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Vaginal Discharge/Vaginitis, Emergency Medicine


Basics


Description


  • Vaginitis is vulvovaginal inflammation with or without abnormal vaginal discharge.
    • Common symptoms: Itching, burning, irritation, pain.
    • Abnormal discharge is defined as an increased amount or change in color.
  • Some amount of vaginal discharge is normal.
    • Glands in the cervix produce clear mucus that may turn white or yellow when exposed to air.

Etiology


  • Bacterial vaginosis (BV):
    • The most common cause
    • Loss of normal Lactobacillus sp. (e.g., antibiotics)
    • Inability to maintain normal vaginal pH
    • Overgrowth of normally present bacteria such as Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus sp., Prevotella sp., and Peptostreptococcal
  • Bacterial infections:
    • Trichomonas vaginalis (Trichomoniasis)
    • Group A strep
    • Staphylococcus aureus
  • Fungal infections:
    • Candida sp. most common
    • Often underlying immune dysfunction:
      • Diabetes
      • HIV
  • Chemical irritants
  • Foreign body
  • Atrophic vaginitis:
    • Caused by estrogen deficiency
  • Hypersensitivity
  • Collagen vascular disease
  • Herpes simplex virus (HSV):
    • Vulvovaginitis
    • Cervicitis
  • Lichen sclerosis (atrophic)
  • Fistula

Diagnosis


Signs and Symptoms


  • Abnormal discharge
  • Vaginal or vulvar irritation
  • Localized pain
  • Dyspareunia
  • Erythema
  • Edema
  • Dysuria
  • Pruritus
  • Excoriations
  • Abnormal odor
  • Can be asymptomatic

History
  • Description and duration of symptoms
  • Description of discharge, if any
  • Timing with regard to menses
  • Sexual history of patient and partners
  • Sexual practices
  • Hygienic practices
  • Use of oral contraceptives and/or antibiotics
  • Likelihood of pregnancy
  • Other symptoms (e.g., abdominal pain; must rule out pelvic inflammatory disease [PID])

Physical Exam
  • Abdominal exam to assess for tenderness
  • Inspection of vulva, vaginal os, perineal area
  • Speculum and bimanual exam

Essential Workup


  • Pelvic exam
  • Saline and KOH wet prep of vaginal discharge

Diagnosis Tests & Interpretation


Lab
  • Ž ²-human chorionic gonadotropin ( Ž ²-hCG)
  • pH of discharge with Nitrazine paper:
    • Normal in premenopauseal adults: <4.5
    • >4.5: BV, trichomoniasis
    • pH normal in candidiasis
  • Saline wet prep of discharge:
    • Clue cells: BV
    • Motile flagellated protozoa: Trichomoniasis
    • Presence of polymorphonuclear leukocytes
  • Potassium hydroxide (KOH) wet prep of discharge:
    • Pseudohyphae, budding yeast: Candidiasis
  • KOH prep "Whiff "  test:
    • Amine or "fishy "  odor suggests BV, trichomoniasis.
  • Trichomonas Rapid Test:
    • Point-of-care test
    • Immunochromatographic dipstick
  • PIP test card for BV:
    • Point-of-care test
    • Detects proline aminopeptidase
  • Nucleic acid probe test for Trichomonas, G. vaginalis, and Candida albicans
  • Gram stain:
    • Large, gram-positive rods: Lactobacilli (normal flora)
    • Small, gram-variable coccobacilli and curved rods: Gardnerella, Prevotella, Mobiluncus (BV)
  • Vaginal culture:
    • Gardnerella: Not routinely recommended
    • Candida: Recommended for recurrently symptomatic patients
    • Trichomoniasis: Gold standard
  • Endocervical swab for gonorrhea (culture " ”Thayer " “Martin media; DNA probe; amplification techniques " ”PCR/LCR) and chlamydia (DNA probe or amplification techniques " ”PCR/LCR)
  • Viral cultures for HSV, DFA, or Tzanck smear for multinucleated giant cells if ulcers or vesicles are present
  • Urinalysis/urine culture if c/o dysuria
  • Rule out sexually transmitted infections:
    • GC/Chlamydia testing
    • Consider RPR to rule out syphilis.
    • Discuss HIV testing.

Imaging
N/A unless fistula is suspected. ‚  

Differential Diagnosis


  • UTI
  • PID
  • Dermatitis
  • Discharge from cervicitis can be mistaken for vaginitis
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae

Treatment


Ed Treatment/Procedures


  • BV:
    • Metronidazole vaginal gel daily ƒ — 5 days or
    • Metronidazole 500 mg PO BID ƒ — 7 days or
    • Clindamycin vaginal cream ƒ — 7 days or
    • Clindamycin ovules PV daily ƒ — 3 days
    • Rx before certain gynecologic procedures
    • Advise against alcohol intake if taking metronidazole for 24 hrs after treatment.
    • Routine treatment of male sex partner: NO
    • Lactobacillus not found to be more effective than placebo
  • Candidiasis:
    • Single-dose oral fluconazoleor
    • Intravaginal imidazole drug ƒ — 7 days
    • Routine treatment of male sex partner: NO
  • Chemical irritant:
    • Avoid irritant
    • Use sitz baths, cotton underwear.
  • Foreign body:
    • Removal of foreign body
    • Sedation may be required for removal
    • Give appropriate antibiotics if infection present
  • Chlamydia cervicitis:
    • Azithromycin 1 g PO in single dose (for cervicitis, not adequate for PID) or
    • 7 days of doxycycline, ofloxacin, levofloxacin, or erythromycin
    • Treat for presumed concurrent gonococcal infections.
    • Routine treatment of male sex partners: YES
  • Gonococcal cervicitis:
    • Ceftriaxone 250 mg IM ƒ — 1 AND azithromycin 1 g PO ƒ — 1 ordoxycycline 100 mg BID ƒ — 7 days.
    • Oral cephalosporins (cefixime) no longer recommended.
    • Treat for presumed concurrent chlamydial infection.
    • Routine treatment of male sex partners: YES
  • HSV:
    • Acyclovir, famciclovir, or valacyclovir for 7 " “10 days for initial attack; 5 days for recurrences
    • Lidocaine jelly for topical relief
    • Rule out other causes of genital ulcers. Offer RPR, HIV testing, and counseling.
    • Routine treatment of male sex partners: Only if symptomatic; however, patient and partner may shed virus asymptomatically.
  • Lichen sclerosis:
    • Referral to gynecologist for estrogen cream and further treatment
  • Trichomoniasis:
    • Metronidazole 2 g PO once or
    • Tinidazole 2 g PO once or
    • Metronidazole 500 mg PO BID for 7 days (avoid ethanol)
    • Routine treatment of male sex partners: YES
  • All sexually transmitted causes:
    • Advise patient to avoid sexual contact with partner until partner is evaluated and treated when appropriate.
    • Educate regarding STDs/safer sex/HIV/hepatitis vaccines

  • BV:
    • Treat symptomatic women with oral metronidazole or clindamycin
    • Insufficient evidence for screening or treatment of asymptomatic pregnant women
  • Candidiasis:
    • Only topical azole drug recommended in pregnancy; no oral fluconazole.
  • Chlamydia cervicitis:
    • Azithromycin is the 1st-line choice for treating chlamydia in pregnant patients
    • Do not treat with doxycycline, ofloxacin, or levofloxacin.
  • Trichomoniasis:
    • Metronidazole given early in pregnancy shown to increase preterm birth.
    • Give 2 g single-dose metronidazole, preferably after 37 wk gestation.

  • Ask about new irritants: Bubble bath, soap, and laundry detergent.
  • Consider sexual assault/abuse.

Medication


  • Acyclovir: 200 mg PO 5 times per day ƒ — 10 days or 400 PO TID ƒ — 10 days (for initial attack); 200 mg PO 5 times per day ƒ — 5 days or 400 PO TID ƒ — 5 days (for recurrent attack)
  • Azithromycin: 1 g PO ƒ — 1
  • Butoconazole 2% cream: 5 g PV ƒ — 3 days
  • Butoconazole SR 2% cream: 5 g PV ƒ — 1
  • Ceftriaxone: 125 mg IM or 250 mg IM ƒ — 1
  • Ciprofloxacin: 500 mg PO ƒ — 1
  • Clindamycin 2% cream: 1 applicator PV QHS ƒ — 7 days
  • Clindamycin: 300 mg PO BID ƒ — 7 days
  • Clotrimazole 1% cream: 5 g PV ƒ — 7 " “14 days
  • Clotrimazole: 100 mg vaginal tablet ƒ — 7 days
  • Doxycycline: 100 mg PO BID ƒ — 7 days (class D)
  • Erythromycin ethyl succinate: 800 mg PO QID ƒ — 7 days
  • Erythromycin base: 500 mg PO QID ƒ — 7 days
  • Famciclovir: 250 mg PO TID ƒ — 7 " “10 days (for initial attack); 125 mg PO BID ƒ — 5 days (for recurrent infection)
  • Fluconazole: 150 mg PO ƒ — 1
  • Levofloxacin: 500 mg PO per day ƒ — 7 days
  • Metronidazole: 500 mg PO BID for 7 days
  • Metronidazole 0.75% gel: PV daily ƒ — 5 days
  • Miconazole: 1,200 mg PV ƒ — 1
  • Miconazole: 200 mg PV QHS ƒ — 3 days
  • Miconazole 2% cream: 5 g PV QHS ƒ — 7 days or 100 mg supp. PV QHS ƒ — 7 days
  • Nystatin 100,000 unit vaginal tablet: Nightly ƒ — 14 days
  • Terconazole: 80 mg supp QHS ƒ — 3 days
  • Terconazole 0.8% cream: 5 g PV ƒ — 3 days
  • Terconazole 0.4% cream: 5 g PV ƒ — 7 days
  • Tinidazole: 2 g PO daily ƒ — 1 day
  • Tioconazole 6.5% cream: 5 g PV ƒ — 1
  • Valacyclovir: 1 g PO BID ƒ — 7 " “10 days (for initial attack); 500 mg PO BID ƒ — 3 " “5 days or 1 g PO per day ƒ — 5 days (for recurrent attack)

Follow-Up


Disposition


Admission Criteria
  • Disseminated gonococcal infection
  • Sepsis secondary to foreign body
  • PID toxicity
  • Pain control, consequent inability to urinate or pass stool (HSV)

Discharge Criteria
Most can be discharged. Follow-up in ’ ˆ Ό1 wk is suggested. ‚  
Issues for Referral
  • Vaginal discharge and vaginitis can be safely managed as an outpatient by the patients primary physician or gynecologist:
    • Suggested follow-up in 1 wk

Follow-Up Recommendations


  • Recommend good hygiene
  • Advise patient to return to the ED or see her doctor if:
    • Symptoms do not resolve in 3 " “5 days
    • Abdominal pain or cramping
    • Fever or chills
    • Pain during sexual intercourse
    • Lower back or flank pain
    • Difficulty urinating or urinary frequency

Pearls and Pitfalls


  • pH of BV is often >4.5
  • Candidiasis often presents right before menses and can be precipitated by antibiotic use, DM, and immunosuppression.
  • Trichomoniasis often presents after menses and has similar risk factors as other sexually transmitted diseases, including number of sexual partners and sexual practices.
  • Partner treatment required for gonococcal and chlamydial infection, trichomoniasis.

Additional Reading


  • Anderson ‚  MR, Klink ‚  K, Cohrssen ‚  A. Evaluation of vaginal complaints. JAMA.  2004;291(11):1368 " “1379.
  • Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines. 2010.
  • Egan ‚  ME, Lipsky ‚  MS. Diagnosis of vaginitis. Am Fam Physician.  2000;62(5):1095 " “1104.
  • Gore ‚  H. Vaginitis. Emedicine. October 27, 2011.
  • Hainer ‚  BL, Gibson ‚  MV. Vaginitis. Am Fam Physician.  2011;83:807 " “815.
  • Wilson ‚  JF. In the clinic. Vaginitis and cervicitis. Ann Intern Med.  2009;151:ITC3-1 " “ITC3-15.

Codes


ICD9


  • 131.01 Trichomonal vulvovaginitis
  • 616.10 Vaginitis and vulvovaginitis, unspecified
  • 627.3 Postmenopausal atrophic vaginitis
  • 112.1 Candidiasis of vulva and vagina
  • 041.89 Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria
  • 054.11 Herpetic vulvovaginitis
  • 623.5 Leukorrhea, not specified as infective

ICD10


  • A59.01 Trichomonal vulvovaginitis
  • N76.0 Acute vaginitis
  • N95.2 Postmenopausal atrophic vaginitis
  • B37.3 Candidiasis of vulva and vagina
  • A60.04 Herpesviral vulvovaginitis
  • N89.8 Other specified noninflammatory disorders of vagina

SNOMED


  • 30800001 Vaginitis (disorder)
  • 276877003 Trichomonal vaginitis
  • 52441000 Atrophic vaginitis (disorder)
  • 72934000 Candidiasis of vagina (disorder)
  • 14248008 Chronic vaginitis (disorder)
  • 271939006 Vaginal discharge (finding)
  • 27420004 Herpetic vulvovaginitis
  • 419468003 Gardnerella vaginitis (disorder)
  • 419760006 Bacterial vaginosis (disorder)
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