Rosen & Barkin's 5-Minute Emergency Medicine Consult (753 page)

BASICS

• Vaginitis is vulvovaginal inflammation with or without abnormal vaginal discharge.
  
  • Common symptoms: Itching, burning, irritation, pain.
    
  • Abnormal discharge is defined as an increased amount or change in color.
    
• Some amount of vaginal discharge is normal.
  
  • Glands in the cervix produce clear mucus that may turn white or yellow when exposed to air.
    

• Bacterial vaginosis (BV):
  
  • The most common cause
    
  • Loss of normal
    Lactobacillus
    sp. (e.g., antibiotics)
    
  • Inability to maintain normal vaginal pH
    
  • Overgrowth of normally present bacteria such as
    Gardnerella vaginalis
    ,
    Mycoplasma hominis
    ,
    Mobiluncus sp
    .
    , Prevotella sp
    ., and Peptostreptococcal
    
• Bacterial infections:
  
  • Trichomonas vaginalis
    (Trichomoniasis)
    
  • Group A strep
    
  • Staphylococcus aureus
    
• Fungal infections:
  
  • Candida sp.
    most common
    
  • Often underlying immune dysfunction:
    
    • Diabetes
      
    • HIV
      
• Chemical irritants
  
• Foreign body
  
• Atrophic vaginitis:
  
  • Caused by estrogen deficiency
    
• Hypersensitivity
  
• Collagen vascular disease
  
• Herpes simplex virus (HSV):
  
  • Vulvovaginitis
    
  • Cervicitis
    
• Lichen sclerosis (atrophic)
  
• Fistula
  

DIAGNOSIS

• Abnormal discharge
  
• Vaginal or vulvar irritation
  
• Localized pain
  
• Dyspareunia
  
• Erythema
  
• Edema
  
• Dysuria
  
• Pruritus
  
• Excoriations
  
• Abnormal odor
  
• Can be asymptomatic
  

• Description and duration of symptoms
  
• Description of discharge, if any
  
• Timing with regard to menses
  
• Sexual history of patient and partners
  
• Sexual practices
  
• Hygienic practices
  
• Use of oral contraceptives and/or antibiotics
  
• Likelihood of pregnancy
  
• Other symptoms (e.g., abdominal pain; must rule out pelvic inflammatory disease [PID])
  

• Abdominal exam to assess for tenderness
  
• Inspection of vulva, vaginal os, perineal area
  
• Speculum and bimanual exam
  

• Pelvic exam
  
• Saline and KOH wet prep of vaginal discharge
  

• β-human chorionic gonadotropin (β-hCG)
  
• pH of discharge with Nitrazine paper:
  
  • Normal in premenopauseal adults: <4.5
    
  • >4.5: BV, trichomoniasis
    
  • pH normal in candidiasis
    
• Saline wet prep of discharge:
  
  • Clue cells: BV
    
  • Motile flagellated protozoa: Trichomoniasis
    
  • Presence of polymorphonuclear leukocytes
    
• Potassium hydroxide (KOH) wet prep of discharge:
  
  • Pseudohyphae, budding yeast: Candidiasis
    
• KOH prep “Whiff” test:
  
  • Amine or “fishy” odor suggests BV, trichomoniasis.
    
• Trichomonas Rapid Test:
  
  • Point-of-care test
    
  • Immunochromatographic dipstick
    
• PIP test card for BV:
  
  • Point-of-care test
    
  • Detects proline aminopeptidase
    
• Nucleic acid probe test for
  Trichomonas
  ,
  G. vaginalis
  , and
  Candida albicans
  
• Gram stain:
  
  • Large, gram-positive rods: Lactobacilli (normal flora)
    
  • Small, gram-variable coccobacilli and curved rods:
    Gardnerella, Prevotella, Mobiluncus
    (BV)
    
• Vaginal culture:
  
  • Gardnerella:
    Not routinely recommended
    
  • Candida
    : Recommended for recurrently symptomatic patients
    
  • Trichomoniasis
    : Gold standard
    
• Endocervical swab for gonorrhea (culture—Thayer–Martin media; DNA probe; amplification techniques—PCR/LCR) and chlamydia (DNA probe or amplification techniques—PCR/LCR)
  
• Viral cultures for HSV, DFA, or Tzanck smear for multinucleated giant cells if ulcers or vesicles are present
  
• Urinalysis/urine culture if c/o dysuria
  
• Rule out sexually transmitted infections:
  
  • GC/Chlamydia testing
    
  • Consider RPR to rule out syphilis.
    
  • Discuss HIV testing.
    

N/A unless fistula is suspected.

• UTI
  
• PID
  
• Dermatitis
  
• Discharge from cervicitis can be mistaken for vaginitis
  
• Chlamydia trachomatis
  
• Neisseria gonorrhoeae
  

TREATMENT

• BV:
  
  • Metronidazole vaginal gel daily × 5 days
    or
    
  • Metronidazole 500 mg PO BID × 7 days
    or
    
  • Clindamycin vaginal cream × 7 days
    or
    
  • Clindamycin ovules PV daily × 3 days
    
  • Rx before certain gynecologic procedures
    
  • Advise against alcohol intake if taking metronidazole for 24 hrs after treatment.
    
  • Routine treatment of male sex partner: NO
    
  • Lactobacillus
    not found to be more effective than placebo
    
• Candidiasis:
  
  • Single-dose oral fluconazole
    or
    
  • Intravaginal imidazole drug × 7 days
    
  • Routine treatment of male sex partner: NO
    
• Chemical irritant:
  
  • Avoid irritant
    
  • Use sitz baths, cotton underwear.
    
• Foreign body:
  
  • Removal of foreign body
    
  • Sedation may be required for removal
    
  • Give appropriate antibiotics if infection present
    
• Chlamydia cervicitis:
  
  • Azithromycin 1 g PO in single dose (for cervicitis, not adequate for PID)
    or
    
  • 7 days of doxycycline, ofloxacin, levofloxacin, or erythromycin
    
  • Treat for presumed concurrent gonococcal infections.
    
  • Routine treatment of male sex partners: YES
    
• Gonococcal cervicitis:
  
  • Ceftriaxone 250 mg IM × 1 AND azithromycin 1 g PO × 1
    or
    doxycycline 100 mg BID × 7 days.
    
  • Oral cephalosporins (cefixime) no longer recommended.
    
  • Treat for presumed concurrent chlamydial infection.
    
  • Routine treatment of male sex partners: YES
    
• HSV:
  
  • Acyclovir, famciclovir, or valacyclovir for 7–10 days for initial attack; 5 days for recurrences
    
  • Lidocaine jelly for topical relief
    
  • Rule out other causes of genital ulcers. Offer RPR, HIV testing, and counseling.
    
  • Routine treatment of male sex partners: Only if symptomatic; however, patient and partner may shed virus asymptomatically.
    
• Lichen sclerosis:
  
  • Referral to gynecologist for estrogen cream and further treatment
    
• Trichomoniasis:
  
  • Metronidazole 2 g PO once
    or
    
  • Tinidazole 2 g PO once
    or
    
  • Metronidazole 500 mg PO BID for 7 days (avoid ethanol)
    
  • Routine treatment of male sex partners: YES
    
• All sexually transmitted causes:
  
  • Advise patient to avoid sexual contact with partner until partner is evaluated and treated when appropriate.
    
  • Educate regarding STDs/safer sex/HIV/hepatitis vaccines
    

• BV:
  
  • Treat symptomatic women with oral metronidazole or clindamycin
    
  • Insufficient evidence for screening or treatment of asymptomatic pregnant women
    
• Candidiasis:
  
  • Only topical azole drug recommended in pregnancy; no oral fluconazole.
    
• Chlamydia cervicitis:
  
  • Azithromycin is the 1st-line choice for treating chlamydia in pregnant patients
    
  • Do not treat with doxycycline, ofloxacin, or levofloxacin.
    
• Trichomoniasis:
  
  • Metronidazole given early in pregnancy shown to increase preterm birth.
    
  • Give 2 g single-dose metronidazole, preferably after 37 wk gestation.
    

• Ask about new irritants: Bubble bath, soap, and laundry detergent.
  
• Consider sexual assault/abuse.
  

• Acyclovir: 200 mg PO 5 times per day × 10 days or 400 PO TID × 10 days (for initial attack); 200 mg PO 5 times per day × 5 days or 400 PO TID × 5 days (for recurrent attack)
  
• Azithromycin: 1 g PO × 1
  
• Butoconazole 2% cream: 5 g PV × 3 days
  
• Butoconazole SR 2% cream: 5 g PV × 1
  
• Ceftriaxone: 125 mg IM or 250 mg IM × 1
  
• Ciprofloxacin: 500 mg PO × 1
  
• Clindamycin 2% cream: 1 applicator PV QHS × 7 days
  
• Clindamycin: 300 mg PO BID × 7 days
  
• Clotrimazole 1% cream: 5 g PV × 7–14 days
  
• Clotrimazole: 100 mg vaginal tablet × 7 days
  
• Doxycycline: 100 mg PO BID × 7 days (class D)
  
• Erythromycin ethyl succinate: 800 mg PO QID × 7 days
  
• Erythromycin base: 500 mg PO QID × 7 days
  
• Famciclovir: 250 mg PO TID × 7–10 days (for initial attack); 125 mg PO BID × 5 days (for recurrent infection)
  
• Fluconazole: 150 mg PO × 1
  
• Levofloxacin: 500 mg PO per day × 7 days
  
• Metronidazole: 500 mg PO BID for 7 days
  
• Metronidazole 0.75% gel: PV daily × 5 days
  
• Miconazole: 1,200 mg PV × 1
  
• Miconazole: 200 mg PV QHS × 3 days
  
• Miconazole 2% cream: 5 g PV QHS × 7 days or 100 mg supp. PV QHS × 7 days
  
• Nystatin 100,000 unit vaginal tablet: Nightly × 14 days
  
• Terconazole: 80 mg supp QHS × 3 days
  
• Terconazole 0.8% cream: 5 g PV × 3 days
  
• Terconazole 0.4% cream: 5 g PV × 7 days
  
• Tinidazole: 2 g PO daily × 1 day
  
• Tioconazole 6.5% cream: 5 g PV × 1
  
• Valacyclovir: 1 g PO BID × 7–10 days (for initial attack); 500 mg PO BID × 3–5 days or 1 g PO per day × 5 days (for recurrent attack)