Vaginitis Slides 2013
Vaginitis Slides 2013
Vaginitis Slides 2013
Vaginitis Curriculum
Vaginal Environment
Vaginitis Curriculum
Vaginitis
Usually characterized by
Vaginal discharge
Vulvar itching
Irritation
Odor
Common types
Bacterial vaginosis (40%45%)
Vulvovaginal candidiasis (20%25%)
Trichomoniasis (15%20%)
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Vaginitis Curriculum
Mucopurulent cervicitis
Atrophic vaginitis
Vulvar vestibulitis
Foreign bodies
Desquamative inflammatory vaginitis
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Vaginitis Curriculum
Diagnosis of Vaginitis
Patient history
Visual inspection of
internal/external genitalia
Appearance of discharge
Vaginitis Curriculum
Whiff test
Vaginal pH
Vaginitis Curriculum
PMN
Sperm
RBCs
Squamous
epithelial cell
Artifact
Source: Seattle STD/HIV Prevention Training Center at the University of Washington
Vaginitis Curriculum
Lactobacilli
Artifact
NOT a clue cell
Vaginitis Curriculum
Other tests
DNA probe
PIP activity
Rapid test
BVBlue
Nucleic acid
PCR assay
amplification tests
(NAAT)
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Vaginitis Curriculum
Vaginitis Differentiation
Normal
Bacterial Vaginosis
Candidiasis
Trichomoniasis
Symptom
presentation
Itch, discomfort,
dysuria, thick
discharge
Vaginal discharge
Homogenous,
adherent, thin, milky
white; malodorous
foul fishy
Inflammation and
erythema
Cervical petechiae
strawberry cervix
Clear to
white
Clinical findings
Vaginal pH
3.8 - 4.2
> 4.5
> 4.5
Negative
Positive
Negative
Often positive
Lacto-bacilli
Few to many
WBCs
Motile flagellated
protozoa, many
WBCs
Pseudohyphae or
spores if non-albicans
species
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Vaginitis
Bacterial Vaginosis (BV)
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Learning Objectives
Upon completion of this content, the learner will be able to
Lessons
I.
II.
III.
IV.
V.
VI.
Lesson I: Epidemiology:
Disease in the U.S.
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Epidemiology
Epidemiology
Most common cause of vaginitis
Prevalence varies by population
5%25% among college students
12%61% among STD patients
Widely distributed
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Epidemiology
Epidemiology (continued)
BV linked to
Premature rupture of membranes
Premature delivery and low birth-weight delivery
Acquisition of HIV, N. gonorrhoeae, C.
trachomatis, and HSV- 2
Development of PID
Post-operative infections after gynecological
procedures
Recurrence of BV
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Epidemiology
Risk Factors
African American
Two or more sex partners in previous
six months/new sex partner
Douching
Lack of barrier protection
Absence of or decrease in lactobacilli
Lack of H2O2-producing lactobacilli
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Epidemiology
Transmission
Currently not considered a sexually
transmitted disease, but acquisition
appears to be related to sexual activity.
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Pathogenesis
Microbiology
Overgrowth of bacteria species normally present in
vagina with anaerobic bacteria
BV correlates with a decrease or loss of protective
lactobacilli
Vaginal acid pH normally maintained by lactobacilli
through metabolism of glycogen.
Hydrogen peroxide (H2O2) is produced by some
Lactobacilli,sp.
H2O2 helps maintain a low pH, which inhibits bacteria
overgrowth.
Loss of protective lactobacilli may lead to BV.
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Pathogenesis
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Clinical Manifestations
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Diagnosis
Clue cells
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Diagnosis
Amsel Criteria:
Must have at least
three of the
following findings:
Vaginal pH >4.5
Presence of >20% per HPF of
"clue cells" on wet mount
examination
Homogeneous, non-viscous,
milky-white discharge
adherent to the vaginal walls
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Diagnosis
27
Lesson V: Patient
Management
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Management
Treatment
CDC-recommended regimens
Metronidazole 500 mg orally twice a day for 7
days
or
Metronidazole gel 0.75%, one full applicator
(5 g) intravaginally, once or twice a day for 5
days
or
Clindamycin cream 2%, one full applicator
(5 g) intravaginally at bedtime for 7 days 29
Management
Treatment (continued)
Alternative regimens (nonpregnant)
Multiple recurrences
Twice weekly metronidazole gel for 46 months may
reduce recurrences
Oral nitroimidazole followed by intravaginal boric acid
and suppressive metronidazole gel
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Management
Treatment in Pregnancy
Pregnant women with symptomatic disease should
be treated with one of the following recommended
regimens:
Metronidazole 500 mg twice a day for 7 days, or
Management
32
Management
Ampicillin
Erythromycin
Iodine
Dienestrol cream
Tetracycline/doxycycline
Triple sulfa
Ciprofloxacin
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Management
Recurrence
Recurrence rate is 20% to 40% one month after therapy.
Recurrence may be a result of persistence of BV-associated
organisms and a failure of lactobacillus flora to recolonize.
Data do not support yogurt therapy or exogenous oral lactobacillus
treatment.
Under study: vaginal suppositories containing human lactobacillus
strains.
Twice weekly metronidazole gel for 46 months may reduce
recurrences.
Limited data suggest that oral nitroimidazole followed by intravaginal
boric acid and suppressive metronidazole gel might be a treatment
option after multiple occurrences.
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Prevention
Partner Management
Relapse or recurrence is not affected by
treatment of sex partner(s).
Routine treatment of sex partners is not
recommended.
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Prevention
Transmission issues
Association with sexual activity, high concordance in
female same-sex partnerships
Risk reduction
Correct and consistent condom use
Avoid douching
Limit number of sex partners
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Candidiasis Curriculum
Vaginitis
Vulvovaginal Candidiasis (VVC)
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Candidiasis Curriculum
Learning Objectives
Upon completion of this content, the learner will be able to:
Describe the epidemiology of candidiasis in the U.S.
Describe the pathogenesis of candidiasis.
Describe the clinical manifestations of candidiasis.
Candidiasis Curriculum
Lessons
I.
II.
III.
IV.
V.
VI.
Candidiasis Curriculum
Lesson I: Epidemiology:
Disease in the U.S.
41
Candidiasis Curriculum
Epidemiology
VVC Epidemiology
Affects most females during lifetime, with
approximately 50% having two or more
episodes
Most cases caused by C. albicans (85%
90%)
Second most common cause of vaginitis
Estimated cost: $1 billion annually in the
U.S.
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Candidiasis Curriculum
Epidemiology
Transmission
Candida species are normal flora of skin
and vagina and are not considered to
be sexually transmitted pathogens.
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Candidiasis Curriculum
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Candidiasis Curriculum
Pathogenesis
Microbiology
Candida species are normal flora of the skin
and vagina.
VVC is caused by overgrowth of C. albicans
and other non-albicans species.
Yeast grows as oval budding yeast cells or as
a chain of cells (pseudohyphae).
Symptomatic clinical infection occurs with
excessive growth of yeast.
Disruption of normal vaginal ecology or host
immunity can predispose to vaginal yeast
infections.
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Candidiasis Curriculum
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Candidiasis Curriculum
Clinical Manifestations
Candidiasis Curriculum
Clinical Manifestations
Vulvovaginal Candidiasis
Source: Health Canada, Sexual Health and STI Section, Clinical Slide Gallery
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Candidiasis Curriculum
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Candidiasis Curriculum
Diagnosis
Diagnosis
History, signs and symptoms
Visualization of pseudohyphae
(mycelia) and/or budding yeast (conidia)
on KOH or saline wet prep
pH normal (4.0 to 4.5)
If pH > 4.5, consider concurrent BV or
trichomoniasis infection
Candidiasis Curriculum
Diagnosis
Yeast
pseudohyphae
Yeast
buds
PMNs
Squamous epithelial cells
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Candidiasis Curriculum
Diagnosis
Yeast Pseudohyphae
10% KOH: 10X objective
Masses of yeast
pseudohyphae
Lysed
squamous
epithelial cell
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Candidiasis Curriculum
Diagnosis
Folded squamous
epithelial cells
PMNs
Yeast
buds
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Source: Seattle STD/HIV Prevention Training Center at the University of Washington
Candidiasis Curriculum
Lesson V: Patient
Management
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Candidiasis Curriculum
Management
Classification of VVC
Uncomplicated VVC
Sporadic or infrequent
vulvovaginal candidiasis
or
Mild-to-moderate
vulvovaginal candidiasis
or
Likely to be C. albicans
or
Vulvovaginal candidiasis in
nonimmunocompromised
women
Complicated VVC
Recurrent vulvovaginal
candidiasis (RVVC)
or
Severe vulvovaginal
candidiasis
or
Non-albicans candidiasis
or
Vulvovaginal candidiasis in
women with uncontrolled
diabetes, debilitation, or
immunosuppression
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Candidiasis Curriculum
Management
Uncomplicated VVC
Mild to moderate signs and symptoms
Nonrecurrent
75% of women have at least one
episode
Responds to short course regimen
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Candidiasis Curriculum
Management
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Candidiasis Curriculum
Management
Complicated VVC
Recurrent (RVVC)
Four or more episodes in one year
Severe
Edema
Excoriation/fissure formation
Non-albicans candidiasis
Compromised host
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Candidiasis Curriculum
Management
Severe VVC
714 days of topical therapy, or
150 mg oral dose of fluconozole repeated in
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72 hours
Candidiasis Curriculum
Management
Compromised host
714 days of topical therapy
Pregnancy
Fluconazole is contraindicated
7-day topical agents are recommended
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Candidiasis Curriculum
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Candidiasis Curriculum
Prevention
Partner Management
VVC is not usually acquired through sexual
intercourse.
Treatment of sex partners is not
recommended.
A minority of male sex partners may have
balanitis and may benefit from treatment with
topical antifungal agents to relieve symptoms.
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Candidiasis Curriculum
Prevention
Transmission Issues
Not sexually transmitted
Risk reduction
Avoid douching, avoid unnecessary antibiotic
use, complete course of treatment
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Trichomoniasis Curriculum
Vaginitis
Trichomonas vaginalis
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Trichomoniasis Curriculum
Learning Objectives
Upon completion of this content, the learner will be able to:
Describe the epidemiology of trichomoniasis in the United States.
Describe the pathogenesis of T. vaginalis.
Describe the clinical manifestations of trichomoniasis.
Identify common methods used in the diagnosis of trichomoniasis.
List CDC-recommended treatment regimens for trichomoniasis.
Describe patient follow up and partner management for
trichomoniasis.
Trichomoniasis Curriculum
Lessons
I.
II.
III.
IV.
V.
VI.
Trichomoniasis Curriculum
Lesson I: Epidemiology:
Disease in the U.S.
67
Trichomoniasis Curriculum
Epidemiology
NOTE: The relative standard errors for trichomoniasis estimates range from 16% to 27% and for other vaginitis estimates
range from 8% to 13%.
SOURCE: IMS Health, Integrated Promotional Services, IMS Health Report, 19662011.
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Trichomoniasis Curriculum
Epidemiology
Risk Factors
Multiple sexual partners
Lower socioeconomic status
History of STDs
Lack of condom use
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Trichomoniasis Curriculum
Epidemiology
Transmission
Almost always sexually transmitted.
Females and males may be
asymptomatic.
Transmission between female sex
partners has been documented.
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Trichomoniasis Curriculum
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Trichomoniasis Curriculum
Pathogenesis
Microbiology
Etiologic agent
Trichomonas vaginalis is a single-celled,
flagellated, anaerobic protozoan parasite.
Only protozoan that infects the genital tract.
Associations with
Preterm rupture of membranes and preterm delivery.
Increased risk of HIV acquisition and
transmission.
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Trichomoniasis Curriculum
Pathogenesis
Trichomonas vaginalis
Source: CDC, National Center for Infectious Diseases, Division of Parasitic Diseases
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Trichomoniasis Curriculum
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Trichomoniasis Curriculum
Clinical Manifestations
Trichomoniasis Curriculum
Clinical Manifestations
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Source: Claire E. Stevens/Seattle STD/HIV Prevention Training Center at the University of Washington
Trichomoniasis Curriculum
Clinical Manifestations
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Trichomoniasis Curriculum
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Trichomoniasis Curriculum
Diagnosis
Diagnosis in Females
Motile trichomonads seen on saline wet
mount
Vaginal pH >4.5 often present
Culture has been the gold standard
Pap smear sensitivity with traditional
cytology poor, but enhanced by use of
liquid-based testing
DNA probe
Rapid test (antigen detection test, OSOM)
NAAT (urine or vaginal swab)
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Trichomoniasis Curriculum
Diagnosis
Diagnosis in Males
Culture testing of urethral swab, urine,
or semen NAATs
Sex partners of women diagnosed with
T. vaginalis should also be treated
regardless of initial testing
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Trichomoniasis Curriculum
Diagnosis
PMN
Yeast
buds
Trichomonas*
Trichomonas*
PMN
*Trichomonas shown for size reference only: must be motile for identification
Source: Seattle STD/HIV Prevention Training Center at the University of Washington
Squamous
epithelial
cells
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Trichomoniasis Curriculum
Lesson V: Patient
Management
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Trichomoniasis Curriculum
Management
Treatment
CDC-recommended regimen
Metronidazole 2 g orally in a single dose or
Tinidazole 2 g orally in a single dose
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Trichomoniasis Curriculum
Management
Pregnancy
CDC-recommended regimen
Metronidazole 2 g orally in a single dose
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Trichomoniasis Curriculum
Management
Treatment Failure
A common reason for treatment failure is reinfection.
Therefore, it its critical to assure treatment of all sex partners at
the same time.
If treatment failure occurs with metronidazole 2 g orally in a
single dose for all partners, treat with metronidazole 500 mg
orally twice daily for 7 days or tinidazole 2 g orally single dose.
If treatment failure of either of these regimens, consider
retreatment with tinidazole or metronidazole 2 g orally once a
day for 5 days.
If repeated treatment failures occur, contact the Division of STD
Prevention, CDC, for metronidazole-susceptibility testing
(telephone: 404-718-4141, website: www.cdc.gov/std)
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Trichomoniasis Curriculum
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Trichomoniasis Curriculum
Prevention
Partner Management
Sex partners should be treated.
Patients should be instructed to avoid
sex until they and their sex partners are
cured (when therapy has been
completed and patient and partner(s)
are asymptomatic, about 7 days).
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Trichomoniasis Curriculum
Prevention
Transmission issues
Almost always sexually transmitted, fomite
transmission rare, might be associated with
increased susceptibility to HIV acquisition
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Trichomoniasis Curriculum
Prevention
Risk Reduction
The clinician should
Assess patients potential for behavior change.
Discuss individualized risk-reduction plans with
the patient.
Discuss prevention strategies such as
abstinence, monogamy, use of condoms, and
limiting the number of sex partners.
Latex condoms, when used consistently and
correctly, can reduce the risk of transmission of
the T. vaginalis parasite.
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Case Study
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Case Study
History
Tanya Walters
24-year-old single female
Presents with complaints of a smelly, yellow vaginal
discharge and slight dysuria for one week
Denies vulvar itching, pelvic pain, or fever
Two sex partners during the past yeardid not use
condoms with these partnerson oral contraceptives
for birth control
No history of sexually transmitted diseases, except for
trichomoniasis one year ago
Last check-up one year ago
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Case Study
Physical Exam
Vital signs: blood pressure 112/78, pulse 72, respiration
15, temperature 37.3C
Cooperative, good historian
Chest, heart, breast, musculoskeletal, and abdominal
exams within normal limits
No flank pain on percussion
Normal external genitalia with a few excoriations near
the introitus, but no other lesions
Speculum exam reveals a moderate amount of frothy,
yellowish, malodorous discharge, without visible
cervical mucopus or easily induced cervical bleeding
Bimanual examination was normal without uterine or
adnexal tenderness
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Case Study
Questions
1. What is your differential diagnosis
based on history and physical
examination?
2. Based on the differential diagnosis of
vaginitis, what is the etiology?
3. Which laboratory tests should be
offered or performed?
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Case Study
Laboratory Results
Vaginal pH - 6.0
Saline wet mount of vaginal secretions -- numerous
motile trichomonads and no clue cells
KOH wet mount -- negative for budding yeast and
pseudohyphae
Case Study
Partner Management
Jamie
Last sexual contact:
2 days ago
First sexual contact:
2 months ago
Twice a week,
vaginal sex
Calvin
Last sexual contact:
6 months ago
First sexual contact:
7 months ago
3 times a week,
vaginal and oral sex
Case Study
Follow-Up
Tanya was prescribed metronidazole 2 g orally, and
was instructed to abstain from sexual intercourse
until her current partner was treated.
She returned two weeks later. She reported taking
her medication, but had persistent vaginal discharge
that had not subsided with treatment. She reported
abstinence since her clinic visit, and her partner had
moved out of the area. Her tests for other STDs
(including chlamydia and gonorrhea) were negative.
The vaginal wet mount again revealed motile
trichomonads.
7. What is the appropriate therapy for Tanya now?
8. What are appropriate prevention and counseling
messages for Tanya?
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