A Synopsis or AFP's "Vaginitis: Diagnosis and Treatment"

 A synopsis of; Vaginitis: Diagnosis and Treatment
BARRY L. HAINER, MD, and MARIA V. GIBSON, MD, PhD, Medical University of South Carolina, Charleston, South Carolina 
http://www.aafp.org/afp/2011/0401/p807.pdf
Am Fam Physician. 2011 Apr 1;83(7):807-815.

     The three most common causes of vaginitis are bacterial, candidiasis, and trichomoniasis. Bacterial vaginosis is caused by the colonization of gardnerella, mycoplasma, or anaerobic bacteria such as prevotella or mobiluncus. A fishy odor will be present. It is unlikely that bacterial vaginosis is present without a perceived odor .The fishy odor is from the amines that are created by the anaerobic bacteria. The odor becomes more prevalent after menses or unprotected sex (sperm in the vagina) because of the increase in vaginal pH. The discharge may be clear, white or gray. There is no pain, pruritus  or inflammation. It is asymptomatic in up to half of those infected. It is associated with late miscarriages, PROM, preterm birth and increased risk of HIV transmission. Diagnosis can be done using the Amsel criteria. The four parts are:
-thin, homogenous discharge
-vaginal pH >4.5 (normal is 4-4.5)
-positive whiff test 
- > 10% clue cells
The whiff test is done by adding 10% KCl to the culture. A unique odor is produced. Clue cells are vaginal epithelial cells covered in coccobacilli, which obscures the cell border when placed on a wet mount. Three of the Amsel criteria are needed for it to be positive, but 2 of the criteria are just as sensitive. 
     Treatment consists of clindamycin or metronidazole. A one time dose of 2g metronidazole is no longer recommended. It should be given as 500 g twice a day for a week. Topical or oral medications can be used, depending on patient preference (metronidazole has an unpleasant, metallic taste). Screening pregnant women for asymptomatic bacterial vaginitis is not recommended. 
     Trichomoniasis causes dyspareunia, vaginal soreness, and dysuria. The patient may present with the classic "strawberry cervix". Whiff test will be positive. The vaginal pH will be >5.4. A wet mount should show trichomonads, which are a flagellated organism slightly larger than WBCs. Tricomonads can be found on examation of the vagianl fliud or in a centrifuged urine sample. PCR can be done as well. Treatment can be done with metronidazole, with the dosage and frequency individualized for patient comfort. Sexual partners need to be treated as well. Intercourse should be halted until treatment is complete and the patient is asymptomatic. Because of the risk of low birth weight infants, trichomoniasis can be treated in pregnant women after 37 weeks gestation. 
    Candidiasis is a common infection that most woman have in their lifetime. Symptoms consist of itching, burning, vaginal soreness, pain with sexual intercourse, and a thick, cheesy, white discharge. It is odorless. Vaginal pH is normal. Microscopic examination should show budding yeast. A rapid yeast detection test is also available and inexpensive. PCR is an expensive alternative. Treatment is categorised as either complicated or uncomplicated.  Uncomplicated illness is considered mild to moderate. The patient will have less than 4 episodes a year. Hyphae or pseudohyphae will be visible on microscopy. Complicated disease will be moderate to severe. There will be four or more episodes per year. On microscopy, only budding yeast will be seen. Complicated patients may also be pregnant, have diabetes, or be immunocompromised. Uncomplicated candidiasis will require a short course of antifungal medication, where as complicated patients will need a more intense, longer course of medication. 
    Atrophic vaginitis is due to estrogen deficiency. It can cause vaginal dryness, pruritus, discharge, irritation or pain during intercourse. Topical estrogen cream or the estradiol vaginal ring have been effective with minal side effects. 
    The last cause of vaginitis are allergic or irritant contact dermatitis. This can be from latex condoms, spermicide, feminine hygiene products, among many other causes. The cure is removal of the offending product.