1. Common Causes of Cervicitis & Vaginitis
Dana Sprute, MD, MPH
UT Austin Dell Medical School Family Medicine Residency
December 2016

2. Objectives
Understand the common etiologies of cervicitis & vaginitis, both infectious and noninfectious.
Understand the basics of the microscopic exam and be able to identify common vaginal pathogens on microscopy exam.
Know the common treatments for cervicitis & vaginitis in nonpregnant and pregnant women.
Identify infections that require additional STI screening.

4. Are vaginal symptoms ever “normal”?
Few primary studies and most of low quality.
Quantity and quality of vaginal discharge varies considerably across women and during the menstrual cycle.
Some of the symptoms associated with vaginal abnormalities are found in well women.

5. Vaginal symptoms are very common Schaaf et al
Vaginal symptoms are very common Schaaf et al. Arch Intern Med 1990, 150.
The presence or absence of a microbe corresponds poorly with the presence or absence of symptoms.
Clinicians confront symptoms for which there is no obvious cause.
Most women think the vagina should be “dry.”
Among women who accepted that vaginal wetness is normal, there is no agreement about the timing, color or characteristics of discharge.

6. Accuracy of Telephone Triage Allen-Davis et al. OG 2002;99.
26% who called to get refills were treated for similar symptoms in the previous 4 months without exam.
No specific symptoms allow triage personnel (by phone) or clinicians (by visual inspection) to correctly diagnose vaginitis with high degree of certainty.
Telephone triage should be discouraged.***

7. Women with Vaginal Discharge
Type of Vaginitis
Percentage
Normal
30%
Bacterial vaginosis
23-50%
Candida vaginitis
20-25%
Trichomoniasis
20%
Mixed or other STI

8. Common Etiologies Bacterial Vaginosis Candida Trichomonas vaginalis
Gardnerella vaginalis
Mycoplasma hominis, Bacteroides species, mobiluncus species
Candida
Albicans
Glabrata
Tropicalis
Trichomonas vaginalis
Other STIs:
Chlamydia
Gonorrhea
Mycoplasma genitalium (rare)
Allergic vaginitis
Atrophic vaginitis
Lichen planus & lichen sclerosis
Foreign body: tampons, contraceptive devices, pessary, other

9. Appropriate Diagnostic Testing
Might include:
KOH/Wet Prep
Urinalysis
Vaginal Culture or PCR testing
STI screening:
Chlamydia
Gonorrhea
HIV
Hepatitis
Syphilis
Screening for other medical conditions:
Diabetes
Other immunosuppression

10. How to do a Wet Prep & KOH

13. How to do a Wet Prep
Use a cotton-tipped applicator applied to swab vaginal side-wall & culdesac for vaginal discharge.
Place the sample of discharge into normal saline (not water); approximately 3 drops.
Place drop of the suspension on a slide, cover with cover-slip, and carefully examine with the low-power and high-dry objective lenses.
Observe for:
presence & number of white blood cells (WBCs)
Trichomonads, candidal hyphae, or clue cells.
Trichomonads are motile, pear-shaped organisms with active flagella, larger than a WBC but smaller than epithelial cells, that are usually seen swimming or thrashing around in the wet prep.
Clue cells are epithelial cells that have bacteria adhered to their surface, obscuring their borders and causing a stippled appearance.
Yeast or hyphae may be seen on the wet prep.

14. How to Do a KOH
Add a drop of KOH solution to a drop of saline suspension of the discharge.
The KOH lyses epithelial cells in 5 to15 minutes (faster if the slide is warmed briefly over a flame) and allows easier visualization of Candidal hyphae.
Observe for:
Amine release: the "whiff" test; done by placing a drop of KOH on a slide of the wet prep and smelling for a foul, fishy odor. The odor is indicative of anaerobic overgrowth or infection (e.g., bacterial vaginosis or trichomoniasis)
A KOH slide may be made by adding the KOH to the wet prep slide, provided it does not dry out excessively.
Look for hyphae.

15. Diagnostic Values for DDX of Vaginal Infxn
Diagnostic Criteria
Normal
Bacterial Vaginosis
Trichomonas Vaginitis
Candid Vulvovaginitis
Vaginal pH
3.8 – 4.2
> 4.5
< 4.5 (usually)
Discharge
White, thin, flocculent
Thin, white, gray
Yellow, green, frothy
White, curdy, “cottage cheese”
Amine “whiff test”
Absent
Fishy
Microscopy
Lactobacilli, epithelial cells
Clue cells, adherent cocci, no WBCs
Trichomonads, WBCs>10/hpf
Budding yeast, hyphae, pseudohyphae

19. Case 1 32yo asymptomatic female for WWE and PAP
PAP results returned to you with normal epithelial cells, no dysplasia
Bacterial vaginosis noted
Should you treat if asymptomatic?
Any other testing needed?

20. Bacterial Vaginosis 10-30% of vaginitis in childbearing aged women.
Symptoms may include cystitis, odor, pruritis, vaginal discharge
Decrease in normal lactobacilli and increase in gardnerella vaginalis, mycoplasma hominis and anaerobes (mobiluncus, bacteroides, peptostreptococcus species).
Amsel criteria:
Fishy odor; positive amine release on KOH (whiff test)
Positive whiff test is 93% specific
Milky, homogenous, adherent discharge
pH greater than 4.5.
Presence of clue cells
3 of 4 signs present = 90% likelihood of BV

24. Complications of BV Hainer BL et al . AFP: 4/1/11, Vol 83(7): 807-815
Causal relationship between BV and:
endometrial bacterial colonization
Endometritis
postpartum fever
post-hysterectomy vaginal cuff cellulitis
postabortal infection.
BV is a risk factor for:
HIV acquisition and transmission.
HSV-2, gonorrhea and chlamydial infection.
pelvic inflammatory disease (PID), but it is not clear if it is an independent risk factor for this disease.
Pregnant women with BV are at higher risk of preterm delivery.

25. BV: Special Considerations AFP: 4/1/11, Vol 83(7): 807-815
Pregnancy:
BV is a risk factor for preterm labor and perinatal infection.
No evidence to support routine screening in pregnancy.
Treat to reduce risks as above.
Recurrent Infection:
Recurrence is common (15-30%).
Treat for days
Counsel on sexual practices & consider treating male partner

26. Bacterial Vaginosis STD: Summary of 2015 CDC Treatment Guidelines
CDC guidelines recommend treatment to reduce symptoms and prevent infectious complications in pregnancy (e.g., preterm labor)
Treatment may decrease HIV transmission
Treatment:
Metronidazole 500mg BID x 7days; most effective.
Metronidazole vaginal 0.75% daily x 5days
Clindamycin 2% cream QHS x 7days
Metronidazole 2gm PO single dose NOT recommended due to failure rate

27. Treating BV in Pregnancy Hainer BL et al
Treating BV in Pregnancy Hainer BL et al . AFP: 4/1/11, Vol 83(7):
BV present in up to 20% of pregnant women
All pregnancy women with BV should be treated. Oral treatment is effective and not associated with adverse fetal or obstetrical effects.
Treatment options include:
Metronidazole 500 mg orally twice daily for seven days
Metronidazole 250 mg orally three times daily for seven days
Clindamycin 300 mg orally twice daily for seven days
The Centers for Disease Control and Prevention no longer discourage the use of metronidazole in the first trimester.
CDC does not recommend routine BV screening in pregnancy.

28. Case 2
26yo female with complaint of dysuria, vulvar pruritis & thick white vaginal discharge for two weeks
Other history?
Normal external exam

32. Candidiasis Hainer BL et al; AFP: 4/1/11, Vol 83(7): 807-815
Represents approximately 25% of vaginitis.
Etiologies:
Candida Albicans: most common
C. Glabrata: less common & more resistant
C. Tropicalis : less common & more resistant
Risk factors:
Recent antibiotic use
Diabetes, uncontrolled
HIV/AIDS, other immunocompromise

33. Candidiasis Signs: Symptoms:
Thick, white (curdish) cervical discharge
Vulvovaginal erythema, edema, irritation
Symptoms:
Vulvovaginal pruritis (50%)
Vulvovaginal swelling (24%)
Dysuria (33%)
Uncomplicated: sporadic, mild, c. albicans, normal immune system.
Complicated: recurrent, severe infxn, species other than c. albicans, uncontrolled diabetes, HIV, other immunosuppression, pregnant

37. Candidiasis Treatment: Recurrence:
Multiple (see article): topical or oral antifungal
Diflucan is Category C in pregnancy
Severe: Diflucan 150mg PO (2 doses three days apart)
Severe vulvovaginitis: combo of low-dose topical steroid & topical antifungal
Recurrence:
Definition: > 4 infections in one year
Recurrence Tx:
Diflucan 150mg PO (2 doses 3days apart); then daily for 7-14 days; then maintenance
Maintenance:
Diflucan 150mg PO weekly for 6 months
Clotrimazole 100mg vag tablet weekly for 6 months
Control underlying medical condition (eg, T2DM, HIV)

38. Case 3
45 yo female presents with complaint of a fishy odor for one month.

42. Trichomonas 20% of vaginitis
Etiology: trichomonas vaginalis, a flagellate protozoan
Transmission: contact with vaginal or urethral discharge (usually by sexual intercourse, but can occur with fomites)
Risk factors:
Sexual activity.
Coexists with gonococcal infection (up to 40%) and bacterial vaginosis
May facilitate HIV infection
Occurrence:
Highest in women aged 16-35
20% of women are infected sometime in their life.

43. Trichomonas Symptoms: Signs:
Asymptomatic (common) and can live in the genital tract for years.
Cystitis, prostatitis
Signs:
Profuse, thin, yellow-green, foamy foul smelling discharge
Small petechial “strawberry spots” on cervix

47. Trichomonas Treatment: Asymptomatic women should be treated
Need to screen for other STIs:
Gonorrhea: associated co-infection
HIV: increased transmission risk
Chlamydia
Consider syphilis screening
Consider hepatitis screening

49. Case 4
18 yo female told by male sexual partner “you need to get checked”
She denies any symptoms
This is her cervical exam
Now what?

51. Chlamydia Cervicitis

52. Chlamydia Symptoms: Asymptomatic (up to 70% in women & 25% in men)
Pruritis, dysuria, increased vaginal/urethral discharge
Signs:
Normal exam
Mucopurlent discharge from cervix, urethra
Etiology: Chlamydia trachomatis
Transmission:
Unprotected sexual intercourse
Incubation period: 7-14 days (or longer)
Diagnosis:
Gen probe; ThinPrep genetic amplification
Urine PCR
Treatment:
Azithromycin 1gm single dose
Doxycyline 100mg BID x7days
Screen for other STIs: GC, HIV, hepatitis, syphilis

53. Case 5
20 yo female told by male sexual partner “you need to get checked”
She denies any symptoms except minor sore throat on ROS
This is her cervical exam
Now what?

58. Gonorrhea Gonococcal Infections, CDC, Division of STD Prevention, 7/27/16
Symptoms:
Asymptomatic (up to 90% in women & 10% in men)
Pruritis, dysuria, increased vaginal/urethral discharge
Signs:
Normal exam
Mucopurulent discharge from cervix, urethra
Menorrhagia
Etiology: Neisseria gonorrhoeae
Transmission:
Contact with exudates from mucous membranes of infected individuals, usually sexual intercourse
Incubation period: 2-7 days (or longer)
10-20% of females with GC cervicitis have GC pharyngitis
GC pharyngitis more difficult to eradicate than urogenital/rectal GC

60. Antibiotic Resistant Gonorrhea Mayor MT et al
Antibiotic Resistant Gonorrhea Mayor MT et al. Diagnosis & Management of Gonococcal Infections, AFP 86(10), 11/15/12
Natural history of resistance:
Early 2000s, ciprofloxacin resistant GC in Hawaii & West Coast
2004, cipro resistant GC infection in MSM
2006, 14% of GC isolates are cipro resistant
2007, fluoroquinolones not recommended by CDC
2011, 30% of isolates are PCN, tetracycline, cipro resistant
CDC dual treatment recommendations for GC (updated 8/2012, 6/2015)

61. Gonorrhea Gonococcal Infections, CDC, Division of STD Prevention, 7/27/16
Diagnosis:
Culture, gram stain
Gen probe; ThinPrep genetic amplification
DUAL THERAPY: Recommended regime:
Ceftriaxone 250mg IM once PLUS
Azithromycin 1000mg PO single dose
Doxycycline NOT recommended due to tetracycline resistance
Need TOC for pharyngeal GC if treated with alternative Rx (not dual therapy above)
Screen for other STIs

62. Case 6
29 yo female with two weeks of vulvar pruritis and minor dysuria
This is her external exam

63. Allergic or Irritant Contact Vaginitis AFP: 4/1/11, Vol 83(7): 807-815
Common Causes:
Hygiene products, perfumed products (toilet paper, sprays), douching, condom lubricants (nonox-9)
Treatment:
Avoid offending agent
Topical low potency steroid creams for short duration.

64. Case 7
72 yo female with one month of vulvar irritation, pruritis, dysuria
Does she need an exam?

66. Atrophic Vulvitis/Vaginitis

67. Atrophic Vaginitis AFP: 4/1/11, Vol 83(7): 807-815
Due to loss of estrogen at peri/menopause.
Physiologic changes:
Thinning of vaginal epithelium
Loss of glycogen which leads to pH & flora changes
Atrophy diagnosed by:
Symptoms: vaginal irritation, dyspareunia, fragility
Thin, clear or bloody discharge
Vaginal pH 5-7
Loss of vaginal rugae
Parabasal epithelial cells on wet prep microscopy (or may note this on PAP report).
Treatment:
Estrogen: topical cream, ring or tablet
Estrace (cream, ring), Estrogel, FemRing, Premarin cream
Estrogen agonist: Osphena (ospemifene)
Vaginal lubricants & moisturizers: Astroglide, Replens

69. Case 8
68 yo female with vulvar rash for two months

70. Lichen Planus & Lichen Sclerosus
Vulvar lichen sclerosus (LS) and lichen planus (LP) are fairly common, non‑cancerous skin conditions that can occur in the skin on any part of the body.
Can affect children as well as adults.
Changes are not cancer, but rarely over many years, may transform to squamous cell cancer.
Changes in the skin of vulva include a slowly developing inflammation of vulvar skin that can be controlled by treatment but not cured.

71. Pediatric Lichen Planus

72. Lichen Planus

73. Lichen Sclerosus

74. Lichen Sclerosus

75. Lichen Planus & Lichen Sclerosus
Symptoms:
Skin in affected area is itchy and sore
Skin becomes more fragile than normal skin and may split, causing stinging and pain.
Vulva may become distorted, causing a change in its shape or size. Occasionally, this leads to difficulties with passing urine or having sexual intercourse.
Vagina may become narrowed; sexual intercourse may become uncomfortable.
Symptoms vary from woman to woman; some women are asymptomatic and LP/LS is discovered during medical exam for other health problems.
Cause is unknown but more common in :
Older women
Auto-immune DO, thyroid DO or pernicious anemia.
Not due to sexually transmitted disease or infectious.

76. Treatment of LP & LS Often no treatment needed.
If symptoms are persistent or severe, need to rule out dysplasia, cancer (Vulvovaginal intraepithelial neoplasia: VIN, VaIN).
Punch biopsy to rule out dysplasia/neoplasia
If symptoms are severe, may treat with:
Non-perfumed moisturizer in vulvar area.
Steroid ointment (clobetasol proprionate) BID for three months; maintenance treatment twice a week.
Treatment is safe, should control the symptoms and relieve suffering. However, it will not cure the condition.
Treatment can make the skin more supple and help make intercourse easier.

77. Foreign Bodies Tampons Contraceptive Devices Pessaries Other Nuvaring
Sponges
Retained condoms
Pessaries
Other

78. Recap
30% of women with vaginal complaints have normal exams and no infection.
Women can be asymptomatic and have an STI.
Perform appropriate examination & diagnostic testing to evaluate cervicitis/vaginitis complaints.
No triage or visual exam is conclusive for diagnosis.
Do an exam & appropriate testing!
Do not treat empirically.
Screen for other STIs as appropriate (eg, GC, chlamydia, HIV, hepatitis, syphilis).
Screen for other medical conditions for recurrent vaginitis (e.g., diabetes, HIV)

79. Questions?

80. REFERENCES
Sexually Transmitted Diseases Treatment Guidelines 2015, Centers for Disease Control & Prevention, US Dept Health & Human Services, June 2015.
Reported STDs in the United States: National Data for Chlamydia, Gonorrhea, and Syphilis. CDC Fact Sheet, October 2016.
Emerging Issues. Centers for Disease Control & Prevention, Division of STD Prevention, 6/4/2015.
Gonococcal Infections, Centers for Disease Control & Prevention, Division of STD Prevention, 7/27/2016.
Hormone Therapy & Other Treatments for Symptoms of Menopause, AFP: Vol 94(11), 12/1/2016,
Pelvic Inflammatory Disease, AFP: Vol 85(8), 4/15/2012,
Vaginitis: Diagnosis & Treatment, AFP: Vol 83(7), 4/1/2011,
“Vaginitis,” Information from Your Family Doctor series, American Family Physician, 4/1/2011
Vaginitis: Update on Diagnosis & Treatment, B. Apgar, MD, Seminar, AAFP Scientific Assembly, Chicago, 10/2007.

81. Websites American Academy of Family Physicians: www.aafp.org
American Society for Colposcopy & Cervical Pathology:
Centers for Disease Control:
USPHSTF: