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Vaginal Discharge/Vaginitis, Emergency Medicine

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Vaginal Discharge/Vaginitis, Emergency Medicine

Basics

Description

N/A unless fistula is suspected.

  • 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.
  • Common symptoms: Itching, burning, irritation, pain.
  • Abnormal discharge is defined as an increased amount or change in color.
  • Glands in the cervix produce clear mucus that may turn white or yellow when exposed to air.

Etiology

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

Diagnosis

Signs and Symptoms

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

  • Ž ²-human chorionic gonadotropin ( Ž ²-hCG)
  • pH of discharge with Nitrazine paper:Normal in premenopauseal adults: <4.5>4.5: BV, trichomoniasispH normal in candidiasis
  • Saline wet prep of discharge:Clue cells: BVMotile flagellated protozoa: TrichomoniasisPresence 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 testImmunochromatographic dipstick
  • PIP test card for BV:Point-of-care testDetects 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 recommendedCandida: Recommended for recurrently symptomatic patientsTrichomoniasis: 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 testingConsider RPR to rule out syphilis.Discuss HIV testing.
  • Normal in premenopauseal adults: <4.5
  • >4.5: BV, trichomoniasis
  • pH normal in candidiasis
  • Clue cells: BV
  • Motile flagellated protozoa: Trichomoniasis
  • Presence of polymorphonuclear leukocytes
  • Pseudohyphae, budding yeast: Candidiasis
  • Amine or "fishy "  odor suggests BV, trichomoniasis.
  • Point-of-care test
  • Immunochromatographic dipstick
  • Point-of-care test
  • Detects proline aminopeptidase
  • Large, gram-positive rods: Lactobacilli (normal flora)
  • Small, gram-variable coccobacilli and curved rods: Gardnerella, Prevotella, Mobiluncus (BV)
  • Gardnerella: Not routinely recommended
  • Candida: Recommended for recurrently symptomatic patients
  • Trichomoniasis: Gold standard
  • GC/Chlamydia testing
  • Consider RPR to rule out syphilis.
  • Discuss HIV testing.

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 orMetronidazole 500 mg PO BID ƒ — 7 days orClindamycin vaginal cream ƒ — 7 days orClindamycin ovules PV daily ƒ — 3 daysRx before certain gynecologic proceduresAdvise against alcohol intake if taking metronidazole for 24 hrs after treatment.Routine treatment of male sex partner: NOLactobacillus not found to be more effective than placebo
  • Candidiasis:Single-dose oral fluconazoleorIntravaginal imidazole drug ƒ — 7 daysRoutine treatment of male sex partner: NO
  • Chemical irritant:Avoid irritantUse sitz baths, cotton underwear.
  • Foreign body:Removal of foreign bodySedation may be required for removalGive appropriate antibiotics if infection present
  • Chlamydia cervicitis:Azithromycin 1 g PO in single dose (for cervicitis, not adequate for PID) or7 days of doxycycline, ofloxacin, levofloxacin, or erythromycinTreat 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 recurrencesLidocaine jelly for topical reliefRule 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 orTinidazole 2 g PO once orMetronidazole 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
  • 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
  • Single-dose oral fluconazoleor
  • Intravaginal imidazole drug ƒ — 7 days
  • Routine treatment of male sex partner: NO
  • Avoid irritant
  • Use sitz baths, cotton underwear.
  • Removal of foreign body
  • Sedation may be required for removal
  • Give appropriate antibiotics if infection present
  • 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
  • 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
  • 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.
  • Referral to gynecologist for estrogen cream and further treatment
  • 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
  • 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 clindamycinInsufficient 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 patientsDo 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.
  • Treat symptomatic women with oral metronidazole or clindamycin
  • Insufficient evidence for screening or treatment of asymptomatic pregnant women
  • Only topical azole drug recommended in pregnancy; no oral fluconazole.
  • Azithromycin is the 1st-line choice for treating chlamydia in pregnant patients
  • Do not treat with doxycycline, ofloxacin, or levofloxacin.
  • 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

  • Disseminated gonococcal infection
  • Sepsis secondary to foreign body
  • PID toxicity
  • Pain control, consequent inability to urinate or pass stool (HSV)
  • Vaginal discharge and vaginitis can be safely managed as an outpatient by the patients primary physician or gynecologist:Suggested follow-up in 1 wk
  • 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 daysAbdominal pain or crampingFever or chillsPain during sexual intercourseLower back or flank painDifficulty urinating or urinary frequency
  • 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)