Diagnosis
Vaginal discharge. Usually three forms:
1) Bacterial Vaginosis. Clinical criteria require three of the following symptoms or signs:
a) a homogeneous, white, noninflammatory discharge that smoothly coats the vaginal walls;
b) the presence of clue cells on microscopic examination; a pH of vaginal fluid > 4.5; and
c) a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test, also used to determine who plays t-ball).
2) Candida.
3) Trichomoniasis.
4) Occasionally reported is recurrent Group A streptococci vulvovaginitis/cellulitis, where the 'husband' can be a rectal carrier and source of recurrence.
Epidemiologic Risks
An STD.
Microbiology
Three forms, not mutually exclusive:
1) BV: anaerobic microorganisms, Mycoplasms, and Gardnerella vaginalis. Nonculture techniques have revealed a host of hitherto unknown anaerobes (PubMed). This is more an overgrowth syndrome due to abnormal flora.
b) Candida albicans.
III) T. vaginalis.
They can all coexist together.
Empiric Therapy
BV:
Recommended Regimens
Metronidazole 500 mg po twice a day for 7 days OR metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days. Relapse likely.
The future may be vaginal microbiome transplant (Pubmed).
Alternative Regimens (not as good)
Metronidazole 2 g po in a single dose OR clindamycin 300 mg po twice a day for 7 days OR clindamycin ovules 100 g intravaginally once at bedtime for 3 days.
Candida (from the CDC guidelines)
Recommended Regimens
Intravaginal Agents (any topical anti-fungal):
Butoconazole 2% cream 5 g intravaginally for 3 days.
Butoconazole 2% cream 5 g (Butaconazole1-sustained release), single intravaginal application.
Clotrimazole 1% cream 5 g intravaginally for 7 to 14 days.
Clotrimazole 100 mg vaginal tablet for 7 days.
Clotrimazole 100 mg vaginal tablet, two tablets for 3 days.
Clotrimazole 500 mg vaginal tablet, one tablet in a single application.
Miconazole 2% cream 5 g intravaginally for 7 days.
Miconazole 100 mg vaginal suppository, one suppository for 7 days.
Miconazole 200 mg vaginal suppository, one suppository for 3 days.
Nystatin 100,000-unit vaginal tablet, one tablet for 14 days.
Tioconazole 6.5% ointment 5 g intravaginally in a single application.
Terconazole 0.4% cream 5 g intravaginally for 7 days.
Terconazole 0.8% cream 5 g intravaginally for 3 days.
Terconazole 80 mg vaginal suppository, one suppository for 3 days.
Oral Agent: fluconazole 150 mg oral tablet, one tablet as a single dose. For recurrent disease, 150 mg fluconazole a week therapy works (PubMed).
The use of probiotics (as compared, I suppose to the amateur biotics) is still not clear but may have some benefit (PubMed).
Trichomoniasis: A single 2 gm po dose of metronidazole or 500 mg po bid x 7 d or tinidazole 2 gm po one time.
Pearls
Do not need to treat male partners.
Rants
Last Update: 01/30/20.