Pφ

Candida species (mainly C. albicans) can be part of the vaginal flora in asymptomatic women. Risk factors for symptomatic infection include antibiotic use, poorly controlled diabetes, and the use of oral contraceptives; however, the majority of women with vulvovaginal candidiasis (VVC) have no predisposing risk factor for infection. VVC is exceedingly common; it is estimated that almost 75% of women will have at least one episode in their lifetime.

TP

The most common complaint of women with VVC is vulvar irritation, burning, and/or pruritus. Patients may complain of dysuria without other urinary tract symptoms, and dyspareunia. Discharge is typically not a prominent complaint; if present, it is typically scant. Examination of the vulvar area and the vaginal mucosa reveals erythema; linear ulcerations (fissures) and excoriations may be seen in the vulvar region. The presence of erythematous papules beyond the area of vulvar erythema (satellite lesions) is characteristic of candidal infection. Thick, clumped (“cottage cheese–like”) discharge that is typically adherent to the vaginal mucosa is characteristic.

Dx

The vaginal pH is normal (≤4.5), and the whiff test is negative. Microscopic examination of the saline wet mount will reveal leukocytes; microscopic examination of the KOH specimen reveals mycelia or budding yeast. There is no clear correlation between the severity of symptoms and the burden of organisms in women with VVC. In the presence of a typical clinical presentation, if fungal organisms are not visualized on the KOH preparation, a fungal culture should be obtained before the diagnosis is excluded.

Pφ

Trichomoniasis, caused by Trichomonas vaginalis, a pear-shaped, motile protozoan, is generally a sexually transmitted infection with a variable (a few days to 1 month) incubation period. Nonvenereal transmission is also occasionally described. Mucosal damage (microulcerations, inflammation) is believed to be due to direct contact by the microorganism; attachment to host cells appears to be mediated by surface proteins. The organism attracts PMNs and activates the alternative complement pathway.

TP

Women with trichomoniasis typically present with vulvovaginal irritation, pruritus, and/or soreness; profuse white or yellow discharge is common. Patients may have dysuria and dyspareunia; although trichomoniasis is not believed to cause ascending infection of the genital tract, 5% to 10% of women may complain of lower abdominal pain. Vulvar erythema may be present. On pelvic examination there is erythema of the vaginal walls and the cervix; punctuate hemorrhages of the cervix (colpitis macularis or strawberry cervix) are characteristic of this infection but can be visualized in only a very small proportion of women unless colposcopy is performed. Copious amounts of yellow to yellow-green discharge are typically present in the vaginal vault; the discharge is often frothy in appearance. Men with trichomoniasis are often asymptomatic. Symptomatic infection presents as urethritis; penile discharge is often quite scant.

Dx

The pH of vaginal secretions is >4.5, and the whiff test is positive in up to a third of cases. Trichomonas infection may impact the normal vaginal flora, and up to a third of women with trichomoniasis meet diagnostic criteria for BV. On microscopic examination of a saline wet-mount specimen, numerous leukocytes and organisms with a characteristic twitching motility can be visualized. It is important that the wet mount be examined promptly after preparation. The sensitivity of wet-mount examination in women is 60% to 70%. For women with a compatible clinical presentation and a negative wet mount, the clinician will need to obtain an additional sample of vaginal secretions for culture; alternatively, several rapid diagnostic tests are commercially available. Wet-mount preparations are not sufficiently sensitive for the diagnosis of trichomoniasis in men, and culture should be performed.

Pφ

BV occurs when the normal Lactobacillus-predominant vaginal flora are replaced by other microbes including Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, and anaerobes such as Prevotella, Bacteroides, and Mobiluncus. Lactobacilli produce hydrogen peroxide, which results in a low-pH environment that is not conducive to other organisms. The pathogenic factors that lead to the shift in vaginal flora resulting in BV are poorly understood. BV is not considered a sexually transmitted infection, although it is very rare in women who have never been sexually active. Multiple sex partners, a recent new partner, and douching are risk factors for BV. The infection does not elicit an impressive inflammatory response, hence the term vaginosis as opposed to vaginitis. Many patients describe vaginal discharge with a “fishy odor”; this is due to the volatilization of amines produced by G. vaginalis.

TP

As many as half of women with BV may be asymptomatic. The most common presenting complaint is vaginal discharge and odor, commonly described as “fishy.” Vulvovaginal irritation, dysuria, and dyspareunia are uncommon.

Dx

On pelvic examination there is no evidence of inflammation of the vulvar region, vaginal mucosa, or cervix. A thin white or gray discharge is seen that coats the walls of the vagina and often the labia minora. The examiner often notes a strong odor. The diagnosis is most typically confirmed using clinical criteria (the Amsel criteria). Three of the following four signs should be present to make a diagnosis of BV: (1) thin, homogeneous, white or gray discharge that coats the vaginal mucosa; (2) vaginal pH > 4.5; (3) positive whiff test (fishy odor of vaginal discharge before or after the addition of 10% KOH); and (4) presence of clue cells (epithelial cells studded with tiny cocco-bacilli) on saline wet-mount examination. As discussed above, BV is not associated with significant inflammation; the finding of increased leukocytes on the wet mount should prompt evaluation for another infection.

Pφ

Mucopurulent cervicitis (MPC) in women and urethritis in men are most commonly caused by the sexually transmitted pathogens N. gonorrhoeae and C. trachomatis. In women, urethritis often occurs in conjunction with vaginitis, which may be due to any of the conditions reviewed above. N. gonorrhoeae organisms attach to mucosal epithelial cells via pili and outer membrane proteins and then penetrate into the submucosa eliciting an intense host inflammatory response, resulting in microabscess formation and sloughing of the epithelial surface. Chlamydia is an obligate intracellular organism. The extracellular infectious form (the elementary body) attaches to the host epithelial cell and enters via endocytosis; the organism then differentiates into its metabolically active form (reticulate body). Infected cells produce proinflammatory cytokines that elicit a host inflammatory response.

Herpes simplex may also cause cervicitis. Nongonococcal urethritis (NGU) can also be caused by Trichomonas and HSV; the potential role of other pathogens including Mycoplasma genitalium, U. urealyticum, and adenovirus has not yet been clearly established.

TP

Women with MPC typically present with a complaint of purulent discharge. Intermenstrual bleeding, especially after intercourse, is common. Symptoms of vulvar irritation are absent, although patients may have dysuria. Lower abdominal pain or any signs of systemic toxicity (fever, nausea, vomiting) suggest ascending infection of the genital tract (pelvic inflammatory disease). On examination, the vulva and vaginal mucosa are normal in appearance; mucopurulent discharge is visualized emanating from the endocervical canal.

Men with urethritis present with dysuria (particularly with the first void in the morning) and penile discharge. If discharge is not readily apparent at the urethral meatus, attempts to “milk” the urethra (as described above under physical examination) should be made.

Dx

The vaginal pH is often elevated (>4.5) in women with MPC, and the whiff test is negative. Increased numbers of leukocytes are seen on the wet mount. The diagnosis of GC should be confirmed by nucleic acid amplification testing (NAAT) of cervical samples. The presence of intracellular gram-negative diplococci on a Gram stain of cervical secretions is highly specific for gonorrhea, but the sensitivity is poor.

NAAT should be utilized to confirm the etiology of urethritis in men; NAAT can be performed on a sample of urethral discharge or a urine sample. The sensitivity of a Gram stain of urethral discharge for N. gonorrhoeae is much higher in men with symptomatic urethritis.