1. Vaginal Infections
NURS 541: Women’s Healthcare – Diagnosis and Management

2. Let’s talk normal… Normal vaginal discharge
Contains predominantly Lactobacilli, Döderlein’s bacilli
pH –
Clear to white discharge
Thin/mucoid
Dependent on menstrual cycle
No odor, itching, burning, or discomfort

3. Common Vaginal Discharge Concerns
#1: Bacterial vaginosis (BV)
#2 Candida vulvovaginitis
#3 Cervicitis (usually chlamydia)
#4 Excessive but normal secretions
#5 Trichomoniasis
#6 Atrophic vaginitis
Carcio & Secor, 2015

4. Vaginal Infections: Presenting Concern
Abnormal discharge
Dysuria
Itching
Vaginal odor
Burning
Vulvar ulceration
Dyspareunia

5. Vaginal Infections: History
OLDCARTS
Risk of pregnancy?
Onset
Previous history of vaginal infections?
Location
Duration
Risk for sexually transmitted infections?
Character
Aggravating factors
Partner assessment
Relieving factors
Condom/barrier use
Timing
Exposure?
Severity
Menstrual history

6. Vaginal Infections: Physical Exam
Abdomen: assess for pain, tenderness, guarding
Pelvic exam:
External genitalia: look for discharge, irritation, ulcers, lesions
Vagina: look for discharge, lesions, irritation; note any odor
Cervix: look for discharge, lesions; check for cervical motion tenderness
Uterus/adnexae: note any tenderness, abnormalities
Lymphadenopathy: assess inguinal lymph nodes

7. Vaginal Infections: Labs
Sample of vaginal discharge
Wet prep/mount
Vaginal DNA probe
STI screening
Chlamydia/gonorrhea NAAT
Other testing if high risk

8. Wet mount for vaginal specimens
Preparation of the slides
One saline prep
One KOH prep
Use KOH to detect amine odor (whiff test)
Test pH of discharge while preparing or during exam

9. Wet mount reading
Assess for clue cells, hyphae, yeast buds, trichomonas, WBCs

10. Bacterial Vaginosis (BV)
Most often caused by Gardnerella or other anaerobic bacteria
Signs/Symptoms
Thin, homogenous, grey-white discharge
Mild itching (if any)
Odor, especially after intercourse
Occasional pain with intercourse
Exam/lab findings
Negative exam, except for discharge (above) and odor
Presence of clue cells, pH >4.5, amine odor (positive whiff)

11. Bacterial Vaginosis (BV)
Amsel’s criteria
Need three of the four:
White, thin, adherent discharge
pH > 4.5
Positive whiff test
Clue cells on wet mount (more than 20% of epithelial cells are clue cells)

12. Wet mount reading

13. Bacterial Vaginosis (BV)
Treatment options for BV
Metronidazole 500mg orally BID x 7 days
Metronidazole gel 0.75% vaginally QD x 5 days
Clindamycin cream 2% vaginally at HS x 7 days
Pregnant women
Metronidazole 250mg orally TID x 7 days
Clindamycin 300mg orally BID x 7 days

14. Vulvovaginal Candidiasis
Most often caused by Candida albicans
Signs/Symptoms
Thick, curd-like white discharge
Significant itching or burning
No odor
Exam/lab findings
Vulvar or vaginal irritation/redness
Yeast buds/hyphae on wet mount
pH < 4.5

15. Wet mount reading

16. Vulvovaginal Candidiasis
Treatment options
OTC treatments (Monistat, Gyne-Lotrimin, etc)
Miconazole 2 or 4% cream intravaginally for 3 or 7 days
Butoconazole 2% cream intravaginally for 3 days
Clotrimazole 1 or 2% cream intravaginally for 3-7 days
Terconazole 0.4% cream intravaginally for 7 days
Fluconazole 150mg orally x 1

17. Trichomoniasis
Protozoan infection of the vagina – Trichomonas vaginalis
Technically an STI, but presents as a vaginal infection
Signs/Symptoms
Sometimes asymptomatic
Yellow-green frothy malodorous discharge
Irritation of the vulva/vagina/urethra
Dyspareunia, dysuria, itching
Discharge/irritation worsens during and after menstruation

18. Trichomoniasis Exam/lab findings Management
Wet mount with protozoa seen, must be motile for diagnosis
pH > 4.5
Characteristic discharge
Management
Metronidazole 2gm orally x 1 dose (preferred), or
Metronidazole 500mg orally BID x 7 days
Treatment of sexual partners (technically an STI)
Abstinence from intercourse x 7 days or until asymptomatic

19. Wet mount reading

20. Quick Note: Bartholin’s Cyst
Bartholin’s glands located in vulvar vestibule (at introitus)
Obstruction of duct = Bartholin’s cyst
Presents as non-tender mass on one side of vulvar vestibule
Infection of cyst = Bartholin’s abscess
Presents with varying amounts of pain, tenderness
Systemic symptoms rare
Most spontaneously rupture within 3-4 days
May require incision and drainage