A 31-year-old female, with a medical history of asthma, presents with vaginal pain. She states that yesterday she noticed vaginal pain and discovered ulcers in her vagina. She also endorses scant amount of white foul-smelling discharge and vaginal itching. She endorses vaginal spotting over the past 2 days. Of note, she states that she was seen by her gynecologist four days ago for a routine follow-up and was diagnosed with bacterial vaginosis (due to white, foul smelling discharge on exam) and started on metronidazole, which she has been taking over the past 2 days. She endorses chills last night. She denies nausea, vomiting, chest pain or shortness of breath, abdominal pain, constipation diarrhea, dysuria, or hematuria.
Exam reveals two shallow, circular ulcers, about 1.5 cm in diameter, on bilateral vaginal walls, cervical erythema, white/grey clumpy discharge consistent with vaginitis secondary to yeast infection.
Her urinalysis is positive with 53 WBCs and moderate leukocyte esterase.
She is prescribed keflex 500 mg q12h x 7d and fluconazole 150 mg x1 in the ED with a script for a 2nd dose of 150 mg in 72 hrs.
Case follow-up:
Patient was seen by her gynecologist the following day and reported improvement in urinary symptoms and decreased vaginal discomfort. Her provider instructed the patient to continue the prescribed antibiotics and to return in 2 weeks.
What are common causes of vaginitis?
Chlamydia:
Most common STD, >1.4 million cases per year
Obligate intracellular organism, 50-70% of infected patients are asymptomatic
Presents with scant mucoid uretheral discharge, mucopurulent cervical discharge, postcoital bleeding. If untreated may progress to pelvic inflammatory disease (PID) or orchitis
Diagnosis: Nucleic acid amplification test (sens 90% spec 99%)
Treatment: Azithromycin 1 gm PO, or doxycycline 100 mg BID x 7days (Azithromycin in pregnancy), PID is a 14d course
Gonorrhea:
2nd most common STD, >300,000 cases per year. More common among younger/high risk sex people
Gram negative, intracellular diplococci; incubation period 3-7 days
Presents with copius purulent uretheral discharge, vag discharge, dyspareunia, intermenstrual bleeding, proctitis (rectal pain, tenesmus, rectal discharge, bleeding), gonococcal pharyngitis (erythema, sore throat, lymphadenopathy). Some are asymptomatic for long periods.
Disseminated gonococcal infection (DGI) – hematogenous spread, petechial rash, polyarthalgia, tenosynovitis, septic arthritis. Rarely – hepatitis, meningitis, myocarditis.
Diagnosis: Gram stain of secretions or nucleic acid amplification
Treatment: Ceftriaxone 250 mg IM x1. DGI and arthritis get ceftriaxone IV 1 gm QD
Trichomoniasis:
Most common curable STD worldwide.
Trichomonas vaginalis – flagellated protozoan
Women more symptomatic than men, but can also be asymptomatic. Has been associated with PID, preterm birth, prostatitis, epididymitis, and increased susceptibility to HIV infection
Presents with vaginal discharge (malodorous, frothy, greenish), pruritis, dysuria, frequency, dyspareunia, and post-coital bleeding. Vulva/mucosa erythema, cervical punctate hemorrhage (Strawberry Cervix) ~ 10%.
Diagnosis: examination of wet mount slide – flagellated trichomonas and leukocytes (sens 50% spec 65%), nucleic acid amplification test, culture
Treatment: indicated in symptomatic and asymptomatic patients, metronidazole or Tinidazole 2 gm PO x1 (90-95% cure rates) OR metronidazole 500 mg BID x7 days. Avoid ETOH when taking metronidazole - disulfiram reaction)
Bacterial Vaginosis
Most common cause of abnormal vaginal discharge in the US. Not an STD.
Caused by alteration of normal flora, and replacement of lactobacillus species by polymicrobial organisms such as Gardnerella vaginalis and anaerobes.
Presents with malodorous thin white discharge. Fishy odor (10% KOH – whiff test), PH > 4.5, clue cells. Associated with increased risk for PID and preterm rupture of membranes and preterm delivery.
Treatment: Metronidazole 500 BID x 7 days OR metronidazole gel 0.75% g5 intravaginally at bedtime x 7d
Vulvovaginal Candidiasis
~75% of women will experience at least 1 episode over their lifetime
Caused by Candida albicans, Not considered an STD
Presents with pruritus, abnormal discharge, dyspareunia, dysuria.
Pelvic exam will reveal vulvar erythema and edema with sattelite lesions, erythema of vaginal mucosa, and thick curdy white discharge.
Diagnosis: Wet mount – budding yeast, culture, usually clinical
Treatment: multiple azole drugs recommended (Clotrimazole, terconazle, etc…) x7 days OR Fluconazole 150 mg PO x1 (contraindicated in pregnancy). May repeat x1 in 72 hrs for complictaed/severe cases.
Bonus: How do the urine and swab tests for gonorrhea/chlamydia compare?
It appears that both tests are highly specific and sensitive when testing in high-risk groups:
"Sensitivity for cervical swabs and urine samples with the BDPT were 89.0% (95% CI 78.8, 98.6) and 90.2% (95% CI 78.1, 95.5), respectively. The corresponding values for specificity were 99.2% (95% CI 98.3, 100) and 98.3% (95% CI 96.4, 100)."
Vladimir Kotelnik, MD is a current third year resident at Stony Brook Emergency Medicine.
References:
Haugland, S., Thune, T., Fosse, B., Wentzel-Larsen, T., Hjelmevoll, S. O., & Myrmel, H. (2010). Comparing urine samples and cervical swabs for Chlamydia testing in a female population by means of Strand Displacement Assay (SDA). BMC women's health, 10, 9. doi:10.1186/1472-6874-10-9
Edited by Bassam Zahid, MD