Vaginal Infections NURS 541: Women’s Healthcare – Diagnosis and Management

Let’s talk normal… Normal vaginal discharge Contains predominantly Lactobacilli, Döderlein’s bacilli pH – 3.8-4.2 Clear to white discharge Thin/mucoid Dependent on menstrual cycle No odor, itching, burning, or discomfort

Common Vaginal Discharge Concerns #1: Bacterial vaginosis (BV) #2 Candida vulvovaginitis #3 Cervicitis (usually chlamydia) #4 Excessive but normal secretions #5 Trichomoniasis #6 Atrophic vaginitis Carcio & Secor, 2015

Vaginal Infections: Presenting Concern Abnormal discharge Dysuria Itching Vaginal odor Burning Vulvar ulceration Dyspareunia

Vaginal Infections: History OLDCARTS Risk of pregnancy? Onset Previous history of vaginal infections? Location Duration Risk for sexually transmitted infections? Character Aggravating factors Partner assessment Relieving factors Condom/barrier use Timing Exposure? Severity Menstrual history

Vaginal Infections: Physical Exam Abdomen: assess for pain, tenderness, guarding Pelvic exam: External genitalia: look for discharge, irritation, ulcers, lesions Vagina: look for discharge, lesions, irritation; note any odor Cervix: look for discharge, lesions; check for cervical motion tenderness Uterus/adnexae: note any tenderness, abnormalities Lymphadenopathy: assess inguinal lymph nodes

Vaginal Infections: Labs Sample of vaginal discharge Wet prep/mount Vaginal DNA probe STI screening Chlamydia/gonorrhea NAAT Other testing if high risk

Wet mount for vaginal specimens Preparation of the slides One saline prep One KOH prep Use KOH to detect amine odor (whiff test) Test pH of discharge while preparing or during exam

Wet mount reading Assess for clue cells, hyphae, yeast buds, trichomonas, WBCs

Bacterial Vaginosis (BV) Most often caused by Gardnerella or other anaerobic bacteria Signs/Symptoms Thin, homogenous, grey-white discharge Mild itching (if any) Odor, especially after intercourse Occasional pain with intercourse Exam/lab findings Negative exam, except for discharge (above) and odor Presence of clue cells, pH >4.5, amine odor (positive whiff)

Bacterial Vaginosis (BV) Amsel’s criteria Need three of the four: White, thin, adherent discharge pH > 4.5 Positive whiff test Clue cells on wet mount (more than 20% of epithelial cells are clue cells)

Wet mount reading

Bacterial Vaginosis (BV) Treatment options for BV Metronidazole 500mg orally BID x 7 days Metronidazole gel 0.75% vaginally QD x 5 days Clindamycin cream 2% vaginally at HS x 7 days Pregnant women Metronidazole 250mg orally TID x 7 days Clindamycin 300mg orally BID x 7 days

Vulvovaginal Candidiasis Most often caused by Candida albicans Signs/Symptoms Thick, curd-like white discharge Significant itching or burning No odor Exam/lab findings Vulvar or vaginal irritation/redness Yeast buds/hyphae on wet mount pH < 4.5

Wet mount reading

Vulvovaginal Candidiasis Treatment options OTC treatments (Monistat, Gyne-Lotrimin, etc) Miconazole 2 or 4% cream intravaginally for 3 or 7 days Butoconazole 2% cream intravaginally for 3 days Clotrimazole 1 or 2% cream intravaginally for 3-7 days Terconazole 0.4% cream intravaginally for 7 days Fluconazole 150mg orally x 1

Trichomoniasis Protozoan infection of the vagina – Trichomonas vaginalis Technically an STI, but presents as a vaginal infection Signs/Symptoms Sometimes asymptomatic Yellow-green frothy malodorous discharge Irritation of the vulva/vagina/urethra Dyspareunia, dysuria, itching Discharge/irritation worsens during and after menstruation

Trichomoniasis Exam/lab findings Management Wet mount with protozoa seen, must be motile for diagnosis pH > 4.5 Characteristic discharge Management Metronidazole 2gm orally x 1 dose (preferred), or Metronidazole 500mg orally BID x 7 days Treatment of sexual partners (technically an STI) Abstinence from intercourse x 7 days or until asymptomatic

Wet mount reading

Quick Note: Bartholin’s Cyst Bartholin’s glands located in vulvar vestibule (at introitus) Obstruction of duct = Bartholin’s cyst Presents as non-tender mass on one side of vulvar vestibule Infection of cyst = Bartholin’s abscess Presents with varying amounts of pain, tenderness Systemic symptoms rare Most spontaneously rupture within 3-4 days May require incision and drainage