questions 13

Vaginitis

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Topic updated on 11/19/17 11:34pm

Overview
 
Characteristics 
Bacterial Vaginosis Trichomonas Vaginalis Yeast
Typical organism
  • Gardnerella vaginalis
  • Trichomonas vaginalis
  • Candida albicans
Class
  • Bacteria
  • Protozoa
  • Yeast
Frequency
  • 50%
  • 25%
  • 25% - more common in diabetics
Presents
  • Fishy smell on KOH prep and increased pH
  • Severe itching and increased pH 
  • Itching, burning, erythema, and decreased pH
Discharge
  • Fishy, watery, and grayish
  • Yellow and green
  • Cottage cheese
Microscopy
  • Clue cells
  • Motile trichomonads
  • Pseudohyphae - more pronounced with KOH prep
Treatment
  • Metronidazole or clindamycin
  • Treatment of male partner not indicated    
  • Metronidazole for patient and partner  
  • Fluconazole or nystatin  
  • Treatment of male partner not indicated
  • In pregnancy, treat with topical miconazole  
 
Snapshot 
  • A 40-year-old woman with diabetes mellitus presents with pruritic and grayish vaginal discharge. On KOH prep a "fishy" smell is appreciated. The vaginal pH is 5.5. Microscopy reveals the presence of clue cells.
Introduction
  • The normal vaginal environment
    • mixed bacterial flora
    • acidic environment maintained by lactic acid producing lactobacilli
    • any change in the pH can lead to an overgrowth of other bacterial species
  • Candida albicans is also a cause
  • If caused by Trichomonas vaginalis, pregnant patients are at risk for preterm delivery
  • Vulvovaginitis may also be caused by Enterobius vermicularis, though it is rare
    • often presents as recurrent pinworm infection
  • Epidemiology 
    • bacterial vaginosis is common
    • most often caused by Gardnerella vaginalis
Presentation
  • Symptoms   
    • vulvovaginal pruritis
    • burning sensation
    • increased vaginal discharge
    • odor
Evaluation
  • Rule out noninfectious cause (chemical or allergic source)
  • Rule out pregnancy
  • Diagnose by pelvic exam with microscopic analysis of discharge
  • Vaginal discharge slide smear with
    • KOH prep
    • Gram stain
  • Other tests   
    • chlamydia antigen test
    • clean catch urine culture with urinalysis
Differential
  • Contact dermatitis
  • Sexually transmitted infections
    • chlamydia and gonorrhea
  • Atrophic vaginalis
  • Cervical polyps
Treatment
  • Bacterial vaginosis
    • metronidazole or clindamycin
      • considered first-line treatment
      • if prescribing metronidazole, instruct patient to avoid alcohol due to risk of disulfiram-like reaction 
  • Trichomoniasis
    • metronidazole
      • treat sex partners
  • Candidiasis
    • oral flucanozole or topic antifungals (e.g., clotrimazole)
Prognosis, Prevention, and Complications
  • Prevention
    • avoid douching
    • consistent use of condoms (T. vaginalis infection is an STI)
    • better glycemic control if diabetic
  • Complications
    • recurrent vaginitis
    • increased risk of STIs and PID
    • increased risk of pre-term delivery (T. vaginalis)


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Qbank (6 Questions)

TAG
(M2.GN.5) A 24-year-old male presents to the clinic complaining of pain on urination. On exam, watery, non-purulent discharge is noted at the urethra without evidence of sores or ulcers on the penis. The patient is accompanied by his girlfriend who is not your patient, but complains of a, "nasty greenish," discharge from her vagina and asks if it could be related. Which of the following is the most appropriate next step in management? Topic Review Topic

1. Penicillin for the patient and his girlfriend
2. IM ceftriaxone and azithromycin for the patient only
3. Metronidazole for the patient and his girlfriend
4. IM ceftriaxone and azithromycin for the patient and his girlfriend
5. Metronidazole for the patient only

PREFERRED RESPONSE ▶
TAG
(M2.GN.47) A 9-year-old girl is brought to the pediatrician by her mother who reports that the girl has been complaining of genital itching over the past few days. She is an otherwise healthy girl, but was most recently treated with mebendazole for a parasitic infection of the gastrointestinal tract. Her mother is concerned that she may now have a yeast infection. The pediatrician performs a diagnostic test (Figure A). What is the most likely diagnosis? Topic Review Topic
FIGURES: A          

1. Candida infection
2. Bacterial vaginosis
3. Herpes simplex virus
4. Enterobius vermicularis
5. Giardiasis

PREFERRED RESPONSE ▶
TAG
(M2.GN.105) A 28-year-old female with no past medical history presents to your clinic with complaints of several days pale green frothy vaginal discharge. A sample of the discharge reveals pear-shaped motile cells (see Figure A). You diagnose her with Trichomonas vaginalis and prescribe her metronidazole. She states that she has had a single sexual partner and requests treatment for him as well. Which of the following is NOT a pathogen that requires treatment for the partner as well? Topic Review Topic
FIGURES: A          

1. Pediculosis pubis
2. Treponema pallidum
3. Neisseria gonorrhoeae
4. Chlamydia trachomitis
5. Gardnerella vaginalis

PREFERRED RESPONSE ▶
TAG
(M2.GN.206) A 23-year-old female presents to your clinic for an annual gynecologic examination. She has no known medical problems and no history of abnormal Pap smears. She is sexually active with a new male partner and uses condoms inconsistently. Pelvic examination demonstrates a grayish discharge with a fishy smell upon potassium hydroxide preparation. Cervical cells from a Pap smear conducted at the visit are shown in Figure A. Which of the following is the most appropriate next step in management? Topic Review Topic
FIGURES: A          

1. Metronidazole for the patient
2. Metronidazole for the patient and her partner
3. Fluconazole for the patient
4. Fluconazole for the patient and her partner
5. Clindamycin for the patient and her partner

PREFERRED RESPONSE ▶
TAG
(M2.GN.208) A 24-year-old female presents to your office complaining of a malodorous vaginal discharge. Her past medical history is unremarkable, and she does not take any medications. She is sexually active with one male partner and uses condoms inconsistently. Pelvic examination is notable for a yellow-green, malodorous discharge. Vaginal pH is 5.6. Urinalysis is positive for white blood cells. Pap smear results are shown in Figure A. Which of the following is the most appropriate next step in management? Topic Review Topic
FIGURES: A          

1. Oral clindamycin for the patient
2. Oral clindamycin for the patient and her partner
3. Oral metronidazole for the patient
4. Oral metronidazole for the patient and her partner
5. Oral fluconazole

PREFERRED RESPONSE ▶
TAG
(M2.GN.4734) A 26-year-old G2P1001 presents for a routine obstetric visit at 13 weeks gestation complaining of increased vaginal discharge for one week. The discharge is “white and clumpy” with accompanying severe vulvar itching. The patient has no other complaints. She has no past medical history, and her previous delivery was a spontaneous vaginal delivery. She states that she has been using panty liners for the last month or so due to mild stress incontinence, and she has no new sexual partners. At this visit, her temperature is 98.7 °F (35.1 °C), blood pressure is 119/74 mmHg, pulse is 82/min, and respirations are 14/min. The patient has no evidence of oral thrush. On pelvic exam, the vulva is erythematous with multiple excoriations. Speculum exam findings are shown in Figure A. Wet mount of a vaginal swab is shown in Figure B. Which of the following is the best treatment for this patient? Topic Review Topic
FIGURES: A   B        

1. Oral fluconazole
2. Oral nystatin
3. Avoidance of panty liners
4. Low potency topical corticosteroids
5. Topical miconazole

PREFERRED RESPONSE ▶
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