NR602 Wk6 Grand Rounds -Vulvovaginal Infections

NR602 Wk6 Grand Rounds -Vulvovaginal Infections

NR602 Wk6 Grand Rounds -Vulvovaginal Infections

• Hello, My name is KJ and this is my grand rounds presentation on vulvovaginal infections for NR602.
• Vulvovaginal infections is an umbrella term for several different infections and conditions in the vaginal area. For the sake of time, I am only going to focus on two, and I’m going to talk about them simultaneously.
  • Bacterial vaginosis is a polymicrobial syndrome, meaning that there are multiple different bacteria that could be causative.
  • The entire pathophysiology of bacterial vaginosis is not completely understood, but what is known is that the presence of lactobacillus, which is normally present in the vagina, gets replaced with an anaerobic bacteria.
  • The most common of these bacteria are Gardnerella vaginalis and mycoplasma, but as stated a minute ago, there are quite a few different bacteria that could cause the infection.
  • An imbalance in the vaginal microflora causes discharge as well.
• The second most common vulvovaginal infection is vaginal candidiasis.
  • The pathophysiology behind this is not well understood either, but we do know it is caused most often by candida albicans, but can be caused by other types of candida and other yeasts as well.
  • The basic pathophysiology of vaginal candidiasis is that there is an overgrowth of yeast in the vagina and this causes an imbalance, thus causing the symptoms.
• The epidemiology of these two conditions is similar, but there are some
  • There is an estimated 20-30% of patients with vaginal discharge where the cause is bacterial vaginosis.
  • In high-risk patients, this can be as high as 50-60%.
  • African Americans have a rate of about 51%, Hispanics 32%, and Caucasians 23%.
  • Approx 50% of all cases have recurrence within 12 months.
• In candidiasis, there is an estimate that 75% of all women will have at least 1 episode of candidiasis in their lifetime.
  • 40-45% of women have 2 or more and there is an estimated 5-10 million women worldwide that will seek treatment every year.
• The risk factors for bacterial vaginosis are associated with multiple or new partners, douching, not using condoms during sex, and low vaginal lactobacilli.
  • If a patient is positive for bacterial vaginosis, they are at increased risk for getting other sexually transmitted disease, including the risk of giving HIV to male partners.
  • There is also an increased risk of gynecological postsurgical complications and pregnancy complications.
  • And there is a high risk of a recurring bact vaginosis infection.
  • Also important to note is that if a patient has HIV, or are otherwise immunocompromised, they are at much higher risk of getting bacterial vaginosis.
• The risk factors for candidiasis are largely socio-demographic and can be caused by a number of different issues, though the research regarding this is conflicted.
  • However, we do know that antibiotics use and oral birth control use seem to make a patient more likely to get it.
  • Patients with diabetes also seem to be more at risk.
  • Poor diet habits, poor personal hygiene, risky or unprotected sex, and certain immunological defects all seem to put a person at risk as well.
• Typical assessment findings for bacterial vaginosis and candidiasis are quite similar, but there are a few distinct characteristics usually seen.
  • With BV there will be a thin, white discharge that will have a very foul odor, most often described as “fishy.”
  • There is also irritation of the vagina and vulvar area.
  • With candidiasis in general, there is also vaginal discharge and irritation, but one of the biggest complaints tends to be pruritis of the vaginal area.
  • There can also be vaginal soreness, painful sex, and external dysuria.
• Candidiasis is further broken down into uncomplicated and complicated.
  • The symptoms for both are basically the same as the overall clinical picture that we just covered, but there can be fissures, excoriations, and swelling to the vulvar area.
  • Also to note is that the discharge is thick and curdy, unlike BV which is thin.
  • The major difference between complicated and uncomplicated candidiasis is that complicated is considered 4 or more episodes of symptomatic VC in 1 year.
• Three differentials that could be considered and should be ruled out are trichomoniasis, gonorrhea, and chlamydia.
  • Trich is similar to BV and candidiasis in that there is vaginal discharge, irritation and it is sexually transmitted.
  • However, typically the discharge seen with trich is usually yellowish-green instead of white and most patients are actually asymptomatic.
  • Gonorrhea is similar, except that almost all women are asymptomatic until there is a complication from the infection, such as pelvic inflammatory disease.
  • And chlamydia is much the same in that it is a vaginal infection that is sexually transmitted, but again, there is usually no symptoms until there is complication and many times the only time it is detected is with annual screening.

NR602 Wk6 Grand Rounds -Vulvovaginal Infections

• In order to diagnose BV, 3 out of the 4 following clinical findings must be present:
  • A homogenous, thin, white discharge
  • Clue cells under microscope
  • Vaginal ph >4.5
  • Or a fishy odor
  • A gram stain is the gold standard for diagnosing, although much of the time it is diagnosed initially by the clinical signs above.
• In order to diagnose candidiasis, the patient must have s/s of vaginitis plus one of the following:
  • Either a wet prep or gram stain showing budding yeasts, hyphae, or pseudohyphae; or a culture or similar test must be positive for yeast.
  • Again, much of the time the initial diagnosis until testing comes back is based on clinical signs and symptoms.
• Prevention for both conditions is pretty much the same:
  • Avoid risky sexual activity
  • Practice good personal hygiene
  • Avoid douching
  • Limit the amount of antibiotics you take
  • And eat a balanced diet.
• This is where BV and candidiasis starts to differ is in their treatment.
  • BV is caused by bacteria and candidiasis is caused by yeast overgrowth, so they must be handled differently.
  • Treatment for BV is recommended for all patients with symptoms, pregnant or non pregnant because it will relieve the symptoms, reduces the risk of miscarriage or adverse neonatal outcomes in pregnant women with BV, and there is also a risk reduction for getting trich, gonorrhea, chlamydia, HIV, and herpes simplex type 2.
  • The treatment is either topical or oral, depending on how severe the symptoms.
  • Usually topical is tried first and if that doesn’t get rid of it, then oral is prescribed.
  • The first line oral is metronidazole 500mg PO BID x7 days, which is also approved for pregnant and breastfeeding women.
  • Metronidazole is also the first line topical, but clindamycin topical can be used as well.
  • It’s important to note that treatment of the sexual partner is not necessary.
• For candidiasis, if s/s are present and the wet prep is positive, treat it.
  • If s/s are present but the wet prep is negative, attempt to get candida cultures, which is the gold standard. But if this is not possible for some reason, you might want to consider treating empirically.
  • If there are no s/s, but the candida culture is positive, there is actually no indication for treatment, since most women have candida and other yeasts in their vagina normally.
  • To treat uncomplicated candidiasis, usually a 1-3 day course of a topical antifungal takes care of it. This is usually an azole because it is more effective than nystatin in this case.
  • For immunocompromised patients, longer therapy like 7-14 days may be needed.

NR602 Wk6 Grand Rounds -Vulvovaginal Infections

• Here is a pretty comprehensive list of the over the counter options, which is usually what is recommended to start with. Notice that the lower concentrations require a longer duration of therapy, so keep that in mind when considering compliance.
• This is a list of some prescription intravaginal options should the over the counter therapy not work.
  • The first line for PO meds is a single dose of fluconazole, though longer therapy may be needed for complicated cases and if it is recurring enough, then 6mo of therapy may be needed.
  • It’s important to note that not all yeast infections are caused by albicans. When it is nonalbicans, it is recommended that a nonfluconazole azole be used for 7-14 days and if there is a recurrence, use 600mg boric acid intravaginally daily for 2 weeks. Note that no optimal treatment has been found, but this is the best one that is known currently.
• Patient education for BV and candidiasis are very similar.
  • The patient must be educated on prevention.
  • They should know that ETOH should be avoided if they are having to take nitroimidazoles and avoid it for at least 24 hours after stopping metronidazole.
  • They also need to be aware that clinda might weaken condoms or diaphragms for at least 5 days after it has been stopped.
  • The pt should void sex or use condoms correctly while they are being treated.
  • And they absolutely need to stay away from douching.
• Education for candidiasis should include the fact that creams and suppositories can weaken latex condoms and diaphragms.
  • They need to know, just as in BV, there is no need to treat their partner.
  • They should be taught that creams can sometimes cause some localized irritation and that PO azoles can sometimes cause nausea, abd pain, HA, and elevated LFTs, though this is rare.
• The optimal outcomes of course include complete resolution of the outbreak with no recurrences preferably, or at least a limited number of recurrences.
  • Proper education must also be completely understood and practiced by the patient.
  • Using these best practices that we have talked about will help us to get the best outcomes for our patients.

NR602 Wk6 Grand Rounds -Vulvovaginal Infections

• Typically, there is no follow up care needed for either of these conditions as long as the symptoms resolve with the treatment.
  • If they do not, then they need to follow up after the treatment is complete.
  • For BV, they may need to be put on a different antibiotic or a longer course of the same one. If there are multiple recurrences, 0.75% metronidazole gel can be tried for 4-5mo twice weekly.
  • For candidiasis, if the symptoms persist after over the counter meds or if they recur within 2mo after treatment, then the patient should come back in to be re-evaluated and tested.
  • If the pt has recurrent candidiasis and has completed the 6mo of maintenance therapy, but the cultures remain positive and the pt remains symptomatic, then they need a referral to urology.

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