INFECTION PRACTICE POINTS VAGINITIS EVALUation AND MANAGEMENT Dear FOGSIANs, The theme of FOGSI this year is “We for Stree”. I would like to thank every FOGSIAN who has helped making every woman Safer, Stronger and Smarter. Through various academic and social programs FOGSI aims to uplift the quality of care that is given to every woman who comes to us. TOG IPP (Infection Practice Points) is one such conclave that brings to light some of challenging health issues like Vaginitis, Pelvic inflammatory disease (PID) and Urogenital infections. I would like to thank Zuventus for their contributions towards the TOG IPP Conclave. We, as clinical practitioners are always busy, therefore the TOG IPP that is released has been a quick and easy way to update you with the latest evidence in the field of Infections. This year we ask all FOGSIANs to focus on the Stree and help make them safer, smarter and stronger. Select FOGSIANs across India came together to deliberate and create these practice points. I am sure that you will appreciate the efforts which has gone into preparing the Infection Practice Points and find them useful in your day to day practice. Best wishes! Dr. Nandita Palshetkar MD, FCPS, FICOG President 2019 - Federation of Obstetrics & Gynecological Societies of India (FOGSI) 1 VAGINITIS Evaluation & Management FOGSI President : Dr. Nandita Palshetkar Moderators : Dr. Hrishikesh Pai Dr. Parag Biniwale Panelists : Dr. Ashwini Bhalerao, Dr. Brajbala Tiwari, Dr. Suvarna Khadilkar, Dr. B. S. Jodha, Dr. Sunil Jindal, Dr. Sunita Arora, Dr. Milind Shah, Dr. Monika Doshi, Dr. Mahesh Gupta, Dr. Vidya Pancholia, Dr. Oby Nagar, Dr. Usha Shekhawat, Dr. Reena Wani, Dr. Meeta Nakhare Clinical Reporters : Dr. Jiteeka Thakkar From left to right: Dr. Meeta Nakhare, Dr. Suvarna Khadilkar, Dr. Vidya Pancholia, Dr. B.S. Jodha, Dr. Jiteeka Thakkar, Dr. Sunita Arora, Dr. Parag Biniwale, Dr. Sunil Jindal, Dr. Nandita Palshetkar, Dr. Hrishikesh Pai, Dr. Monika Doshi, Dr. Milind Shah, Dr. Reena Wani, Dr. Brajbala Tiwari, Dr. Usha Shekhawat, Dr. Oby Nagar This is an independent publication owned by Science Integra®. The advice, opinion, statements, materials and other information expressed and contained in this book are solely those of the experts in the relevant field. The contents including text, graphics and images of the book are meant for educational and informational purposes only. Although great care has been taken in compiling and checking the information, neither Zuventus © 2020 or Science Integra shall be responsible/ liable in any way for the present and/or continued accuracy of the information or for any errors, omissions or inaccuracies in this publications whether arising from negligence or otherwise howsoever, or for any consequences arising therefrom. 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VAGINITIS Evaluation & Management Introduction also showed that 68.7% strains were resistant to metronidazole and all strains were sensitive Vaginitis is indicative of a condition with symptoms of abnormal vaginal discharge, to both clindamycin and amoxicillin/clavulanic 3 odor and irritation, itching, or burning. acid. The most common causes of vaginitis are Bacterial Vaginitis is characterized by an vulvovaginal candidiasis, bacterial vaginosis overgrowth of predominantly anaerobic and trichomoniasis. Bacterial vaginosis affects organisms (e.g. Gardnerella vaginalis, about 40% to 50% of women, which includes Prevotella spp., Mycoplasma hominis, vulvovaginal candidiasis accounting for 20% to Mobiluncus spp.) in the vagina leading to a 25% and trichomoniasis for about 15% to 20% replacement of lactobacilli and an increase of cases. Noninfectious causes such as atrophic, in vaginal pH. Other commonly seen are irritant, allergic and inflammatory vaginitis are vaginal candidiasis and trichomoniasis. less common, accounting for about 5% to 10% of all cases of vaginitis.1 In cases of vulvovaginal candidiasis, diagnosis Diagnosis of vaginitis involves the use of a is made using a combination of clinical signs combination of symptoms, physical examination findings and office-based or laboratory testing. and symptoms with potassium hydroxide Bacterial vaginosis is conventionally diagnosed microscopy. However, DNA probe testing is also using Amsel criteria, but the diagnostic available. The culture is useful for the diagnosis standard is Gram staining. Advances in the of complicated vulvovaginal candidiasis by laboratory tests has enabled to detect ion identifying nonalbicans strains of Candida. of Gardnerella vaginalis DNA or vaginal fluid Treatment of vulvovaginal candidiasis involves sialidase activity. These tests have sensitivity oral fluconazole or topical azoles, although and specificity similar to Gram stain. Bacterial only topical azoles are recommended during vaginosis is treated with oral metronidazole, pregnancy. Trichomoniasis is treated with oral intravaginal metronidazole, or intravaginal metronidazole or tinidazole and patients’ sex clindamycin.1 However, treatment of bacterial partners should be also be treated. Treatment vaginosis with clindamycin is associated with of non-infectious vaginitis should be directed at marked evidence of antimicrobial resistance the underlying cause. Atrophic vaginitis is treated among vaginal anaerobic bacteria, which with hormonal and non-hormonal therapies. increases the vaginal reservoir of macrolide- Probiotics positively effects on vaginal microflora resistant bacteria.2 In a study, researchers composition by promoting the proliferation have shown that all tested strains, except one, of beneficial microorganisms, alters the were sensitive to clindamycin and amoxicillin/ intravaginal microbiota composition, prevents clavulanic acid. The susceptibility test results vaginal infections in postmenopausal women.1 3 First-line non-hormonal treatment recommen- RECURRENT VAGINITIS6 dations include vaginal lubricants and moisturizers; continued sexual activity • Vaginitis recurring within 3 to 4 months should be encouraged.4 Probiotics reduce the and within 3-4 years. symptoms of vaginal infections (e.g., vaginal • Investigation of female partner: PAP discharge, odor, etc.) and are useful in the smear, HPV screening, vaginal swab treatment and prevention of bacterial vaginosis • Investigation of male partner: Culture and vulvovaginal candidiasis.5 Inflammatory from the prepuce, urine routine & vaginitis may improve with topical clindamycin microscopy, semen culture, blood sugars as well as steroid application. Signs and symptoms of vaginitis Table 1. Signs and symptoms of vaginitis1 Diagnosis Etiology Symptoms Signs Other risks Bacterial Anaerobic bacteria Fishy odor; thin, off-white No inflammation Increased risk of vaginosis (Prevotella, homogenous discharge HIV, gonorrhoeae, Mobiluncus, that may worsen after chlamydia and Gardnerella intercourse; pelvic herpes infections vaginalis, discomfort may be present Ureaplasma, Mycoplasma) Vulvovaginal Candida albicans, White, thick, cheesy, or Vulvar erythema - candidiasis can have other curdy discharge; vulvar and edema Candida species itching or burning; no odor (pruritis dysuria) Trichomoniasis Trichomonas Green or yellow, frothy Inflammation; Increased risk of vaginalis discharge; foul odor; vaginal strawberry HIV infection pain or soreness cervix Increased risk of copious, malodorous, preterm labor yellow- green (or discolored) Should be discharge screened for Pruritus other sexually Vaginal irritation transmitted No symptoms in 20% to infections 50% of the affected women Atrophic Estrogen deficiency Thin, clear discharge; vag- Inflammation; - vaginitis inal dryness; dyspareunia; thin, friable itching vaginal mucosa Irritant/allergic Contact irritation or Burning, soreness Vulvar erythema - vaginitis allergic reaction Inflammatory Possibly Purulent vaginal discharge, Vaginal Associated with vaginitis autoimmune burning, dyspareunia atrophy and low estrogen levels inflammation HIV = human immunodeficiency virus. 4 Risk factors contributing to vaginitis7 Low socioeconomic status, vaginal douching, smoking, use of an intrauterine Bacterial contraceptive device, new/multiple sex partners, unprotected sexual intercourse, vaginosis homosexual relationships, frequent use of higher doses of spermicide nonoxynol-9 Low socioeconomic status, multiple sex partners, lifetime frequency of sexual activity, Trichomoniasis other sexually transmitted infections, lack of barrier contraceptive use, illicit drug use, smoking Vulvovaginal Vaginal or systemic antibiotic use, diet high in refined sugars, uncontrolled diabetes candidiasis mellitus, HIV Menopause, other conditions associated with estrogen deficiency, oophorectomy, Atrophic radiation therapy, chemotherapy, immunologic disorders, premature ovarian failure, vaginitis endocrine disorders,