VAGINITIS and SEXUALLY TRANSMITTED DISEASES
E.J. Mayeaux, Jr., M.D.
Associate Professor of Family Medicine
Clinical Associate Professor Obstetrics and Gynecology
Louisiana State University Medical Center Shreveport, Louisiana
Vaginitis (Vaginal Discharge)
Introduction
Vaginal itching and/or discharge are very common complaints in out-patient settings. The differential diagnosis contains five common problems; i.e., Chlamydia trachomatis, Neisseria gonorrhea, Trichonomas vaginalis, yeast infections, and bacterial vaginosis. Physical examination and laboratory testing can usually establish a clear provisional diagnosis.
General Approach to Diagnosis
A thorough history is important for evaluating this complaint. The primary symptom is usually vaginal discharge, which may be accompanied by itching, dysuria, or pelvic discomfort. The discharge may be discovered on routine pelvic exam without any patient complaints at all. The physician should find out about antibiotic or other drug usage prior to symptom development. It should also be determined whether the patient douched recently, because this can lower the yield of diagnostic tests and predispose to bacterial vaginosis or yeast infections.
The physical exam should include inspection of the external genitalia for irritation or discharge from the introitus. Speculum exam is done to determine the amount and character of discharge and presence of cervical involvement. A chlamydiazyme and culture for gonorrhea should always be done on any appreciable discharge in sexually active females. Bimanual exam may demonstrate tenderness of cervix, uterus, or adnexa indicating more extensive involvement (PID). Laboratory work should include chlamydiazyme, GC culture, KOH, and wet preps.
The N. gonorrhea culture starts with a sample taken with a cotton-tipped swab from the cervical os and immediately transferred to a Thayer-Martin agar plate. The swab should be rolled across the surface since these organisms are extremely delicate and can be killed (i.e., a false negative test obtained) by the simple friction of dragging the applicator across the agar. Cultures should be stored in a low oxygen container (CO2 jar) for transport to the lab.
Wet preps are obtained using a second cotton-tipped applicator applied to the vaginal side-wall and placing the sample of discharge into normal saline (not water). A drop of the suspension is then placed on a slide, covered with a cover-slip, and carefully examined with the low power and high dry objective lenses. Under the microscope, observe for presence and number of white blood cells (WBCs), trichomonads, or clue cells. Trichomonads are motile pear-shaped organisms with active flagella, larger than a WBC but smaller than epithelial cells, that are usually seen swimming or thrashing around in the wet prep. Clue cells are epithelial cells that have bacteria adhered to their surface, obscuring their borders and causing a stippled appearance. Yeast or hyphae may also be seen on the wet prep.
The KOH prep is made by adding a drop of 10% KOH solution to a drop of saline suspension of the discharge. The KOH lyses epithelial cells in about 5 minutes (faster if the slide is warmed briefly) and allows easier microscopic visualization of Candidal hyphae. A "whiff" test may be done afterwards by placing the drop of KOH on the slide and smelling for a foul, fishy odor. The odor is indicative of anaerobic overgrowth, and thus, bacterial vaginosis.
The vaginal pH can be determined by touching pH paper to the sidewall or transferring secretions from the sidewall to pH paper via an applicator. Be careful not to get cervical mucus in your sample since its high pH may change your results.
Table 1. Typical laboratory characteristics of common vaginal infections in adult women.
Diagnostic Normal Bacterial Trichomonas Candida
Criteria Vaginosis Vaginitis Vulvovaginitis
Vaginal pH 3.8 - 4.2 > 4.5 4.5 < 4.5 (usually nl)
Discharge White, Thin, Thin, white, Yellow, green, White, curdy,
flocculent gray frothy "cottage cheese"
"Whiff" test Absent Fishy Fishy Absent
Microscopic Lactobacilli, Clue cells Trichomonads, Budding yeast,
epithelial adherent cocci WBCs >10/hpf hyphae,
cells no WBCs pseudohyphae
Cervicitis /Vaginitis
Chlamydia trachomatis, Neisseria gonorrhea, Trichomonas vaginalis
Yeast infections, Bacterial Vaginosis
C. trachomatis is an intracellular parasite that is one of the most common sexually-transmitted diseases. Its onset is often indolent. It may be the most common cause of infertility, secondary to tubal obstruction. The organism's life cycle has two stages: the infectious stage (elementary body) and the metabolic-reproductive stage (reticulate or inclusion body). Prevalence varies from 3%-20%. Risk factors include: age < 25 years, new sexual partner within 3 months, and multiple sexual partners.
Chlamydia - Diagnosis
Look for associated urethritis, endometritis, salpingitis, perihepatitis, and mucopurulent cervicitis. Dysuria is a very common complaint, but the infection is often asymptomatic. The wet prep usually has only WBCs and is negative for other organisms. Collect samples with dacron or metal handled swabs (not wood) since chemicals in the wood can kill the organism. Culture on McCoy cells - sensitivity 70%-90%, specificity 100% (use for legal purposes). Direct flourescein antibody test (MicroTrak) - sensitivity 86%-93%, specificity 93%-99%. ELISA technique (Chlamydiazyme) - sensitivity 70%-96% specificity 90%-98%. False negative and positive rates change with prevalence of disease in population studied.
Chlamydia - Treatment
N. gonorrhea is a sexually transmitted disease that can lead to salpingitis, tuboovarian abscess, and/or sterility if not treated promptly. It is a Gram negative diplococcus that most commonly infects the endocervix. It may produce systemic symptoms: fever, arthritis, dermatitis, pericarditis, endocarditis, and meningitis.
N. gonorrhea - Diagnosis
75% of women have no symptoms. It produces a profuse, yellow, irritating mucopurulent discharge and may cause urethritis, cervicitis, endometritis, salpingitis, perihepatitis. Culture is taken from the cervix or urethra, placed on selective media (Thayer-Martin), and incubated in low oxygen. A Gram stain from cervix (not vagina) is 70% sensitive. Wet prep may show many polys (WBCs). Look for Bartholin's or Skene's glands involvement. Test or treat for concurrent Chlamydia (50% coexistence) and test for syphilis and HIV.
Uncomplicated N. gonorrhea - Treatment
Disseminated N. gonorrhea - Treatment
Trichomonas vaginalis is a common, sexually transmitted, mobile, anaerobic, protozoan that is not part of the normal human flora. It is associated with use of non-barrier contraceptives and multiple sexual partners.
Trichomonas - Diagnosis
It may cause dysuria or abdominal pain but is often asymptomatic, especially in males. The discharge is often profuse, grayish white, frothy, and foul-smelling. The vagina is usually red and pruritic. The cervix is red and may have "strawberry spots." The wet prep demonstrates mobile pear-shaped trichomonads with lashing flagella.
Trichonomas - Treatment
Avoid metronidazole during first trimester of pregnancy. Treat both partners - same dose for males. Warn the patient about Antabuse effect during treatment (avoid alcohol intake) and about the possibility of amber urine and a metallic taste. Sexual activity need not be restricted during treatment if both partners are treated at same time.
Usually acquired from one's own rectum or the environment (not restricted to sexual transmission). It is a frequent iatrogenic complication of antibiotic treatment (from altered vaginal flora) and OCPs. Candida albicans most common organism but other species (C. tropicalis and Torulopsis glagbata) are found. It is common in uncontrolled diabetics and patients with impaired cell-mediated immunity. It usually is intensely pruritic on vulva.
Yeast Infections - Diagnosis
The discharge is watery to heavy cottage cheese in appearance with a fermentation odor. The vagina and cervix usually show pruritis and edema. The vulva is often red and pruritic with characteristic satellite lesions. KOH prep demonstrates pseudohyphae and budding yeast.
Yeast Infections - OTC Treatment
miconazole (Monistat-7) 2% vaginal cream or 100 mg suppository, 1 application high in vagina qd for 7 nights. May be used during 2nd and 3rd trimesters.
clotrimizole (Gyne-Lotrimin, Mycelex-7, Fem Care, etc) 1% vaginal cream or 100 mg vaginal tablet, qd for 7-14 nights. May be used during 2nd and 3rd trimesters.
Yeast Infections - Rx Treatment
Bacterial Vaginosis is a polymicrobial condition with Gardnerella vaginalis commonly being present. There is a shift from the normal lactobacillus flora to a facultative anaerobic species. Inflammation is not a major component of BV so it is no longer called 'bacterial vaginitis'. The characteristic fishy odor is produced by increased volatile amines generated by the bacteria. BV is linked to post-surgical infections, preterm delivery, and amnioitis.
BV - Diagnosis
The discharge is thin, homogeneous grayish, with a fishy odor. There is no redness or swelling of cervix or vagina. The wet prep demonstrates clue cells and few WBCs. KOH added to the sample produces a fishy odor (whiff test). The vaginal Ph is usually > 4.5.
BV - Treatment
This problem has no proven major sequella except in pregnancy. It is not necessary to treat unless the patient is symptomatic or pregnant. It will also be present with other infection, and treating the concomitant infection usually causes the bacterial vaginosis to resolve. Stop all douching!! Only treat partners if there are recurrent infections.
Syphilis, Herpes, Chancroid,
Granuloma Inguinale, Lymphogranuloma Venereum
T. pallidum is an anaerobic spirochete that has been increasing in incidence in the United States in the last 10 years. There was a Louisiana public health emergency in 1994 and special screening programs, partner notification, and increased clinical services were instituted.
Syphilis - Primary. The incubation period is 10 to 90 days (average 21). A chancre appears at the site of infection (vulvar, vaginal, cervical). Inguinal adenopathy is common. The lesion heals in 2 to 6 weeks without treatment. Serologic tests turn positive 4 to 6 weeks after exposure or 1 to 2 weeks after appearance of chancre.
Syphilis - Secondary. Results from hematogenous dissemination of spirocetes. It occurs 6 weeks to 6 months after the chancre. Systemic symptoms including fever, malaise, and HA may be present. The hallmark is a maculopapular rash that includes the palms and soles. Vulvar lesions (Condyloma lata) may also appear at this stage.
Syphilis - Latent & Tertiary. Latency follows secondary disease and lasts 2 to 20 years. 33% of inappropriately treated patients develop tertiary disease. Manifestations are optic atrophy, tabes dorsalis, generalized paresis, aortic aneurysm, and gummas of skin and bones. With latent disease > 1 year duration, examine the CSF to rule-out asymptomatic neurosyphilis.
Syphilis - Diagnosis
Classically diagnosed with dark field microscopy. Screening with serologic testing such as RPR or VDRL is more common. 1% of tests are false positive, usually with low titers. False positive tests are more common with pregnancy, SLE, sarcoidosis, malaria, recent febrile illness, chronic active hepatitis. Confirm with a specific treponemal test (MHA-TP, FTA-ABS).
Syphilis - Treatment
Syphilis - Follow up
Perform a RPR or VDRL every 3 months for 1 year. A four-fold decrease in titer expected. If the decrease is not seen, repeat treatment is required for probable treatment failure or re-infection. Serology may become negative over time. MHA-TP remains reactive for life.
Syphilis - Perinatal Infection
Congenital Syphilis rates have risen with the increase in Primary and Secondary disease. It is seen more commonly in women of color, low socio-economic status, and no prenatal care. For high risk patients, screen at the initial visit (routine) and repeat screen at 28 to 32 weeks and at delivery. The fetus can be infected anytime in pregnancy, but disease is not manifested until after 16 weeks. Transmission is highest in primary and secondary disease . There is a 50% probability of congenital infection and a 50% rate of perinatal death. There is an associated higher rate of preterm labor and IUGR. Manifestations of congenital syphilis are less likely and less severe with latent disease. Classic signs at birth are rash, snuffles, mucous patches, jaundice, hepatosplenomegaly, lymphadenopathy, and chorioretinitis. Signs of late congenital syphilis are Hutchinson's teeth, mulberry molars, 8th nerve deafness, saddle nose, and saber shins.
Syphilis - Perinatal Treatment
90% of genitial herpes is caused by Type II Herpes Simplex Virus . It is the most common ulcerative genital disease in the U.S. Its incubation period is 3-7 days. 75% of exposed partners become infected. The incidence increases with age and sexual activity, and is related to socioeconomic status.
HSV - Primary Infection. Symptoms start with burning or pain in genital area, pubic area, or buttocks, followed by vesicles on a red base. Local symptoms include vulvar paresthesis, bilateral vesicles / ulcers, and bilateral inguinal adenopathy. Systemic symptoms may include fever, malaise, myalgia, and headache. Symptoms last 2 weeks, and healing occurs in 1-2 weeks. Viral shedding lasts 2-3 weeks.
HSV - Recurrent Infection. 50% occur within 6 months of the initial episode. There are an average of 4 recurrences in first year. They are related to stress and the onset of menses. There is a prodrome of vulvar burning or itching. The lesions tend to be smaller and unilateral, and may be painless. Lesions usually shed virus for 5 days and heal in 7 days.
HSV - Diagnosis
Diagnosis is usually made by the clinical picture. Viral culture results are available in 3 days but there is a 20% - 30% false negative rate. The Tzanch test involves scraping the base of the lesion, applying Wright's stain, and looking for multi-nucleated giant cells.
HSV - Treatment
HSV - Perinatal Infection
HSV shedding occurs in 0.1%-0.4% of deliveries, and HSV neonatal infection occurs in 0.01%-0.04%. There is a protective effect from maternal antibody. HSV II are identified in 75% of isolates. 90% are infected at the time of birth or from ascending infection with PROM. With primary infection at vaginal delivery, 50% of neonates are infected, 60% of neonates die, and 50% of survivors have significant sequelae. Always obtain personal history of HSV infection or infection of any partners on obstetrical patients. If lesions are present during pregnancy, culture them to confirm diagnosis. At the time of labor, inspection for lesions and history of prodrome. C-section is indicated if lesions or prodrome are present.
Haemophilus ducreyi is an anaerobic gram negative streptobacillus. It has a "school of fish" appearence on gram stain. It is usually seen in tropics and subtropics (including in US). The male to female ratio is between 5:1 and 10:1. Its incubation period is 3 to 6 days.
CHANCROID - Diagnosis
H. ducreyi produces a small papule which ulcerates, producing a soft chancre that is painful and tender. The ulcers are gray and necrotic, and have an exudate. There is often unilateral adenopathy that can lead to abscess formation. Diagnosis is obtained by culture of the organism.
CHANCROID - Treatment:
Granuloma Inguinale (formerly known as Donovanosis) is a disease of the tropics. C. granulomatis reproduces in cells, forming vacuoles with 20-30 bacteria . Wright or Giemsa stain of specimens show intracytoplasmic bipolar "safety-pin" shaped "Donovan bodies." The incubation period is 1 to 12 weeks. 10 -50% of partners are infected.
Granuloma Inguinale - Diagnosis
The initial nodule ulcerates with granulation of edges. Lesions coalesce and destroy the vulvar anatomy. Diagnosis is by appearance, culture, and staining of specimen.
Granuloma Inguinale - Treatment
LGV is a Chlamydia trachomatis infection of lymphatic tissue (serotypes L1, L2, L3.) It is a tropical disease with a male to female ratio 5:1. The incubation period is 3-12 days. The primary stage consists of a small genital papule or ulcer that heals spontaneously.
LGV - Secondary Stage. Marked by acute lymphadenitis with suppuration (bubo formation) and acute proctitis. The incubation period is 10-30 days. Unilateral adenopathy of inguinal and femoral nodes separated by Poupart's ligament produce the "groove sign". Half of patients have systemic symptoms (fever, malaise).
LGV - Tertiary Phase Marked by genitorectal fistulas, ulcers, elephantiasis, and strictures. Diagnosis is by culture of organism or mono-clonal antibody testing of bubo aspirate. Complement fixation titer > 1/64 is also diagnostic.
LGV - Treatment
Pediculosis Pubis, Scabies,
Molluscum Contagiosum, Human Papillomavirus
Pediculosis Pubis
The crab louse, Phthirus pubis, is caught by close contact or from bedding. 90% are infected from a single exposure. It has three stages: nit, nymph, adult. The nits are found at the base of pubic hairs. The adults are 1 mm long and found on the hair shaft. Itching is from allergic sensitization. Treatment: permethrin (Rid, Nix) cream rinse and wash off in 10 minutes.
The mite, Sarcoptes scabiei, is transmitted by close contact. The infestation is widespread over the body. The adult burrows under skin. Itching is most prominent at night. Papules, vesicles, or burrows may be present. The affected area can be scraped onto a slide under mineral oil and examined. The crab louse has six legs with claws but no lateral legs. It has two anterior hairy buds. Treatment: permethrin (Rid, Nix) 5% cream to all areas and wash off in 8-14 hours, or Lindane (Kwell) Treat family members and environment
Accounts for 1 million new cases per year in the U.S. Young sexually active adults account for most office visits. Manifestations range from subclinical infections to multiple hyperplastic exophytic lesions, and malignant potential exists with some viral types. A latency period of many years may occur before the disease becomes apparent. HPV types can be classified into those causing benign, low-risk lesions (types 6, 11), those causing moderate-risk of oncogenic potential, (types 33, 35, 39, 40, 43, 45, 51 - 56, and 58), and those associated with high-risk for oncogenic potential, (types 16 and 18). Multiple viral types often coexist.
HPV - Diagnosis
Condylomata can usually be identified by their hypertrophic appearance. Slide tests for detection of HPV DNA are commercially available, but are expensive and the benefits are not clearly defined. There is not a screening test for HPV. HPV infection may involve all genital areas including the perianal areas, perineum, and surrounding skin. A biopsy with pathological study should be done of any atypical, pigmented, or persistent lesions to rule out malignancy.
HPV - Treatment
Specific therapies include cryotherapy, podophyllin, podofilox (Condylox), trichloroacetic acid (TCA), laser ablation, loop electrosurgical excisional procedure (LEEP) , 5-Fluorouracil (5-FU, Efudex), and alpha interferon. The goal of treating noncervical HPV infections is the elimination of troublesome lesions, since eradication of the virus is impossible. Treating male sexual partners with HPV infection has not changed treatment failure or recurrence rates in women with cervical dysplasia. Patients are contagious to sexual partners. Sexual abstinence, monogomous relationships, and condoms may help decrease spread of the virus. Cryotherapy, LEEP, TCA, and podofilox are the treatments of choice for perineal lesions. Warts on the anal verge are best treated with cryotherapy, TCA and simple excision. Cryotherapy, podofilox, and TCA are the treatments of choice for penile lesions.
One million women seek treatment for PID annually. There are approxiparely 250,000 hospitalizations and 110,000 surgical procedures performed at an annual cost of $3.5 billion in the United States. Possible sequelae include infertility, ectopic pregnancy, TOA, chronic pelvic pain, and TAH-BSO. The infection is usually a polymicrobial ascending infection, with both gonorrhea and chlamydia being present.
PID Diagnosis
The classic clinical presentation includes lower abdominal pain, fever, and tenderness to uterine and adnexal palpation. Look for the "PID shuffle" where patients slide their feet while walking to avoid jarring the pelvic organs. There is no correlation between severity of symptoms and risk of complications. Must rule-out ectopic pregnancy!
PID Clinical Criteria
These three MUST be present: lower abdominal pain, cervical motion tenderness, and adnexal tenderness. At least ONE of the following also must be present: temperature >38O C (100.4 F), WBC elevated >10K/mm3 , tender mass on bimanual exam, elevated sedimentation rate or C-reactive protein, or detection of N. gonorrhoeae or C. trachomatis in endocervix.
PID Hospitalization Criteria
Uncomplicated Outpatient PID Treatment
Rocephin 250 mg IM + Doxycycline 100 mg bid or erythromycin 50mg PO qid x 14 days. Re-evaluate in 72 hrs and admit if not improved.
Uncomplicated Inpatient PID Treatment
Cefotetan 2 gm q 12 or Cefoxitin 2 gm q 6h + Doxycycline 100 mg po q 12 hrs x 14 days.
Complicated (TOA or Complex) PID Treatment
Clindamycin 900 mg q 8 hr or Metronidazole 400 mg q 8h + Gentamycin loading + maintenance