginal clotrimazole cream tenderness. Mixing the vaginal dis- plus 7-day course of charge with a normal saline preparation metronidazole reveals the presence of clue cells. Which of the following is the most 4. A 34-year-old woman presents for likely diagnosis? advice on prevention of sexually

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/ to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

© 2009 American College of Physicians ITC3-16 In the Clinic Annals of Internal Medicine 1 September 2009