Sandbox: Reddy

Overview

Vulvovaginitis is a common condition for which women seek medical care accounting for approximately 10 million office visits every year. It is defined as symptoms that cause itching, irritation, burning and abnormal vaginal discharge. The three common causes of vaginal discharge in reproductive age group include: most common being Bacterial Vaginosis followed by Candida vulvovaginitis and Trichomoniasis.

Synopsis

Symptoms

Disease	Symptoms						Examination Findings
	Discharge	Dysuria	Vaginal odor	Dyspareunia	Genital skin lesion	Genital pruritus
Candida Vulvovaginitis	✔	✔	✔	✔	✔	✔✔	Vulvar edema, fissures, excoriations Thick curdy vaginal discharge
Bacterial Vaginosis	✔		✔	—	—	—	Fishy-odor from the vagina Thin, white/gray homogeneous vaginal discharge Lack of significant vulvovaginal inflammation
Trichomoniasis	✔	✔	✔	✔	—	✔	Strawberry cervix: petechial haemorrhages on the ectocervix, specific to trichomoniasis Frothy, mucopurulent, yellow-green or gray vaginal discharge
Atrophic Vaginitis	✔	✔	✔	✔✔	✔	✔	Pale and dry vaginal epithelium Increased friability of the vaginal epithelium with patchy erythema and petechiae Sparsity of pubic hair, fusion of the labia minora, narrow and a shortened vagina
Aerobic Vaginitis	✔	✔	✔	✔	—	✔	Vaginal mucosa is red and inflamed, severe ecchymotic bleeding points and ulcers can be seen in severe cases Erosions, hyperaemia, scattered bleeding points and ulcers can be demonstrated on the cervix
Chlamydia	✔	✔		✔	—	✔	Cloudy, yellow mucoid discharge from the cervical os Friable appearance of cervix Cervical motion tenderness may be present Clear or white urethral discharge in men Testicular tenderness and swelling may be present
Gonnorrhea	✔	✔	✔	✔	—	—	Mucopurulent urethral, cervical or vaginal discharge Positive cervical motion tenderness Friable cervical mucosa Abdominal pain with negative rebound tenderness Lower abdominal pain (consistent with PID) Right upper quadrant pain (Fitz-Hugh-Curtis syndrome) Labial edema and Bartholin’s gland enlargement and tenderness (Bartholinitis)

Diagnosis and Treatment

Disease	Investigation			Diagnostic Approach	Treatment
	pH	Saline Wet mount preparation	Gold Standard test
Candida Vulvovaginitis	Normal	Hyphae and pseudohyphae can be demonstrated	Culture	In patients with normal pH and positive microscopy, culture is not neccessary and treatment can be initiated In patients with normal pH and negative microscopy, culture for candida is done	Topical Azoles for uncomplicated infection Oral Fluconazole one dose of 150mg for complicated infection
Bacterial Vaginosis	>4.5	Clue cells are demonstrated	Gram Stain to determine the relative concentration of lactobacilli, G. vaginalis, Prevotella, Porphyromonas, peptostreptococci and Mobiluncus	Amsel’s criteria: Presence of three out of four criteria is required to make the diagnosis of BV Vaginal fluid pH >4.5 >20% of epithelial cells are “clue” cells (cells with unclear borders, dotted with bacteria) Milky homogenous, adherent vaginal discharge Positive “whiff” test, which is an amine or “fishy” odor noted after the addition of 10% potassium hydroxide Correlation of the criteria and gram stain is performed to aid diagnosis	Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
Trichomoniasis	Normal	Motile Trichomonads Positive Whiff test	Nucleic acid amplification test(NAAT)	NAAT is highly sensitive for the diagnosis of Trichomonas vaginalis. Treatment is initiated after confirmation of the diagnosis	Metronidazole 2g or Tinidazole 2g in a single dose
Atrophic Vaginitis	Normal	Vaginal smear cytology shows increased parabasal cells	Leftward shift of the vaginal maturation index	Diagnosis requires the correlation of clinical presentation and vaginal cytology findings. Other causes causing atrophic changes in the vagina should be ruled out.	Lubricants and moisturizers for mild symptoms Topical or Oral estrogen therapy for moderate to severe symptoms
Aerobic Vaginitis	Increased >6	Numerous leukocytes are present	No gold standard confirmative test but excessive growth of aerobes on culture helps to confirm diagnosis when the vaginal smear findings are indeterminate	Microscopic diagnosis is made by Lactobacillus grade( LBG) and the severity is scored based on number of leucocytes, proportion of toxic leucocytes and parabasl epitheliocytes , and background flora	Probiotics Kanamycin and Clindamycin vaginal suppositories