1 In patients with recurrent symptoms of vaginal discharge and/or perineal itching, have a broad differential diagnosis (e.g., lichen sclerosus et atrophicus, vulvar cancer, contact dermatitis, colovaginal fistula), take a detailed history, and perform a careful physical examination to ensure appropriate investigation or treatment. (Do not assume that the symptoms indicate just a yeast infection.) – See OSCE post for hx and PEx
Vaginal D/c ddx:
- physiologic d/c & cervical mucus production
- Non-physiologic
- Genital tract infection or inflammation (non-infection)
- Vulvovaginitis: candidiasis, trichomoniasis, BV, polymicrobial superficial infection
- G & C
- Salpingitis / pyosalpinx
- Local: chemical irritants, douches, sprays, FB, trauma, atrophic vaginitis, desquamative inflammatory vaginitis, focal vulvitis
- neoplasia:
- vulvar ca (average age >65 –
- 1) squamous associated with HPV,
- 2) Paget dz with red lesions in postmenopausal white women & associated with GI /GU/breast ca,
- 3) Melanoma –
- dx confirmed by biopsy & Tx with vulvectomy + node excision
- vaginal, cervical, endometrial
- vulvar ca (average age >65 –
- Systemic: toxic shock syndrome, Crohn’s dz, collagen dz,
- dermatologic – lichen sclerosis (bluish-white papula → white plaque → Thin parchment-like skin → sub epithelial fat is diminished → thin atrophic labia)
- usually in postmenopausal women, dx confirmed by Biopsy
- Tx: potent topical steroids (0.05% clobetasol ointment qhs x 6-12 wk then 1-3x/wk maintenance)
- IUD, OCP (due to progesterone)
Vaginal atrophy
- Vestibule thin, dry, pale, mildly erythematous
- Menopause, anorexia, prolonged breast feeding pt
- Tx: a trial of non hormonal vaginal lubricants & moisturizers (Replens / KY jelly) for dyspareunia / vaginal dryness
- if fails, low-dose vaginal estrogen is recommended (see menopause post)
- Premarin 0.625mg conjugated estrogen / g of cream – 0.5 of cdm intravaginally 2x/wk
- Vagifem 10mcg estradiol tabintravaginally daily x 2wk then 2x/wk
- Estring – 7.5mcg of estradiol daily over 90days
- Estrace – 100 mcg estradiol/g of crm, 2-4g daily x 1-2 wk then gradually half dose; maintenance: 1g intravaginally 1-3x / wk
- Progesterone protection not required if + hysterectomy (debatable with intact uterus – see postmenopausal post)
- Caution with breast ca pt
- Progressive mechanical vaginal dilatation (vaginal dilators)
2 In patients with recurrent vaginal discharge, no worrisome features on history or physical examination, and negative tests, make a positive diagnosis of physiologic discharge and communicate it to the patient to avoid recurrent consultation, inappropriate treatment, and investigation in the future.
Physiologic d/c:
- Clear white flocculent odourless d/c: ph 3.8 – 4.2
- Smear contains epithelial cells, Lactobacilli
- ↑ with ↑ estrogen states: pregnancy, OCP, mid-cycle, PCOS, premenarchal
- If ↑ in perimenopausal / postmenopausal woman, consider investigation for other effects of xs estrogen (eg. endometrial cancer)
3 When bacterial vaginosis and candidal infections are identified through routine vaginal swab or Pap testing, ask about symptoms and provide treatment only when it is appropriate. – SEE STI PART 3 POST: https://ccfpprep.wordpress.com/2014/12/10/sti-part-3-canadian-guideline/
Treatment of bacterial vaginosis
Asymptomatic – Treatment is unnecessary except in cases of:
- High-risk pregnancy (history of preterm delivery)
- Prior to IUD insertion
- Prior to gynecologic surgery, therapeutic abortion or upper tract instrumentation
Symptomatic
- Metronidazole 500 mg PO bid for 7 days
- Metronidazole gel 0.75%, one applicator (5 g) once a day intravaginally for 5 days
- Clindamycin cream 2%, one applicator (5 g) intravaginally once a day for 7 days
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.
Treatment of uncomplicated vulvovaginal candidiasis
Asymptomatic – Treatment is unnecessary
Symptomatic
- Intravaginal, over-the-counter azole ovules and creams (e.g., clotrimazole, miconazole)
- Fluconazole 150 mg PO in a single dose. (Contraindicated in pregnancy)
- Topical and oral azoles are equally effective, Oil-based ovules and creams may cause latex condoms or diaphragms to fail.
- In most cases, expect resolution of symptoms in 2–3 days
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)
Induction treatment
- Fluconazole 150 mg PO once every 72 hours for three doses – Contraindicated in pregnancy
- Topical azole for 10–14 days
- Boric acid 300–600 mg gelatin capsule intravaginally once a day for 14 days. Less mucosal irritation experienced when 300 mg used. Contraindicated in pregnancy
Notes:
- Each individual episode of RVVC caused by C. albicans usually responds to a course of oral or topical azoles, with a longer course usually more effective than a shorter one.
- Without maintenance therapy, VVC recurs in 50% of patients within 3 months. Start maintenance therapy as soon as initial treatment has been completed.
Maintenance treatment
- Fluconazole 150 mg PO once a week
- Ketoconazole 100 mg PO once a day
- Patients receiving long-term ketoconazole should be monitored for hepatotoxicity
- Itraconazole 200–400 mg PO once a month
- Clotrimazole 500 mg intravaginally once a month
- Boric acid 300 mg capsule intravaginally for 5 days each month beginning the first day of the menstrual cycle
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
- Fluconazole 150 mg PO once every 72 hours for two doses. Contraindicated in pregnancy
- Topical azole for 10–14 days
4 In a child with a vaginal discharge, rule out sexually transmitted infections and foreign bodies. (Do not assume that the child has a yeast infection.)
Prepubertal Vulvovaginitis
Clinical Features
- Irritation – vulvar erythema, pruritis, d/c
- Vaginal bleeding (specifically due to GAS & shigella)
DDx
- Non-specific vulvovaginitis (25-75%), psychosomatic vaginal complaints (specific to vaginal d/c)
- Infections (respiratory, enteric, systemic, sexually acquired), Candida (if using diapers), Pinworms
- FB (Toilet paper most common), Trauma (accidental straddle injury, sexual abuse)
- Polyps, tumour (ovarian malignancy)
- Vulvar skin dz (lichen sclerosis – area of white patches & thinning of skin, condyloma aruminata)
- Specific vaginal bleeding: Endocrine abnormalities & blood dyscrasia
Etiology
- Infectious:
- poor hygiene, proximity of vagina to anus,
- recent infection (respiratory, enteric, systemic),
- STI – investigate sexual abuse
- Nonspecific:
- Lack of protective hair & labial fat pads
- lack of estrogenization
- Susceptible to chemicals, soaps (bubble baths), medications & clothing
- Enuresis
Ix:
- Vaginal swab for Cx (specify that it is a Pre-pubertal specimen)
- Cellophane tape test – Pinwarms
Tx
1) Enhanced hygiene & local measures: (no evidence link vulvovaginal candidiasis & hygienic habits / wearing tight / synthetic clothing)
- hand washing, sitz baths, avoid bubble baths,
- white cotton underwear, no nylon tights, no tight fitting clothes, no sleeper pyjamas,
- use mild detergent, eliminate fabric softener,
- avoid prolonged exposure to wet bathing suits, urination with legs spread apart
2) Vitamin A&D dermatological ointment to protect vulvar skin
3) Infectious: Tx with Abx for organism identified
4) Pinwarms: Empirical Tx with mebendazole
5) Lichen Sclerosis: Topical steroid creams
6) FB: Irrigation of vagina with saline, may require local anesthesia or an exam under anaesthesia
5 In a child with a candidal infection, look for underlying illness (e.g., immunocompromise, diabetes).
Candidiasis
- Candida albicans / glabrata / tropicalis
Predisposing factors:
- Immunosuppressed host: DM, AIDS etc
- Recent abx use
- Increased estrogen levels: pregnancy, OCP
S/Sx: – 20% asymptomatic
- Intense pruritis, vulvar burning, dysuria, dyspareunia
- Swollen, inflamed genitals
- D/C: white, cottage cheese, minimal
- pH ≤ 4.5
- Saline wetmount: KOH wetmount – hyphae & spores
Tx
- Clotrimazole, miconazole suppositories (pregnancy) / crm for 1/3/7d
- Fluconazole 150mg po x 1 (ok in pregnancy?)
- Prophylaxis for recurrent infection: boric acid, vaginal suppositories, luteal phase fluconazole
- Tx of partner not recommended
References:
- TN2014
- Canadian STI guideline 2013
- UpToDate 2015
Preparing for the CCFP Exam 2015 
Fluconazole 150mg PO x1 is not contra-indicated during pregnancy. It is category C. Source: uptodate
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Oral azoles are contraindicated in pregnancy. Topical creams and vaginal tab azoles are not contraindicated due to low systemic absorbtion.
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