Vaginitis and Urethritis (Case 50)

Vaginitis and Urethritis (Case 50)


Patricia D. Brown MD


Case: A 28-year-old woman presents acutely with complaints of discomfort in the vulvar region of 3 days, accompanied by pain with intercourse (dyspareunia). The patient complains of intense itching and burning in the vulvar area. She has noticed a small amount of thick, whitish-yellow discharge in her underwear; the discharge does not have any odor. She also complains of dysuria but denies urgency, frequency, or hesitancy; she has no lower abdominal pain or fever. The patient has no chronic medical illness and takes no regular medications except oral contraceptives. She was HIV-negative when tested during a routine visit for contraception 1 year ago. She is sexually active with a new (past 3 months) male partner who uses condoms inconsistently; she has had two additional partners in the preceding year. She states that her partner has no symptoms, but she is very concerned about the possibility of an STD. She has never been pregnant; her last menstrual period was 2 weeks ago and was normal.


Differential Diagnosis










Candida vaginitis


Bacterial vaginosis (BV)


Trichomoniasis


Cervicitis/urethritis


 


Speaking Intelligently



When approaching a patient with vaginal complaints, the physician can narrow the differential diagnosis on the basis of the symptoms and characteristics of the discharge (if present). However, a specific etiologic diagnosis cannot be made without a pelvic examination and examination of vaginal secretions that includes measurement of the pH and microscopy. In the absence of symptoms suggestive of bladder irritation that would suggest urinary tract infection (urgency, hesitancy, frequency), women with dysuria may have vaginitis or urethritis; men with isolated dysuria are likely to have urethritis and may also complain of penile discharge.


 


PATIENT CARE


Clinical Thinking


• The differential diagnosis of vaginal symptoms consists mainly of infectious etiologies, although noninfectious causes of vaginal symptoms are also possible.


• Cervicitis can also present with complaints of vaginal discomfort, dyspareunia, and vaginal discharge; the differential diagnosis of cervicitis consists mainly of sexually transmitted pathogens (Neisseria gonorrhoeae and Chlamydia trachomatis); these two pathogens are also the major causes of urethritis in men.


• A focused history (including a detailed sexual history) may allow the clinician to narrow the differential diagnosis; however, as discussed above, accurate diagnosis requires pelvic examination and examination of vaginal secretions.


• The clinician should carefully address the patient’s concerns regarding the possibility of a sexually transmitted infection.


History


• The history should include the specific symptoms (vaginal/vulvar pain, irritation, itching, dysuria, dyspareunia, intermenstrual bleeding) and the characteristics of the vaginal discharge, if present.


• The history must include a detailed gynecologic history (menstrual history, pregnancy history, history of previous infections, contraceptive use) and sexual history (sexual preference, number of partners/recent new partner, symptoms in partners, types of sexual activity).


• Question the patient regarding the use of any products that may cause vaginal irritation (spermicides, lubricants, douches).


• Review the past medical history, particularly any history of diabetes or conditions associated with immunosuppression.


• In men with complaints suggestive of urethritis, obtain a detailed sexual history including history of prior infections and general medical history.


Physical Examination


• Physical examination will focus on a detailed examination of the external genitalia and a careful pelvic examination.


• Examine the external genitalia for the presence of any lesions or erythema; note the presence of inguinal adenopathy.


• Examine the urethral meatus and vaginal mucosa for evidence of erythema or lesions, and describe the appearance of vaginal secretions; take samples of vaginal secretions for pH testing and microscopic examination.


• Examine the cervix for any visible abnormalities, and obtain a sample of cervical secretions if there is evidence of cervicitis.


• Perform a bimanual examination, especially in women with evidence of cervicitis and/or complaints of lower abdominal discomfort.


• In men with symptoms suggestive of urethritis, perform a careful examination of the external genitalia and the inguinal region.


Palpate the testes, spermatic cords, and epididymis to look for tenderness or masses.


Often, discharge will be visible at the urethral meatus; obtain a sample for microscopic examination (if available) and further testing. If no discharge is present, the examiner can “milk” the urethra by holding the base of the penis between the thumb (on the ventral surface) and the index finger (on the dorsal surface) and moving the hand slowly down the shaft of the penis to the urethra with gentle pressure. If discharge still cannot be obtained, the examiner can obtain a sample by spreading the urethral meatus.


Tests for Consideration













• In women with evidence on examination of vaginitis, document the pH of the vaginal secretions using commercially available pH paper strips to test a sample of secretions collected from the lateral wall of the vaginal vault with a cotton-tipped applicator. Prepare two slides for microscopic examination (wet mount), one utilizing normal saline and the other 10% KOH; upon adding a drop of KOH to a sample of vaginal secretions, the presence of a fishy odor (positive whiff test) is supportive of a diagnosis of BV.


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• Cultures are generally not utilized in the diagnosis of vaginitis; however, microbiologic confirmation is required in patients with cervicitis and in men with urethritis; non–culture-based (DNA amplification–based) testing is most commonly utilized to confirm the diagnosis of gonorrhea (GC) or chlamydia.


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• Any patient with an STD should be screened for other STDs, including screening for HIV. In light of the recent CDC recommendation that routine HIV screening should be offered to all patients in all health-care settings at least once, screening should be offered even if the final diagnosis is not an STD.


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Clinical Entities Medical Knowledge

















Candida Vaginitis (Vulvovaginal Candidiasis)



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.


Tx


A number of topical antifungal agents (creams and suppositories) are available for the treatment of VVC; several are now available without prescription. A single 150-mg dose of oral fluconazole is also highly effective and may be preferred by many women because of ease of dosing and convenience.


Complicated VVC is defined as follows: (1) recurrent VVC (≥4 episodes per year); (2) severe symptoms or clinical findings; (3) pregnancy, poorly controlled diabetes, underlying immunosuppression; and (4) infection with a Candida species other than C. albicans. These patients should be treated with oral fluconazole every third day for three doses; patients with recurrent infection may also require long-term suppressive therapy. Only topical agents (for 7 days) are recommended for the treatment of pregnant women. See Cecil Essentials 107.


 


















Trichomoniasis



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.


Tx


Either metronidazole or tinidazole given as a 2-g single oral dose is the treatment of choice for trichomoniasis. Metronidazole (500 mg twice daily for 7 days) is an alternative. Sexual partners of patients with trichomoniasis should be treated. Occasionally trichomonads will be reported in the results of cervical cytologic examination (Pap smear). There is not uniform consensus as to the appropriate approach in such cases. Some experts recommend treatment based on these findings in women who are at high risk for an STD, while other experts believe that the diagnosis should always be confirmed by wet mount or culture. See Cecil Essentials 107.


 


















Bacterial Vaginosis



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.


Tx


The treatment of choice for BV includes metronidazole 500 mg orally twice daily for 7 days; metronidazole gel 0.75%, 5 g intravaginally daily for 5 days; or clindamycin cream 2%, 5 g intravaginally for 7 days. Treatment is effective in relieving the symptoms of BV. Additional potential benefits of treatment include reducing the risk of genital tract infection after elective termination of pregnancy and hysterectomy, and reducing the risk of acquisition of STDs including HIV. There is currently insufficient evidence to recommend routine treatment of women who are asymptomatic. BV during pregnancy has been associated with preterm labor, amniotic infection, and postpartum endometritis.


Treatment of male sexual partners of women with BV is not indicated. See Cecil Essentials 107.


 


















Cervicitis/Urethritis



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.


Tx


Once a clinical diagnosis of MPC or urethritis in men is established, a decision must be made whether to treat empirically or to wait for the results of diagnostic testing. Patients who are unlikely to follow up for the results of diagnostic testing can be treated with single-dose regimens that cover both GC and chlamydia. Treatment options for GC include ceftriaxone 250 mg IM or cefixime 400 mg orally, each given as a single dose; ceftriaxone is preferred. Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) had been previously recommended for single-dose treatment of GC, but the increasing prevalence of fluoroquinolone resistance among GC isolates in the United States prompted the CDC to remove these agents from the list of preferred therapeutics. Because the prevalence of coinfection is high, patients with GC should also be treated for chlamydia. Treatment of chlamydia includes azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days. Sexual partners must be referred for evaluation and treatment; azithromycin is preferred.


Men with persistent or recurrent symptoms should be evaluated to confirm objective evidence of urethritis. If compliance with treatment was questionable or repeat exposure to an untreated partner occurred, retreatment with the same regimen is reasonable. Otherwise the patient should be evaluated for trichomoniasis with a culture. If compliance with the initial treatment was likely and repeat exposure has not occurred, the CDC STD Treatment Guidelines recommend treatment with metronidazole or tinidazole 2 g orally as a single dose plus azithromycin 1 g orally as a single dose if azithromycin was not a component of the initial treatment regimen (it is thought that azithromycin may be more effective than doxycycline for treatment of M. genitalium infection). See Cecil Essentials 107.


 



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Oct 3, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Vaginitis and Urethritis (Case 50)

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