Vaginitis Do I have to look?

Transcription

1 Vaginitis Do I have to look? { Josette D Amato, D.O. Assistant Professor Department of Obstetrics & Gynecology Wright State University Boonshoft School of Medicine

2 Pre-test Amsel s Diagnostic Criteria include all of the following except: A. Presence of homogenous, thin, white vaginal discharge B. ph of vaginal fluid > 4.5 C. Amine-like odor of vaginal discharge when mixed with 10% KOH D. Presence of motile trichomonads on microscopic exam E. Presence of clue cells on microscopic exam 10 Countdown

3 You are a primary care provider through an ambulatory clinic at Grandview Hospital. Today, you encounter a female patient with a women s health issue. The exam rooms in this clinic are equipped to perform pelvic exams and PAP testing. Your patient, Stephanie, is a 22 yo WF G0P0 with a LMP 10 days ago. She is currently taking an OCP for contraception. She presents today complaining of a vaginal discharge of approximately 4 days duration.

4 The nursing staff has obtained the patients vitals and weight. She remains dressed and is now ready to see you. You enter the room after knocking, introduce yourself as her provider, and further elaborate on her chief complaint and health history.

5 CC: Vaginal discharge HPI: New onset vaginal discharge for past 4 days. Unpleasant Thin yellow-green, with odor Discharge heavy enough to use pantiliner No pelvic or abdominal discomfort No fever, chills, N/V Denies irregular vaginal spotting or bleeding Concerned boyfriend unfaithful, requesting STD testing

6 PMHx: Hayfever PSHx: Tonsillectomy Meds: Birth control pills All: NKDA FMHx: mother HTN father HTN, DM, obesity, tobacco use

7 SocHx: Attending community college, working part time ETOH 1 2 glasses beer/wine several nights/week, occasional binging, consuming 5 or more drinks at a time. Admits to few episodes of drinking until passing out Tobacco 1 ppd x 5 yrs Denies illicit drug use Few cups of coffee/day Lots of fast food Doesn t adhere to regular exercise plan

8 GYN Hx: Denies Hx STD She has never had a PAP Menarche at age 14, regular menses on BCP 1 st sexual intercourse 16 yo 6 lifetime partners Monogamous, heterosexual relationship x 6 mo Last intercourse 5 d ago

9 Which element(s) of Stephanie s history concern you regarding her risk of acquiring an STD? A. Using BCP s and smoking. B. Binge drinking C. Lack of regular exercise D. Excessive caffeine consumption 0% 0% 0% 0% 10 A. B. C. Countdown D.

10 Other factors that can place her at risk for STD s include: Young age (15-24 years old) African American race Unmarried status Geographical residence New sex partner in the past 60 days Multiple sex partners Hx prior STD Illicit drug use Admission to correctional facility of juvenile detention center Meeting partners on the internet Contact with sex workers

11 You step out of the room to allow Stephanie to undress and put on the exam gown. You alert the nurse that you will need to proceed with a pelvic exam. Additionally, you may offer Stephanie the chance to empty her bladder prior to the exam and briefly demonstrate how the gown and drape is worn to protect her privacy.

12 Before proceeding with the pelvic exam, it is proper to Obtain verbal consent from the patient Explain the exam process to the patient Ensure that the patient is properly draped and her privacy is observed Ensure approved chaperone is present Ensure all equipment is in the room

13 PE: External genitalia no lesions Speculum exam moderate amount greenishyellow discharge, frothy appearance Cervix patchy, small red spots, strawberry cervix

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15 Based on these findings, what specimens would you collect? A. PAP smear, wet prep/koh, and cultures for gonorrhea and chlamydia B. Wet prep/koh, cultures for gonorrhea and chlamydia, and vaginal cultures C. PAP smear, cultures for gonorrhea and chlamydia, and vaginal cultures D. PAP smear, wet prep/koh, cultures for gonorrhea and chlamydia, and vaginal cultures 0% 0% 0% 0% 10 A. B. C. D. Countdown

16 Results: PAP, vaginal aerobic culture and Gonorrhea/chlamydia culture sent to lab Notice fishy, amine odor when prepare slide for KOH

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18 What is your working diagnosis? A. Bacterial vaginosis B. Gonorrhea/ chlamydia C. Vulvovaginal candidiasis D. Trichomoniasis 0% 0% 0% 0% A. B. C. D. 10 Countdown

19 Wet mount microscopy demonstrates flagellated organisms Abundant WBC s Vaginal culture also confirms Trichomoniasis PAP and Gonorrhea/Chlamydia culture both return negative

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21 Protozoan, T.vaginalis Unicellular, flagellated, motile organism Highly contagious, transmission rate >70% Most common non-viral, non-chlamydial STI Trichomoniasis

22 Clinical diagnosis: Frothy, yellow-green vaginal discharge Strawberry cervix <10% ph > 4.5 Microscopic diagnosis: Observation of motile trichomonads saline wet prep, % sensitivity Point of care diagnostics OSOM Trichomonas Rapid Test, Affirm VP III, >83% sensitivity Vaginal aerobic culture, 88 97% sensitivity Trichomoniasis

23 Trichomoniasis Now that you know the culture is positive for Trichomoniasis, what is the best treatment option for Stephanie? A. Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days B. Metronidazole 2 g orally in a single dose C. Metronidazole 500 mg orally twice a day for 7 days D. Miconazole 2% cream 5 g intravaginally for 7 days 0% 0% 0% 0% 10 A. B. C. Countdown D.

24 Treatment: CDC recommends: Metronidazole (Flagyl): one time 2 gm oral dose (4-500 mg tabs taken once) Oral Tinidazole (tindamax) 2 gm single dose Alternatively Metronidazole 500mg BID x 7 days Not recommended: Metrogel less effective Trichomoniasis

25 Follow-up: Rescreening at 3 months following initial infection Recurrent infections may be reinfection, persistent, or resistant If treatment failure with metronidazole 2 g single dose Metronidazole 500 mg orally BID for 7 days Tinidazole or metronidazole at 2 g orally for 5 days Treatment of sex partners Trichomoniasis

26 Stephanie presents to your office 2 months later. She has taken all of your previously prescribed medication, her partner was treated, and they abstained from intercourse until they were asymptomatic. Initially, her discharge went away, but it came back about one week ago.

27 HPI: New onset vaginal discharge x 7 days White, musty odor No pelvic or abdominal discomfort No irregular vaginal bleeding/spotting

28 PE: External genatilia no lesions Speculum exam - Homogeneous, thin, watery, white discharge Vagina no lesions Cervix no CMT on bimanual exam Obtain wet prep/koh, vaginal aerobic cultures

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30 Results: Amine odor when vaginal secretions mixed with 10% KOH Vaginal culture sent to lab

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32 Based on this information, what is your working diagnosis? A. Bacterial vaginosis B. Gonorrhea/ chlamydia C. Vulvovaginal candidiasis D. Trichomoniasis 0% 0% 0% 0% 10 A. B. C. D. Countdown

33 Polymicrobial clinical syndrome High concentrations of anaerobic bacteria replace Lactobacillus sp. Most prevalent cause of symptomatic vaginitis Risk factors: New/multiple sex partners Lesbian couples Dousching Social stressors (e.g. homelessness) Bacterial Vaginosis

34 Diagnosis: Clinical (Amsel s) Criteria: 1. ph > Milky homogeneous discharge 3. Clue cells on wet mount 4. Release of amine odor when mixed with KOH (whiff test) Gram stain: Gold standard DNA probes, Test cards, OSOM BVBlue test Bacterial Vaginosis

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36 Treatment: Recommended: Metronidazole 500mg orally twice a day for 7 days Metronidazole gel 0.75%, one full applicator (5g) intravaginally, once a day for 5 days Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days Alternative: Tinidazole 2 g orally once daily for 2 days Tinidazole 1g orally once daily for 5 days Clindamycin 300mg orally twice daily for 7 days Clindamycin ovules 100mg intravaginally once at bedtime for 3 days Bacterial Vaginosis

37 You treat Stephanie with metronidazole 500 mg orally twice a day for 7 days. She returns 14 days later with persistent symptoms despite taking the medication.

38 Common Detection of certain BV-associated organisms has been associated with resistance Limited data regarding optimal management for women with treatment failure. Different treatment regimen vs same topical regimen Multiple recurrences: Recurrent BV Recommended induction regimen followed by weekly suppressive regimen (e.g., 10 day induction therapy vaginal metronidazole, followed by twice weekly use of 0.75% metronidazole gel x 16 weeks 75% clinical cure)

39 Stephanie presents again 6 months later Vaginal itching for past 3 days Same monogamous, heterosexual relationship

40 HPI: Intense vulvar itching x 3 days Small amount white vaginal discharge Burning with urination No odor Admits to recent antibiotic treatment for URI

41 PE: External genatilia: erythematous with pustules that extend beyond line of erythema Speculum exam: thick, white discharge Vagina: thick clumps adherent to vaginal wall Bimanual exam: no CMT Collect wet prep/koh, vaginal cultures

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44 Based on this information, what is your working diagnosis? A. Bacterial vaginosis B. Gonorrhea/chlamydia C. Vulvovaginal candidiasis D. Trichomoniasis 0% 0% 0% 0% 10 A. B. C. D. Countdown

45 Causes: C. albicans (90%), C. glabrata or C. tropicalis (5 10%) Typical symptoms: puritis, vaginal soreness, dyspareunia, external dysuria, abnormal vaginal discharge 3 most important factors that can enhance growth Hormonal factors Depressed cell-mediated immunity Antibiotic use Vulvovaginal Candidiasis

46 Diagnosis: Wet preparation (saline, 10% KOH) or Gram stain of vaginal discharge demonstrates yeast, hyphae, or pseudohyphae Culture or other test yields a yeast species ph testing is not a useful diagnostic tool Vulvovaginal Candidiasis

47 Treatment: Multiple azole preparations available Single oral agent, Fluconazole, approved for treatment Short-course topical formulations (single dose and regimens of 1 3 days) effective Vulvovaginal Candidiasis

48 Over-the-Counter Intravaginal Agents: Butoconazole 2% cream 5 g intravaginally for 3 days Clotrimazole 1% cream 5 g intravaginally for 7 14 days Clotrimazole 2% cream 5 g intravaginally for 3 days Miconazole 2% cream 5 g intravaginally for 7 days Miconazole 4% cream 5 g intravaginally for 3 days Miconazole 100 mg vaginal suppository, one suppository for 7 days Miconazole 200 mg vaginal suppository, one suppository for 3 days Miconazole 1,200 mg vaginal suppository, one suppository for 1 day Tioconazole 6.5% ointment 5 g intravaginally in a single application Vulvovaginal Candidiasis

49 Prescription Intravaginal Agents: Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally for 1 day Nystatin 100,000-unit vaginal tablet, one tablet for 14 days Terconazole 0.4% cream 5 g intravaginally for 7 days Terconazole 0.8% cream 5 g intravaginally for 3 days Terconazole 80mg vaginally suppository, one suppository for 3 days Oral Agents: Fluconazole 100 mg oral tablet, one tablet in single dose Vulvovaginal Candidasis

50 Recurrent Vulvovaginal Candidiasis Small percentage of women (< 5%) 4 or more episodes of symptomatic VVC in 1 year Non-albicans candidiasis Not easily recognized on microscopy Conventional antimycotic therapies are not as effective Vulvovaginal Candidiasis

51 Treatment Complicated VVC: Recurrent VVC: Longer duration of initial therapy followed by maintenance regimen ( e.g., 7 14 days topical therapy or 100 mg, 150 mg, or 200 mg oral dose fluconazole every 3 rd day for total of 3 dosages, followed by oral fluconazole 100 mg, 150 mg, 200 mg dose weekly for 6 months. Severe VVC: 7 14 days topical azole or 150 mg fluconazole in 2 sequential doses 72 hours apart Nonalbicans VVC: Unknown optimal treatment Longer duration of therapy 600 mg boric acid vaginally once daily for 2 weeks Vulvovaginal Candidiasis

52 1. Presence of homogenous, thin, white vaginal discharge 2. ph of vaginal fluid > Amine-like odor of vaginal discharge when mixed with 10% KOH 4. Presence of motile trichomonads on microscopic exam* 5. Presence of clue cells on microscopic exam Post-test

53 Amsel s Diagnostic Criteria include all of the following except: 1. Presence of homogenous, thin, white vaginal discharge 2. ph of vaginal fluid > Amine-like odor of vaginal discharge when mixed with 10% KOH 4. Presence of motile trichomonads on microscopic exam 5. Presence of clue cells on microscopic exam 0% 0% 0% 0% 0% Countdown

54 Amsel s Diagnostic Criteria include all of the following except: Presence of... 20% 20% ph of vagin... 20% 20% Amine-like... 20% 20% Presence of... 20% 20% Presence of... 20% 20% First Slide Second Slide

55 Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, MMWR 2010;59(No. RR- 12): Katz, VL et al; Comprehensive Gynecology, 5 th ed, Philadelphia, Mosby Elsevier Eckert, LO: Clinical Practice: Acute Vulvovaginitis. N Engl J Med 355:1250,2006. References

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