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The most common gynecologic complaint addressed by the physician rendering ambulatory care to the female patient is vulvovaginitis, which may be due to an allergic reaction, infection, or lack of hormones. The three most common causes of vaginitis are bacteria, Candida albicans, and Trichomonas vaginalis. Although a variety of bacteria may cause vaginitis, the two most common types of bacterial vaginitis are Gardnerella vaginalis infection and anaerobic vaginitis (bacterial vaginosis). The latter is a polymicrobial infection due to an overgrowth of anaerobic bacteria but may also involve G. vaginalis. In addition to T. vaginalis, other parasites may cause vulvovaginitis.
Vulvovaginitis due to a lack of estrogen is referred to as atrophic vaginitis, whereas inflammation due to the application of an external irritant is referred to as contact vulvovaginitis. The differentiation of microbial and nonmicrobial vulvovaginitis can be established by performing colposcopically directed biopsy of the vulva and a macroscopic as well as a microscopic examination of the vaginal discharge. The vaginal discharge reflects the status of the lower genital tract environment. In an asymptomatic or healthy or normal vagina, the discharge has a pH of 3.2 to 4.2, is white to slate gray, and does not have an odor. Microscopic examination reveals squamous epithelial cells that are estrogenized and not covered with bacteria, thus obliterating the nucleus and cell membranes. There is not an abundance of white blood cells (WBCs). The bacteria seen in the surrounding milieu are usually not clumped together and consist mainly of bacilli.
The examination of a patient complaining of vaginal burning, discomfort, dyspareunia, or abnormal vaginal discharge should begin with a detailed history. It is often helpful to show the patient a photograph or diagram of the vulva, vestibule, introitus, and vagina and then ask her to indicate on the diagram where her symptoms are located. Frequently, the patient states she has vaginal itching when in reality the inflammation is localized to the introitus. Questions should be asked as to whether she douches; if so, how often, and with which agent? Does the douching agent contain perfume? Is the patient utilizing a new soap or a new laundry detergent? Questions should be asked regarding her sexual habits. Is she using a new form of birth control? For example, has she begun to use a spermicidal cream or jelly or a coital lubricant? Does she practice cunnilingus, which may lead to excessive moisture on the
Patients with contact vaginitis present with complaints of itching or burning that involves the vulva but usually does not involve the vagina. The vagina is affected only if the inflammatory agent is introduced into the vagina. The tissues appear erythematous and excoriated. Inspection of the vulva with the aid of a colposcope does not reveal any discrete lesions. The vagina commonly has a normal pH, unless the patient has been douching repeatedly with either an acidic or an alkaline solution.
Elimination of the suspected agent often results in resolution of the symptoms. In some instances, a topical steroid ointment or cream may be required. The patient should be advised to apply the cream lightly and rub it into the affected area thoroughly. It should not be applied for longer than 10 days, because prolonged administration of a topical steroid may result in thinning of the tissues and thus in continuing symptoms.
Postmenopausal patients not receiving estrogen replacement therapy often develop atrophic vaginitis. The hallmark of this condition is regression of the genital structures; the labia become less prominent, the vaginal mucosa becomes smooth owing to the loss of the rugae, and the epithelium thins. The pink color gives way to a pale pink to white. The pH often is above 4.5 and may be as high as 7.5. There is a change in the bacterial flora, with the lactobacilli no longer being dominant. The patient commonly complains of burning, dyspareunia, and vaginal spotting. In addition, the patient may complain of urinary incontinence and burning when she urinates. The latter complaint is due to the passage of urine over the atrophic tissue.
Pelvic examination reveals the vulva to be smooth with loss of definition of the external genitalia, especially loss of the labia minora. The vagina is as described previously. The vaginal discharge is scant and appears gray. The pH is between 5.0 and 7.5. Microscopic examination of the discharge reveals few epithelial cells; those present tend to be elliptical to round and are referred to as parabasal cells. The bacteria tend to be few in number, and numerous WBCs may be present. If a specimen of the vaginal discharge is cultured for aerobes and anaerobes, there will be a noticeable decrease in or absence of lactobacilli as well as an increase in anaerobic colonization. It is important to remember that the same presentation is found in patients who have had a total hysterectomy with bilateral salpingo-oophorectomy.
It is extremely important in patients with vaginal bleeding or spotting that the origin of the bleeding be determined. The etiology of the bleeding should be established before estrogen therapy is instituted. If the patient has a uterus, an endometrial biopsy should be performed. Other possible sites of origin are the lower urinary tract and rectum, which should be investigated.
Treatment for this condition is not systemic or topical antibiotics but hormonal replacement. This can be accomplished by applying topical estrogen cream or oral estrogen or a combination of both. If topical estrogen cream is utilized after the acute phase has been corrected, the patient may require a maintenance program of once-weekly or as-needed use of the estrogen cream.
The physician attempting to treat the patient with complaints of vaginal itching, burning, or discomfort must be familiar with the normal status of the healthy or asymptomatic vagina. The symptomatic vagina has a pH of greater than 4.5 and usually above 5. The discharge is usually a cream color, green, yellow, or dirty gray. The odor is usually offensive and described as fishlike or foul (fetid). The discharge is frequently frothy, that is, it appears to contain air bubbles. The amount of discharge may vary from scant to copious, depending on the phase of the menstrual cycle, the concentration of estrogen and progesterone influencing the vagina, and the number of growing microbes present.
The lower genital tract has an endogenous microflora made up primarily of aerobic and anaerobic bacteria. The predominant bacterium of an asymptomatic vagina is Lactobacillus. This bacterium may play a pivotal role in maintaining the equilibrium of the healthy vagina by maintaining a pH of 3.8 to 4.2 through the production of lactic acid. This pH is not favorable to the growth of other more pathogenic bacteria, such as the facultative and obligate anaerobes. In addition, it is theorized that the ability of lactobacilli to produce hydrogen peroxide may also play a role in suppressing the growth of anaerobic bacteria. Thus, when a patient is found to have vaginitis, the pH is often above 5 and there is a marked reduction in the number of lactobacilli.
Before examining the patient, the physician should ask questions focusing on factors that may influence the normal vaginal environment. The patient should attempt to describe the characteristics of the initial episode and how the episodes have changed over time. Has she used antibiotics? Have they been used for maintenance or therapeutic indications? Does the patient douche? If so, how often and with what agent? Questions regarding sexual habits should be asked. How many sexual partners does she have? Does she know whether her partner has sexual contact with others? Does she practice cunnilingus, fellatio, or rectal intercourse? The patient should be asked to localize her symptoms, that is, are they located at the opening of the vagina or in the vagina proper? Finally, she should be asked to characterize
The examination should begin with the external genitalia. Attention should be paid to the medial aspect of the labia minora and majora, especially the area of the vestibule and introitus. Patients often complain of itching or burning and dyspareunia in this area. Examination often reveals a horseshoe-shaped area of erythema, which is commonly painful or tender to palpation. Examination under magnification reveals the presence of glistening papules. Application of 5% acetic acid turns this epithelium white, which is characteristic of human papillomavirus (HPV) infection. It is best to refer the patient for further evaluation to a gynecologist specializing in infections of the genital tract. Colposcopically directed biopsies are required to establish a diagnosis. Treatment is usually initiated with laser ablation of this area followed by intravaginal application of 5-fluorouracil cream. The patient should undergo colposcopic examinations of the vulva, vagina, and cervix every 3 to 4 months for the next 2 years to determine whether there is a recurrence. The patient s partner requires a similar examination to determine whether there are HPV lesions present on his penis.
Typically, yeast favors a pH of 4.5 or lower, but not always. WBCs are usually present, and the number of free-floating bacteria is usually reduced. The discharge is white and tends to be pasty but may be liquid. Classically, the discharge is cottage cheese-like and clings to vaginal epithelium. The microscopic picture may be that of elliptical yeast cells, budding cells, cells with germ tubes present, or long strands of pseudohyphae. These different forms of the yeast can easily be seen when the vaginal discharge is mixed with potassium hydroxide (KOH). It is not necessary to culture routinely for yeast, except when the patient s symptoms suggest a yeast infection but no fungal forms are seen microscopically.
Atypically, the patient may have a vaginal pH above 4.5 and there may be an increase in the number of bacteria seen in a wet preparation of the vaginal discharge. The physician should rely on a wet preparation mixed with KOH to rule out the presence of yeast.
Initial treatment should be with an intravaginal cream, ointment, or suppository such as clotrimazole (Lotrimin, Gyne-Lotrimin, Mycelex G), miconazole (Monistat), terconazole (Terazol), or nystatin. These are all beneficial in treating yeast vulvovaginitis. There are different dosing regimens ranging from a single dose to 3-day and 7-day courses. A patient with an initial infection may do well with a short treatment schedule if the precipitating factors can be established. Patients with recurrent infection require longer treatment regimens and the possible use of maintenance therapy. Some patients benefit from gentian violet applied as a vaginal paint or tampon. In addition, consideration should be given to examination and treatment of the patient s sexual partner. Ketoconazole (Nizoral) has been used in single doses of 400 mg with good results. However, hepatic and renal toxicities have been reported, and use of ketoconazole for vaginal yeast infection has not been encouraged.
The vagina houses a complex ecosystem. One component consists of a large number and variety of bacteria. The endogenous bacterial flora comprises gram-positive and gram-negative aerobic, facultative, and obligate anaerobes. The bacteriology of a healthy vaginal ecosystem is dominated by Lactobacillus acidophilus. This bacterium appears to exert its influence by maintaining the pH between 3.8 and 4.2, resulting in the suppression of the potentially pathogenic bacteria. This pH range also favors the growth of lactobacilli as well as other commensal bacteria, such as Corynebacterium, diphtheroids, and other nondescript streptococci.
These bacteria, as well as others, may act synergistically with one another, whereas others, such as lactobacilli and facultative and obligate anaerobes, may act antagonistically. Some strains, such as L. acidophilus, produce hydrogen peroxide, which is toxic to anaerobic bacteria; because they lack the enzyme catalase, anaerobic bacteria cannot convert hydrogen peroxide to oxygen and water. Other mechanisms by which bacteria, such as lactobacilli, inhibit the growth of other bacteria are the production and secretion of lysozyme and bacteriocins. It is important to note that the equilibrium of the vaginal ecosystem is extremely delicate and can easily be disrupted. Once the equilibrium is significantly disturbed, the growth of lactobacilli is retarded. This, in turn, may result in a decrease in the hydrogen ion concentration or an increase in pH. The alteration in pH causes a further decline in the growth of lactobacilli and greater growth of the potentially pathogenic bacteria.
The initial insult or factor that begins the change in the ecosystem is not known. However, if this alteration favors the growth of G. vaginalis, a further decrease in hydrogen ion concentration occurs. When the pH reaches a value of 5 or greater, facultative anaerobic bacterial growth occurs. Growth of G. vaginalis and the facultative anaerobes results in a progressive decrease in the oxygen concentration, favoring growth of obligate anaerobic bacteria. This causes the condition known as bacterial vaginosis (BV). Another organism that can alter the ecosystem in a similar manner is T. vaginalis. This protozoan favors a more alkaline pH (>4.5), which favors growth of the facultative and obligate anaerobic bacteria.
BV is characterized by a vaginal pH greater than 4.5, the presence of clue cells, and a fishlike odor. This odor is typically manifested when a drop of vaginal discharge is mixed with a drop of concentrated KOH, releasing catecholamines (whiff test). The patient may also complain of a copious, dirty gray vaginal discharge with a foul or fishy odor. This odor may also be noted by the patient s sexual partner. However, approximately 50% of patients with BV are asymptomatic and are diagnosed because they are being examined for another reason.
BV is not an infection but should be viewed as a disturbance in the vaginal ecosystem. This disturbance in the endogenous vaginal microflora is significant, because it has been linked to postpartum endometritis, posthysterectomy pelvic infection, and preterm labor. Therefore, many obstetrician-gynecologists recommend that pregnant and preoperative patients be screened for BV. The differences between a healthy vaginal ecosystem and BV are listed in Table 1 .
The color of the vaginal discharge is not a reliable characteristic with regard to establishing a diagnosis. However, any color other than white or slate gray should be considered abnormal. The key characteristics that can be utilized during the pelvic examination to assist in establishing an accurate diagnosis are pH, the presence of a fishlike odor when the vaginal discharge is mixed with KOH, and the presence of clue cells.
The pH can be determined easily and inexpensively by placing a ColorpHast pH strip on the lateral vaginal wall and comparing the wall s color with the accompanying chart. A pH lower than 4.5 essentially rules out the presence of BV. A pH higher than 4.5 does not establish, but is strongly suggestive of, the diagnosis of BV. A microscopic examination of the vaginal discharge must be performed to determine whether clue cells are present and whether there is an absence of a dominant bacterial morphotype. Evaluation of the vaginal discharge can be of assistance in differentiating among a variety of causes of vaginitis (Table 2) . Although the conditions are presented as pure entities in Table 2 , it should be understood that any of these conditions can be present simultaneously. The noticeable presence of WBCs (>5 per high-power field) indicates that an inflammatory response has been triggered. Women with pure BV do not have WBCs in their vaginal discharge.
A specimen of the vaginal discharge should be collected by swabbing the lateral vaginal wall with a cotton-tipped applicator. The applicator is immersed in 2 to 3 mL of normal saline and vigorously agitated to dilute the specimen. A drop of the resulting solution should be placed on a glass slide, covered with a glass coverslip, and examined with the assistance of 40× magnification.
The microscopic picture of BV is characterized by the presence of numerous individual free-floating bacteria, the absence of a dominant bacterial morphotype, the presence of clue cells, and the relative absence of WBCs. Clue cells are defined as squamous epithelial cells that have numerous bacteria adherent to their cytoplasmic membrane. If a Gram stain is performed, clue cells are seen to have gram-negative bacteria adherent to the cytoplasmic membrane. This is characteristic of G. vaginalis infection. The whiff test is performed by placing a drop of vaginal discharge on a glass slide and mixing in a drop of concentrated KOH; if there is a significant concentration of anaerobic bacteria present, a fishlike odor is detected.
Typically, in uncomplicated BV, WBCs are not present in the vaginal discharge. The presence of an obvious leukorrhea should alert the physician to the possible existence of an associated condition, i.e., a sexually transmitted disease (STD). The frequency of recurrent BV is linked to the frequency of sexual intercourse. Patients who experience recurrent episodes of BV should be queried as to their sexual practices. The presence of vaginal leukorrhea should alert the physician to the possible existence of pelvic inflammatory disease (PID). Therefore, the patient presenting with BV and leukorrhea should be evaluated for PID, trichomoniasis, cervical gonorrhea, and chlamydial infection.
Patients found to have BV may be treated with one of the regimens listed in Table 3 .
The patient should be re-evaluated 7 and 30 days after the completion of therapy to ensure that the condition has resolved. She should be advised to either refrain from intercourse or have her partner wear a condom. This practice should continue throughout the follow-up period.
Individuals who have recurrent or persistent BV should be treated as described earlier and, when found to be free of BV, should be considered for maintenance therapy. There are no good data available with regard to maintenance therapy, but two factors that may contribute to recurrent BV are (1) the vaginal ecosystem is cleared of clue cells, and there is now a high-density mixture of bacteria, but noticeable lactobacilli are lacking, and (2) the vaginal pH remains above 4.5. A patient with both these factors is likely to have a relapse in a short time, and unless the pH is restored to a range of 3.8 to 4.2, lactobacilli will not resume a place of dominance in the vaginal ecosystem. Thus, a healthy vaginal ecosystem will not become re-established, and the BV cycle is likely to begin again.
Unfortunately, there are no specific medications or treatments for
restoring the vaginal pH to a range of 3.8 to 4.2. However, acid gel can be
administered twice daily for 10 to 14 days in an attempt to lower the pH of the
vagina. One week after the completion of therapy, the patient should be
re-evaluated to determine whether a healthy vaginal ecosystem has been
restored. Failure of the patient to respond to
The most common agent of parasitic genital infection is T. vaginalis. Other common but less frequent parasites are Phthirus pubis, Sarcoptes scabiei, and Enterobius vermicularis.
P. pubis, commonly referred to as ""the crabs,"" is one of three species of lice that infect humans; the others are Pediculus humanus corporis, the body louse, and Pediculus humanus capitis, the head louse. Lice are transmitted by person-to-person contact. Although the pubic louse is most commonly transmitted via sexual contact, cases have been documented in which transmission has occurred from toilet seats, bed linen, and infected loose hairs. The incidence of infection is highest among individuals with gonorrhea and syphilis. The affected patient presents with itching, evidence of excoriation, erythema, irritation, and inflammation. Patients who have a large number of bites may even develop a mild elevation in body temperature, malaise, and irritability.
The diagnosis is established by taking a detailed history and carefully examining the patient. The adult crab louse and nits (eggs) can be seen by the naked eye. A simple magnifying glass facilitates examining the pubic area. The pubic lice may appear as scabs; however, when the scab is removed and examined microscopically, the crab louse becomes easy to identify. If no adults are present, the eggs or nits can be identified.
Treatment must be effective against both the adult lice and the nits. The partner of the infected patient must also be examined, as should other household members. Several agents are available, including preparations with pyrethrins and piperonyl butoxide (RID (liquid and shampoo); Triple X Kit (liquid and shampoo); and Barc (liquid)), lindane (Kwell (lotion, shampoo, and cream)), crotamiton (Eurax (cream and lotion)), 20% benzyl benzoate, and 10% sulfur ointment. The pediculicide should remain in contact with the infected area for at least 1 hour to be ovicidal. Kwell is probably the most commonly used pediculicide. The proper use of this agent requires the patient to shower before applying the Kwell (1% gamma-benzene hexachloride), which then remains on the body surface for 8 hours. This process should be followed for three applications of Kwell, and each 8-hour application is followed by a shower. The patient should wash thoroughly with soap and water to remove the Kwell. After the final shower, no further treatment should be necessary.
Kwell is absorbed, especially if the skin has been severely excoriated, and may cause neurotoxicity. This agent should not be used on children or pregnant women.
The patient s clothing and fomites should also be treated for adult lice and nits. Clothes should be washed in hot water (125°F), and nonwashable items
Sarcoptes scabiei is the causative agent of scabies, which is transmitted via close personal contact. The organism is transmitted by sexual and nonsexual contact. The hands and feet are initially infected. The female breast may have lesions resembling those of Paget s disease. Infection may occur in skin folds such as the umbilicus, the groin, and where the buttocks meet the thigh. The characteristic lesion is a burrow. Most sites are erythematous and excoriated, as is most commonly seen in the web between the fingers.
The infection can be diagnosed by taking skin scrapings and examining them microscopically for the presence of the mite. Other diagnostic modalities are needle extraction of a mite from a burrow; epidermal shave biopsy of a burrow or papule; covering the burrow with ink and wiping with alcohol (if a mite is present, it will be stained by the ink); scraping the burrow, mixing the scrapings with mineral oil, and examining microscopically; punch biopsy; and placing topical tetracycline on the infected area, wiping, and then examining under ultraviolet light for fluorescence.
Treatment of scabies is best accomplished with topical agents such as 1% gamma-benzene hexachloride (lindane cream or lotion, Kwell, or Scabene), crotamiton (Eurax), or sulfur.
T. vaginalis is a protozoan with five flagella, four located anteriorly and one located in an undulating membrane. The organism has the ability to adhere to epithelial cells. The hallmark of T. vaginalis infection is vaginal discharge, which may vary in color from a dirty gray to a yellow-green. The discharge appears frothy owing to the presence of gas bubbles. The pH of the discharge is usually greater than 5. The patient may complain of dyspareunia, dysuria, pruritus, and a foul vaginal odor. She also may note an exacerbation of symptoms shortly after her menses.
Pelvic examination may reveal the vulva to be erythematous, slightly edematous, and excoriated. Petechiae may be present on the cervix and vaginal walls. A urine specimen may also reveal the presence of trichomonads. One or two drops of the vaginal discharge mixed with 1 to 2 mL of normal saline and examined microscopically typically shows numerous bacteria, WBCs, and mobile trichomonads. However, if no protozoans are seen, it would be beneficial to inoculate a medium designed for the growth of T. vaginalis (e.g., Diamond s medium), because this is a more sensitive method of detecting T. vaginalis than microscopic examination of vaginal discharge.
Treatment should be instituted with metronidazole, 250 mg given orally three times daily for 7 days or 375 mg orally twice a day for 7 days. I prefer this regimen over intravaginal suppositories, because the organism commonly infects extravaginal sites, such as the bladder, urethra, or periurethral glands. I have found that the single 2-gram dose is not well tolerated by the patient because of gastric upset. The male partner should be treated to achieve a cure in the female patient. Condoms should be utilized during the treatment period. The patient should be re-examined to determine whether the organism has been eradicated and the vaginal environment restored to a healthy state.
Patients who present to the physician with vulvovaginitis of microbial etiology should be considered to have an STD. Consideration should be given to obtaining a culture specimen to test for the presence of Neisseria gonorrhoeae and Chlamydia trachomatis. In addition, serologic study for syphilis should be performed. These recommendations should be followed especially for the patient who is between the ages of 15 and 30 years, unmarried, and sexually active.
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