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Vaginitis
Kamala Jain, MD R1 Immersion Block Summer 2012
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Symptoms- vaginal discharge, often causes itching or odor, may cause dysuria and dyspareunia
Vaginitis
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Vaginitis Differential
• Bacterial Vaginosis ( BV) • Candida vulvovaginitis • Trichomonal Vaginitis • Atrophic Vaginitis • Chemical Vaginitis
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Vaginitis Diagnosis • History
– Detailed history – Characteristic of discharge
• Odor, quantity, pruritis
• Examination of the vulva, vagina and the discharge and upon microscopic evaluation of the vaginal discharge and determination of its pH.
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Vaginitis Diagnosis
History alone is NOT enough to make the
specific diagnosis, a pelvic examination and vaginal pH and microscopy testing must also be performed.
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Case #1
A 23 y.o. GoPo presents to your office complaining of a vaginal discharge and odor. What further questions do you want to ask her?
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History & Vaginitis • Risk Factors for Bacterial Vaginosis ( BV)
– Douching, prior history of BV • Candida vulvovaginitis
– HIV, diabetes, recent antibiotics, steroid use, any immunosupresive agents
• Trichomonal Vaginitis – Sexual history
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pH Testing and Microscopy • Obtain vaginal pH
– Normal vaginal pH 3.8-4.2 • Perform Whiff Test • Perform Microscopy
– Saline wet Prep – KOH testing
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Factors Falsely Affecting pH • Saline falsely elevates pH • Endocervical secretions have a higher pH
than vaginal secretions • Menstrual secretions, blood, increase pH • Sperm increases pH
– Ask when last sexual intercourse occurred
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Microscopy At the VA
ONLY USE IN CLINIC FOR TEACHING PURPOSES, Do not document what you see under the microscope in CPRS note.
We must also send a vaginal in pouch specimen
to the VA Lab for diagnosis. Be certain to obtain this specimen at the same time you collect the specimen to view in the lab.
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Differential: elevated vaginal pH • Bacterial Vaginosis • Trichomonas Vaginitis • Atrophic vaginitis • Menstrual secretions, blood, increase pH • Sperm increases pH
– Ask when last sexual intercourse occurred
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Diagnosis of Bacterial Vaginosis
• the presence of homogeneous discharge • pH > 4.5 • positive KOH whiff test • Presence of clue cells on microscopic
assessment of a saline smear
Clinical Diagnosis of BV is defined by three out of four of the following:
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Treatment of Bacterial Vaginosis • Metronidazole 500 mg bid x 7 days • No need to treat partner
– Not considered a STI • If douching, counsel to stop
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Diagnosis Candidiasis • Vaginal ph 4 • Microscopy
– Pseudohyphae on saline wet prep – Microfilaments on KOH – May be some WBCs
• Perform culture only for refractory cases or non-responsive to standard therapy.
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Treatment of Candidiasis • Intravaginal azoles • Fluconzole 150 mg po now then 150 mg
again if no response in 72 hours • Perform culture only for refractory cases or
non-responsive to standard therapy.
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Diagnosis Trichomonas • Vaginal ph 5, amine odor • Microscopy
– Motile Trich on saline wet prep – Increase in WBCs
Treatment Metronidzole 500 mg bid x 7 days or one
time dose 2 grams *** must treat partner too, STI
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Diagnosis of Atrophic Vaginitis • Characteristic vaginal symptoms and
appearance on physical exam • Vaginal ph 5 • Microscopy
– Parabasal cells ( cuboidal) – May be some WBCs
Treatment: Topical estrogen or estring
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Examination of Vaginal Wet Preps: Training