A woman complains of itching and irritation of the labia and vagina, perhaps with vaginal discharge or odor, vague low abdominal discomfort, or dysuria. (Suprapubic discomfort and urinary urgency and frequency suggest cystitis.) Abdominal examination is benign but examination of the introitus may reveal erythema of the vulva and edema of the labia (especially with Candida). Speculum examination may disclose a diffusely red, inflamed vaginal mucosa, with vaginal discharge either copious, thin, and foul-smelling (characteristic of Trichomonas or anaerobic overgrowth) or thick, white, and cheesy (characteristic of Candida and associated with more intense vulvar pruritis). Bimanual examination should show a non-tender cervix and uterus, without adnexal tenderness or masses or pain on cervical motion.
What to do:
Take a brief sexual history. Ask if partners are experiencing related symptoms.
Perform speculum and bimanual pelvic exam. Collect urine for possible culture and pregnancy tests which may influence treatment. Swab the cervix or urethra to culture for N. gonorrheae and swab the endocervix to test for Chlamydia. Touch pH indicator paper to the vaginal mucus (a pH>4.5 suggests anaerobic vaginosis, but this is only useful if there is no blood or semen to buffer vaginal secretions).
Dab a drop of vaginal mucus on a slide, add a drop of 0.9% saline and a cover slip, and examine under 400x for swimming protozoa (Trichomonas vaginalis), epithelial cells covered by adherent bacilli ("clue cells" of Gardnerella vaginalis and other anaerobes), or pseudohyphae and spores ("spaghetti and meatballs" appearance of Candida albicans).
If epithelial cells obscure the view of yeast, add a drop of 10% KOH, smell whether this liberates the odor of stale fish (characteristic of Gardnerella, Trichomonas and semen) and look again under the microscope.
Gram stain a second specimen. This is an even more sensitive method for detecting Candida and clue cells, as well as a means to assess the general vaginal flora, which is normally mixed, with occasional predominance of gram-positive rods. Many white cells and an overabundance of pleomorphic gram-negative rods suggests Gardnerella infection. Gram-negative diplococci inside white cells suggests gonorrhea.
If Trichomonas vaginalis is the etiology, discuss with the patient the options of metronidazole (Flagyl) 500mg bid x 7d, or 2000mg once. The latter has practically as good a cure rate, but obviously better compliance, and shortens the time
she must abstain from alcohol for 24 hours after the last dose because of metronidazole's disulfiram-like activity. Sexual partners should receive the same treatment. In the first trimester of pregnancy, substitute intravaginal clotrimazole 100mg vaginal suppository qhs x7d, which is less effective, but safer than metronidazole vaginal gel. Metronidazole is contraindicated in the first trimester and controversial thereafter. Treatment of asymptomatic patients can be be delayed until after delivery.
If Candida albicans is the etiology, prescribe miconazole (Monistat) or clotrimazole (Gyne-Lotrimin) 200mg vaginal suppositories to be inserted qhs x 3d. These treatments are available without prescription. Prescription alternatives for
recurrences, which is active against fungi other than Candida, are butoconazole (Femstat) and terconazole (Terazol) one 5 gram applicator of cream qhs for three days and seven days, respectively. Use of cream also allows its soothing application on irritated mucosa. A single oral dose of fluconazole (Diflucan) 150mg po is at least as effective as intravaginal treatment of vulvovaginal candidiasis, and many patients seem to prefer it. Gastrointestinal side effects are fairly common and serious side effects can occur. In pregnancy, halve the dose and double the course of topical clotrimazole, (the same as the regimen for Trichomonas above).
If the diagnosis is bacterial vaginosis, which is an overgrowth of Gardnerella vaginalis or other anaerobes, the strongest treatment is metronidazole 500mg bid or clindamycin 300mg bid x 7d. Metronidazole vaginal gel 0.75% 5 grams bid x
7d is an alternative which is more expensive but carries fewer gastrointestinal side effects than the oral form. Sex partners need not be treated unless they have balinitis.
To prevent rebound Candida vaginitis after antibiotics decimate the normal vaginal flora, or for treatment of mild vaginitis, consider douching with 1% acetic acid (half-strength vinegar) to maintain a normal low pH ecology.
remember that any given patient may harbor more than one infection.
Arrange for followup and instruct the patient in prevention of vaginitis .
What not to do:
Do not prescribe sulfa creams for non-specific vaginitis. The treatments above are more effective.
Do not miss underlying pelvic inflammatory disease, pregnancy, or diabetes, all of which can potentiate vaginitis.
Do not miss candidiasis because the vaginal secretions appear essentially normal in consistency, color, volume and odor. Non-pregnant patients may not develop thrush patches, curds or caseous discharge.
Both Candida albicans and Gardnerella vaginalis (previously known as Hemophilus vaginalis or Corynebacterium vaginale), are part of the normal vaginal flora. A number of anaerobes share the blame in bacterial vaginosis. An alternate therapy uses active-culture yogurt douches to repopulate the vagina with lactobacilli. Candida vaginitis is more common in the summer, under tight or nonporous clothing (jeans, synthetic underwear, wet bathing suits), and in users of antibiotics and contraceptives (which alter vaginal mucus), as well as in diabetes mellitus, steroid-induced immuinosupression and use of broad-spectrum antibiotics. Trichomonas can be passed back and forth between sexual partners, a cycle that can be broken by treating both. Ask patients with vulvar pruritis, erythema and edema, but with otherwise normal saline, KOH and Gram stain microscopy, about the use of hygene sprays or douches, bubble baths or scented toilet tissue. Contact vulvovaginitis may result from an allergic or chemical reaction to any one of these or similar products and can be treated by removing the offending substance and prescribing a short course of a topical or systemic corticosteroid.
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Swedberg J, Steiner JF, Deiss F, et al: Comparison of a single-dose vs one-week course of metronidazole for symptomatic bacterial vaginosis. J Am Med Assoc 1985;254:1046-1049.
Martin DH, Mroczkowski TF, Dalu ZA et al: A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. N Eng J Med 1992;327:921-925.