Vulvovaginitis in Emergency Medicine Follow-up

  • Author: Mark J Leber, MD, MPH, FACEP; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: Aug 12, 2009
 

Further Outpatient Care

  • Premenarchal:[8] Most patients do not have an identifiable etiologic agent for infection. Therefore, treatment aims at improving perineal hygiene and decreasing moisture.
    • A period of supervised defecation may be helpful, stressing the need to wipe thoroughly and anteriorly to posteriorly. Stress the importance of wearing loose-fitting, cotton undergarments. Stress the need to avoid vaginal irritants such as bubble baths and creams. A sitz bath with baking soda may be helpful. Thoroughly drying the perineum and avoiding unnecessary moisture, such as prolonged exposure to a wet bathing suit, may be helpful. If these methods are unsuccessful, perform a vaginal culture.[8]
    • If a bacterial etiology seems likely, consider a course of broad-spectrum antibiotics.
    • Topical estrogen cream for up to 2 weeks may help if local measures do not work. If pruritus is severe, a short trial of a topical steroid such as 0.5% hydrocortisone may be used.[4]
    • Remove vaginal foreign bodies, possibly with the use of sedation.
    • Streptococcal infections respond to penicillin or erythromycin.
    • Treat pinworms with mebendazole or pyrantel pamoate. The entire family may need to be treated to eradicate the infection.[8]
    • Treat STDs appropriately using pediatric doses. All STDs should prompt an evaluation for sexual abuse.
  • Childbearing age: In women of childbearing age, treat irritant causes of vulvovaginitis by removing the offending agent.
    • Perform a pregnancy test, since the treatments may be contraindicated in pregnancy.
    • Bacterial vaginosis is treated in women with metronidazole, orally or intravaginal. Several dosing regimens are available. The recommended treatment is metronidazole 500 mg PO twice a day for 7 days. Clindamycin may be used as an alternative except in late pregnancy. Treatment of sexual partners generally is not beneficial. Follow-up visits are unnecessary if symptoms resolve.[5]
    • Because recurrence of bacterial vaginosis is not unusual, women should be advised to return for additional therapy if symptoms recur. Another recommended treatment regimen may be used to treat recurrent disease. No long-term maintenance regimen with any therapeutic agent is recommended.
    • Condom use is recommended to reduce incidence of bacterial vaginosis.[10]
    • Douching is not recommended.[23]
    • Trichomonas species infection is treated very effectively with metronidazole in nonpregnant women. Several dosing regimens are available. Sexual partners should be treated, even if asymptomatic, although re-infection rate appears to be low even if the partner is not treated.[4] Patients should be instructed to avoid sex until she and her sex partner are cured (ie, when therapy has been completed and patient and partner are asymptomatic [in the absence of a microbiologic test of cure]). The primary treatment is metronidazole 2 g PO for 1 dose. Follow-up is unnecessary for men and women who become asymptomatic after treatment or who are initially asymptomatic. If treatment failure occurs with either regimen, the patient should be retreated with metronidazole 500 mg twice a day for 7 days. If treatment failure occurs again, the patient should be treated with a single, 2-g dose of metronidazole once a day for 3-5 days.[4]
    • Trichomonas infection in pregnant women is treated in the same manner as in nonpregnant women. There is no evidence that metronidazole is related to preterm birth.[31]
    • Candida species infection can be treated successfully with a variety of topical antifungals. Many are now available over-the-counter with 1-, 3-, 5-, and 7-day dosing regimens. Oral therapy with single-dose fluconazole is effective but may repeat on the third day. Recurrent and chronic infections are best treated more aggressively with low-dose prophylactic fluconazole.[4, 3, 23]
  • Postmenarchal: In postmenopausal women with atrophic vaginitis, therapy focuses on topical estrogen replacement. Some women on oral estrogen replacement still develop atrophic vaginitis.
    • A variety of topical estrogen preparations is available for intravaginal, once-a-day use, generally for 1-2 weeks. When symptoms improve, frequency may be decreased to once or twice per week.
    • Though rarely place in the emergency department, the estradiol vaginal ring is preferred rather than topical estrogen.[32]
    • Systemic estrogen absorption from the vagina seems to diminish as the vaginal epithelium matures. Tamoxifen may be used for women who are very concerned about estrogen exposure.
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Deterrence/Prevention

  • A randomized study of metronidazole gel for 5 days followed by metronidazole gel twice weekly for up to 6 months prevented the acquisition of sexually transmitted diseases.[25, 2]
  • Patients with recurrent vulvovaginal candidiasis may require individually tailored maintenance fluconazole to prevent relapse.[33]
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Complications

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Prognosis

  • Premenarchal
    • Improved hygiene and methods to decrease moisture may help 50% of these patients.
    • If symptoms persist, consider the possibility of a foreign body.
    • A course of antibiotics or topical estrogen occasionally helps.
    • Streptococcal and pinworm infections respond promptly to antimicrobials.
  • Childbearing age
    • Bacterial vaginosis is cured with single-dose treatment in 80% of patients and with weeklong treatment in 90%.
    • Cure rates for Trichomonas species infection are higher than for bacterial vaginosis.
    • Candidal treatment with topical or oral therapy yields a cure rate of 90%. Approximately 5% of women have difficult-to-treat infections. Recurrence is common.
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Patient Education

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Contributor Information and Disclosures
Author

Mark J Leber, MD, MPH, FACEP  Attending Physician and Faculty, Department of Emergency Medicine and Residency Program, Lincoln Medical and Mental Health Center

Mark J Leber, MD, MPH, FACEP is a member of the following medical societies: American College of Emergency Physicians and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Anuritha Tirumani, MD  Research Coordinator, Department of Emergency Medicine, Brooklyn Hospital Center

Disclosure: Nothing to disclose.

Specialty Editor Board

David S Howes, MD  Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Reza Keshavarz, MD, to the development and writing of this article.

References

  1. B Angotti L, C Lambert L, E Soper D. Vaginitis: making sense of over-the-counter treatment options. Infect Dis Obstet Gynecol. 2007;2007:97424. [Medline].

  2. Nyirjesy P. Vulvovaginal candidiasis and bacterial vaginosis. Infect Dis Clin North Am. Dec 2008;22(4):637-52, vi. [Medline].

  3. Katz. Vaginitis. In: Mosby. Katz:Comprehensive Gynecology. 5th ed. Elsevier; 2007:588-596.

  4. Szumigala JA, Alveredo R. Vulvovaginitis. In: Mosby. Ferri: Ferri's Clinical Advisor 2009. ed. Elsevier; 2009:155,1008-1012.

  5. [Guideline] Workowski KA, Berman SM. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. 2009;[Full Text].

  6. Eckert LO. Clinical practice. Acute vulvovaginitis. N Engl J Med. Sep 21 2006;355(12):1244-52. [Medline].

  7. Margesson LJ. Vulvar disease pearls. Dermatol Clin. Apr 2006;24(2):145-55, v. [Medline].

  8. Braverman Paula k. Urethritis, Vulvovaginitis, and Cervicitis. In: Churchill Livingstone. Principals and Practice of Pediatric Infectious Diseases. 3rd ed. Elsevier; 2008:55.

  9. Farage MA, Miller KW, Ledger WJ. Determining the cause of vulvovaginal symptoms. Obstet Gynecol Surv. Jul 2008;63(7):445-64. [Medline].

  10. Biggs WS, Williams RM. Common gynecologic infections. Prim Care. Mar 2009;36(1):33-51, viii. [Medline].

  11. Hampton T. High prevalence of lesser-known STDs. JAMA. Jun 7 2006;295(21):2467. [Medline].

  12. Helms DJ, Mosure DJ, Metcalf CA, Douglas JM Jr, Malotte CK, Paul SM, et al. Risk factors for prevalent and incident Trichomonas vaginalis among women attending three sexually transmitted disease clinics. Sex Transm Dis. May 2008;35(5):484-8. [Medline].

  13. Jasper J. Vulvovaginitis in the prepubertal child. Clin Pediatr Emerg Med. Mar 2009;10.

  14. Freeto JP, Jay MS. "What's really going on down there?" A practical approach to the adolescent who has gynecologic complaints. Pediatr Clin North Am. Jun 2006;53(3):529-45, viii. [Medline].

  15. Johnson E, Berwald N. Evidence-based emergency medicine/rational clinical examination abstract. Diagnostic utility of physical examination, history, and laboratory evaluation in emergency department patients with vaginal complaints. Ann Emerg Med. Sep 2008;52(3):294-7. [Medline].

  16. Ferris DG, Francis SL, Dickman ED, Miler-Miles K, Waller JL, McClendon N. Variability of vaginal pH determination by patients and clinicians. J Am Board Fam Med. Jul-Aug 2006;19(4):368-73. [Medline].

  17. Kulp JL, Chaudhry S, Wiita B, Bachmann G. The accuracy of women performing vaginal pH self-testing. J Womens Health (Larchmt). May 2008;17(4):523-6. [Medline].

  18. Chatwani AJ, Mehta R, Hassan S, Rahimi S, Jeronis S, Dandolu V. Rapid testing for vaginal yeast detection: a prospective study. Am J Obstet Gynecol. Apr 2007;196(4):309.e1-4. [Medline].

  19. Hollier LM, Workowski K. Treatment of sexually transmitted infections in women. Infect Dis Clin North Am. Dec 2008;22(4):665-91, vi. [Medline].

  20. Pillay A, Radebe F, Fehler G, Htun Y, Ballard RC. Comparison of a TaqMan-based real-time polymerase chain reaction with conventional tests for the detection of Trichomonas vaginalis. Sex Transm Infect. Apr 2007;83(2):126-9. [Medline].

  21. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. Feb 17 2006;5:4. [Medline].

  22. Heller DS, Maslyak S, Skurnick J. Is the presence of Trichomonas on a Pap smear associated with an increased incidence of bacterial vaginosis?. J Low Genit Tract Dis. Jul 2006;10(3):137-9. [Medline].

  23. [Guideline] Huntzinger A. Practice Guideline Briefs. American Family Physician. Nov 2006;74.

  24. Mania-Pramanik J, Kerkar SC, Mehta PB, Potdar S, Salvi VS. Use of vaginal pH in diagnosis of infections and its association with reproductive manifestations. J Clin Lab Anal. 2008;22(5):375-9. [Medline].

  25. Schwebke JR, Desmond R. A randomized trial of metronidazole in asymptomatic bacterial vaginosis to prevent the acquisition of sexually transmitted diseases. Am J Obstet Gynecol. Jun 2007;196(6):517.e1-6. [Medline].

  26. Schwebke JR, Desmond RA. A randomized trial of the duration of therapy with metronidazole plus or minus azithromycin for treatment of symptomatic bacterial vaginosis. Clin Infect Dis. Jan 15 2007;44(2):213-9. [Medline].

  27. Swadpanich U, Lumbiganon P, Prasertcharoensook W, Laopaiboon M. Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery. Cochrane Database Syst Rev. Apr 16 2008;CD006178. [Medline].

  28. Carey JC, Klebanoff MA, Hauth JC, et al. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med. Feb 24 2000;342(8):534-40. [Medline].

  29. Nailor MD, Sobel JD. Tinidazole for the treatment of vaginal infections. Expert Opin Investig Drugs. May 2007;16(5):743-51. [Medline].

  30. Marrazzo J. Vulvovaginal candidiasis. BMJ. Sep 14 2002;325(7363):586. [Medline].

  31. Mann JR, McDermott S, Zhou L, Barnes TL, Hardin J. Treatment of trichomoniasis in pregnancy and preterm birth: an observational study. J Womens Health (Larchmt). Apr 2009;18(4):493-7. [Medline].

  32. [Best Evidence] Buckling J. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst. Rev. 2006;4:[Medline].

  33. Donders G, Bellen G, Byttebier G, Verguts L, Hinoul P, Walckiers R, et al. Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial). Am J Obstet Gynecol. Dec 2008;199(6):613.e1-9. [Medline].

  34. Van Der Pol B, Kwok C, Pierre-Louis B, Rinaldi A, Salata RA, Chen PL, et al. Trichomonas vaginalis infection and human immunodeficiency virus acquisition in African women. J Infect Dis. Feb 15 2008;197(4):548-54. [Medline].

  35. Gabbe SG. Vaginal infections. In: Obstetrics - Normal and Problem Pregnancies. 4th ed. 2002.

  36. Johns Hopkins. Diagnostic features and management of vaginal infections. In: The Harriet Lane Handbook: A Manual for Pediatric House Officers. 17th ed. 2005.

  37. Owen MK, Clenney TL. Management of vaginitis. Am Fam Physician. Dec 1 2004;70(11):2125-32. [Medline].

  38. Sobel JD. Vaginitis, vulvitis, cervicitis and cutaneous vulval lesions. In: Infectious Diseases. 2nd ed. Cohen & Powderly; 2004.

 
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The photomicrograph reveals bacteria adhering to vaginal epithelial cells known as clue cells. The presence of clue cells is a sign that the patient has bacterial vaginosis. Source CDC Phil/ M.Rein.
Candida albicans photomicrograph. Source CDC.
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