What’s Going on Down There? Denise Rizzolo, PhD, PA-C Introduction • Vulvovaginitis is inflammation of the vulva and vaginal tissues. • Characterized by vaginal discharge and/or vulvar itching and irritation as well as possible vaginal odor. • Accounts for 10 million visits yearly in the US and is the most common gynecologic complaint in prepubertal girls. History- What should you ask? • Pruritus -General or just one spot • Soreness: stinging / burning / pain • Difficulty with sex • Lumps • Discharge • Partner’s have any symptoms • History of similar symptoms Physical Examination • Careful gynecologic exam • Inspection of discharge • Close examination of vulvovaginal area • Careful inspection of cervix • Look at perineum as well Physiologic Discharge • Responsible for 10 percent of cases of vaginal discharge. • Composed of vaginal squamous cells suspended in fluid medium. • Clinical characteristics: • clear to slightly cloudy • non-homogeneous • highly viscous • Changes throughout the month Normal Vaginal Discharge • Not associated with: • itching • burning • malodor • Normal increase in volume • ovulation • following coitus • after menses • during pregnancy The Big 3 •Three most common causes of vulvovaginitis include: • Bacterial Vaginosis • Vaginal candidiasis • Trichomonas Vaginalis •Others include: atrophic vaginitis, irritant vaginitis, and other STIs. Vaginal Candidiasis- Overview • Less common in postmenopausal women, unless taking estrogen. • 90% of yeast infections are secondary to Candida Albican (Most common). • Risk Factors include: • Pregnancy • Oral contraceptives • Uncontrolled DM • Recent antibiotic use • Discussing around tight underwear, cotton underwear, spandex • Literature has been mixed to support this theory. Vaginal Candidiasis- Signs and Symptoms Patient Reports Physical Exam • The discharge varies from • Whitish cottage cheese watery to thick cottage cheese discharge discharge • Vulvar erythema and edema • Vaginal soreness • Vaginal erythema • Dyspareunia • Severe vaginal itching • External dysuria Vaginal Candidiasis- Diagnosis • Normal pH4-4.5 • Positive results on microscopic exam (yeast buds and pseudohyphae) • Culture if unsure Vaginal Candidiasis- Treatment • The topically applied azole drugs are more effective than nystatin (CDC) • Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally in a single application OR • Terconazole 0.4% cream 5 g intravaginally daily for 7 days OR • Terconazole 0.8% cream 5 g intravaginally daily for 3 days OR • Terconazole 80 mg vaginal suppository, one suppository daily for 3 days • Oral Agent: • Fluconazole 150 mg orally in a single dose Case: • Beth is a 33-year-old single woman who has been in your practice for several years and left a message with your nurse that she has a pruritic vaginal discharge that has persisted for 2 weeks despite her attempts at using an over-the-counter yeast cream. Is it ever appropriate to treat without an examination? • Very frequently, women will attempt to self-diagnose their vaginitis and self-treat with any number of readily available topical or oral agents. • However, the accuracy of self-diagnosis is often worse than is widely assumed. • Given the non-specific nature of vulvovaginal symptoms, patients requesting treatment by telephone should be asked to come in for evaluation, particularly – as in this patient – if she has treated herself with a non-prescription antifungal without success. ** May also depend on the relationship with the patient How do you confirm the diagnosis of candidiasis? What is the treatment? • The diagnosis may be suggested on the basis of history and physical examination, but confirmation requires either • (1) visualization of branched and budding hyphae on KOH wet mount or • (2) a positive culture in a symptomatic woman. • Uncomplicated patients may be treated with either topical clotrimazole or oral fluconazole. • Occasionally, in more severe cases, a second dose or repeated doses of fluconazole will be required. CASE 28 year old housewife is seen by you for a one week history of a frothy, greenish, malodorous vaginal discharge. She also complains of dyspareunia and vaginal irritation. Vaginal pH is 6.5 What is the most likely diagnosis? a.Herpes genitalis b.Trichomonas vaginalis c.Mycoplasma genitalium d.Bacterial vaginosis e.Chlamydia trachomatis Trichomonas Vaginalis -Overview • Almost always sexually transmitted. • In US, an estimated 3.7 million people have the infection. • However, only about 30% develop any symptoms of trichomoniasis. • Associated with adverse pregnancy outcomes. • T. vaginalis infection is associated with two- to threefold increased risk for HIV acquisition. Trichomonas Vaginalis -Signs and Symptoms Patient Reports Physical Exam • Itching, burning, redness or • Classic strawberry cervix in only soreness of the genitals 2% of patients • Discomfort with urination • Diffuse erythema seen in 10- • A change in their vaginal 33% discharge (i.e., thin discharge or increased volume) that can be • Discharge will be noted clear, white, yellowish, or greenish) • *** Can have no symptoms at all Trichomonas Vaginalis -Diagnosis • Vaginal pH greater than 4.5 • Flagella on saline microscopy • Nucleic acid amplification tests NAATs are the most sensitive tests for T.vaginalis and are now considered the gold standard for diagnosis (can use vaginal swab or urine) Trichomonas Vaginalis -Treatment • Partners must be treated! • Metronidazole 2 g orally in a single dose OR • Tinidazole 2 g orally in a single dose • Alternative Regimen • Metronidazole 500 mg orally twice a day for 7 days Treatment Failure • A common reason for treatment failure is reinfection. Therefore, it its critical to assure treatment of all sex partners at the same time. • If treatment failure occurs with metronidazole 2 g orally in a single dose for all partners, treat with metronidazole 500 mg orally twice daily for 7 days or tinidazole 2 g orally single dose. • If treatment failure of either of these regimens, consider retreatment with tinidazole or metronidazole 2 g orally once a day for 5 days. • If repeated treatment failures occur, contact the Division of STD Prevention, CDC, for metronidazole-susceptibility testing (telephone: 404-718-4141, website: www.cdc.gov/std) 21 Case •28 y/o female graduate student is seen for a 5- day history of a thin, greyish-white vaginal discharge associated with vaginal burning and a fishy odor. Whiff test: (+) . Vaginal pH: 5.5 What is the diagnosis? a.Bacterial vaginosis b.Candida vaginitis c.Trichomonas vaginitis d.Mixed infection e.Normal discharge Let’s Focus More on …. Bacterial Vaginosis What percent of women will return with a recurrent BV infection within 12 months after the initial infection? • 20% • 30% • 40% • 50% Bacterial Vaginosis - Overview • Bacterial Vaginosis (BV), formally known as Gardnerella vaginitis, is a common dysbiosis affecting approximately 21 million women in the United States. • BV is often recurrent after treatment with 50% of women having return of symptoms within twelve months. • BV affects 29% of women overall and is more common in Black and Hispanic women with rates of 51% and 32%, respectively. Bacterial Vaginosis - Overview • Some research suggests that it may precipitate preterm labor and has been associated with the development of Pelvic Inflammatory Disease (PID). • USPSTF- has recent EBM question posed on website regarding BV and Pre term labor ----will discuss more later. • BV predisposes women to the acquisition of Sexually Transmitted Infections (STIs), including Human Immunodeficiency Virus (HIV). Bacterial Vaginosis - Pathophysiology • In women with BV the native vaginal flora, hydrogen peroxide producing lactobacilli, that are responsible for maintaining an acidic environment, are replaced with invasive pathogens, G. vaginalis, Prevotella species, and Mobiluncus species. • This promotes a basic pH that sets the environment for BV. • Bacteria is capable of producing a biofilm that provides a matrix for other pathogenic bacteria to cling to as well as making it harder for antibiotic therapy to penetrate and eradicate the infection. Bacterial Vaginosis – Risk Factors • Increased incidence among women: • douche regularly, smoke tobacco , have an IUD in place and have sex with women. • Women that have sex with women have a higher rate of BV and usually both women are affected. • Recurrent BV is higher in women who have multiple sex partners and do not use condoms. • Conversely those that use oral contraceptives such as the pill, have lower rates of BV. • Oral estrogen is thought to have a nurturing effect on the lactobacilli in the vagina perhaps explaining the lower overall rate of BV in women that use oral contraceptives. Most women with BV present with symptoms? • True • False Bacterial Vaginosis – History and Physical Exam • Most women with BV are asymptomatic and unaware they have BV. • Symptomatic women typically present with: • vaginal discharge • odor • sometimes irritation • It is not uncommon for women to report a previous episode of BV within the previous three months to a year. • Physical examination • thin milky discharge • at times a fishy odor is detectable • bimanual exam normal unless another STI is present Bacterial Vaginosis – Diagnosis • Collection of vaginal discharge with a cotton tipped swab from the lateral and posterior vaginal walls for pH measurement and will demonstrate an alkaline environment greater than 4.5. • A saline wet mount slide made from the vaginal secretions will show clue cells.