Presentation on theme: "DIAGNOSIS AND TREATMENT OF VAGINITIS"— Presentation transcript:
1 DIAGNOSIS AND TREATMENT OF VAGINITIS Stephanie N. Taylor, MDLSUHSC Department of MedicineSection of Infectious Diseases
2 DISCLOSUREI have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.
3 VAGINITISInflammation of the vagina leading to vaginal irritation and dischargeBoth cervicitis and vaginitis can cause vaginal discharge and distinction can be difficult (Speculum Exam)
4 ETIOLOGY OF VAGINITIS YEAST (CANDIDA SP.) TRICHOMONAS VAGINALIS BACTERIAL VAGINOSISALLERGIC RXN, ESTROGEN DEF., etc.
5 VULVOVAGINAL CANDIDIASIS Candida albicans, Candida glabrata, etc. colonize vaginaProliferation or allergic reaction caused by known and unknown factors (Antibiotic use, diabetes, pregnancy, etc.)Estimated that >75% of women will have at least one episode during lifetime
6 VULVOVAGINAL CANDIDIASIS VVC causes 20-25% of vaginitis in STD clinicsNot truly sexually transmitted - males can acquire the organism however (Candida balanitis or dermatitis)
7 VULVOVAGINAL CANDIDIASIS SymptomsVulvar pruritis, burning or pain“External dysuria” - 20 to inflammed labiaComplaint of dischargePhysical ExaminationVulvar erythema, edema, fissures, vulvar dermatitis with satellite lesionsClumped, white, adherent discharge - classicOccasionally scant, homogeneous, purulent
8 VULVOVAGINAL CANDIDIASIS DiagnosisKOH Prep - Pseudohyphae in ~80%Vaginal pH < 4.5, Negative amine odor, absent or scant PMNsTreatmentFluconazole mg po (single dose)Any of several imidazole creams or suppositories administered 3-7 daysPartner - imidazole cr. for dermatitis/balanitis
12 TRICHOMONAS VAGINITIS Caused by the unicellular parasite Trichomonas vaginalisCauses 5-15% of vaginitis in STD clinicsSexually transmitted - (Older women - delayed diagnosis of chronic infection)Colonizes male urethra - mostly asymptomatic but can cause NGU
14 TRICHOMONAS VAGINITIS DiagnosisMotile trichomonads and predominant PMNs on saline wet prepVaginal pH > 5.0, Positive amine odorTreatmentMetronidazole 2.0 gm (single dose)Metronidazole 500 mg po bid for 7 days if single dose failsPartner - Eval. and Metro. 2.0 gm po (single dose)
17 WHAT IS BACTERIAL VAGINOSIS? Most prevalent cause of vaginal symptoms in women of childbearing ageCharacterized by:Increased malodorous dischargeDecrease or absence of Lactobacillus sp. (L. crispatus and L. jensenii most common)Overgrowth of Gardnerella vaginalis, Mycoplasma sp. and other anaerobic organismsAltered pattern of organic acids from these bacteria (e.g., putrescine, cadaverine, etc.) producing odorLack of inflammation – vaginosis (not vaginitis)
18 HISTORY OF BACTERIAL VAGINOSIS 1892 – Doderlein described normal vaginal bacteria in pregnant women – Later became known as Lactobacillus1899 – Menge and Kronig isolated facultative and strictly anaerobic bacteria, as well as the Doderlein bacillus from the vaginal bacteria of most womenEarly Studies – Established the normal flora of women – Lactobacillus sp. and a mixture of other organisms
19 HISTORY OF BACTERIAL VAGINOSIS Early 1900’s – “Leukorrhea” – white discharge from the vagina became focus of researchInitially thought to have come from the uterusTreated by curettage of the endometrium1913 – A. H. Curtis demonstrated the bacteria that later became known as Gardnerella1913 – Curtis also demonstrated:a. The discharge was of vaginal origin, not endometrialb. Women with leukorrhea did not have many Dordelein bacillic. Presence of anaerobic bacteria correlated with leukorrhea
20 HISTORY OF BACTERIAL VAGINOSIS 1920’s – R. Schroder reported 3 types of vaginal flora1. Acid-producing rods – Doderlein’s bacilli – and the least pathogenic flora2. Mixed flora with Doderlein bacilli in the minority3. Mixed vaginal flora with no Doderlein bacilli and the most pathogenic flora1950 – J.D. Weaver also noted the association of mixed flora with BV
21 HISTORY OF BACTERIAL VAGINOSIS 1955 – Gardner and Dukes demonstrated that Haemophilus vaginalis caused non-specific vaginitis (Later named Gardnerella vaginalis)1955 – Gardner and Dukes erroneously failed to find association with mixed floraFor 25 years research focused on Gardnerella vaginalis as the cause of BV and ignored the potential role of other organisms.
22 WHAT’S IN A NAME? Leukorrhea Non-specific vaginitis Haemophilus vaginalis vaginitisGardnerella vaginitisAnaerobic vaginosis (but not just anaerobes)Bacterial vaginosis (since inflammation is not a feature of BV, the term vaginosis has replaced vaginitis)
23 EPIDEMIOLOGY Prevalence depends upon population studied Student Health Clinics – 4-10%Family Planning Clinics – 17-19%Pregnant women – 16-29%Infertility Clinics – 30%STD Clinics – 24-40%
24 EPIDEMIOLOGY Prevalence also depends on ethnicity Large U.S. Study of pregnant women13,747 at weeks gestation16.3% of women had BVAsians – 6.1%Caucasians – 8.8%Hispanics – 15.9%African American – 22.7%51% of 4,718 women in Ugandan study
25 EPIDEMIOLOGY BV is common in most populations More common in STD clinics than in family planning or prenatal clinicsMore common in women with dischargeRelated to ethnicity for unknown reasonsEspecially common in Sub-Saharan Africa
26 WHAT ABOUT SEXUAL TRANSMISSION? Conflicting and controversial areaWomen who use condoms have decreased prevalence of BVYet multiple partner treatment trials have failed to demonstrate benefit to women with BVEvidence of sexual transmission of BV in women who have sex with women
27 WHAT ABOUT SEXUAL TRANSMISSION? Females with no sexual exposure have significantly lower prevalence of BVSome studies have found association with younger age of sexual debutIn college women, Amsel demonstrated that 0 of 18 virgins versus 69 of 293 (24%) sexually experienced women had BV
28 WHAT ABOUT SEXUAL TRANSMISSION? Association with number of partners also seenWomen with new or multiple sex partners also have higher prevalence of BVEvidence of NGU in male partners of patients with BV
29 WHAT ABOUT SEXUAL TRANSMISSION? Sexual transmission of Gardnerella vaginalis has been demonstratedGardner and Pheifer detected G. vaginalis in the urethras of 79 and 86% of male sex partners of women with BV but not in controlsPiot et al. developed a typing system and demonstrated that Gardnerella isolates in women with BV and from the urethras of their partners were the sameIson and Easmon recovered G. vaginalis and other anaerobes at 103 to 107 org/ml from semen in 16% of men attending an infertility clinic
30 PREDISPOSING/RISK FACTORS DouchingIUD as contraceptive methodYounger ageNew sex partnerMultiple sex partners
31 PREDISPOSING/RISK FACTORS Decrease or absence of Lactobacillus sp.Non-white ethnicitySmoking in some studiesFailure to use condomsFemale sexual partners
32 ETIOLOGY BV represents a complex change in vaginal flora Reduction in H2O2-producing lactobacilliIncrease prevalence and concentration of G. vaginalis, M. hominis, and anaerobes such as Prevotella, Bacteroides sp., Porphyromonas, Peptostreptococcus sp., etc.These organisms found in low levels in normal vagina – also argues against sexual transmission alone as cause
33 PATHOGENESISDecreased Lactobacilli – decreased lactic acid causes increased pHOvergrowth of anaerobes associated with increased enzymes that breakdown vaginal peptides into amines that are malodorousTrimethylamine, cadaverine, putrescine, etc.
34 PATHOGENESISAmines – increase vaginal transudation and squamous cell exfoliation causing the dischargeAt elevated pH – G. vaginalis adheres to squamous cells (“Clue cells”)Amines also provide substrate for growth of M. hominis
35 PATHOGENESISLactobacilli are essential for normal vaginal pH and inhibit growth of other bacteriaLactobacilli are also acidophilic and are attracted to an acid environmentAnaerobic environment of BV is not conducive to growth of lactobacilli or dominanceRemains unknown whether the loss of lactobacilli occurs first or follows the flora disturbance
37 CLINICAL MANIFESTATIONS “Fishy-smelling” discharge – More noticeable after intercourse (Addition of semen with alkaline pH is similar to addition of KOH)Discharge is gray or off-white, thin, homogeneous, and adherent to vaginal wallNo erythema or inflammationSome patients report vaginal itchingCervix usually normal
40 DIAGNOSIS Amsel’s Criteria (3 of 4 criteria for dx.) Adherent, homogeneous gray-white dischargePositive amine or whiff test with addition of 10% KOHElevated vaginal pH of >4.5Presence of “clue cells” – Squamous cells with adherent bacteria (>20% of cells on wet mount)
43 COMPLICATIONS OF BV IN PREGNANCY 7 studies have reported increased risk of pre-term birth in women with BVRelative risk from directly attributable to BV~40% elevated risk of pre-term, low birth weight delivery16-29% of pregnant women with BVLarge number of women at risk
44 COMPLICATIONS OF BV IN PREGNANCY Considerable reduction in pre-term births in high risk women treated for BVScreening and treatment is currently recommended in high-risk patients (previous pre-term delivery)Similar results have not been seen in low-risk patients with asymptomatic BVTherefore routine screening and treatment of BV in all asymptomatic pregnant women is not indicated
45 INFECTIOUS COMPLICATIONS OF BV Organisms found in the lower genital tract in women with BV are found in ~50% with positive cultures of amniotic fluid or placentaGreatly increased risk of postpartum endometritis and post-Ceasarian endometritisIncreased rates of wound infections
46 INFECTIOUS COMPLICATIONS OF BV Vaginal cuff cellulitis after hysterectomyPost-abortion PIDPre-operative antibiotic prophylaxis that covers BV-associated flora can reduce these complicationsSince the 1970’s BV has also been associated with PID, especially in the absence of GC or CT
47 BV AND HIV ASSOCIATIONPresence of BV or absence of lactobacilli associated with heterosexual transmission of HIV2-fold increased prevalence of HIV in Thai and Ugandan women with BVStudy of African pregnant and postnatal women in Malawi found that women with BV were more likely to seroconvert to HIVThese data raise the question of whether BV should be treated more aggressively (In the past – asymptomatic BV was not treated)
48 TREATMENT OF BV Treatment Metronidazole 500 mg po bid for 7 d Metronidazole 2.0 gm no longer recommendedMetro. 0.75% gel qd or bid for 5 dClinda 2% Cr., 5 gm qd for 7 dClinda 300 mg po bid for 7d (Active against Lactobacillus - interferes with re-establishment of normal floraPartner tx. - No treatment requiredNew Drug - Tinidazole 500 bid po x 5 days – 95% efficacy/ Vaginally once daily – 80% eff.
49 SIDE EFFECTS OF TREATMENT Overall in about 15% of patientsNauseaMetallic tasteHeadachesGastrointestinal complaintsOral metronidazole assoc. with Disulfiram-like or “antabuse” reaction after consumption of alcohol – Patient education point3-5% will stop therapy due to side-effects
50 RECURRENT BV 80-90% cure rates at 1 week 15-30% recur within 3 months Single Dose versus 7 day course – 73% vs. 82%Higher recurrence rates for single dose tx.
51 RECURRENT BVSeveral trials have demonstrated that partner treatment does not improve clinical outcome of BV or reduce recurrenceDiscrepancy between data suggesting sexual transmission and lack of benefit with treatment of male partners is puzzlingExcellent opportunities for further research
52 RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Reduction in Lactobacilli – Decreased H2O2 ProductionReplaceLactobacilliOral or vagOvergrowth ofBV-associated bacteriaRaised pHMaintain4.5 pH – vag. gelIntermittent Tx.
53 RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Replacement or Restoration of Lactobacilli (LB)(Bacteriotherapy)Unfortunately lack of efficacy with few controlled trialsLB used needs to be able to adhere and produce H2O2If given orally, LB needs to survive pass through GI tract and ascend from the perianal area into the vaginal areaLactobacilli used have not been vaginal strains
54 RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Lactobacilli in yogurt strains do not bind to vaginal epithelial cellsOnly 1 of 14 women were cured after applying yogurt intravaginally twice daily for 7 daysLittle utility for therapies employing yogurt
55 RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS Other types of capsules, powders, etc. in health food stores are also dairy derivedIn addition, 9 of 16 preparations were contaminated with other types of bacteria and 5 of 16 did not contain peroxide producing strainsPlacebo-controlled trial of purified Lactobacillus suppositories being studied by Sharon Hillier.~50% of women improved during therapyOnly 4 of 29 remained free of BV at 2nd visit
56 RECURRENT BV – COMBINED OR ALTERNATIVE TREATMENTS DisinfectantsChlorhexidine – 79% effective but 50% recurred at one monthPovidone-iodine – bid for 2 wks – only 20 % efficacyAcidifiersLactic Acid suppository – 20% efficacyLactic acid gel x 7 days – 77% - 7 day follow-up – not repeated5% acetic acid tampon – 38% efficacySuppressive therapy – Currently being studied (Sobel)Metronidazole or Tinidazole twice a weekResults pending
57 WHAT CAN WE OFFER PATIENTS WITH RECURRENT BV? Clearly explain bacterial vaginosisCarefully go through personal hygiene practices to remove douching, etc. that may disrupt normal floraExplain that course of therapy may relieve symptoms but it takes time for the bacterial imbalance normalize and recolonize with LactobacilliLonger course of antibiotics or combination therapy for recurrences (2 weeks/ oral + vaginal therapy)???Suppressive and alternative combination therapy in the future