Vaginitis – CANADIAN Guideline 2013

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:
  1. physiologic d/c & cervical mucus production
  2. 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
    • 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

  1. Vestibule thin, dry, pale, mildly erythematous
  2. Menopause, anorexia, prolonged breast feeding pt
  3. 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
  4. 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

 

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Posted in 97 Vaginitis, 99 Priority Topics, FM 99 priority topics, Gyne
One comment on “Vaginitis – CANADIAN Guideline 2013
  1. Tao says:

    Fluconazole 150mg PO x1 is not contra-indicated during pregnancy. It is category C. Source: uptodate

    Like

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