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

2. 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.

3. 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.

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

5. 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)

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

7. 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

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

9. Malignancy
Cervical
Vaginal
Uterine
Tubal

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

11. 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.

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

13. 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 

14. 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.

15. Clue cells 
High power magnification

16. 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

17. 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

18. 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

19. Candida species

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

21. 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 and 48-50

22. Strawberry cervix
About 2 % of cases…

23. T. vaginalis
Microscopy with staining

24. 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

25. 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

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

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