Lower Genitourinary Infections in Women

CLINICAL REVIEW Lower Genitourinary Infections in Women Alfred 0. Berg, MD, MPH, and Michael P. Soman, MD, MPH Seattle, Washington Vaginitis, cystitis, urethritis, and cervicitis are common diagnoses made in women attending family physicians’ offices. Recent research has fundamen tally altered available information on the diagnosis and management of these common genitourinary infections. This clinical review discusses presenting symptoms, physical findings, laboratory diagnostic aids, treatment, and follow-up for each lower genitourinary syndrome in women concluding with a summary flow chart illustrating an overall recommended approach. aginitis, cystitis, urethritis, and cervicitis collec toms predicts diagnosis accurately enough so that one V tively account for between 5 and 15 percent of all or more diagnoses can be eliminated from considera visits by women to family physicians.1 Women rarely, tion at the outset. Evidence is mixed. Komaroff2 found however, volunteer such diagnoses as complaints: ap that differentiating dysuria into external and internal pointments- are made for vaginal discharges and was helpful in establishing diagnoses of vaginitis and malodor, dysuria, urgency, vulvar pruritus, and other cystitis-urethritis, respectively. He further identified symptoms. Translating symptoms into treatable diag three clinical groups that would allow the physician to noses is an important part of the physician’s task dur focus the remainder of the examination: ing the office visit. Unfortunately, clinical syndromes 1. Vaginal discharge and irritation absent, internal overlap, physical findings may be nonspecific, and dysuria and frequency present. This group had a very microbiological confirmation of diagnoses may be both low probability of vaginitis and high probability of uri expensive and untimely. The picture is further compli nary tract infection, thus allowing the elimination of cated by recent challenge to many long-held beliefs pelvic examination and urinalysis, and necessitating about the diagnosis and treatment of these common only urine culture. problems. This article reviews recent diagnostic and 2. Vaginal discharge or irritation present, internal therapeutic advances in managing lower genitourinary dysuria and frequency absent. This group had a low infections in women and outlines some of the unan probability of urinary tract infection, allowing the swered questions that hamper physicians’ ability to elimination of urinalysis and culture. deal with these problems and that require further in 3. Vaginal discharge or irritation present, internal vestigation. dysuria or frequency present. This group had equal probabilities of both vaginitis and urinary infection, thus requiring pelvic examination, urinalysis, and PRESENTING COMPLAINTS urine culture. Generalizability of Komaroff s recommendations to Symptoms are the ticket for admission to an office visit other primary care settings is hampered by patient and largely determine the physician’s initial approach. selection and by the lack of uniform database on all The list of potential complaints for lower genitourinary patients seen. A more recent study performed in infections is long: dysuria, vaginal discharge or itch Seattle3 found that up to one third of women could not ing, urgency, frequency, incontinence, dyspareunia, distinguish between internal and external dysuria or hematuria, and many others. The immediate question claimed to have both. In the same study, although for the physician is whether any combination of symp- Komaroff s clinical strategies were generally helpful, some women were misclassified by these criteria. In summary, presenting complaints are suggestive Submitted, revised, December 7, 1984. but not diagnostic of specific groups of infections. horn the Department of Family Medicine, University of Washington, Further research in the family practice setting will be Seattle, Washington. Requests for reprints should be addressed to Dr. necessary to accurately assess predictive value of Alfred Berg, Department of Family Medicine, University of Washington, 110-30, Seattle, WA 98195. symptoms for specific diagnoses. c 1986 Appieton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 23, NO. 1: 61-67, 1986 61 LOWER GU INFECTIONS IN WOMEN VAGINAL INFECTIONS aration. Additional use of cultures for Candida albi cans has been recommended by some.8 Demonstration Vaginitis is the most common lower genitourinary clin of Candida by culture is the gold standard, a standard ical syndrome seen by the primary care practitioner, compared with which the potassium hydroxide prep accounting for two thirds of all visits for genitourinary aration performs poorly.9 Additionally, it is well problems. Recent studies have fundamentally changed known that asymptomatic women may harbor yeast the diagnosis and treatment of nonspecific vaginitis organisms.8 Thus, the physician is left with a dilemma: and have suggested new ways of evaluating women the potassium hydroxide preparation is insensitive in with yeast and trichomonal infections as well. identifying yeast in symptomatic women, yet use of Vaginal discharge and vulvar irritation are the usual the culture technique routinely would undoubtedly presenting complaints of vaginal infection. Certain falsely identify some carriers of Candida as infected. symptoms are associated with particular infections— An answer to this dilemma awaits further research pruritus with yeast, purulent and copious discharge testing the efficacy of treatment in symptomatic with trichomonas, and foul-smelling discharge with women who are potassium hydroxide negative but cul nonspecific vaginitis. Such symptoms, though charac ture positive. In the interim, some have suggested that teristic of given infections once the diagnosis is estab cultures for Candida be used selectively in symptoma lished, may have poor predictive value during the ini tic women with negative potassium hydroxide prep tial evaluation phase. Thus, of all women with vaginal arations.9 discharge and vulvar pruritus, only one half may be The diagnosis of vaginitis caused by Trichomonas found to have yeast on examination. Recent attempts vaginalis has problems similar to those in making the to correlate groups of symptoms with specific diag diagnosis of Candida. Traditionally, the diagnosis of noses have been only marginally successful. trichomonal infection has been based upon direct mi On physical examination, vaginal infections are croscopic observation of the organism in a bit of the associated with specific findings. Thick, curdlike dis discharge mixed with saline. Culture methods are charge and external vulvitis are typical of yeast vag available that detect the organism in a larger propor initis; copious purulent discharge with cervical tion of women, however.1011 Because women may petechiae and friability are characteristic of tricho have asymptomatic Trichomonas infections, the situa monal infections; and a thin, adherent, foul-smelling tion is similar to that confronting the physician at discharge is the hallmark of nonspecific vaginitis. tempting to make the diagnosis of vaginitis caused by Again, however, the predictive value of these charac yeast. Again, trichomonal cultures may be used selec teristic physical findings for the three diagnoses is un tively in symptomatic women with negative micro known, and a recent Seattle study suggests that addi scopic examinations. tional factors need to be explored.3'4 Treatment protocols for vaginal infections are fairly Significant changes in laboratory aids to the diag straightforward. Yeast infections are effectively nosis of vaginal infections have been recently pro treated using suppositories or creams containing the posed, especially in making the diagnosis of polyene (nystatin) or imidazole (clotrimazole, mi nonspecific vaginitis. Formerly a diagnosis of exclu conazole) antibiotics. Oral ketoconazole for resis sion, nonspecific vaginitis may now be diagnosed tant infections is currently under study. Trichomonal using Amsel’s5 recommendation that at least three of vaginitis may be effectively treated using single-dose the following four criteria be present: (1) thin, adher metronidazole in a 2-g dose. The treatment of bacterial ent, homogenous discharge, (2) vaginal pH of 4.5 or vaginosis formerly included several regimens, includ higher, (3) amine odor upon application of potassium ing topical sulfa creams and oral ampicillin or hydroxide to discharge, or (4) clue cells on micro amoxicillin. It is now clear that metronidazole is more scopic examination of saline suspension. Recent mi- effective, although exact dosage and duration of crobiologic investigation has strongly implied that the treatment are still being studied.12 Currently recom Gardnerella vaginalis organism (formerly Hemophilus mended is 500 mg of metronidazole twice daily for vaginalis) may play only a partial role in a mixed infec seven days, longer if symptoms persist (metronidazole tion of several bacteria collectively responsible for is not approved for this application by the Federal symptoms.6 Finally, at a recent international sym Drug Administration).13 The necessity of treatment of posium, nonspecific vaginitis was renamed to be sexual partners for these infections is still being bacterial vaginosis, reflecting the mixed bacterial studied. Most yeast infections do not require treatment noninvasive nature of this condition.7 of the sexual partner, although men with yeast The diagnosis of yeast vaginitis

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