Differential Diagnosis:
- physiological – (neonate – sticky greyish d/c from mat. est.; thin whitish d/c 6-12 months before menarche; mid-cycle d/c with preg & OCP)
- infectious (cervicitis – gonorrhea, chlamydia; vulvovaginitis – bacterial vaginosis, yeast, trich)
- enterovaginal fistula
- foreign body
- neoplasm – vaginal SC Ca, cervical Ca, fallopian Ca
Bacterial vaginosis
- not sexually transmitted, but more common in very sexually active women
- qual/quantitative shift in normal vaginal flora (increased anaerobes, decreased lactobacilli)
- Symptoms:
- many asymptomatic; dyspareunia
- discharge: moderate amount, white/grey, homogenous/ coats vagina, fishy
- bubbles in d/c due to anaerobes
- no vulvar or vaginal inflammation
- pH > 4.7, + amine test
- saline microscopy – clue cells, coccobacilli
- Criteria for diagnosis (need 3/4):
- 1) white homogeneous d/c
- 2) vaginal pH> 4.7
- 3) fishy amine odor (with addition of 10% KOH)
- 4) clue cells
- gram stain criteria
- Not culture
- Treatment:
- metronidazole 500 mg po bid x 7 days
- metrogel 5 g pv x 6 days
- dalacin 100 mg pv x 7 days (clindamycin)
Candidiasis
- associated with pregnancy, OCP, ABx, DM, immunosuppression
- Symptoms
- vulvar pruritus, external dysuria, dyspareunia
- discharge: scant – mod, white, cottage-cheese consistency, no bubbles
- vulva/ vagina may have erythema, edema, whitish areas
- Diagnosis:
- pH < 4.5, amine test -‘ve
- saline microscopy – blastospores, pseudohyphae
- wet prep (KOH) – buds/ hyphae
- culture
- Treatment:
- topical azole derivatives (eg monostat x 10-14 days, canesten x 1-7 days) or polyenes
- single oral dose fluconazole 150 mg (or x 3 days) – GI SEs common
Trichomoniasis
- sexually transmitted protozoan
- Symptoms:
- men usually asymptomatic
- vulvar pruritus, external dysuria (due to rawness around vulva), dyspareunia
- discharge: profuse, yellow/green, homogenous, frothy, malodorous
- vagina/ vulva – erythema, edema, “strawberry cervix”
- Diagnosis:
- pH 5-6, amine test occ +
- saline microscopy – ++ PMNs, motile trichomonads, no clue cells
- wet prep (saline microscopy), culture, pap
- Treatment:
- metronidazole 2 g stat (95% cure, esp if Rx partner)
- metronidazole 500 mg bid x 7 days (teratogenic so don’t use in pregnancy)
Chlamydia & Gonorrhea — See STI Notes