2 Vaginitis CurriculumVaginal EnvironmentThe vagina is a dynamic ecosystem that contains approximately 109 bacterial colony-forming units.Normal vaginal discharge is clear to white, odorless, and of high viscosity.Normal bacterial flora is dominated by lactobacilli – other potential pathogens present.Acidic environment (pH ) inhibits the overgrowth of bacteriaSome lactobacilli also produce H2O2, a potential microbicide
4 Other Causes of Vaginitis Vaginitis CurriculumOther Causes of VaginitisMucopurulent cervicitisHerpes simplex virusAtrophic vaginitisAllergic reactionsVulvar vestibulitisForeign bodies
5 Diagnosis of Vaginitis Vaginitis CurriculumDiagnosis of VaginitisPatient historyVisual inspection of internal/external genitaliaAppearance of dischargeCollection of specimenPreparation and examination of specimen slide
6 Other Diagnostics for Vaginitis Vaginitis CurriculumOther Diagnostics for VaginitisDNA probesCulturesFem Examine Test Card™PIP Activity Test Card™
7 Wet Preps: Common Characteristics Vaginitis CurriculumWet Preps: Common CharacteristicsRBCsSquamous epithelial cellPMNSpermArtifactSaline: 40X objectiveSource: Seattle STD/HIV Prevention Training Center at the University of Washington
8 Wet Prep: Lactobacilli and Epithelial Cells Vaginitis CurriculumWet Prep: Lactobacilli and Epithelial CellsLactobacilliArtifactNOT a clue cellSaline: 40X objectiveSource: Seattle STD/HIV Prevention Training Center at the University of Washington
9 Vaginitis Differentiation Vaginitis CurriculumVaginitis DifferentiationNormalTrichomoniasisCandidiasisBacterial VaginosisSymptom presentationItch, discharge, 50% asymptomaticItch, discomfort, dysuria, thick dischargeOdor, discharge, itchVaginal dischargeClear to whiteFrothy, gray or yellow-green; malodorousThick, clumpy, white “cottage cheese”Homogenous, adherent, thin, milky white; malodorous “foul fishy”Clinical findingsCervical petechiae “strawberry cervix”Inflammation and erythemaVaginal pH> 4.5Usually < 4.5KOH “whiff” testNegativeOften positivePositiveNaCl wet mountLacto-bacilliMotile flagellated protozoa, many WBCsFew WBCsClue cells (> 20%), no/few WBCsKOH wet mountPseudohyphae or spores if non-albicans species
11 Trichomoniasis Curriculum Learning ObjectivesUpon completion of this content, the learner will be able to:Describe the epidemiology of trichomoniasis in the U.S.Describe the pathogenesis of T. vaginalis.Describe the clinical manifestations of trichomoniasis.Identify common methods used in the diagnosis of trichomoniasis.List CDC-recommended treatment regimens for trichomoniasis.Describe patient follow up and partner management for trichomoniasis.Describe appropriate prevention counseling messages for patients with trichomoniasis.
12 Lessons Epidemiology: Disease in the U.S. Pathogenesis Trichomoniasis CurriculumLessonsEpidemiology: Disease in the U.S.PathogenesisClinical manifestationsDiagnosisPatient managementPrevention
13 Lesson I: Epidemiology: Disease in the U.S. Trichomoniasis CurriculumLesson I: Epidemiology: Disease in the U.S.
14 Incidence and Prevalence Trichomoniasis CurriculumEpidemiologyIncidence and PrevalenceMost common treatable STDEstimated 7.4 million cases annually in the U.S. at a medical cost of $375 millionEstimated prevalence:2%-3% in the general female population50%-60% in female prison inmates and commercial sex workers18%-50% in females with vaginal complaints
15 Trichomoniasis Curriculum EpidemiologyTrichomoniasis and other vaginal infections — Initial visits to physicians’ offices: United States, 1966–2003SOURCE: National Disease and Therapeutic Index (IMS Health)
16 Risk Factors Multiple sexual partners Lower socioeconomic status Trichomoniasis CurriculumEpidemiologyRisk FactorsMultiple sexual partnersLower socioeconomic statusHistory of STDsLack of condom use
17 Transmission Almost always sexually transmitted Trichomoniasis CurriculumEpidemiologyTransmissionAlmost always sexually transmittedT. vaginalis may persist for months to years in epithelial crypts and periglandular areasTransmission between female sex partners has been documented
19 Microbiology Etiologic agent Possible association with Trichomoniasis CurriculumPathogenesisMicrobiologyEtiologic agentTrichomonas vaginalis - flagellated anaerobic protozoaOnly protozoan that infects the genital tractPossible association withPre-term rupture of membranes and pre-term deliveryIncreased risk of HIV acquisition
20 Trichomonas vaginalis Trichomoniasis CurriculumPathogenesisTrichomonas vaginalisSource: CDC, National Center for Infectious Diseases, Division of Parasitic Diseases
22 Clinical Presentation and Symptoms in Women Trichomoniasis CurriculumClinical ManifestationsClinical Presentation and Symptoms in WomenMay be asymptomatic in womenVaginitisFrothy gray or yellow-green vaginal dischargePruritusCervical petechiae ("strawberry cervix") - classic presentation, occurs in minority of casesMay also infect Skene's glands and urethra, where the organisms may not be susceptible to topical therapy
23 “Strawberry cervix” due to T. vaginalis Trichomoniasis CurriculumClinical Manifestations“Strawberry cervix” due to T. vaginalisSource: Claire E. Stevens/Seattle STD/HIV Prevention Training Center at the University of Washington
24 Trichomoniasis Curriculum Clinical ManifestationsT. vaginalis in MenMay cause up to 11%-13% of nongonococcal urethritis in malesUrethral trichomoniasis has been associated with increased shedding of HIV in HIV-infected menFrequently asymptomatic
26 Diagnosis Motile trichomonads seen on saline wet mount Trichomoniasis CurriculumDiagnosisDiagnosisMotile trichomonads seen on saline wet mountVaginal pH >4.5 often presentPositive amine testCulture is the “gold standard”
28 Wet Prep: Trichomoniasis Trichomoniasis CurriculumDiagnosisWet Prep: TrichomoniasisPMNTrichomonas*Squamous epithelial cellsYeast budsSaline: 40X objective*Trichomonas shown for size reference only: must be motile for identificationSource: Seattle STD/HIV Prevention Training Center at the University of Washington
30 Treatment CDC-recommended regimen CDC-recommended alternative regimen Trichomoniasis CurriculumManagementTreatmentCDC-recommended regimenMetronidazole 2 g orally in a single doseCDC-recommended alternative regimenMetronidazole 500 mg twice a day for 7 daysNo follow-up necessary
31 Pregnancy CDC-recommended regimen No evidence of teratogenicity Trichomoniasis CurriculumManagementPregnancyCDC-recommended regimenMetronidazole 2 g orally in a single doseNo evidence of teratogenicity
32 Trichomoniasis Curriculum ManagementTreatment FailureIf treatment failure occurs after 1 treatment attempt with both regimens, the patient should be retreated with metronidazole 2 g orally once a day for 3-5 daysAssure treatment of sex partnersIf repeated treatment failures occur, contact the Division of STD Prevention, CDC, for metronidazole-susceptibility testing
34 Partner Management Sex partners should be treated Trichomoniasis CurriculumPreventionPartner ManagementSex partners should be treatedPatients should be instructed to avoid sex until they and their sex partners are cured (when therapy has been completed and patient and partner(s) are asymptomatic)
35 Patient Counseling and Education Trichomoniasis CurriculumPreventionPatient Counseling and EducationNature of the diseaseMay be symptomatic or asymptomatic, douching may worsen vaginal discharge, untreated trichomoniasis associated with adverse pregnancy outcomesTransmission issuesAlmost always sexually transmitted, fomite transmission rare, may persist for months to years, associated with increased susceptibility to HIV acquisition
36 Risk Reduction The clinician should: Trichomoniasis CurriculumPreventionRisk ReductionThe clinician should:Assess patient’s potential for behavior changeDiscuss individualized risk-reduction plans with the patientDiscuss prevention strategies such as abstinence, monogamy, use of condoms, and limiting the number of sex partnersLatex condoms, when used consistently and correctly, can reduce the risk of transmission of T. vaginalis
38 Candidiasis Curriculum Learning ObjectivesUpon completion of this content, the learner will be able to:Describe the epidemiology of candidiasis in the U.S.Describe the pathogenesis of candidiasis.Describe the clinical manifestations of candidiasis.Identify common methods used in the diagnosis of candidiasis.List CDC-recommended treatment regimens for candidiasis.Describe patient follow-up and partner management for candidiasis.Summarize appropriate prevention counseling messages for patients with candidiasis.
39 Lessons Epidemiology: Disease in the U.S. Pathogenesis Candidiasis CurriculumLessonsEpidemiology: Disease in the U.S.PathogenesisClinical manifestationsDiagnosisPatient managementPrevention
40 Lesson I: Epidemiology: Disease in the U.S. Candidiasis CurriculumLesson I: Epidemiology: Disease in the U.S.
41 VVC Epidemiology Affects most females during lifetime Candidiasis CurriculumEpidemiologyVVC EpidemiologyAffects most females during lifetimeMost cases caused by C. albicans (85%-90%)Second most common cause of vaginitisEstimated cost: $1 billion annually in the U.S.
42 Candidiasis Curriculum EpidemiologyTransmissionCandida species are normal flora of skin and vagina and are not considered to be sexually transmitted pathogens
44 Microbiology Candida species are normal flora of the skin and vagina Candidiasis CurriculumPathogenesisMicrobiologyCandida species are normal flora of the skin and vaginaVVC is caused by overgrowth of C. albicans and other non-albicans speciesYeast grows as oval budding yeast cells or as a chain of cells (pseudohyphae)Symptomatic clinical infection occurs with excessive growth of yeastDisruption of normal vaginal ecology or host immunity can predispose to vaginal yeast infections
46 Clinical Presentation and Symptoms Candidiasis CurriculumClinical ManifestationsClinical Presentation and SymptomsVulvar pruritis is most common symptomThick, white, curdy vaginal discharge ("cottage cheese-like")Erythema, irritation, occasional erythematous "satellite" lesionExternal dysuria and dyspareunia
47 Vulvovaginal Candidiasis Candidiasis CurriculumClinical ManifestationsVulvovaginal CandidiasisSource: Health Canada, Sexual Health and STI Section, Clinical Slide Gallery
49 Diagnosis History, signs and symptoms Candidiasis CurriculumDiagnosisDiagnosisHistory, signs and symptomsVisualization of pseudohyphae (mycelia) and/or budding yeast (conidia) on KOH or saline wet preppH normal (4.0 to 4.5)If pH > 4.5, consider concurrent BV or trichomoniasis infectionCultures not useful for routine diagnosis
50 PMNs and Yeast Buds Folded squamous epithelial cells Yeast buds PMNs Candidiasis CurriculumDiagnosisPMNs and Yeast BudsFolded squamous epithelial cellsYeast budsPMNsSaline: 40X objectiveSource: Seattle STD/HIV Prevention Training Center at the University of Washington
51 PMNs and Yeast Pseudohyphae Candidiasis CurriculumDiagnosisPMNs and Yeast PseudohyphaeYeast pseudohyphaePMNsSquamous epithelial cellsYeast budsSaline: 40X objectiveSource: Seattle STD/HIV Prevention Training Center at the University of Washington
52 Yeast Pseudohyphae Lysed squamous epithelial cell Candidiasis CurriculumDiagnosisYeast PseudohyphaeLysed squamous epithelial cellMasses of yeast pseudohyphae10% KOH: 10X objectiveSource: Seattle STD/HIV Prevention Training Center at the University of Washington
54 Classification of VVC Uncomplicated VVC Complicated VVC Candidiasis CurriculumManagementClassification of VVCUncomplicated VVCSporadic or infrequent vulvovaginal candidiasisOrMild-to-moderate vulvovaginal candidiasisLikely to be C. albicansNon-immunocompromised womenComplicated VVCRecurrent vulvovaginal candidiasis (RVVC)OrSevere vulvovaginal candidiasisNon-albicans candidiasisWomen with uncontrolled diabetes, debilitation, or immunosuppression or those who are pregnant
55 Uncomplicated VVC Mild to moderate signs and symptoms Non-recurrent Candidiasis CurriculumManagementUncomplicated VVCMild to moderate signs and symptomsNon-recurrent75% of women have at least one episodeResponds to short course regimen
56 CDC-Recommended Treatment Regimens Candidiasis CurriculumManagementCDC-Recommended Treatment RegimensIntravaginal agents:Butoconazole 2% cream, 5 g intravaginally for 3 days†Butoconazole 2% sustained release cream, 5 g single intravaginally applicationClotrimazole 1% cream 5 g intravaginally for 7-14 days†Clotrimazole 100 mg vaginal tablet for 7 daysClotrimazole 100 mg vaginal tablet, 2 tablets for 3 daysClotrimazole 500 mg vaginal tablet, 1 tablet in a single applicationMiconazole 2% cream 5 g intravaginally for 7 days†Miconazole 100 mg vaginal suppository, 1 suppository for 7 days†Miconazole 200 mg vaginal suppository, 1 suppository for 3 days†Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 daysTioconazole 6.5% ointment 5 g intravaginally in a single application†Terconazole 0.4% cream 5 g intravaginally for 7 daysTerconazole 0.8% cream 5 g intravaginally for 3 daysTerconazole 80 mg vaginal suppository, 1 suppository for 3 daysOral agent:Fluconazole 150 mg oral tablet, 1 tablet in a single doseNote: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom product labeling for further information.† Over-the-counter (OTC) preparations.
57 Complicated VVC Recurrent (RVVC) Severe Non-albicans candidiasis Candidiasis CurriculumManagementComplicated VVCRecurrent (RVVC)Four or more episodes in one yearSevereEdemaExcoriation/fissure formationNon-albicans candidiasisCompromised hostPregnancy
58 Complicated VVC Treatment Candidiasis CurriculumManagementComplicated VVC TreatmentRecurrent VVC (RVVC)7-14 days of topical therapy, or150 mg oral dose of fluconozole repeated 3 days laterMaintenance regimens (see CDC STD treatment guidelines)Severe VVC150 mg oral dose of fluconozole repeated in 72 hours
59 Complicated VVC Treatment (continued) Candidiasis CurriculumManagementComplicated VVC Treatment (continued)Non-albicansOptimal treatment unknown7-14 days non-fluconozole therapy600 mg boric acid in gelatin capsule vaginally once a day for 14 daysCompromised host7-14 days of topical therapy
61 Candidiasis Curriculum PreventionPartner ManagementVVC is not usually acquired through sexual intercourse.Treatment of sex partners is not recommended but may be considered in women who have recurrent infection.A minority of male sex partners may have balanitis and may benefit from treatment with topical antifungal agents to relieve symptoms.
62 Patient Counseling and Education Candidiasis CurriculumPreventionPatient Counseling and EducationNature of the diseaseNormal vs. abnormal vaginal discharge, signs and symptoms of candidiasis, maintain normal vaginal floraTransmission IssuesNot sexually transmittedRisk reductionAvoid douching, avoid unnecessary antibiotic use, complete course of treatment
64 Bacterial Vaginosis Curriculum Learning ObjectivesUpon completion of this content, the learner will be able to:Describe the epidemiology of bacterial vaginosis in the U.S.Describe the pathogenesis of bacterial vaginosis.Describe the clinical manifestations of bacterial vaginosis.Identify common methods used in the diagnosis of bacterial vaginosis.List CDC-recommended treatment regimens for bacterial vaginosis.Describe patient follow up and partner management for patients with bacterial vaginosis.Summarize appropriate prevention counseling messages for patients with bacterial vaginosis.
65 Lessons Epidemiology: Disease in the U.S. Pathogenesis Bacterial Vaginosis CurriculumLessonsEpidemiology: Disease in the U.S.PathogenesisClinical manifestationsDiagnosisPatient managementPrevention
66 Lesson I: Epidemiology: Disease in the U.S. Bacterial Vaginosis CurriculumLesson I: Epidemiology: Disease in the U.S.
67 Epidemiology Most common cause of vaginitis Bacterial Vaginosis CurriculumEpidemiologyEpidemiologyMost common cause of vaginitisPrevalence varies by population:5%-25% among college students12%-61% among STD patientsWidely distributed
68 Epidemiology (continued) Bacterial Vaginosis CurriculumEpidemiologyEpidemiology (continued)Linked to premature rupture of membranes, premature delivery and low birth-weight delivery, acquisition of HIV, development of PID, and post-operative infections after gynecological proceduresOrganisms do not persist in the male urethra
69 Risk Factors African American Bacterial Vaginosis CurriculumEpidemiologyRisk FactorsAfrican AmericanTwo or more sex partners in previous six months/new sex partnerDouchingAbsence of or decrease in lactobacilliLack of H2O2-producing lactobacilli
70 Bacterial Vaginosis Curriculum EpidemiologyTransmissionCurrently not considered a sexually transmitted disease, but acquisition appears to be related to sexual activity
72 Bacterial Vaginosis Curriculum PathogenesisMicrobiologyOvergrowth of bacteria species normally present in vagina with anaerobic bacteriaBV correlates with a decrease or loss of protective lactobacilli:Vaginal acid pH normally maintained by lactobacilli through metabolism of glucose/glycogenHydrogen peroxide (H2O2) is produced by some Lactobacilli,sp.H2O2 helps maintain a low pH, which inhibits bacteria overgrowthLoss of protective lactobacilli may lead to BV
73 H2O2 -Producing Lactobacilli Bacterial Vaginosis CurriculumPathogenesisH2O2 -Producing LactobacilliAll lactobacilli produce lactic acidSome species also produce H2O2H2O2 is a potent natural microbicidePresent in 42%-74% of femalesThought to be toxic to viruses like HIV
75 Clinical Presentation and Symptoms Bacterial Vaginosis CurriculumClinical ManifestationsClinical Presentation and Symptoms50% asymptomaticSigns/symptoms when present:50% report malodorous (fishy smelling) vaginal dischargeReported more commonly after vaginal intercourse and after completion of menses
77 Wet Prep: Bacterial Vaginosis Bacterial Vaginosis CurriculumDiagnosisWet Prep: Bacterial VaginosisNOT a clue cellClue cellsSaline: 40X objectiveSource: Seattle STD/HIV Prevention Training Center at the University of Washington
78 BV Diagnosis: Amsel Criteria Bacterial Vaginosis CurriculumDiagnosisBV Diagnosis: Amsel CriteriaAmsel Criteria:Must have at least three of the following findings:Vaginal pH >4.5Presence of >20% per HPF of "clue cells" on wet mount examinationPositive amine or "whiff" testHomogeneous, non-viscous, milky-white discharge adherent to the vaginal walls
81 Treatment CDC-recommended regimens: Bacterial Vaginosis CurriculumManagementTreatmentCDC-recommended regimens:Metronidazole 500 mg orally twice a day for 7 days, ORMetronidazole gel 0.75%, one full applicator (5 grams) intravaginally, once a day for 5 days, ORClindamycin cream 2%, one full applicator (5 grams) intravaginally at bedtime for 7 daysAlternative regimens:Metronidazole 2 g orally in a single dose, ORClindamycin 300 mg orally twice a day for 7 days, ORClindamycin ovules 100 g intravaginally once at bedtime for 3 days
82 Treatment in Pregnancy Bacterial Vaginosis CurriculumManagementTreatment in PregnancyPregnant women with symptomatic disease should be treated withMetronidazole 250 mg orally 3 times a day for 7 days, ORClindamycin 300 mg orally twice a day for 7 daysAsymptomatic high-risk women (those who have previously delivered a premature infant)May be screened at first prenatal visitFollow up 1 month after completion of therapy
83 Screening and Treatment in Asymptomatic Patients Bacterial Vaginosis CurriculumManagementScreening and Treatment in Asymptomatic PatientsAsymptomatic screening of low-risk pregnant women is not recommended.Therapy is not recommended for male partners of women with BV.Female partners of women with BV should be examined and treated if BV is present.Screen and treat women prior to surgical abortion or hysterectomy.
84 Recurrence 20% recurrence rate after 1 month Bacterial Vaginosis CurriculumManagementRecurrence20% recurrence rate after 1 monthRecurrence may be a result of persistence of BV-associated organisms and failure of lactobacillus flora to recolonize.Data do not support yogurt therapy or exogenous oral lactobacillus treatment.Under study: vaginal suppositories containing human lactobacillus strains
86 Bacterial Vaginosis Curriculum PreventionPartner ManagementAfter multiple occurrences, some consider empiric treatment of male sex partners to see if recurrence rate diminishes, but this approach has not been validated.
87 Patient Counseling and Education Bacterial Vaginosis CurriculumPreventionPatient Counseling and EducationNature of the DiseaseNormal vs. abnormal discharge, malodor, BV signs and symptoms, sexually associatedTransmission IssuesNot sexually transmitted between heterosexuals, high association in female same-sex partnershipsRisk ReductionAvoid douchingLimit number of sex partners
89 History Tanya Walters 24-year-old single female Case StudyHistoryTanya Walters24-year-old single femalePresents with complaints of a smelly, yellow vaginal discharge and slight dysuria for 1 weekDenies vulvar itching, pelvic pain, or fever2 sex partners during the past year—did not use condoms with these partners—on oral contraceptives for birth controlNo history of sexually transmitted diseases, except for trichomoniasis 1 year agoLast check up 1 year ago
90 Case StudyPhysical ExamVital signs: blood pressure 112/78, pulse 72, respiration 15, temperature 37.3° CCooperative, good historianChest, heart, breast, musculoskeletal, and abdominal exams within normal limitsNo flank pain on percussionNormal external genitalia with a few excoriations near the introitus, but no other lesionsSpeculum exam reveals a moderate amount of frothy, yellowish, malodorous discharge, without visible cervical mucopus or easily induced cervical bleedingBimanual examination was normal without uterine or adnexal tenderness
91 Case StudyQuestionsWhat is your differential diagnosis based on history and physical examination?2. Based on the differential diagnosis of vaginitis, what is the etiology?3. Which laboratory tests should be offered or performed?
92 Case StudyLaboratory ResultsVaginal pHSaline wet mount of vaginal secretions -- numerous motile trichomonads and no clue cellsKOH wet mount -- negative for budding yeast and hyphae4. What may one reasonably conclude about Tanya’s diagnosis?5. What is the appropriate CDC-recommended treatment for this patient?
93 Partner Management Jamie Last sexual contact: 2 days ago Case StudyPartner ManagementJamieLast sexual contact: 2 days agoFirst sexual contact: 2 months agoTwice a week, vaginal sexCalvinLast sexual contact: 6 months agoFirst sexual contact: 7 months ago3 times a week, vaginal and oral sex6. How should Jamie and Calvin be managed?
94 Case StudyFollow-UpTanya was prescribed metronidazole 2 g orally, and was instructed to abstain from sexual intercourse until her partner was treated.She returned two weeks later. She reported taking her medication, but had persistent vaginal discharge that had not subsided with treatment. She reported abstinence since her clinic visit, and her partner had moved out of the area. Her tests for chlamydia and gonorrhea were negative.The vaginal wet mount again revealed motile trichomonads.What is the appropriate therapy for Tanya now?What are appropriate prevention recommendations for Tanya?