Akiva D. Gimpelevich, DO Complete Women’s Healthcare Cumming, GA Vaginitis Akiva D. Gimpelevich, DO Complete Women’s Healthcare Cumming, GA

Vaginitis is one of the most common conditions encountered in gynecology Vaginitis is the general term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora. Every Primary Care Physician should be able to recognize and treat a simple version of this condition.

Presenting symptoms Vaginal discharge – color, odor, volume Pruritus Burning Irritation Erythema Dyspareunia Spotting Dysuria Although normal discharge may be yellowish, slightly malodorous, and accompanied by mild irritation, it is not accompanied by pruritus, pain, burning or significant irritation, erythema, local erosions, or cervical or vaginal friability. The absence of these signs and symptoms helps to distinguish normal vaginal discharge from discharge related to a pathological process, such as vaginitis or cervicitis.

Non Infectious Vaginitis Atrophic Vaginitis Mechanical, chemical, or allergic irritation Desquamative inflammatory vaginitis Surgical sequeli Malignancy

Atrophic Vaginitis Estrogen deficiency is treated via: Systemic Estrogen PO, Gels, Patches Vaginal Estrogen Tablet (Vagifem), Suppository (Invexxa), Cream (Estrace, Premarin), Estring Vaginal Steroid Prasterone (synthetic DHEA) – (Itrarosa) Systemic SERM – Ospemifene (Osphena)

Mechanical, chemical, or allergy Trauma, foreign object Tampon Douching with caustic substance (i.e. Coca Cola) Allergy to a lubricant or sense enhancer

Desquamative inflammatory vaginitis Rare idiopathic condition that  presents with pain and copious vaginal discharge. Treat with vaginal Clindamycin or corticosteroid For diagnosis all of the following criteria are needed: At least one of the following symptoms: vaginal discharge, dyspareunia, pruritus, burning, irritation Vaginal inflammation Vaginal pH >4.5 Saline microscopy showing increased numbers of parabasal and inflammatory cells

Surgical sequeli Poor healing of a recent surgical scar Granulation tissue, dehiscence Prolapsing fibroid Fistula Recto-vaginal Vesico-vaginal

Malignancy Cervical Vaginal Uterine Tubal

Infectious Vaginitis Bacterial Yeast Trichomonas Other Chlamydia, Gonorrhea, Mycoplasma, Condyloma

Predictive value of the clinical diagnosis of lower genital tract infection in women. Landers DV, Wiesenfeld HC, Heine RP, Krohn MA, Hillier SL.  Am J Obstet Gynecol. 2004;190(4):1004.  OBJECTIVE: diagnostic approaches to lower genital tract infections. STUDY DESIGN: Clinical diagnoses were made with symptoms, direct observation, wet mount, vaginal pH, and amines in 598 women with genital complaints. Laboratory testing for N gonorrhoeae, yeast, T vaginalis, C trachomatis, and bacterial vaginosis by Gram stain. RESULTS: The most frequent symptoms were vaginal discharge (64%), change in discharge (53%), malodor (48%), and pruritus (32%). The infection rates were 46% bacterial vaginosis, 29% yeast, 12% trichomoniasis, 11% chlamydia or gonorrhea; 21% of the patients had no infection. The symptoms did not predict laboratory diagnosis. Clinical signs and symptoms with office-based tests and microscopy improved the accuracy of diagnoses. Amsel's clinical diagnosis of bacterial vaginosis was the most sensitive at 92%. The sensitivity of wet mount diagnosis of trichomoniasis was 62%, of yeast by microscopy was 22%, and of prediction of gonorrhea and/or chlamydia was 30%. CONCLUSION: Symptoms alone should not be used to direct treatment in instances in which resources permit more complete evaluation with office-based testing that includes microscopy. Treatment failures or diagnostic uncertainty should prompt specific laboratory testing.

SEX BV Risk Factors Immune Suppression Smoking Douching Other infections Not a factor: Race, Age, Diet

Bacterial Vaginitis Gardnerella vaginalis Prevotella species Porphyromonas species Bacteroides species Peptostreptococcus species Mycoplasma hominis Ureaplasma urealyticum Mobiluncus Megasphaera Sneathia, and  Clostridiales species.  Fusobacterium species Atopobium vaginae 

Diagnosing BV Amsel criteria: at least three criteria must be present Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls. Vaginal pH >4.5. Positive whiff-amine test, defined as the presence of a fishy odor when a drop of 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge. Clue cells on saline wet mount. Clue cells are vaginal epithelial cells studded with adherent coccobacilli that are best appreciated at the edge of the cell. For a positive result, at least 20 percent of the epithelial cells on wet mount should be clue cells. The presence of clue cells diagnosed by an experienced microscopist is the single most reliable predictor of BV.

Clue cells  High power magnification

Commercial tests Affirm VP III test is an automated DNA probe assay for detecting G. vaginalis when present at a high concentration. 1 hour. Needs a machine. (95% sensitivity and specificity) OSOM BV Blue system is a chromogenic diagnostic test based on the presence of elevated sialidase enzyme activity in vaginal fluid. This enzyme is produced by bacterial pathogens associated with BV.  10 min. CLIA waived. (90-93% sensitivity and specificity) PCR-based assays are based upon molecular quantification of G. vaginalis and Atopobium vaginae, other bacteria - Megasphaera and BV-associated bacteria (BVAB) 1 and 2. Expensive lab test

Candida Vaginitis Normal flora of approximately 25 percent of women. Second most common cause of vaginitis after BV Commonly self-diagnosed and treated by patients

Symptoms of Vaginal Candidiasis Vulvar pruritus Vulvar burning, soreness, and irritation Dysuria and dyspareunia Discharge may be present or absent Classic – white, thick and clumpy Thin and loose, watery and homogeneous

Candida species

Candida Vaginitis - RISK Diabetes mellitus Antibiotic use Increased estrogen levels Pregnancy Oral contraceptive or Estrogen therapy Immunosuppression

Trichomonas Cervical and vaginal infection by a flagellated protozoan. Mimics BV symptoms Cervical involvement produces “strawberry cervix” 26% prevalence in symptomatic patients AA>H>W population Age 21-22 and 48-50

Strawberry cervix About 2 % of cases…

T. vaginalis Microscopy with staining

Vulvovaginal candidiasis Parameter Normal findings Vulvovaginal candidiasis Bacterial vaginosis Trichomoniasis Symptoms None or mild, transient Pruritus, soreness, dyspareunia Malodorous discharge, no dyspareunia Malodorous discharge, burning, postcoital bleeding, dyspareunia, dysuria Signs Normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or transparent, thin or thick, and mostly odorless Vulvar erythema and/or edema. Discharge may be white and clumpy and may or may not adhere to vagina. Off-white/gray thin discharge that coats the vagina Thin green-yellow discharge, vulvovaginal erythema Vaginal pH 4.0 to 4.5 >4.5 5.0 to 6.0 Amine test Negative Positive (in 70 to 80% of patients) Often positive Saline microscopy PMN:EC ratio <1; rods dominate; squames +++ PMN:EC ratio <1; rods dominate; squames +++; pseudohyphae (present in about 40% of patients); budding yeast for nonalbicans Candida PMN:EC <1; loss of rods; increased coccobacilli; clue cells comprise at least 20% of epithelial cells (present in >90% of patients) PMN ++++; mixed flora; motile trichomonads (present in about 60% of patients) 10% potassium hydroxide microscopy Pseudohyphae (in about 70% of patients) Other tests – If microscopy nondiagnostic: Quantitative Gram stain (eg, Nugent criteria, Hay/Ison criteria) Culture DNA hybridization probe (eg, Affirm VPIII) Culture (eg, InPouch TV culture system) DNA hybridization probe (eg, Affirm VP III) Culture of no value Rapid antigen test (eg, OSOM Trichomonas Rapid Test)   Nucleic acid amplification test (eg, APTIMA Trichomonas vaginalis test) DNA Hybridization probe (eg, Affirm VPIII) Differential diagnosis Physiologic leukorrhea Contact irritant or allergic vulvar dermatitis, chemical irritation, focal vulvitis (vulvodynia) Elevated pH in trichomoniasis, atrophic vaginitis, and desquamative inflammatory vaginitis Purulent vaginitis, desquamative inflammatory vaginitis, atrophic vaginitis, erosive lichen planus

Treatments for BV Clindamycin (Cleocin) Secnidazole (Solosec) 300mg PO BID x 7d Clindam. Phos – 1 Ap-ful QHS Vag. x 7d Cleocin Ovules – 1 supp. QHS Vag. x 3d Clindesse – 1 Ap-ful QHS Vag. once Secnidazole (Solosec) Mix 1 packet (2g) with soft food – one PO dose Tinidazole (Tindamax) 2g PO QD x 2d or 1g PO x 5d Metronidazole (Flagyl) 500mg PO BID x 7d ER 750mg PO Q am fasting X 7d Vaginal (MetroGel) - 1 Ap-ful QHS x 5d

Treatments for Vaginal Candidiasis Fluconazole PO – 150 mg once or 200 mg x 3 doses 3 days apart ( if severe) Vaginal Preparations: Boric acid - 600 mg capsule QHS x 14d Clotrimazole, Miconazole, Terconazole (OTC) for simple infections and 7-14 days for severe

Trichomonas Treatment Metronidazole 2 g PO single dose 500 mg PO BID x 7d Tinidazole Should treat all sex partners simultaneously!