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 is characterized by increased vaginal discharge without WBCs or inflammation. Vaginal infections are common in HIV-infected women. This chapter focuses on 2 of the most common types of vaginal infections: trichomoniasis and bacterial vaginosis (BV). For information on the topic of vulvovaginal candidiasis, see the chapter Candidiasis, Vulvovaginal. S: SubjectiveThe 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 partner(s), 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 (eg, sprays, deodorants)
- Douching
- Use of perfumed toiletries (eg, 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 sexually transmitted infections (STIs), pelvic inflammatory disease (PID)
- Medications, including supplements
O: ObjectivePerform 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)
- Erythema, edema, erosions, lesions
- Cervical friability
- Foreign body
Perform a bimanual examination for masses or tenderness, if indicated. A: AssessmentA partial differential diagnosis includes the following: - Bacterial vaginosis (BV)
- Candidiasis
- Trichomoniasis
- Pelvic inflammatory disease (PID)
- Latex or condom allergy
- Urinary tract infection (UTI)
- Condyloma
- Herpes simplex virus (HSV)
- Contact dermatitis from irritants, perfumes, etc
- Chlamydia
- Gonorrhea
- Normal vaginal discharge
P: PlanDiagnostic Evaluation - Obtain a cervical sample for STI testing, if indicated.
- Obtain smears from the vaginal wall for wet mounts and pH.
- 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, presume BV).
Treatment depends on the specific diagnosis, and in general is the same as for HIV-negative 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 is usually made by visualization of motile trichomonads on microscopic examination of wet mounts. The sex partners of patients with trichomoniasis should be treated. Patients should avoid sexual intercourse until they and their partners have completed treatment and symptoms have resolved. Treatment: Recommended regimen - Metronidazole 2 g orally in a single dose
Treatment: Alternative regimen - Metronidazole 500 mg orally twice a day for 7 days
Note: Patients must avoid alcohol while taking metronidazole. This combination may cause a disulfiram-like reaction. Patients taking ritonavir or tipranavir may also 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 doses. If treatment failure occurs with either regimen, repeat treatment using metronidazole 500 mg orally twice daily for 7 days. If treatment failure occurs again, the patient should be treated with metronidazole 2 g once daily for 3-5 days. If this regimen 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 bacteria such as Gardnerella vaginalis and Mycoplasma hominis. BV appears as a homogeneous, white, noninflammatory discharge on the vaginal walls. The diagnosis is made by the detection of clue cells on the wet-mount slide, a vaginal fluid pH of >4.5, and a fishy odor to the vaginal discharge before or after the addition of KOH (whiff test). 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 regimen - Metronidazole 500 mg orally twice daily for 7 days
- Metronidazole gel 0.75%, 1 full applicator (5 g) intravaginally at bedtime for 5 days
- Clindamycin cream 2%, 1 full applicator (5 g) intravaginally at bedtime for 7 days
Treatment: Alternative regimens - Metronidazole 2 g orally in a single dose
- Clindamycin 300 mg orally twice daily for 7 days
- Clindamycin ovules 100 g intravaginally at bedtime for 3 days
Note: Patients must avoid alcohol while taking metronidazole. This combination may cause a disulfiram-like reaction. Patients taking ritonavir or tipranavir may also experience symptoms because of the small amount of alcohol in the capsules. Treatment Failure 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 STIs or related conditions, see the CDC's treatment guidelines at http://www.cdc.gov/std/treatment. Patient Education- Patients must avoid any form of alcohol while taking metronidazole and for 24 hours after the last dose. Alcohol and metronidazole together can cause severe nausea, vomiting, and other immobilizing symptoms.
- Patients taking ritonavir may experience symptoms because of the small amount of alcohol in the capsules and should call their health care providers if nausea and vomiting occur.
- 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 providers 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 2002. MMWR Recomm Rep. 2002 May 10;51(RR-6):1-78.
- 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 ed. New York: Tiresias Press, Inc.; 2000.
- Joesoef MR, Schmid GP, Hillier SL. Bacterial vaginosis: review of treatment options and potential clinical indications for therapy. Clin Infect Dis. 1999 Jan;28 Suppl 1:S57-65.
- Schwebke JR. Gynecological consequences of bacterial vaginosis. In: Obstetrics and Gynecology Clinics of North America, Vol. 30; 2003:685-694.
|
