STI Part 3 – Canadian Guideline

7. Vaginal Discharge (Bacterial Vaginosis, Vulvovaginal Candidiasis, Trichomoniasis)

Etiology

• The three infections most commonly associated with vaginal discharge in adult women are:
  1. Bacterial vaginosis (BV) – Not STI
     • Most common cause of vaginal discharge.
     • Characterized by an overgrowth of genital tract organisms (e.g., Gardenerella, Prevotella, Mobiluncus spp.) and a depletion of lactobacilli.
  2. Vulvovaginal candidiasis (VVC) – Not STI
     • ~ 90% of cases caused by Candida albicans; remainder caused by other Candida spp. (e.g., C. glabrata) or Saccharomyces cerevisiae.
  3. Trichomoniasis – STI
     • Caused by Trichomonas vaginalis, a protozoa.
  4. On occasion, vaginal discharge may be seen in cervicitis caused by G&C
• Non-infectious causes of vaginal discharge include the following:
  • Excessive physiologic secretions
  • Desquamative inflammatory vaginitis
  • Atrophic vaginitis (scant discharge)
  • Foreign bodies
• Non-infectious causes of vulvovaginal pruritus without discharge should also be considered:
  • Irritant or allergic dermatitis (e.g., latex, soaps, perfumes)
  • Skin disorders, such as the following:
    • Lichen sclerosus (may increase the risk of vulvar cancer)
    • Squamous cell hyperplasia
    • Lichen planus
    • Psoriasis

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Epidemiology

• Vaginal complaints are common in primary care and are among the most common reasons for gynecological consultation.

Bacterial vaginosis

• Prevalence has been estimated at 10–30% of pregnant women and 10% of family practice patients.
• BV during pregnancy is associated with PROM, chorioamnionitis, preterm labour / birth and post-cesarean delivery endometritis.
• The presence of BV during an invasive procedure: (IUD) insertion, endometrial biopsy or uterine curettage, has been associated with post-procedure PID and vaginal cuff cellulitis.
• Presence of BV is associated with increased acquisition of HIV.

Vulvovaginal candidiasis

• ~ 75% of women exp 1 episode of VVC during their lifetime, and 5–10% > 1 episode.
• The incidence of recurrent VVC (≥ 4 symptomatic episodes of VVC a year) has been estimated at 5% of women of reproductive age.
• Among HIV-positive women, lower CD4 counts and high viral loads are associated with persistent Candida colonization and an increased incidence of VVC.

Trichomoniasis

• the prevalence was estimated to range from 10–35%; Among men attending STI clinics, the prevalence has been estimated at 3–20%.
• Trichomoniasis is associated with an increased risk of HIV acquisition and transmission in women.

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Manifestations and Diagnosis

• Nonspecific s/sx, Definitive diagnosis is based on laboratory testing

Diagnostic features and laboratory diagnosis

Clue cells are vaginal epithelial cells covered with numerous coccobacilli. Culture is more sensitive than microscopy for T. vaginalis.
Sexual transmission	Not usually considered STI	Not usually considered STI	STI
Predisposing factors	Often absent sexually active New sexual partner IUD use	Often absent sexually active Current or recent antibiotic use Pregnancy Corticosteroids Poorly controlled diabetes Immuno-compromised	Multiple partners
Symptoms	Vaginal discharge Fishy odour 50% asymptomatic	Vaginal discharge Itch External dysuria Superficial dyspareunia Up to 20% asymptomatic	Vaginal discharge Itch Dysuria 10–50% asymptomatic
Signs	White or grey, thin, copious discharge	White, clumpy, curdy discharge Erythema and edema of vagina and vulva	Off-white or yellow, frothy discharge Erythema of vulva and cervix (“strawberry cervix”)
Vaginal pH	>4.5	<4.5	>4.5
Wet mount	PMNs Clue cells	Budding yeast Pseudohyphae	Motile flagellated protozoa (38–82% sensitivity)
Gram stain	Clue cells + Decreased normal flora Predominant Gram-negative curved bacilli and coccobacilli	PMNs Budding yeast Pseudohyphae	PMNs Trichomonads
Whiff test	Positive	Negative	Negative
Preferred treatment	Metronidazole Clindamycin	Antifungals	Metronidazole Treat partner; practice safe sex

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Specimen collection

• Speculum examination.
• Rule out cervicitis.
• Collect a sample of the discharge from the vaginal wall for microscopy (if microscopy is not available on-site – syndrome Rx)
• Although not a sensitive test, Gram stain may be helpful in diagnosing mucopurulent cervicitis (MPC) and gonorrhea in symptomatic females.
• A negative wet mount does not rule out an infectious cause of vaginitis.
• Culture is rarely needed in acute cases of vaginitis.

Test	Procedure	Normal result
While KOH destroys cellular debris and allows one to more clearly detect yeast cells and hyphae, it also destroys the epithelial cells in clue cells needed to diagnose BV and lyses trichomonads. Therefore, for vaginitis, saline is necessary.
pH test	Use narrow-range pH paper	pH ≤4.5
Wet mount	Place a drop of vaginal discharge on a slide; mix with a drop of 0.9% saline; apply a cover slip; examine immediately under a microscope at low and high power Examine for leukocytes, clue cells, lactobacilli, yeast and trichomonads	Epithelial cells and rare white blood cells
Whiff test/ KOH slide (optional)	Place a drop of discharge on a slide; mix with a drop of 10% KOH; an amine (fishy) odour after applying the KOH is a positive test; apply a cover slip; examine under a microscope at low and high power Examine for yeast	Negative
Gram stain		Predominantly large Gram-positive bacilli

Syndromic management of vaginal discharge

If no on-site microscopy, use the WHO algorithm for management of vaginal discharge.

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Consideration for Other STIs

• In a case of trichomoniasis, other STIs need to be considered. Specimens can be taken for the following:
  • Gonorrhea and chlamydia and Syphilis
  • HIV and Hepatitis B
• Discuss HPV vaccine with women

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Treatment of bacterial vaginosis

Recurrent bacterial vaginosis

• 15–30% of patients develop a recurrence in the first 1–3 months after treatment and need to Reconfirm diagnosis.

Treatment of recurrent bacterial vaginosis

Reporting and Partner Notification

• Bacterial vaginosis is not a reportable disease.
• Treatment of male sexual partners is not indicated and does not prevent recurrence.

Follow-up

• No follow-up is necessary unless the patient is pregnant or symptoms recur.

Special Considerations

Pregnancy

• Routine screening for BV during pregnancy is not recommended, but can screen & Tx at 12–16 weeks in high-risk pregnancies. However, symptomatic women should be tested and treated.
• Treatment of asymptomatic BV in women with a previous preterm birth may reduce the risk of preterm prelabour rupture of the membranes and low birth weight
• Treat with oral antibiotics: oral metronidazole and clindamycin are not contraindicated during pregnancy or breastfeeding.
• Topical antibiotics have no effect on preterm birth, though topical clindamycin treatment has been associated with adverse outcomes in the newborn when used in pregnancy
• Testing should be repeated after 1 month to ensure that therapy was effective.

HIV – The same therapy is recommended for HIV-positive as for HIV-negative patients.

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Treatment of uncomplicated vulvovaginal candidiasis

Complicated vulvovaginal candidiasis

• Defined as recurrent VVC, severe VVC, a non-albicans species or occurring in a compromised host.

Recurrent VVC (RVVC)

• ≥ 4 of VVC in a 12-month period.
• Confirm the diagnosis of RVVC by obtaining a vaginal culture and full identification of the isolated species, which should be used to guide therapy. Non-albicans Candidaspecies are found in 10–20% of patients with RVVC. Conventional antifungal therapy is not as effective against some of these species
• Tx requires induction, usually followed by a 6-month maintenance regimen
• For patients prone to RVVC who require a course of antibiotics, prophylactic topical or oral azoles, such as fluconazole 150 mg PO, can be given at the start of the antibiotic course and once a week during the duration of the course 

Treatment of recurrent vulvovaginal candidiasis (RVVC)

Notes:

• Duration of maintenance therapy is a minimum of 6 months. After 6 months, discontinue therapy and observe.
• Relapse rate is high, with approximately 60% of women relapsing within 1–2 months of discontinuing maintenance therapy.
• If recurrence occurs, treat the episode and then reintroduce a maintenance regimen.
• Fluconazole and boric acid are contraindicated in pregnancy.
• Oil-based ovules and creams may cause latex condoms or diaphragms to fail.

Severe VVC

• Extensive vulvar erythema, edema, excoriation or fissure formation.

Treatment of severe vulvovaginal candidiasis

Non-albicans VVC

• Most commonly due to C. glabrata, which is 10- to 100-fold less susceptible to azoles than C. albicans.

Treatment of non-albicans vulvovaginal candidiasis

Compromised host

• Corticosteroids, uncontrolled diabetes.
• C. glabrata and other non-albicans species are isolated more frequently in women with diabetes than in those without.
• Treat with a longer (10–14 day) course of an intravaginal azole OR boric acid600 mg capsule intravaginally once a day for 14 days

Reporting and Partner Notification

• Vulvovaginal candidiasis is not a reportable disease.
• Routine screening and treatment of male partners is not indicated. However, male sexual partners should be treated if Candida balanitis is present. Use a topical azole cream twice a day for 7 days.

Follow-up

• No follow-up necessary unless symptoms persist or recur.
• Consider C&S of yeast if not responding to appropriate therapy or if infection recurs.

Special Considerations

Pregnancy

• Only topical azoles are recommended for treatment of vulvovaginal candidiasis during pregnancy. Treatment for 7 days may be necessary.

HIV

• The treatment of candidiasis is the same in HIV-positive as it is in HIV-negative individuals.
• Vaginal candidiasis is often recurrent and more severe in HIV-positive women and, in some cases, will require more aggressive and long-term therapy.

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Treatment of trichomoniasis

Reporting and Partner Notification

• Trichomoniasis is a reportable disease in some jurisdictions.
• Current partners should be treated for trichomoniasis, regardless of symptoms (it is not necessary to screen partners for trichomonas). The majority of men infected with T. vaginalis are asymptomatic, but some may have mild urethritis. Treat sexual partners with the same therapy as recommended for the case.

Follow-up

• No follow-up necessary unless symptoms recur; usually due to reinfection.
• Prevalence of metronidazole-resistant T. vaginalis estimated at 5%. Usually responds to high-dose metronidazole.

Special Considerations

Pregnancy

• Trichomoniasis may be associated with premature rupture of the membranes, preterm birth and low birth weight.
• Symptomatic pregnant women should be treated with metronidazole 2 g PO in a single dose for symptom relief. An alternative treatment is metronidazole 500 mg PO bid for 7 days.
  • It is not known whether treatment will improve pregnancy outcomes
• It is not recommended that asymptomatic pregnant women be treated
• Metronidazole is not contraindicated during pregnancy or breastfeeding.

HIV – The same therapy is recommended for HIV-positive as for HIV-negative patients.

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The Use of Live Lactobacilli to Restore Normal Vaginal Flora

• Lactobacilli preparations are commonly used in the treatment of BV and VVC. One small randomized trial in healthy women showed that the use of oral Lactobacilli was safe and resulted in increased vaginal Lactobacilli and decreased yeast as compared to the placebo group.
• However, in a more recent, well-conducted randomized, controlled trial of 278 women, oral and vaginal L. rhamnosus was ineffective in the prevention of post-antibiotic VVC.
• Two randomized, controlled trials have studied the use of a topical L. acidophilus–low dose estriol combination, one in the management of BV, the other for several infections (BV, VVC, trichomoniasis). Both showed a statistically significant greater reduction in symptoms and microscopic restoration of normal flora than the placebo group.

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Reference: http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-4-8-eng.php