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| ==Vaginitis==
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| | Congenital Toxoplasmosis |
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| ==Overview== | | ==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. All the patients with vulvovaginitis present with common symptoms like vaginal discharge, itching and dysuria. Diagnosis of vulvovaginitis requires a complete history of the description of the symptoms and sexual history as they aid in diagnosis. Physical examination of the external genitalia and speculum examination should focus on documenting the nature of the discharge present, the presence of any vulvar and labial lesions, foreign body, presence of cervical inflammation, cervical lesions, and any cervical motion or adnexal tenderness with a bimanual examination. It is essential to rule out pelvic infammatory disease and cervical lesions as the cause of vaginal discharge. Estimation of vaginal pH and vaginal smear wet mount examination is the initial diagnostic test which helps in differentiation of the common etiologies. Treatment of vulvovaginitis includes medical therapy targeted against the causative pathogen and a counseling on hygiene, voiding techniques and sexual practices . Prognosis is good in most patients but minority of patients have recurrence.
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| ==Synopsis== | | ==Historical Perspective== |
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| | ==Causes== |
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| | ==Risk Factors== |
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| | ==Screening== |
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| | ==Demographics, Epidemiology== |
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| | ==Natural History, Complications, Prognosis== |
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| | ==Diagnosis== |
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| | ===History and Symptoms=== |
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| | ===Physical Examination=== |
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| | ===Laboratory Findings=== |
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| | ==Treatment== |
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| | ===Medical Therapy=== |
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| | ===Surgical Therapy=== |
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| | ==Prevention== |
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| | ===Primary Prevention=== |
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| | ===Secondary Prevention=== |
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| ===Symptoms and Examination=== | | ==References== |
| {| class="wikitable" style="border: 2; background: none;"
| | Reflist|2 |
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| ! rowspan="2" | Disease
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| ! colspan="6" rowspan="1" | Symptoms
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| ! rowspan="2" | Examination Findings
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| ! rowspan="1" | Discharge || Dysuria || Vaginal odor || Dyspareunia || Genital skin lesion || Genital pruritus
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| | [[Candida Vulvovaginitis]] ||✔ ||✔ ||✔ || ✔
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| ||✔ ||✔✔
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| *Vulvar edema, fissures, excoriations
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| *Thick curdy vaginal discharge
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| | [[Bacterial Vaginosis]] ||✔||||✔|| <small>—</small>
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| || <small>—</small>
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| ||<small>—</small>
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| * Fishy-odor from the [[vagina]]
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| * Thin, white/gray homogeneous [[vaginal discharge]]
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| * Lack of significant vulvovaginal inflammation
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| |-
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| | [[Trichomoniasis]] ||✔||✔|| ✔
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| || ✔
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| || <small>—</small>
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| || ✔
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| * Strawberry cervix: petechial haemorrhages on the ectocervix, specific to trichomoniasis
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| * Frothy, mucopurulent, yellow-green or gray vaginal discharge
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| | [[Atrophic Vaginitis]] ||✔||✔|| ✔
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| || ✔✔
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| ||✔||✔
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| *Pale and dry vaginal epithelium
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| *Increased friability of the vaginal epithelium with patchy erythema and petechiae
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| *Sparsity of pubic hair, fusion of the [[labia minora]], narrow and a shortened vagina
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| |Aerobic Vaginitis
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| |✔
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| |✔
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| |✔
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| |✔
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| | <small>—</small>
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| |✔
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| *Vaginal mucosa is red and inflamed, severe ecchymotic bleeding points and ulcers can be seen in severe cases
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| *Erosions, hyperaemia, scattered bleeding points and ulcers can be demonstrated on the cervix
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| |Chlamydia
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| |✔
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| |✔
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| |✔
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| | <small>—</small>
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| |✔
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| *Cloudy, yellow mucoid discharge from the cervical os<ref name="pmid16669564">{{cite journal| author=Miller KE| title=Diagnosis and treatment of Chlamydia trachomatis infection. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 8 | pages= 1411-6 | pmid=16669564 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16669564 }}</ref>
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| *Friable appearance of cervix<ref name="pmid16669564">{{cite journal| author=Miller KE| title=Diagnosis and treatment of Chlamydia trachomatis infection. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 8 | pages= 1411-6 | pmid=16669564 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16669564 }} </ref>
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| *[[Cervical motion tenderness]] may be present<ref name="abc">Chlamydia CDC Fact Sheet. CDC.http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm#_ENREF_3. Accessed on January 11, 2016</ref>
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| *Clear or white urethral discharge in men<ref name="pmid16669564">{{cite journal| author=Miller KE| title=Diagnosis and treatment of Chlamydia trachomatis infection. | journal=Am Fam Physician | year= 2006 | volume= 73 | issue= 8 | pages= 1411-6 | pmid=16669564 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16669564 }} </ref>
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| *Testicular tenderness and swelling may be present<ref name="abc">Chlamydia CDC Fact Sheet. CDC.http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm#_ENREF_3. Accessed on January 11, 2016</ref>
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| |Gonnorrhea
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| |✔
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| |✔
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| |✔
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| |✔
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| | <small>—</small>
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| | <small>—</small>
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| *[[Mucopurulent discharge|Mucopurulent]] [[urethral]], [[cervical]] or [[vaginal]] discharge
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| *Positive cervical motion tenderness
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| *Friable cervical mucosa
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| *Abdominal pain with negative [[rebound tenderness]]
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| **Lower abdominal pain (consistent with [[PID]])
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| **Right upper quadrant pain ([[Fitz-Hugh-Curtis syndrome]])
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| *Labial edema and Bartholin’s gland enlargement and tenderness [[Bartholinitis|(Bartholinitis]])
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| |}
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| ===Diagnosis and Treatment===
| | {{WH}} |
| {| class="wikitable" style="border: 2; background: none;" | | {{WS}} |
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| ! rowspan="2" | Disease
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| ! colspan="3" rowspan="1" | Investigation
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| ! rowspan="2" | Diagnostic Approach
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| !rowspan="2" | Treatment
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| ! rowspan="1" | pH|| Saline Wet mount preparation|| Gold Standard test
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| | [[Candida Vulvovaginitis]] ||Normal|| Hyphae and pseudohyphae can be demonstrated || Culture
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| *In patients with normal pH and positive microscopy, culture is not neccessary and treatment can be initiated
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| *In patients with normal pH and negative microscopy, culture for candida is done
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| * Topical Azoles for uncomplicated infection
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| * Oral Fluconazole one dose of 150mg for complicated infection
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| | [[Bacterial Vaginosis]] ||>4.5|| Clue cells are demonstrated||Gram Stain to determine the relative concentration of lactobacilli, G. vaginalis, Prevotella, Porphyromonas, peptostreptococci and Mobiluncus
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| Amsel’s criteria: Presence of three out of four criteria is required to make the diagnosis of BV
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| *Vaginal fluid pH >4.5
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| *>20% of epithelial cells are “clue” cells (cells with unclear borders, dotted with bacteria)
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| *Milky homogenous, adherent vaginal discharge
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| *Positive “whiff” test, which is an amine or “fishy” odor noted after the addition of 10% potassium hydroxide
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| *Correlation of the criteria and gram stain is performed to aid diagnosis
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| *Metronidazole 500 mg orally twice a day for 7 days OR
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| *Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR
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| *Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
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| | [[Trichomoniasis]] ||Normal||
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| *Motile Trichomonads
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| *Positive Whiff test
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| || Nucleic acid amplification test(NAAT)
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| *NAAT is highly sensitive for the diagnosis of Trichomonas vaginalis.
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| *Treatment is initiated after confirmation of the diagnosis
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| *Metronidazole 2g or Tinidazole 2g in a single dose
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| | [[Atrophic Vaginitis]] ||Normal|| Vaginal smear cytology shows increased parabasal cells||Leftward shift of the vaginal maturation index
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| *Diagnosis requires the correlation of clinical presentation and vaginal cytology findings.
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| *Other causes causing atrophic changes in the vagina should be ruled out.
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| *Lubricants and moisturizers for mild symptoms
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| *Topical or Oral estrogen therapy for moderate to severe symptoms
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| |Aerobic Vaginitis
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| |Increased
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| >6
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| |Numerous leukocytes are present
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| |No gold standard confirmative test but excessive growth of aerobes on culture helps in diagnosis when the vaginal smear findings are indeterminate
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| |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
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| *Probiotics
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| *Kanamycin and Clindamycin vaginal suppositories
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| |}
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