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Home , Atrophic vaginitis, Ovarian disease, Strawberry cervix, Vaginal bleeding

How to Evaluate Vaginal and Discharge Is the bleeding normal or abnormal? When does reflect something as innocuous as irritation caused by a new soap? And when does it signal something more serious? The authors’ discussion of eight actual patient presentations will help you through the next differential diagnosis for a woman with vulvovaginal complaints.

By Vincent Ball, MD, MAJ, USA, Diane Devita, MD, FACEP, LTC, USA, and Warren Johnson, MD, CPT, USA

bnormal or discharge is typically due to either inadequate levels of one of the most common reasons women or a persistent corpus luteum. Structural causes of come to the emergency department.1,2 bleeding include leiomyomas, endometrial polyps, or Because the possible underlying causes malignancy. Infectious etiologies include pelvic in- Aare diverse, the patient’s age, key historical factors, flammatory disease (PID). Additionally, a variety of and a directed physical examination are instrumental bleeding dyscrasias involving platelet or clotting fac- in deciding on diagnosis and treatment. This article tors can complicate the normal menstrual period. Iat- will review some common case presentations of rogenic causes of vaginal bleeding include nonpregnant female patients with abnormal vaginal replacement therapy, steroid hormone contraception, bleeding, inflammation, or discharge. and contraceptive intrauterine devices.3-5 Anovulatory bleeding is common in perimenar- ABNORMAL VAGINAL BLEEDING chal girls as a result of an immature hypothalamic- To ensure appropriate patient management, “Is she pituitary axis and in perimenopausal women due to pregnant?” should be the first question addressed, declining levels of estrogen. During reproductive since some vulvovaginal will years, dysfunctional uterine differ in significance and urgency depending on the bleeding (DUB) is the most >>FAST TRACK<< answer. If the patient is not pregnant, the gyneco- common cause of abnormal During reproductive logic causes of abnormal vaginal bleeding can be vaginal bleeding.5 Almost years, dysfunctional functionally grouped into three categories: ovula- 90% of DUB results from uterine bleeding is the tory, anovulatory, and nonuterine bleeding.3 .5 During an an- most common cause Ovulatory bleeding is associated with regular men- ovulatory cycle, the corpus of abnormal vaginal strual periods. This form of bleeding can be further luteum does not form, caus- bleeding. subdivided as hormonal, structural, infectious, or iat- ing a failure of progesterone rogenic.3 Premenstrual spotting or delayed menses is secretion. This results in continued unopposed es- tradiol, stimulating endometrial proliferation and Dr. Ball is a staff physician and the medical student subsequent irregular vaginal bleeding. Continued clerkship director, Dr. Devita is a staff physician and the chief of emergency department operations, and Dr. elevated levels of estrogen place a woman at risk for Johnson is a resident in the department of emergency developing endometrial . Conversely, break- medicine at Madigan Army Medical Center in Fort Lewis, through bleeding may occur in patients taking oral Washington. The opinions or assertions contained contraceptives that have inadequate doses of estro- herein are the private views of the authors and are not to be construed as official or reflecting the views of the gen and progestin for the patient or in perimeno- Department of the Army or the Department of Defense. pausal women with declining levels of estrogen. 3-5 www.emedmag.com APRIL 2009 | EMERGENCY MEDICINE 27 VAGINAL BLEEDING AND DISCHARGE

Suspect DUB when the patient (typically an ado- risk of venous thromboembolic disease, or hepatic lescent or a woman over 40) presents with unpredict- dysfunction. Typical dosing of micronized oral pro- able vaginal bleeding despite a normal pelvic exami- gesterone is 200 mg once daily for the first 10 to 12 nation. As we said earlier, first and foremost, rule out days of each month.7 Menses should occur within . Perform a pelvic ultrasound to rule out one week of the last dose of progesterone. Other structural abnormalities, such as leiomyoma, ovarian formulations and dosing schedules are available.3-7 cysts, and endometrial polyps. Patients who have had Mild DUB is defined as longer than normal menses irregular menses since may have polycystic for more than two months.7 Hormonal therapy is not ovarian syndrome, which is characterized by anovula- necessary but may be offered if symptoms worsen. All tion or oligo-ovulation and . These patients treated for abnormal vaginal bleeding must patients will classically be obese, infertile, hirsute, and follow up with their gynecologist or primary doctor possibly hyperinsulinemic. Patients with adrenal en- for the completion of their DUB workup.3 zyme defects, hyperprolactinemia, , or other metabolic disorders might also present with SIGNS AND SYMPTOMS OF vaginal bleeding with anovulation. Thyroid hormone Vaginitis or, more correctly, vulvovaginitis, is inflam- studies and a head computed tomography (CT) scan mation of the and vaginal tissues. Typical signs may be required to confirm the diagnosis.5 and symptoms are vulvar itching, vaginal discharge, Dysfunctional uterine bleeding can be catego- and a vaginal odor. The most common causes of acute rized as severe, moderate, or mild.6 Severe bleed- vulvovaginitis include infections, irritant or allergic ing is associated with hemodynamic instability. Such contact, and .2,9 The three most patients will require resuscitation with intravenous frequent infections are caused by fluids, parenteral estrogen, and possibly dilation an imbalance of the normal flora by Gardnerella vagi- and curettage, necessitating hospital admission. The nalis; candidiasis, most commonly caused by Candida dose of intravenous estrogen is 25 mg every four to albicans; and trichomoniasis caused by Trichomonas six hours until the bleeding stops.6 The minimum vaginalis.9 Infectious vulvovaginitis is typically found amount of estrogen to stop the bleeding should be in sexually active women, while candidiasis, contact administered to avoid the potential complication vaginitis, and atrophic vaginitis can occur in women of venous thromboembolism. Giving an antiemetic who are not sexually active.2,8,9 prior to the estrogen will alleviate the side effects of Obtain a detailed gynecological and sexual history nausea and vomiting.5,6 and perform a in all women with Moderate DUB is associated with prolonged symptoms of vulvovaginitis. Ascertain the use of soaps, bleeding and mild without hemodynamic in- douches, and tight clothing or other irritants that may stability. Treatment typically involves hormonal ther- cause inflammation. A history of improperly treated apy with combined estrogen-progesterone four times sexually transmitted diseases (STDs), unprotected sex- a day for seven days.5 Estrogen stimulates hemostasis, ual intercourse, and immunosuppression place women which will curtail vaginal bleeding. Advise patients of at higher risk for infectious vulvovaginitis. Key aspects the increased risk of venous thromboembolic events of the pelvic examination include the presence and while on estrogen, especially if they smoke. Such type of discharge, odor, ulcerations, cervical abnor- oral contraception may also malities, cervical discharge, and cervical motion or >>FAST TRACK<< aggravate an immature hy- adnexal tenderness to palpation. A urine pregnancy Candidiasis, contact pothalamic-ovarian axis and test should be performed on all female patients: Some vaginitis, and atrophic is recommended only for infectious causes of discharge are associated with ad- vaginitis can occur in patients with an established verse pregnancy outcomes if not treated.2,9 women who are not menstrual history.3-6 The cause of vaginal symptoms can typically be sexually active. Progestin-only determined by history, physical examination, dis- are recommended if the pa- charge pH determination, and examination of a wet tient is not actively bleeding, can take oral medica- mount. If PID is suspected, a “dirty” or initial-stream tion, and has a contraindication to high-dose estro- urine sample can be obtained for testing of gonor- gen, such as an estrogen-dependent tumor, a high rhea and if that modality is available. Al-

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ternatively, endocervical samples may be obtained • laceration for gonorrhea and chlamydia testing. Also obtain a • coagulopathy midstream urine sample for urinalysis if there is a • menarche suspicion of . • nonaccidental trauma/assault Because symptoms of vulvovaginitis are nonspecific, • vaginal checking a pH with phenaphthazine (nitrazine) paper • infection/STD and obtaining a wet preparation are recommended for The diagnosis is menarche. (This might seem proper diagnosis of discharge. Obtain two discharge obvious, but a surprising number of parents bring samples. Dilute one sample in one to two drops of their daughters in for evaluation under these cir- 0.9% normal saline solution and the second in one to cumstances.) The average age of menarche in North two drops of 10% potassium hydroxide (KOH) solu- America is 12.5 years, with 10 years being the lower tion.9 An amine odor after applying the KOH suggests limit.3 However, a perineal and pelvic examination bacterial vaginosis or trichomoniasis. should be performed to ensure the patient does not Each sample is placed on an individual slide with have a laceration, retained foreign body, or infection. a cover slip and examined as soon as possible under Maintain a low threshold of suspicion for nonacci- low and high power, looking for characteristics sug- dental trauma and question the patient alone. Vaginal gestive of each disorder. Motile T. vaginalis tricho- foreign bodies, especially toilet paper, are more com- monads are pear-shaped flagellated organisms best mon in younger children, and do not typically pre- seen within 20 minutes of being placed on the saline sent with bleeding but rather infectious concerns. slide specimen.10 Clue cells are epithelial cells with If the patient does not have significant borders obscured by small bacteria, characteristic of loss, urinary symptoms, or family history of bleed- bacterial vaginosis, also seen on the normal saline ing dyscrasias, she can be discharged with primary specimen. Yeast or pseudohyphae of Candida species physician follow-up as needed and should be told are more easily identified in the KOH specimen. that her menstrual period may not become regular However, the absence of trichomonads or pseudohy- for another one to five years.3 phae does not rule out these infections due to the low sensitivity of microscopy (approximately 60%).10 PATIENT PRESENTATION: CASE 2 Vulvar inflammation in the absence of vaginal A 19-year-old woman has had daily vaginal bleed- pathogens, along with a minimal discharge, suggests ing for months. She has no history of pregnancy, chemical, allergic, or other noninfectious causes of , or sexual activity and does not use vulvovaginitis. birth control. Her last normal was Often the clinical impression suffices to make one year ago. She denies visual problems, heat or treatment decisions, and at times the clinician must cold intolerance, bleeding treat the patient presumptively prior to the results from other sources, or a >>FAST TRACK<< of laboratory analysis. In cases of sexually transmit- family history of bleeding Vaginal foreign bodies table causes of vulvovaginitis, it is recommended disorders. Her vital signs are more common in that sexual partners be referred for evaluation and are normal. She appears younger children and do treatment and patients abstain from intercourse until obese and reports an unin- not typically present with symptoms have resolved.9 tentional weight gain of 10 bleeding. pounds in the last year. She PATIENT PRESENTATION: CASE 1 has a moderate amount of facial hair and severe acne. Concerned parents bring in a 12-year-old girl who Pelvic examination reveals a small amount of blood in has had vaginal discomfort and vaginal spotting for the vaginal vault without active bleeding. No masses the last two days. She says she has not had menstrual or tenderness to palpation are elicited on bimanual periods. She denies sexual activity, other vaginal dis- examination. The urine is negative. charge, fever, and medication use. She has no past What is the most likely diagnosis? medical history or significant family history. Her • urine pregnancy test is negative. • polycystic What is the most likely diagnosis? • leiomyoma www.emedmag.com APRIL 2009 | EMERGENCY MEDICINE 29 VAGINAL BLEEDING AND DISCHARGE

• pelvic inflammatory disease PATIENT PRESENTATION: CASE 3 • A 59-year-old patient reports pain with sexual inter- • hyperprolactinemia course, reduced lubrication during intercourse, and • dysfunctional uterine bleeding vaginal spotting. She stopped menstruating nine • nonaccidental trauma/assault years ago and has not used hormone replacement • vaginal foreign body therapy. She has no abnormal vaginal discharge and This patient’s presentation is suggestive of DUB no history of STDs. She has not changed soaps, due to polycystic ovarian syndrome. The main clues powders, or panty liners. On physical examination, are consistent with hyperandrogenism: obesity, fa- her external genitalia appear thin and friable. Her cial hair, and acne. Family and patient history and vaginal vault is poorly rugated with a small area of physical examination findings are inconsistent with ecchymosis at the posterior fourchette. cancer, trauma, or vaginal foreign bodies. What is the most likely diagnosis? Dysfunctional uterine bleeding is the most com- • candidiasis mon cause of abnormal vaginal bleeding in repro- • bacterial vaginosis ductive-age women and is a diagnosis of exclusion • contact irritation when other organic or structural causes of bleed- • atrophic vaginitis ing have been ruled out.5 Patients with DUB will • cervical cancer have otherwise unremarkable gynecological exam- The diagnosis is atrophic vaginitis. Up to 40% inations. Endometriosis has a more waxing-and- of postmenopausal women have symptoms of this waning course. condition.8 The vaginal and urethral epithelia are Leiomyoma, or , is a structural cause estrogen-dependent. After , circulating of vaginal bleeding diagnosed by ultrasound. Visual levels of estrogen are reduced to approximately one- field deficits, enlarged thyroid, or galactorrhea would tenth of previous levels. Reduced suggest a pituitary lesion or hyperprolactinemia. is the earliest finding of hormone insufficiency. A Refer a patient with vaginal bleeding sugges- long-term decline in estrogen is required before tive of DUB for an ultrasound to rule out structural symptoms of atrophic vaginitis occur. abnormalities as well as metabolic studies (such as Typical signs and symptoms of burning, vulvar

thyroid-stimulating hormone and free T4 levels) and pruritus, and yellow malodorous discharge can be ex- a head CT scan if there are concerns for a pituitary acerbated by a simultaneous infection of candidiasis, tumor or hyperprolactinemia.5 A wet preparation trichomoniasis, or bacterial vaginosis; those infec- and point-of-care testing may be necessary if there tions should be ruled out prior to diagnosing atro- are concerns for an infec- phic vaginitis. Women who smoke, have not given >>FAST TRACK<< tious process. birth vaginally, or were naturally estrogen-deficient An elevated vaginal pH This patient exhibits mod- before menopause will have more severe symptoms.8 is suggestive of vaginal erate DUB and it would be An elevated vaginal pH (exceeding 5 in the vaginal , but can also appropriate to treat her with vault) is suggestive of vaginal atrophy, but can also be found in bacterial a combination estrogen- be found in bacterial vaginosis and candidiasis.8 vaginosis and progestin or progestin-only Refer the patient to her primary physician to candidiasis. oral contraceptive.5 Treat- discuss the risks and benefits of systemic estrogen ment of DUB is basically therapy if she is interested. Over-the-counter mois- the same whether the patient has polycystic ovar- turizers and lubricants can be used as an alternative or ian syndrome or not, but if she does, a progestin adjunctive therapy and help maintain natural secre- with minimal androgenic activity (such as ethyno- tions for the short term.8 diol diacetate, , and ) is preferred.11 PATIENT PRESENTATION: CASE 4 When treating vaginal bleeding suspicious for A 25-year-old woman reports having had malodor- DUB, it is important that patients be referred for ous vaginal discharge and itching for a week. She has sonography and laboratory analysis to rule out struc- a history of unprotected sex with multiple partners. tural, endocrine, and neoplastic disorders.3 Her last menstrual period was two weeks ago and

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normal for her. She denies a history of STDs, fevers, abdominal pain, or urinary symptoms. Gynecological examination reveals white discharge coating the vagi- nal walls but no cervical motion tenderness or cervical discharge. The vaginal pH is greater than 4.5. What is the most likely diagnosis? • vaginal candidiasis • trichomoniasis • bacterial vaginosis • • pelvic inflammatory disease The key to the diagnosis—bacterial vaginosis—is the malodorous discharge, although it is not unique to this condition. Bacterial vaginosis occurs when the anaero- bic bacteria G. vaginalis and Mycoplasma hominis replace the normal Lactobacillus species in the .1,9 Although malodorous discharge is common in bacterial vaginosis, many women who meet the clini- cal criteria for diagnosis are asymptomatic. It is not FIGURE 1. Characteristic clue cells suggesting clear if the condition is an STD; however, it is rarely bacterial vaginosis. seen in virgins and is associated with having multiple sex partners.9 Bacterial vaginosis has been associated with ad- charge and itching. She has a history of unprotected verse pregnancy outcomes, PID, and postsurgical sex with multiple partners. She denies a history of vaginal cellulitis. A commonly accepted decision tool STDs, fevers, abdominal pain, or urinary symptoms. to diagnose the condition is the Amsel Criteria, which Gynecological examination reveals a thin, frothy dis- requires three of the following for the diagnosis: thin, charge. Her has areas of punctate hemorrhage white, homogeneous discharge smoothly coating but is without discharge or motion tenderness. Her vaginal walls; the presence of clue cells on microscopy vaginal pH is greater than 4.5. (Figure 1); a vaginal fluid pH above 4.5; and release What is the most likely diagnosis? of a fishy odor on adding 10% KOH.1,2,12,13 • vaginal candidiasis All symptomatic patients, including pregnant • trichomoniasis patients, should be treated with metronidazole un- • bacterial vaginosis less they are allergic. Cure rates are similar for the • cervicitis seven-day metronidazole oral regimen, vaginal gel, • chemical vaginitis and clindamycin vaginal cream, but non-oral metro- • foreign body vaginitis nidazole regimens have higher rates of recurrence.2 The diagnosis is trichomoniasis, an STD com- Vaginal preparations have fewer adverse effects, such monly manifested by vaginitis and discharge. The as gastrointestinal upset. All patients should avoid al- discharge can be thin and frothy but is often thick cohol during use of these preparations and 24 hours and yellow, easily confused with that of candidiasis. after oral metronidazole because a disulfiram-like re- The most specific physical examination finding is a action can occur. A woman’s response to treatment “strawberry cervix” with punctate hemorrhage and and likelihood of relapse is not affected by her part- vesicles or papules. Wet preparation slides must be ner being treated. Therefore, it is not necessary to read within 20 minutes to identify the characteristic refer male sexual partners for treatment.12 trichomonads (Figure 2).10 As with bacterial vagino- sis, the KOH whiff test produces a strong fishy odor. PATIENT PRESENTATION: CASE 5 More sensitive point-of-care testing is available. A A 25-year-old woman comes to the emergency de- single dose of metronidazole or tinidazole is effective partment after seven days of malodorous vaginal dis- treatment. It is recommended that all sexual partners www.emedmag.com APRIL 2009 | EMERGENCY MEDICINE 31 VAGINAL BLEEDING AND DISCHARGE

FIGURE 2. Pear-shaped, flagellated tricho- FIGURE 3. Multicellular yeast indicating vulvo- monad seen in trichomoniasis. vaginal candidiasis.

be treated and refrain from intercourse until symp- The diagnosis is vulvovaginal candidiasis, which toms resolve.10 is usually caused by C. albicans. Most women in Advise any patient who plans to become pregnant the United States will have at least one episode of that trichomoniasis during pregnancy is associated with vulvovaginal candidiasis in their lifetime.14 Women adverse outcomes, such as premature rupture of mem- with diabetes are more prone to this condition due branes, preterm delivery, and low birth weight.10 to their immunocompromised state. Typical symp- toms include pruritus, soreness, , and PATIENT PRESENTATION: CASE 6 the distinguishing curdy discharge. History, physical A 30-year-old diabetic woman comes to the emer- examination, and wet preparation, identifying the gency department after three days of curdy dis- characteristic yeast, will confirm diagnosis. Using charge, vaginal pruritus, and pain at her urethral 10% KOH on the wet prep will improve visualiza- opening on . She denies other symptoms. tion by disrupting the cellular material obscuring Her home glucose measurements have been normal. the yeast.12 On gynecological examination she has a thick white The majority of infections are uncomplicated. discharge on her vaginal vault, but no cervical mo- Between 5% and 8% of healthy women will have tion tenderness or discharge. Her vaginal pH is less complicated infections—that is, those that recur than 4.5; the finding on the saline with 10% KOH four or more times a year or are not caused by C. wet preparation slide is shown in Figure 3. albicans.12,14 Oral fluconazole and a variety of over- What is the most likely diagnosis? the-counter vaginal preparations are available for • vaginal candidiasis uncomplicated infections. As vulvovaginal candi- • trichomoniasis diasis is not an STD, treatment of sexual partners • bacterial vaginosis is not typically indicated except in cases of recurrent • pelvic inflammatory disease infections or when the male is experiencing balanitis • genital herpes (inflammation of the glans penis).12

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PATIENT PRESENTATION: CASE 7 A 17-year-old has painful lesions on her . She admits to having unprotected sex with her boyfriend; she denies systemic symptoms. On physical examina- tion she does not have inguinal lymphadenopathy. What is the most likely diagnosis? • syphilis • chancroid • genital herpes • pelvic inflammatory disease • condylomata acuminata The diagnosis is genital herpes caused by the her- pes simplex virus (HSV), the most prevalent genital ulcerative lesion in the United States among young sexually active patients.12 The appearance on the ulcer on physical examination has been likened to a dew drop on a rose petal (Figure 4). However, the lesions may be difficult to visualize or to distinguish from those of syphilis or chancroid. The main dif- ferences are that syphilis lesions are typically pain- less, with jagged margins, and chancroid ulcerations FIGURE 4. Painful labial lesions resulting from are painful with a punched-out appearance and are genital herpes. associated with inguinal adenopathy. The other possibilities are ruled out by the patient’s history and physical examination. Pelvic inflammatory disease is associated with cervical rent lesions, and sensitivity declines as lesions begin motion or adnexal tenderness. Condylomata acumi- to heal.12 (Polymerase chain reaction testing has a nata, or anogenital warts, an STD caused by human higher sensitivity.) Consequently, the practical step papilloma virus (HPV) infection, can cause vaginal is to treat for the diagnosis discharge but does have an ulcerative appearance. considered most likely on >>FAST TRACK<< Treatment is cryotherapy or topical podophyllin. the basis of clinical presen- It is recommended that Distinguishing the ulcerative lesions by physical tation. Referral for HIV all patients with genital examination alone is inaccurate. Therefore, it is testing should be strongly ulcerations undergo recommended that all patients with genital ulcer- considered for all patients serologic testing for ations undergo serologic testing for syphilis and a with genital ulcers caused syphilis and a diagnostic diagnostic evaluation for genital herpes. In areas by HSV and should be per- evaluation for genital where chancroid is prevalent, a test for Haemophi- formed for all patients with herpes. lus ducreyi should be performed. Syphilis serology ulcers caused by T. pallidum and either darkfield examination or direct immu- or H. ducreyi. Patients should also advise all sexual nofluorescence testing is available for Treponema partners to seek evaluation and treatment. pallidum, the causative agent for syphilis. A viral culture or HSV antigen test is appropriate for HSV. PATIENT PRESENTATION: CASE 8 Culture is required for H. ducreyi as no FDA-cleared A 20-year-old woman has had lower and polymerase chain reaction test is available in the abnormal vaginal discharge for four days. She has a United States.12 history of an unknown STD that was treated with Even after a complete diagnostic evaluation, ap- antibiotics. She has been sexually active with mul- proximately 25% of patients who have genital ulcers tiple partners. Her last menstrual period was 10 days are without a confirmed diagnosis because the sen- ago and normal for her. She has no vaginal bleeding. sitivity of a viral culture is low, especially for recur- She has never been pregnant, although her part- www.emedmag.com APRIL 2009 | EMERGENCY MEDICINE 33 VAGINAL BLEEDING AND DISCHARGE

TABLE. Treatment Recommendations

Bacterial vaginosis • Acyclovir 200 mg orally five times a day for 7–10 days First-line treatment options • Metronidazole 500 mg orally twice a day for • Famciclovir 250 mg orally three times a day for 7 days 7–10 days • Metronidazole gel 0.75%, one full applicator • Valacyclovir 1 g orally twice a day for 7–10 days (5 g) intravaginally, once a day for 5 days Note: Treatment can be extended if healing is • Clindamycin cream 2%, one full applicator (5 g) incomplete after 10 days of therapy. intravaginally at bedtime for 7 days Pelvic inflammatory disease Alternatives First-line treatment options • Clindamycin 300 mg orally twice a day for • Levofloxacin 500 mg orally once daily for 7 days 14 days** • Clindamycin ovules 100 mg intravaginally once • Ofloxacin 400 mg orally twice daily for at bedtime for 3 days 14 days** Candidiasis WITH OR WITHOUT Oral agent Metronidazole 500 mg orally twice a day for • Fluconazole 150-mg oral tablet in single dose 14 days Intravaginal agents Alternatives • Butoconazole 2% cream* 5 g intravaginally for • Ceftriaxone 250 mg IM in a single dose and 3 days doxycycline 100 mg orally twice a day for 14 days • Butoconazole 2% cream 5 g (butaconazole1- sustained release), single intravaginal WITH OR WITHOUT application Metronidazole 500 mg orally twice a day for • Clotrimazole 1% cream 5 g intravaginally for 7- 14 days 14 days* • Cefoxitin 2 g IM in a single dose and • Miconazole 2% cream 5 g intravaginally for 7 probenecid 1 g orally administered concurrently days* in a single dose and doxycycline 100 mg orally twice a day for 14 days • Miconazole 200 mg vaginal suppository, one suppository for 3 days* WITH OR WITHOUT • Miconazole 1200 mg vaginal suppository*, one Metronidazole 500 mg orally twice a day for suppository for 1 day 14 days • Nystatin 100,000 unit vaginal tablet, one tablet Trichomoniasis for 14 days First-line treatment options • Tioconazole 6.5% ointment* 5 g intravaginally • Metronidazole 2 g orally in a single dose in a single application • Tinidazole 2 g orally in a single dose Genital herpes Alternative • Acyclovir 400 mg orally three times a day for 7–10 days • Metronidazole 500 mg orally twice a day for 7 days * over-the-counter preparations ** Quinolones should not be used in persons with a history of recent foreign travel or partners’ travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased prevalence of quinolone-resistant Neisseria gonorrhoeae. Source: Workowski KA, Berman SM.12 continued on page 48

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continued from page 34

ners use condoms irregularly. On physical examina- The Table summarizes the treatment options for tion she is noted to be afebrile. Her pelvic examin- the various conditions discussed in this article.12 ation is remarkable for purulent cervical discharge and exquisite cervical motion tenderness. No uter- PREVENTIVE TREATMENT ine or adnexal tenderness is appreciated. The urine Patients with vulvovaginitis and vaginal bleeding are pregnancy test is negative. often seen in the emergency department. A thorough What is the most likely diagnosis? history, focused physical examination, and point-of-care • cervicitis testing are typically sufficient to determine treatment. • pelvic inflammatory disease Beyond that, some common-sense recommendations • genital herpes can help prevent further complications. First, all women • appendicitis should be encouraged to have a Pap smear three years The diagnosis is PID, which comprises a spec- after their first sexual experience or at age 21, whichever trum of disorders of the upper female genital tract comes first, and annually till the age of 30, to screen for that includes , , tubo-ovarian cervical cancer. And when STDs are suspected, ideally abscess, and pelvic peritonitis. Neisseria gonorrhoeae all partners should be evaluated and treated. Q and C. trachomatis are the most commonly implicated organisms; however, normal vaginal flora, anaerobes, REFERENCES and enteric pathogens, as well as cytomegalovirus 1. ACOG Committee on Practice Bulletins—Gynecology. Clinical management guidelines for obstetrician-gynecologists, Number and mycoplasma organisms, have been associated 72, May 2006: Vaginitis. Obstet Gynecol. 2006;107(5):1195-1206. with PID.15 Rates of PID are higher among young 2. Clenney TL, et al. Vaginitis. Clin Fam Pract. 2005;7(1):57-66. 3. Morrison LJ, Spence JM. Vaginal bleeding in the nonpregnant sexually active women where rates of gonorrhea and patient. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emer- chlamydia are high.12 gency Medicine: A Comprehensive Study Guide. McGraw-Hill, Pelvic inflammatory disease is difficult to diag- 6th ed., 2004:647-653. 4. Bayer SR, DeCherney AH. Clinical manifestations and treatment nose clinically due to the range of symptoms and of dysfunctional uterine bleeding. JAMA. 1993;269(14):1823-1828. signs. But delayed diagnosis and treatment may 5. Dodds NR, Sinert R. Dysfuntional uterine bleeding. Emedicine. com. http://emedicine.medscape.com/article/795587-overview. result in upper reproductive tract abnormalities. Updated November 12, 2007. Accessed April 3, 2009. Empiric treatment should be initiated in sexually 6. Jurema M, Zacur HA. Menorrhagia. UpToDate.com. Updated active young women if they are experiencing pelvic October 1, 2008. Accessed January 10, 2009. 7. DeSilva NK, Zurawin RK. Management of abnormal uterine or lower abdominal pain and no other cause can be bleeding in adolescents. UpToDate.com. Updated August 1, 2007. identified, and if cervical motion, uterine tender- Accessed January 10, 2009. 8. Bachmann GA, Nevadunsky NS. Diagnosis and treatment of ness, or adnexal tenderness is present. Additional atrophic vaginitis. Am Fam Physician. 2000;61(10):3090-3096. criteria such as fever, elevated erythrocyte sedimen- 9. Kuhn GJ. Vulvovaginitis. In: Tintinalli JE, Kelen GD, Stapczynski tation rate, elevated C-reactive protein, or docu- JS, eds. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill, 6th ed., 2004:647-653. mented cervical infection with N. gonorrhoeae or C. 10. Wilkerson RG, Sinert RH, Friedman BW, Brillman JC. Tricho- trachomatis support the diagnosis.12,15 moniasis. Emedicine.com. http://emedicine.medscape.com/ article/787722-overview. Updated November 12, 2008. Accessed Treatment should be started after a presumptive April 3, 2009. diagnosis is made and should cover gonorrhea and 11. Rosenfield RL. Treatment of polycystic syndrome in ado- lescents. UpToDate.com. Updated January 5, 2009. Accessed chlamydia. Debate exists as to whether metronidazole January 10, 2009. should be prescribed to cover anaerobic organisms as 12. Workowski KA, Berman SM. Centers for Disease Control and well as coexisting infection with bacterial vaginosis. A Prevention. Sexually transmitted diseases treatment guidelines 2006: Diseases characterized by vaginal discharge. http://www. variety of CDC-recommended parenteral regimens cdc.gov/std/treatment/2006/vaginal-discharge.htm. Accessed are available.11 Only mild to moderate cases should April 6, 2009. 13. Association for Genitourinary Medicine, Medical Society for be treated on an outpatient basis with oral antibiot- the Study of Venereal Disease. 2002 national guideline for the ics; follow-up within 72 hours is essential to ensure management of bacterial vaginosis. http://www.guideline.gov. improvement. Male sexual partners should be evalu- Accesses January 20, 2009. 14. Carpenter Rose EA, Hedayati T. Candidiasis. Emedicine.com. ated and treated if they have had sexual contact with http://emedicine.medscape.com/article/78125-overview. Updat- the patient within the last two months of symptom ed December 6, 2007. Accessed April 6, 2009. 15. Behrman AJ. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. onset due to the risk of male urethral infection and Emergency Medicine: A Comprehensive Study Guide. McGraw- patient reinfection.12,15 Hill, 6th ed., 2004:647-653.

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