Pocket ObGyn – Vulvovaginitis – SỔ TAY LÂM SÀNG

Pocket ObGyn – Vulvovaginitis
See Abbreviations

Definition (Obstet Gynecol 2006;107:1195)

Vulvovaginal sx such as itching, burning, irritation, & abn discharge d/t various BV = Most common (MCC), vulvovaginal candidiasis, & Trichomonas vaginalis.
Nml vaginal flora: estrogen ® vaginal epithelial glycogen ® gluc source ®

lactobacilli ® lactic acid ® ¯ vaginal pH @ 3.8–4.5 (NEJM 2006;355:1244)

Pathophysiology & risk factors
Type of vaginitis	Pathogenesis	Risk factors	Sequelae
BV	2° shift in vaginal flora from lactobacilli to mixed flora.	>1 partner, change in partners (last 30 d), lesbian, douching.	risk of STIs, complications after Surg, preterm labor.
Candidiasis	Mostly 2° Candida albicans. Rarely by nonalbicans species (Candida glabrata)	Preg, luteal phase of menses, nulliparity, spermicides, ¯ age, broad-spectrum Abx.	Adverse Preg outcomes (PPROM, PTD, ¯ birth wt).
Trichomonas	Common vaginal parasite. Most common STI in US	New partner, sex ³2´/ week, 3+ partners/ month, presence of other STI.
From NEJM 2006;355:1244; MMWR 2010;59:NO.RR-12.

Clinical Manifestations (NEJM 2006;355:1244)

BV: Copious, thin, whitish-gray, fishy-smelling Less likely pruritus.
Candidiasis: Thick, white, curdy discharge. No + Pruritus, dysuria, vaginal erythema.
Trichomonas: Copious yellow to greenish, frothy Often foul odor. ± pruritus, postcoital bleeding, dysuria. ± vaginal or cervical erythema (“strawberry cervix”).

Diagnostic Studies (NEJM 2006;355:1244)

Amsel clinical criteria for BV requires presence of 3 of 4 clinical findings
1. Vaginal pH >4.5	Touch swab to midportion of vaginal sidewall, then to pH paper. Cervical mucus, semen, or bld can alter pH
2. Thin watery discharge	Visualize/assess on speculum exam.
3. >20% clue cells on wet mount	Clue cells = epithelial cells w/ borders obscured by bacteria
4. “Amine” odor test	Add 10% KOH on slide ® + w/ distinctive amine odor
From Am J Med 1983;74:14; Obstet Gynecol 2006;107:1195.

Candidiasis: Presence of hyphae visible on KOH or wet Yeast cx useful if pt c/o sx but negative wet mount, or if recurrent infxns.
Trichomonas: Presence of mobile trichomonads on wet mount; PMNCs often

Treatment of vulvovaginitis
BV	Metronidazole 500 mg PO BID ´7 d* OR Metronidazole 250 mg PO TID ´7 d* OR Metronidazole gel 0.75% 1 applicator PV QD ´5 d OR Clindamycin 300 mg PO BID ´7 d* OR Clindamycin cream 2%, 1 applicator PV QHS ´7 d
Candida	Rx PO	Fluconazole 150 mg PO ´1
	OTC PV	Butoconazole 2% cream 5 g PV ´3 d Clotrimazole 1% cream 5 g PV ´7–14 d* or 2% cream 5 g PV ´7 d* Miconazole 2% cream 5 g PV ´7 d*, or 4% cream 5 g PV ´3 d, or 100 mg vaginal suppository. 1 tab PV ´7 d, or 200 mg vaginal suppository. 1 tab PV ´3 d, or 1200 mg vaginal supp. 1 tab PV ´1 Tioconazole 6.5% ointment 5 g PV ´1 application

	Rx PV	Butoconazole 2% cream (single dose bioadhesive), 5 g PV ´1 Nystatin 10000-U vaginal tab, 1 tab QD ´14 d Terconazole 0.8% cream 5 g PV ´3 d or Terconazole 80 mg vaginal suppository. 1 tab PV ´3 d
	Recurrent (4+/y)	7–14 d of topical therapy Fluconazole 150 mg, or 200 mg PO every 3rd day ´3 doses ® weekly 6 w
	Sev infxn	7–14 d of topical azole 150 mg of fluconazole q72h ´2 doses
Trichomonas	Metronidazole 2 g PO ´1* or Metronidazole 500 mg PO BID ´7 d (alternative regiment) Tinidazole 2 g PO ´1 Treat sex partners. Abstain from sex until both partners cured. Avoid EtOH during rx. EPT not routinely recommended for trichomoniasis, b/c STI comorbidity needs eval & rx intolerance. Option if partner rx not certain. CDC monits EPT in all states (Curr Opin Obstet Gynecol 2012;24:299)
Safe/preferred in Preg. From Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR* 2010;59(RR12):1.