Vaginitis/Vaginosis

Background

Vaginitis is defined as inflammation of the vagina, usually characterized by a vaginal discharge containing many white blood cells (WBCs); it may be accompanied by vulvar itching and irritation. Vaginosis presents with increased vaginal discharge without inflammation. Vaginitis usually is caused by an infection, but may be caused by other factors, such as chemicals or irritants. Vaginal infections are common among HIV-infected women. The presence of vaginal infections or inflammation, in the case of bacterial vaginosis in particular, may facilitate acquisition of HIV and other sexually transmitted diseases (STDs), and trichomoniasis may facilitate HIV transmission to HIV-uninfected partners. This chapter focuses on two of the most common types of vaginal infections: trichomoniasis and bacterial vaginosis (BV). For information on the topic of vulvovaginal candidiasis, see chapter Candidiasis, Vulvovaginal.

S: Subjective

The patient complains of vaginal discharge with or without odor, itching, burning, pelvic pain, vulvar pain, or pain during intercourse.

Take a focused history, including the following:

  • Duration of symptoms
  • Sexual history, especially recent new partners, unprotected sex
  • Relationship of symptoms to sexual contacts
  • Contraceptive use, especially:
    • Vaginal contraceptive film
    • Other products containing nonoxynol-9 (N-9)
    • Condoms; type of condoms
    • Use of feminine hygiene products (e.g., sprays, deodorants)
    • Douching
  • Use of perfumed toiletries (e.g., bath salts, scented toilet tissue, or sanitary napkins)
  • Use of any vaginal creams
  • Postcoital bleeding
  • Vulvar pain
  • Pain or burning during urination
  • Pain with intercourse
  • Recent antibiotic use
  • History of STDs, pelvic inflammatory disease (PID)
  • Medications, including supplements

O: Objective

Perform a focused physical examination of the external genitalia, including perineum and anal area, for the following:

  • Inflammation
  • Edema
  • Excoriation
  • Lesions

Perform speculum examination for:

  • Discharge (note color, quality; note that the character of the discharge is not diagnostic)
  • Erythema, edema, erosions, lesions
  • Cervical friability
  • Foreign body

Perform a bimanual examination for masses or tenderness, if indicated.

A: Assessment

A partial differential diagnosis includes the following:

  • BV
  • Candidiasis
  • Trichomoniasis
  • PID
  • Latex or condom allergy
  • Urinary tract infection (UTI)
  • Condyloma
  • Herpes simplex virus (HSV)
  • Contact dermatitis (e.g., from irritants, perfumes)
  • Chlamydia
  • Gonorrhea
  • Normal vaginal discharge

P: Plan

Diagnostic Evaluation

  • Obtain a cervical sample for STD testing, if indicated.
  • Obtain samples (swabs) from the vaginal wall for wet mounts and pH testing.
  • Wet mounts: Perform microscopic examination of saline and potassium hydroxide (KOH) preparations for the following:
    • WBCs, clue cells, motile trichomonads (saline slide)
    • Yeast forms (KOH)
  • Perform a whiff test of KOH preparation; if positive, check pH (if >4.5, likely BV or trichomoniasis).

Treatment depends on the specific diagnosis, and in general is the same as for HIV-uninfected women.

Trichomoniasis

Trichomoniasis is caused by the protozoan Trichomonas vaginalis. Many infected women have a diffuse, malodorous, yellow-green discharge. Most men who are infected with T. vaginalis have no symptoms; others have symptoms of nongonococcal urethritis. The diagnosis usually is made by visualization of motile trichomonads on microscopic examination of wet mounts. Antigen or nucleic acid assays have greater specificity and sensitivity than wet mount preparations, and may be used if microscopy is negative. Culture of vaginal secretions is the most sensitive and specific diagnostic test for T. vaginalis, and also may help to rule out other infections.

Treatment: Recommended regimen

  • Metronidazole 2 g PO in a single dose
  • Tinidazole 2 g PO in a single dose

Treatment: Alternative regimen

  • Metronidazole 500 mg PO BID for 7 days

Treatment during pregnancy

  • Metronidazole, as in nonpregnant women (see above); the 7-day regimen may be better tolerated.
  • Counsel patients about the potential risks and benefits of therapy. In pregnant women with asymptomatic trichomoniasis, deferring therapy until after 37 weeks' gestation may be considered; consult with a specialist.

Treatment notes:

  • Single-dose metronidazole is associated with more side effects than the other treatment regimens.
  • Sex partners should be treated. Patients should refrain from unprotected intercourse until both partners have resolution of symptoms and have completed treatment; this should be at least 7 days after single-dose therapy.
  • Patients must avoid alcohol while taking metronidazole or tinidazole, and for at least 1 day after discontinuing metronidazole and 3 days after discontinuing tinidazole. The combination of alcohol and these drugs may cause a disulfiram-like reaction. Patients taking ritonavir capsules or tipranavir also may experience symptoms because of the small amount of alcohol in the capsules.

Treatment failure

Certain strains of T. vaginalis have diminished susceptibility to metronidazole and must be treated with higher dosages. If treatment failure occurs on metronidazole, consider tinidazole as above, or if single-dose metronidazole was used initially, consider metronidazole 500 mg PO BID for 7 days. If this is not effective, consult with a specialist.

Bacterial Vaginosis

BV is a clinical syndrome resulting from loss of the normal vaginal flora, particularly Lactobacillus, and replacement with anaerobic and other bacteria such as Gardnerella vaginalis and Mycoplasma hominis. The diagnosis is made on clinical and laboratory criteria. Usually, three of the following four characteristics should be present (note: only the clue cells are specific to BV):

  • Homogeneous, gray-white, noninflammatory discharge on the vaginal walls
  • Clue cells on the wet-mount slide
  • Vaginal fluid pH level of >4.5
  • Fishy odor to the vaginal discharge before or after the addition of KOH (whiff test)

Vaginal culture does not help establish the diagnosis. Rapid diagnostic test cards are available in some settings.

Many studies have documented an association between BV and infections such as endometritis, PID, and vaginal cuff cellulitis after gynecologic procedures. Therefore, the U.S. Centers for Disease Control and Prevention (CDC) recommends screening for and treating BV before invasive gynecologic procedures.

The sex partners of women with BV do not need to be treated.

Treatment: Recommended regimens

  • Metronidazole 500 mg PO BID for 7 days
  • Metronidazole gel 0.75%, 1 full applicator
    (5 g) intravaginally QHS for 5 days
  • Clindamycin cream 2%, 1 full applicator
    (5 g) intravaginally QHS for 7 days

Treatment: Alternative regimens

  • Tinidazole 2 g PO QD for 2 days
  • Tinidazole 1 g PO QD for 5 days
  • Clindamycin 300 mg PO BID for 7 days
  • Clindamycin ovules 100 g intravaginally QHS for 3 days

Treatment during pregnancy

  • Symptomatic pregnant women should be treated with oral metronidazole (500 mg BID or 250 mg TID) or oral clindamycin 300 mg BID for 7 days.

Treatment notes:

  • Patients must avoid alcohol while taking metronidazole or tinidazole, and for at least 1 day after discontinuing metronidazole and 3 days after discontinuing tinidazole. The combination of alcohol and these drugs may cause a disulfiram-like reaction. Patients taking ritonavir capsules or tipranavir also may experience symptoms because of the small amount of alcohol in the capsules.

Treatment failure

Consider re-treatment for 7 days with metronidazole or clindamycin. Consider the possibility of an alternative or second cause of the patient's symptoms, as multiple conditions or pathogens may present concurrently. Perform testing for other conditions as suggested by symptoms, or if symptoms to do not resolve with initial treatment:

  • Perform herpes culture if indicated by lesions; see chapter Herpes Simplex, Mucocutaneous.
  • Test for chlamydia and gonorrhea if indicated; see chapter Gonorrhea and Chlamydia.
  • Perform urinalysis (with or without culture and sensitivities) if urinary symptoms are prominent.
  • If an irritant or allergen is suspected, including N-9, discontinue use.
  • If symptoms are related to the use of latex condoms, switch to polyurethane male or female condoms.
  • For tenderness on cervical motion or other symptoms of PID, see chapter Pelvic Inflammatory Disease.
  • Perform workup or obtain referral as needed for other abnormalities found on bimanual examination.

For information on other STDs or related conditions, see the CDC treatment guidelines.

Patient Education

  • Advise patients to avoid any form of alcohol while taking metronidazole or tinidazole and for 24 hours after taking the last dose (72 hours after the last tinidazole dose). Alcohol and metronidazole together can cause severe nausea, vomiting, and other immobilizing symptoms.
  • Patients taking ritonavir capsules may experience these symptoms because of the small amount of alcohol in the capsules and should be told to contact their health care provider if nausea and vomiting occur.
  • Advise patients that clindamycin cream and ovules are oil based and will weaken latex condoms, diaphragms, and cervical caps. Patients should use alternative methods to prevent pregnancy and HIV transmission.
  • Recurrence of BV is common. Patients should contact their health care provider and return for repeat treatment if symptoms recur.
  • Instruct patients to avoid douching.
  • To avoid being reinfected by Trichomonas, patients should bring their sex partners to the clinic for evaluation and treatment.

References

  • Abularach S, Anderson J. Gynecologic Problems. In: Anderson JR, ed. A Guide to the Clinical Management of Women with HIV. Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005.
  • Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010 Dec 17; 59 (No. RR-12):1-110. Accessed December 1, 2013.
  • Cohn SE, Clark RA. Sexually transmitted diseases, HIV, and AIDS in women. In: The Medical Clinics of North America, Vol. 87; 2003:971-995.
  • Hawkins JW, Roberto-Nichols DM, Stanley-Haney JL. Protocols for Nurse Practitioners in Gynecologic Settings, 7th Edition. New York: Tiresias Press, Inc.; 2000.
  • Schwebke JR. Gynecological consequences of bacterial vaginosis. In: Obstetrics and Gynecology Clinics of North America, Vol. 30; 2003:685-694.