1. Common Causes of Vaginal Discharge
Including Sexually Transmitted Infections
01/31/13

2. Objectives By the end of this lecture, participants will be able to:
Identify common causes of vaginitis
Describe risk factors, symptoms, and appropriate patient education for common vaginal infections including those that are sexually transmitted (STIs)
Understand the components of a good sexual history

3. Vaginitis Most frequent reason why American women visit the doctor
More than 10 million office visits per year
Many are transmitted by sexual contact, but some infections are not

4. Most Common Causes of Vaginitis
Overgrowth of vaginal flora
Bacterial vaginosis
Yeast (candidiasis)
Sexually transmitted infections
Non-infectious causes
Leukorrhea (discharge occurring during pregnancy)
Atrophic vaginitis (dryness due to thinning tissue and decreased lubrication)
Menopause, lactation, progestin-only contraception
Reactions to deodorants, spermicides, latex, semen
Foreign bodies (e.g., retained tampons)

5. Exam Assessment Discharge:
Color, viscosity, adherence to the vaginal walls
Presence of an odor
Visualization of the cervix to rule out cervicitis
Specimen collection supplies needed
Wet mount
Cultures
DNA probe (Affirm)
Rapid antigen test
Proline IminoPeptidase (PIP) activity test
BV-Blue

6. Vaginitis/STI evaluations may include…
HIV test
Hepatitis B screen
Chlamydia/GC culture
VDRL/RPR
HPV/DNA test (if not done at time of Pap)
Wet mount supplies
pH paper

7. Common Causes of Vaginitis

8. Bacterial Vaginosis (BV)
Cause: lack of protective lactobacilli
Present in 29% of the female population
30% of women have recurrence in 3 mo, 50% in 12
Most common cause of discharge and “fishy” odor, but >50% of women are asymptomatic
Associated with
Pelvic inflammatory disease (PID)
Increased risk of endometritis, cervicitis, post-op infections
Preterm delivery, ruptured membranes, low birth weight in pregnancy
Has been identified in female same-sex partnerships

9. Patient Education for Bacterial Vaginosis
Associated with multiple partners, new partner, douching, lack of vaginal lactobacilli, shared sex toys
Occurrence may be related to sex, but is not considered an STI
Use oral or intravaginal medication as directed
OTC medicines for yeast or other vaginal products don’t work
Recognize potential for recurrence
Recurrence in 3-12 months is common
Treating male partner will not prevent recurrence
Avoid douches/feminine deodorant sprays to treat or prevent recurrence
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

10. Vulvovaginal Candidiasis (Yeast infection)
Overgrowth of yeast that is part of normal vaginal flora
Usually not transmitted sexually, but frequently diagnosed in women being evaluated for STIs
75% of women have it during lifetime; 50% have recurrence
Risk factors: diabetes, antibiotics, spermicide use, douching, contraceptive devices, HIV, pregnancy, corticosteroid use
Symptoms: Itching, redness, burning,
odor-free “cottage cheese” discharge

11. Patient Education for Candidiasis (Yeast infection)
Lack of vaginal lactobacillus bacteria allows overgrowth of fungus
Yeast fungus can spread through oral-genital contact
Associated with antibiotics, pregnancy, diabetes, impaired immune system, douching, sexual activity
Use oral or intravaginal medication as directed
Avoid douches/feminine sprays to treat/prevent recurrence
Mineral-oil in topical antifungal preparations may erode latex condoms /diaphragms. Use plastic/polyethylene condoms.
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

12. Sexually Transmitted Infections in the US
Number of cases (millions)
Trichomoniasis
Genital HPV
Chlamydia
Herpes
Gonorrhea
HIV
Syphilis
Hepatitis B
7.4 mil
5.5 million
1.3 million
1 million
300,000
35,000
40,000
38,000
Sexually Transmitted Infections in the US
New Cases, (CDC data)

13. Trichomoniasis #1 sexually transmitted infection in U.S.
Itching, burning, redness, pain during urination and intercourse (but 85% women asymptomatic)
Frothy, thin, malodorous, yellow-green discharge
Risk factors: multiple partners, low socioeconomic status, history of STIs, lack of condom use
Associated with PID, increased risk for HIV, tubal infertility, cervical cancer, preterm delivery/ruptured membranes/low birth weight in pregnancy
Can be transmitted between female partners

14. Patient Education for Trichomonas
Without treatment, trichomonas can last for years
Be aware of medication side effects:
Metronidazole can trigger cramps, nausea, vomiting, headaches and flushing if combined with alcohol. Avoid alcohol use during treatment and 3 days after. Metronidazole is should not be taken during first trimester of pregnancy.
Avoid sex until patient and partner(s) complete treatment
Douching may worsen discharge
Trichomonas may facilitate HIV transmission
Recurrences/resistance happens - if s/s persist, re-evaluate
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

15. Cervicitis Inflammation of the cervix (not always related to
infection)
Most common causes
Chlamydia and gonorrhea most common. Treat for both.
Foreign objects, radiation, malignancy
Symptoms: Mucopurulent discharge, pain during intercourse, bloody vaginal discharge or spotting between periods. If urethra is also infected, may feel burning upon urination.
Can spread to uterus, fallopian tubes, or ovaries, resulting in PID

16. Gonococcal cervicitis
Bartholin’s abscess
Gonorrhea
Most commonly found in cervix and vagina
Also grows in urethra, mouth, throat, eyes, anus
Associated with ectopic pregnancy, PID, infertility, Bartholin’s abscess
Symptoms: painful urination, increased vaginal discharge, vaginal bleeding between periods (50% of women are asymptomatic)

17. Gonorrhea Diagnosis and Treatment
Endocervical culture
Treatment
Dual antibiotic therapy with ceftriaxone and azithromycin
Retest at 3 months or whenever patient seeks medical care in the next 12 months
Evaluate and treat partners

18. Patient Education for Gonorrhea
In 15% of infected women, untreated gonorrhea spreads to fallopian tubes and causes scarring and infertility
Can increase susceptibility to HIV infection
Use both medications as directed
Avoid sex until patient and partner(s) complete treatment
Some strains of gonorrhea are resistant to certain antibiotics. If symptoms continue after completing course of treatment, another culture may be necessary.
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

19. Chlamydia 1.3 million new infections yearly in U.S.
Found in cervix, urethra, throat, rectum
Symptoms: burning upon urination, frequent and urgent need to urinate, vaginal discharge, light bleeding after intercourse, pain in pelvis or lower abdomen (75% of women are asymptomatic)
Associated with PID, infertility, ectopic pregnancy
Perinatal transmission results in neonatal conjunctivitis in % of exposed babies

20. Chlamydia Screening
CDC and US Preventative Services Task Force recommend screening asymptomatic women…
Yearly for all sexually active women 24 and under
Yearly for sexually active women >24 years with risk factors (African American, new male sex partner, two or more partners in preceding year, inconsistent barrier contraceptive use, history of prior STI)
All pregnant women at the first prenatal visit

21. Chlamydia Diagnosis and Treatment
Swab specimen from endocervix
Urine test
Treatment
Antibiotics
Retest at 3 months or whenever patient seeks medical care in the next 12 months
Evaluate and treat partners

22. Patient Education for Chlamydia
30% of women with chlamydia develop PID
Untreated chlamydia can lead to infertility, chronic pelvic pain, tubal pregnancy. 50,000 women become infertile every year due to chlamydia.
Use medication as directed
Avoid sex until patient and partner(s) complete treatment
Undergo screening for chlamydia at least once a year if under age 25 or if at high risk or if become pregnant
Pregnant women may need repeat testing 3 weeks after completion of therapy
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

23. Human Immunodeficiency Virus (HIV)
Weakens immune defenses by destroying white blood cells that guard body against infection. Eventually, white cells drop below level needed to defend against infections, and AIDS develops.
Growing problem for women
1985: 7% of US AIDS cases were women
2004: 27% of US AIDS cases were women
Black and Hispanic women represent <26% of US women, but account for 82% of female AIDS cases.
Of new HIV infections in 2004…
70% due to heterosexual contact
28% due to IV drug use

24. HIV
Risks:
Women are 4x more likely to contract HIV through vaginal sex with infected men than men are to contract HIV through vaginal sex with infected women
Unprotected anal sex is greater risk for women than unprotected vaginal sex
Nonoxynol-9 spermicide may increase HIV risk (causes irritation and abrasions that allow virus to enter the body)
Gender-specific complications
Recurrent vaginal yeast infections
PID
Increased risk of precancerous cervical changes
Symptoms: % have flu-like illness in first few weeks

25. CDC Screening Recommendations
Screen all patients in all settings unless patient opts-out
Annual screening for persons at high risk:
Unprotected vaginal and anal sex, abuse victims, multiple sexual partners, IV drug and other substance use, history of STIs, poverty, blood transfusions, occupational exposures to blood
Separate written consent should not be required. General consent for medical care is considered sufficient to encompass HIV testing.
Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings
Pregnancy: Include HIV in routine panel of prenatal tests

26. Patient Education for HIV
Transmitted by vaginal/anal/oral sex, needle sharing, occupational exposure, contaminated transfusion/transplant/artificial insemination. Passed from mom to baby during pregnancy/delivery/breastfeeding.
HIV tests not accurate immediately after exposure to virus. Takes a few months to become positive.
If results are positive, another test will measure amount of HIV virus in blood. A white blood cell count will confirm diagnosis.
Cannot completely clear virus from the body. Goal of drug therapy is to suppress virus so it can’t be detected in blood, to increase white blood cell count, and to strengthen weakened immune system.
Time of progression to AIDS depends on amount of HIV virus in blood (viral load) and response to drug therapy
Inform all partners about HIV infection. Use latex condoms.

27. Genital Herpes Simplex Virus (HSV)
25% of US population has serological evidence
HSV-2 is most common subtype; present in 1 in 4 females and 1 in 5 males ages 15-45
Transmission: kissing, skin-to-skin contact, vaginal/oral/anal sex
Can be transmitted when symptoms aren’t present
Primary outbreak usually occurs about 1 week after contact
Fever, chills, headache, painful lymph notes in groin
Pain and itching may precede blisters, skin ulcers
60% of those infected, have no symptoms
C-section recommended for pregnant women with visible ulcers at delivery to prevent newborn infection

28. Genital Herpes Outbreaks : Can reoccur 4-5 times per year
Most frequent in first year
After resolution of primary genital infection, asymptomatic intermittent viral shedding occurs even in absence of genital lesions in up to 23% of people
Daily antiviral medication can decrease recurrences by 75% for people with 6+ episodes per year
Other complications
Herpes most common cause of viral encephalitis
3rd most common cause of sexually transmitted proctitis

29. Genital Herpes
Diagnosis based on history and physical is often inaccurate
*Viral culture for active lesions
*PCR to detect asymptomatic virus shedding
Tzanck prep for lesion scrapings
Direct fluorescent antibody for clinical specimens
*Can determine herpes subtype
Treatment
Antiviral medications to treat primary herpes and suppress recurrent outbreaks
Topical treatments do not work

30. Patient Education for Genital Herpes
No cure. Symptoms can return periodically. Recurrence varies by person.
First attack is usually worst; 40% of people never have second outbreak.
Outbreaks can be related to menses, intercourse, sunbathing, stress
Abstain from sex when symptoms occur. Inform all partners about infection. Even without symptoms, can be transmitted. Latex condoms.
People with herpes more likely to be infected if exposed to HIV through sex. People with HIV and herpes more likely to spread HIV to others.
Take medication as directed to prevent symptoms from returning or to make recurrences less severe
Topical treatments don’t work. Analgesics can help with painful lesions.
Inform provider if you become pregnant

31. Syphilis Infection caused by bacterium Trepomema pallidum
40,000 new cases each year
Occurs in 3 stages
Primary: chancre or ulcer at infection site
Secondary: skin rash, lymphadenopathy
Tertiary: years later - neurological infection

32. Syphilis Diagnosis and Treatment
Serologic test: Venereal Disease Research Laboratory (VDRL) and RPR
Treponemal test (FTA-ABS ) to confirm diagnosis of syphilis
Treatment
Single-dose benzathine penicillin
Late latent infection of unknown duration: benzathine penicillin in 3 doses each at 1 week intervals
Clinical and serological test follow-up at 6 months and 12 months post-treatment
Treat partners presumptively

33. Patient Education for Syphilis
Comply with medications as instructed
Return for 6 and 12 month follow-up appointments
Avoid sex until patient and partner(s) complete treatment
Pregnant women should have blood test for syphilis to prevent passing infection to baby
People with syphilis are more likely to become infected if exposed to HIV through sex. People with HIV and syphilis are more likely to spread HIV to others.
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

34. Hepatitis B Virus (HBV)
800, million people in U.S. chronically infected
5-10% of infected adults become chronic carriers vs. 90% of infected infants and 25-50% of children ages 1-5
Transmitted via intercourse, contaminated blood, mother to child, occupational exposures
Incubation period days
Symptoms: fever, fatigue, nausea, vomiting, malaise, loss of appetite, jaundice, abdominal or joint pain, dark urine
Vaccine given in 3 doses over 6-month period
Multiple medications for treatment available
Adult recovery rate 95%. Acute infection more severe for adults over 60.

35. Patient Education for Hepatitis B
Get vaccinated. Don’t restart series if there is an interruption between doses; however, extra doses of vaccine are not harmful
Vaccine is ok for pregnant, immunocompromised patients
HBV can survive outside body for at least 7 days; don’t share needles, razors, toothbrushes, nail clippers, earrings 
Vaccination within 24 hours of exposure can prevent infection. In certain circumstances adding HBIG (hepatitis B immune globulin) increases protection.
Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

36. HPV-Related Genital Warts
Most commonly caused by HPV types 6 and 11
Flesh-colored spots that are raised or flat, or
growths similar to cauliflower
Can be found:
Inside or outside vagina/anus
On nearby skin
On cervix
On lips, mouth, tongue, throat
Warts can take six months to develop; woman can be infected without symptoms

37. HPV-Related Genital Wart Treatment and Follow-Up
Podophyllin applications, tricholoracetic acid, imiquimod 5% cream
Cryosurgery, electrocauterization, laser therapy, surgical excision
Examine partners; treat if warts identified
Follow-up
Regular Paps
For warts on cervix, may need Pap smears every 3 to 6 months after first treatment
Administer HPV vaccine for females ages 9-26

38. Patient Education for Genital Warts
Even though warts may be removed, viral infection can't be cured. Warts often return: benign but infectious.
Don’t treat genital warts yourself with OTC drugs that remove warts on hands
avoid sex until patient and partner(s) complete treatment
Get regular Pap smears
Best way to prevent genital warts is abstinence or sex with only one uninfected partner. Condoms may help prevent infection, however, they can't always cover all affected skin.
Gardasil immunization for uninfected partners <27 years of age

39. Genital Ulcers
Painless ulcers - think syphilis, but herpes can also present this way
Multiple ulcers - think herpes, but could also be syphilis
Diagnosis based on history and physical is often inadequate
25% of patients with a first episode of genital ulceration have no detectable cause despite a full diagnostic evaluation

40. The Sexual History and Prevention Counseling
Source: CDC. A guide to taking a sexual history. CDC Publication:

41. Two Ideas for Opening the Discussion
(Think of sharing these Interview questions with your Provider)
I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health.
Just so you know, we ask these questions to all adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health.
Add…
Like the rest of our visit, this information is kept in strict confidence. Do you have any questions before we begin?

42. Sexual History Provider should utilize the “Five P’s” Partners
Prevention of pregnancy
Protection from STIs
Practices
Past history of STIs
Questioning and counseling should be provided in a nonjudgmental and caring manner
Sexually Transmitted Diseases Treatment Guidelines,

43. 1. Ask About Partners Are your sex partners men, women, or both?
In the past 2 months, how many sex partners have you had?
In the past 12 months, how many sex partners have you had?
One partner in last 12 months: ask about length of the relationship and partner’s risk factors (current or past sex partners, drug use)
More than one partner in last 12 months: explore more specific risk factors (condom use, or non-use, and partners’ risk factors)

44. 2. Ask About Sexual Practices and Protection from STIs
I am going to be more explicit about the kind of sex you’ve had in the last 12 months to better understand if you are at risk for sexually transmitted diseases.
Do you use any protection against STDs? If not: Could you tell me the reason? If so: What kind of protection do you use?
How often do you use this protection? If “sometimes”: In what situations or with whom do you use protection?

45. 3. Ask About Past History of STIs
Have you ever been diagnosed with an STI? When? How were you treated?
Have you had any recurring symptoms or diagnoses?
Have you ever been tested for HIV, or other STDs? Would you like to be tested?
Has your current partner or any former partners ever been diagnosed or treated for an STI? Were you tested for the same STD(s)?
If yes: When were you tested? What was the diagnosis? How was it treated?

46. 4. Ask About Prevention of Pregnancy
Are you currently trying to conceive a child?
Are you concerned about getting pregnant?
Are you using contraception or practicing any form of birth control?
Do you need any information on birth control?
Think about sharing VA Maternity and Infant Benefits

47. 5. Assess HIV Risk Assess for HIV risk
Injected drug use by her or her partner(s)?
Money or drugs exchanged for sex by her or her partner(s)?
Final probe
What other things about your sexual health and sexual practices should we discuss to help ensure your good health?

48. Be aware during history of these STI risk factors…
Unprotected sex
Young age
Unmarried
Multiple sexual partners
History of a prior STI
Illicit drug use
Contact with sex workers
New sex partner in past 60 days
No vaccination (HPV, hepatitis)

49. Summary of STI Screening for Women
HIV: screen all women ≤ 65 regardless of risk at least once; annual screen for those at increased risk
Gonorrhea: women at high risk; consider those < 25
Chlamydia: all women ≤ 24; all others at high risk
Trichomonas: remember, this is #1 STI, women at high risk
Syphilis: women at risk
Hepatitis B: consider vaccinating women at risk
HPV: encourage consideration of vaccination for women ≤26

50. STI Summary STIs cost U.S. health care system $17 billion every year
Young people represent 25% of sexually experienced population in U.S., but account for nearly half of new STIs
Less than half of people who should be screened actually receive recommended STI screening services
Providers are required to report gonorrhea, chlamydia, and syphilis to local or state public health authorities
Nursing usually tracks and assists with this

51. Helpful References
CDC. A Guide to Taking a Sexual History.
CDC Self Study STD Modules/Vaginitis study/vaginitis.asp
CDC. Sexually transmitted diseases treatment guidelines
Seattle STD/HIV Prevention Training Center. The Practitioner’s Handbook for the Management of Sexually Transmitted Disease.
Workowski KA, Berman SM. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis ;44(s3):S73-6

52. Primary author: Catherine Staropoli, MD VA Maryland Healthcare System, Baltimore, MD Contributors: Linda Baier Manwell, MS University of Wisconsin Center for Women’s Health Research, Madison, WI Kathleen McIntyre-Seltman, MD VA Pittsburgh Healthcare System, Pittsburgh, PA WH Nurse Reviewers: Barbara Palmer, MS, ANP Rebecca Feria, RN, MSN Joan Galbraith, RN, MSN, NP Cindy James, RN, MSN Laurie Pfeiffer, RN, BSN Barbara Polak, RN, MSN 52