VAGINAL INFECTIONS

Vaginal infections usually are evidenced by symptoms of increased or malodorous vaginal discharge or vulvar discomfort. The three major causes are bacterial vaginosis, which is associated with STD risks but has not been demonstrated to be sexually transmitted except in selected circumstances; trichomoniasis, which is sexually acquired and transmitted; and vulvovaginal candidiasis, which generally is not sexually transmitted. Differentiating these conditions requires microscopic examination and pH

measurement of vaginal fluid; while speculum examination may rule out an endocervical

discharge as the source, definitive diagnosis requires microscopy. The differential diagnosis includes physiologic discharge (often increased during ovulation and in pregnancy); allergic reactions to spermicides, lubricants, or douche preparations; estrogen deficiency (atrophic vaginitis); desquamative vaginitis; erosive lichen planus;

and foreign body sequestration.

BACTERIAL VAGINOSIS

A. Diagnosis

1. Symptoms: Vulvovaginal odor (sometimes spontaneously described by the patient as “fishy”) is the most common symptom, sometimes most prominent after intercourse; increased vaginal discharge is common but often is absent; external genital irritation and dysuria usually are absent

2. Signs: Homogeneous, malodorous, non-viscous, milky-white discharge, often uniformly coating the vaginal walls

3. Laboratory: Microscopy of saline preparation or Gram stained smear of vaginal fluid showing clue cells; yeast and trichomonads usually absent; vaginal pH >4.5; Gram stain (optional in lieu of saline preparation) shows increased mixed flora, decreased Gram-positive rods (Lactobacillus morphotypes), and increased small Gram-negative rods, Gram-variable curved rods, and Gram-positive cocci

4. Diagnostic (Amsel) criteria: At least 3 of the following:

a. Homogeneous vaginal discharge

b. pH >4.5 (unreliable if blood present)

c. Amine ("fishy") odor on addition of 10% KOH to vaginal fluid

d. Vaginal fluid microscopy (saline preparation or Gram-stained smear) demonstrating that clue cells comprise at least 20 percent of epithelial cells Other tests (e.g., rapid tests for amines or other products of bacterial overgrowth) may have adjunctive roles in diagnosis, if available

B. Treatment

Symptomatic women should be treated. Asymptomatic women who are found to have prominent signs on examination may also be offered treatment. Other indications for treatment in the absence of symptoms include planned pelvic surgery or instrumentation, including termination of pregnancy.

Note: Systemic treatment with metronidazole should be delayed until at least 12 hours since last ingestion of alcohol; advise patient to avoid alcohol until at least

24 hours following completion of therapy

1. Routine treatment

Metronidazole 500 mg PO bid for 7 days

OR

Metronidazole 0.75% gel, 1 applicator (5 g) intravaginally once

daily for 5 days OR

Clindamycin 2% cream, 1 applicator (5 g) intravaginally once daily for 7 days

2. Alternative regimens

Metronidazole 2.0 g PO single dose (for patients unlikely to comply with multiple-dose regimen; higher risk of relapse than for preceding regimens)

OR

Clindamycin 300 mg PO bid for 7 days

OR

Clindamycin vaginal ovules 100 mg intravaginally once daily at bedtime for 3 days

3. Resistant or recurrent BV

BV recurs in 50-70% of affected women. Options for therapy include retreatment with metronidazole or an alternative regimen. Some experts advise consistent use of condoms in the hope recurrences will be prevented, but no data support its efficacy. Currently available oral or vaginal lactobacillus preparations, yogurt, and other intravaginal therapies are not effective. Vaginal douching is ineffective for treatment or

prevention of BV or any other infection, is potentially harmful, and should not be used.

4. Pregnant women

Pregnant women with BV should be offered treatment, regardless of the presence or absence of symptoms, although such treatment has not been shown to modify the risk of premature labor or other complications of pregnancy. Metronidazole may be used at any time during pregnancy. Oral treatment is preferred rather than an intravaginal regimen, to provide antimicrobial levels in the upper genital tract.

a. Regimen of choice: Metronidazole 500 mg PO bid for 7 days

b. Alternative: Clindamycin 300 mg PO bid for 7 days

C. Follow-up: PRN for persistent or recurrent symptoms

D. Sexual activity and management of sex partners

Encourage the patient to abstain from sex until treatment is complete. No male counterpart of BV in women has been defined, and no treatment of patients’ male sex partners has been shown to prevent recurrence of the syndrome or to have health benefits for the partner. In the event of frequently recurrent BV, discuss possible use of condoms. Many female sex partners of women with BV also have BV; female partners should be examined and treated if BV is present.

TRICHOMONIASIS

A. Diagnosis

1. Symptoms and signs: Suggestive but non-diagnostic features include purulent, malodorous vaginal discharge (rarely with bubbles or overtly foamy); cervical petechiae (“strawberry cervix"); vaginal secretions pH >5.0; liberation of an amine (fishy) odor on addition of 10% KOH; saline preparation or Gram stain showing WBC. External dysuria, pruritis, and vulvovaginal erythema occasionally are present.

2. Laboratory

a. Demonstration of motile trichomonads on saline mount of vaginal exudate (insensitive; misses most cases)

b. Positive culture, direct FA test, or PCR for T. vaginalis

B. Treatment

Note: Systemic treatment with metronidazole should be delayed until at least 12 hours since last ingestion of alcohol; advise patient to avoid alcohol until at least 24 hours following completion of therapy

 

1. Metronidazole 2.0 g PO, single dose

2. Treatment failure, evidenced by persistence or recurrence despite sexual abstention, or after intercourse only with a treated partner: First persistent infection: Metronidazole 2.0 g PO, single dose Second persistent infection: Metronidazole 500 mg PO bid for 7

Days Continued persistence: Discuss with clinic physician or other

consultant

C. Follow-up: Return PRN if symptoms persist

D. Sexual activity and management of sex partners

1. Advise sexual abstention for 1 week, or until symptoms have improved and partner(s) have been treated

2. Routine STD evaluation

3. Metronidazole 2.0 g PO, single dose

VULVOVAGINAL CANDIDIASIS

A. Diagnosis

1. Symptoms and signs: The most frequent symptom is vulvar pruritus or irritation, with or without increased vaginal discharge or external dysuria. Examination may show abnormal vaginal exudate, classically clumped or with adherent exudative plaques on the vaginal mucosa; erythema of the vaginal mucosa and labia may be present.

2. Vaginal fluid pH usually <4.5; amine odor absent after addition of KOH; fungal elements (budding yeast or pseudomycelia) often present (60% sensitivity)

3. Culture for Candida species is indicated for recurrent or treatment resistant infection to exclude infection with C. glabrata or other nonalbicans species

B. Treatment

Treatment usually is indicated if suggestive clinical features are present, even if fungal elements are not seen on KOH prep. However, women with repeatedly negative KOH preparations should not be repeatedly treated; refer to clinic MD or other consultant.

1. Uncomplicated, non-recurrent VVC Intravaginal imidazole therapy and single dose oral fluconazole are equally effective; patient preference and cost should be considered in selecting treatment.

a. Fluconazole 150 mg PO, single dose

b. Intravaginal imidazole therapy

1) Clotrimazole vaginal tablets or cream, 100 mg daily at bedtime for 3 days

2) Other vaginal imidazole (miconazole, tioconozole, terconazole, or butoconazole) in the regimen indicated in each product’s package insert

2. Pregnant women: Clotrimazole or other intravaginal imidazole, for at least 7 days total; avoid fluconazole

3. Complicated VVC

Complicated VVC means frequently recurrent infection (>4 episodes per year); clinically severe disease (e.g., marked vulvar edema, superficial fissures); infection due to a non-albicans species of Candida; or infection in women with uncontrolled diabetes, advanced immunodeficiency, or other debilitating medical conditions.

a. Severe or recurrent VVC

For severe, non-recurrent cases, give initial therapy only; for recurrent VVC, give initial treatment followed by a maintenance regimen usually for 6 months; discuss all cases with clinic physician or other consultant

1. Initial treatment

Fluconazole 150 mg PO, single dose; repeat in 3 days

OR

Clotrimazole or other intravaginal imidazole for 7-14

days

2. Maintenance treatment

Clotrimazole 500 mg vaginal suppository once weekly

OR

Fluconazole 100-150 mg PO once weekly

OR

Ketoconazole 100 mg PO once daily

OR

Itraconazole 100 mg PO once daily

OR

Itraconazole 400 mg PO once monthly

Note: Patients prescribed chronic therapy with fluconazole, ketoconazole, or intraconazole require tests of liver function before starting therapy and periodically thereafter to monitor for possible hepatotoxicity; discuss with clinic physician or

other consultant

b. Infection due to Candida glabrata or other non-albicans species

1. Initial treatment: Clotrimazole or other intravaginal imidazole

for 7-14 days; avoid fluconazole

2. If infection persists or recurs: Boric acid 600 mg in gelatin

capsules, intravaginally once daily for 14 days; avoid boric acid during pregnancy

c. Infection in diabetic, immunodeficient, or debilitated patients: Manage according to the clinical syndrome, as outlined above

C. Follow-up: Return PRN for recurrent or persistent symptoms; fungal culture is

indicated for persistent or frequently recurrent cases

D. Sexual activity and management of partners: Advise sexual abstention as needed for comfort, until symptoms resolve. Examination and treatment of partners usually in unnecessary, but a topical imidazole cream (e.g., miconazole, clotrimazole) is indicated for male partners with symptomatic penile candidiasis.

MUCOPURULENT CERVICITIS

A. Diagnosis

Chlamydia trachomatis is the most common recognized sexually transmitted cause of cervicitis, and treatment of MPC is designed primarily to eradicate presumptive chlamydial infection. Young age is the strongest predictor of chlamydial infection, and signs of MPC are more predictive of chlamydial infection in women under 25 years old than in older women. Gonococcal infection should be suspected primarily in populations and epidemiologic settings in which gonorrhea is common. The etiology of nongonococcal, nonchlamydial MPC is not well understood; Mycobacterium genitalium may cause some cases.

Cervicitis in the absence of these infections is not known to lead to PID or other complications, and the role of antimicrobial therapy in management and the

importance of treating patients’ sex partners are unknown. Other conditions that may cause signs or laboratory indicators of cervicitis (e.g., endocervical leukocytosis) include vaginitis due to a foreign body or chemical irritation, use of an IUD, physiologic cervical ectopy, oral contraceptives or other estrogen therapy, pregnancy, and menstruation.

1. Clinical and Gram stain criteria: Validated criteria for the diagnosis of MPC have not been established; the diagnosis is more likely if at least one of these criteria is present:

a. Purulent endocervical discharge, including positive "swab test"

(yellow or green color on endocervical swab viewed outside the vagina)

b. Edematous cervical ectopy; however, physiologic ectopy (usually without edema) often is present in women <25 years old, in those on systemic estrogen therapy for contraception or other indications, and during pregnancy

c. Endocervical bleeding induced by gentle swabbing (“friability”)

d. Gram-stained smear of endocervical secretions showing >30 PMNs per 1000x (oil immersion) field

2. Endocervical culture or NAAT, or urine NAAT, for C. trachomatis

3. Endocervical culture or NAAT, or urine NAAT, for N. gonorrhoeae

4. When neither gonorrhea nor chlamydial infection is likely, tests may be indicated for HSV infection, T. vaginalis or pregnancy

B. Treatment

Non-chlamydial MPC has not been definitively associated with adverse outcomes in infected women or their sex partners. Therefore, the primary goal of treatment is to eradicate C. trachomatis, if present. Treatment of nonchlamydial MPC is indicated primarily for clinically symptomatic infection.

1. Treatment criteria for non-pregnant women

a. Presence of 2 or more of the 4 clinical or Gram stain signs of MPC (mucopurulent discharge, edematous ectopy, induced bleeding, >30 PMNs)

OR

b. Presence of only one of the 4 signs of MPC, plus any one of the following:

1) Age less than 25 years

2) New sex partner in the past 60 days

3) Otherwise unexplained vaginal discharge or other symptoms consistent with cervicitis

4) Patient unable or unlikely to return for follow-up In the absence of these criteria, treatment decisions for women with MPC normally should be deferred until the results of testing for C. trachomatis and N. gonorrhoeae are available, or until at least one sign of MPC is found to persist at a follow-up evaluation

2. Treatment criteria in pregnant women: Physiologic changes during pregnancy can mimic MPC, including edematous ectopy, swab-induced endocervical bleeding, and perhaps mucopurulent exudate; in the absence of gonococcal and chlamydial infection, treatment decisions should be made by (or in consultation with) the patient’s obstetrical care provider

3. Treatment regimens

Azithromycin 1.0 g PO, single dose

OR

Doxycycline 100 mg PO bid for 7 days

OR

Other regimen (erythromycin, levofloxacin, ofloxacin) as for uncomplicated chlamydial infection

4. Also administer a single-dose regimen for uncomplicated gonorrhea ifclinical or epidemiologic evidence suggest risk for gonorrhea (e.g.,residence in a geographic area with a high rate of gonorrhea, prior gonorrhea within 12 months, substance use, or commercial sex work)

5. Patient counseling: Patients should be advised that nongonococcal, nonchlamydial MPC is a clinical (syndromic) diagnosis of unknown significance and has not been clearly linked to PID or other adverse outcomes. The role of sexual transmission is unknown.

C. Follow-up

1. Treated patients: return PRN for recurrent or persistent symptoms

2. Untreated MPC in non-pregnant women: Return in 7-10 days to reassess symptoms, reexamine, and review diagnostic test results

a. Positive for C. trachomatis or N. gonorrhoeae: treat accordingly

b. Persistent clinical or Gram stain evidence of MPC (e.g., endocervical PMNs): Treat with azithromycin, doxycycline, or other therapy as for uncomplicated chlamydial infection

c. Evidence of MPC resolved: Do not treat; return PRN

3. Following an initial course of antibiotic therapy, repeated treatment is not indicated for women with persistent nonchlamydial, nongonococcal MPC; such women should be reevaluated for trichomoniasis, BV and VVC.

D. Sexual activity and management of partners

1. Advise sexual abstinence until the results of testing for C. trachomatis and N. gonorrhoeae are known, or until completion of treatment.

2. Nonchlamydial, nongonococcal MPC may or may not be sexually transmitted. The syndrome has not been demonstrated to be associated with urethritis or other clinical entities in patients’ male sex partners, and the need for treatment of patients’ sex partners is unknown. Male sex partners of women with MPC should undergo routine STD diagnostic evaluation, including testing for urethral infection with C. trachomatis and

N. gonorrhoeae. The male partners of women who meet criteria for presumptive treatment should be given similar therapy. Partners found to have NGU, chlamydial infection, or gonorrhea should be treated accordingly.

3. Patient-delivered partner therapy is not indicated for the partners of women with MPC unless gonorrhea or chlamydial infection is documented

4. Male partners of women with persistent or recurrent MPC of unknown etiology should not receive repeated courses of antimicrobial therapy

 

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease denotes ascending pelvic infection involving the uterus

(endometritis), fallopian tubes (salpingitis), and sometimes the ovaries (oophoritis) or the peritoneal cavity (pelvic or generalized peritonitis). Manifestations may include tuboovarian abscess or perihepatitis (Fitz-Hugh – Curtis syndrome). In sexually active

young women, the predominant etiologies are C. trachomatis and N. gonorrhoeae; the

proportion of cases due to each depends on their relative prevalences in patients’ sex

partner networks. Regardless of the inciting cause, non-sexually transmitted aerobic,

facultative, and anaerobic bacteria often contribute to pathogenesis. Some cases of

PID are not sexually transmitted and may be caused by Haemophilus influenzae or

other organisms; previous PID and the presence of bacterial vaginosis may predispose

to ascending infection with non-sexually transmitted vaginal bacteria. Long-term

complications, which may occur after either overt or clinically silent PID, include tubal

infertility, ectopic pregnancy, and chronic pelvic pain.Because definitive diagnosis is difficult and often requires tests and procedures that may not be available in STD clinics and other outpatient settings, and because clinically silent PID is common, clinicians should maintain a low threshold for suspecting the diagnosis and treating patients with suspected but unproved PID. Additionally, because the microbial etiology rarely is known when treatment is prescribed, and the presence ofgonorrhea or chlamydial infection does not exclude involvement by other pathogens,treatment must include a broad spectrum of antimicrobial coverage.

A. Diagnosis

Most but not all young women with the minimal diagnostic features summarized below have PID, and all should be treated for presumptive PID. Every patient with suspected PID should be discussed with the clinic physician or other consultant.

1. History: Low abdominal pain usually is present; vaginal discharge,menorrhagia, intermenstrual bleeding, fever, nausea, or vomiting may be present. However, symptoms may be subtle or completely absent, even when marked tubal inflammation is present.

2. Examination: Uterine and/or adnexal tenderness, often accompanied by cervical motion tenderness; enlargement, tenderness, or induration of one or both fallopian tubes; tender pelvic mass; mucopurulent cervicitis; direct or rebound abdominal tenderness; fever. Measure temperature, pulse, and blood pressure of all women with suspected PID.

3. Laboratory

a. Gram-stained endocervical smear: PMNs with ICGND suggests gonococcal PID, but absence of ICGND does not exclude gonococcal etiology

b. Endocervical culture or NAAT for C. trachomatis

c. Endocervical culture or NAAT for N. gonorrhoeae

d. Urine pregnancy test

e. Complete blood count, erythrocyte sedimentation rate, C-reactive protein, pelvic ultrasound, and other tests may be indicated for selected patients (e.g., clinically severe symptoms or signs)

B. Treatment

Treatment for presumptive PID is recommended for all young women (<25 years old) and for other women at risk for STD who have either cervical motion tenderness or uterine or adnexal tenderness. Most patients can be treated in outpatient settings with oral therapy.

1. Patients with the following criteria should be considered for referral for inpatient care and/or parenteral antibiotics:

a. Inability to exclude other causes of intrabdominal infection, appendicitis, ectopic pregnancy, or other surgical conditions

b. Suspected tubo-ovarian abscess or other evidence of clinically severe disease (e.g., peritoneal inflammatory signs, high fever)

c. Nausea and vomiting that preclude oral therapy

d. High risk of poor compliance with oral therapy

e. Clinically severe disease (e.g., peritoneal signs, suspected tuboovarian abscess, high fever)

f. Pregnancy

g. Re-examination in 48-72 hours is not possible

h. Inadequate response to initial outpatient therapy

2. Outpatient antibiotic regimens

There are limited data on long-term sequelae following different outpatient antibiotic regimens. The following regimens provide coverage for the common sexually transmitted etiologic agents and anaerobic bacteria:

a. Ofloxacin 400 mg PO bid for 14 days

AND

Metronidazole 500 mg PO bid for 14 days

OR

b. Ceftriaxone 250 mg IM, single dose

AND

Doxycycline 100 mg PO bid for 14 days

AND

Metronidazole 500 mg bid for 10-14 days

Note: The need for coverage against anaerobic bacteria is uncertain. For either regimen, if gastrointestinal intolerance develops on combination oral therapy, or if a contraindication to metronidazole is present (e.g., alcohol addiction, allergy), delete or discontinue metronidazole and continue ofloxacin or doxycycline.

2. If an IUD is present, it need not be routinely removed. However, removal should be considered if there is not a prompt clinical response to antibiotic therapy.

3. Ibuprofen 400-800 mg PO tid (or other non-steroidal anti-inflammatory drug in equivalent dosage) as needed for pain relief

4. Advise abstention from sexual intercourse for 2 weeks or longer, until symptoms resolve

C. Follow-up

Return for reexamination, including bimanual pelvic exam, 2-3 days after starting

treatment, 4-7 days after completing treatment, and 2-4 weeks after completing treatment. If significant improvement is not seen within 3 days, consult with clinic

physician or other specialist. If symptoms are worsening, further diagnostic evaluation is indicated and hospitalization may be necessary.

D. Sexual activity and management of partners

1. Advise sexual abstention until treatment has been completed, symptoms have resolved, and partner(s) have been treated

2. Refer the patient and partners to DIS staff, or otherwise arrange for partner management, according to recommendations for chlamydial infection and gonorrhea. Perform examination and tests for gonorrhea and chlamydia for all partners within the preceding 2 months, regardless of symptoms. Most partners of women with acute, non-recurrent PID should receive a regimen effective for both gonorrhea and chlamydial infection