Sickle Cell Information Center Guidelines

Edited by James Eckman, M.D. and Allan Platt, PA-C

Vaginitis  by Hiba Tamim, MD

Vaginitis is a common problem in all females. Frequent treatment with antibiotics make the problem more common in the female with sickle syndromes. The presence of vaginal discharge or symptoms can indicate serious illness requiring specific therapy.

Present Illness. Define onset, duration, color, amount, odor, irritation, and itching of discharge. Ask about dysuria, urinary frequency, nocturia, pelvic pain, location, dyspareunia, abnormal vaginal bleeding, labial lesions, and swelling.

Document last normal menses, exposure to STDs, IUD use, new vaginal products such as spermicide, douche, feminine powders, deodorant soap, or synthetic underwear. Define sexual activity, last intercourse, and number of partners.

Past Medical History. Determine past history or family history of diabetes. Number and results of past pregnancies, past pelvic surgery, last PAP smear and result, recent use of antibiotics, or oral contraceptives.

• Vital Signs. Temperature, blood pressure, and pulse.
• Skin. Skin rash, palms and sole lesions.
• Lymphatics. Generalized, inguinal, or femoral lymphadenopathy, consistency tenderness.
• Cardiac. Heart murmur - new changed?
• Abdomen. Hepatomegaly tenderness.
• Pelvic Examination
• External. Lesions, nits, insects, Bartholin’s abscess, ulcers, vesicles.
• Speculum. Cervicitis, cervix lesions, discharge, PAP, wet prep, GC smear and culture, atrophic vaginitis, foreign body (tampon)
• Bimanual. Pain with cervical motion, masses, enlarged uterus, tubes, ovaries, or adnexal tenderness

Minimum Lab. CBC with differential and reticulocyte count. Wet mount of vaginal discharge for trichomonas, and clue cells (epithelial cells with bacteria, in Gardnerella), KOH for pseudohyphae and yeast forms in candida infections, GC smear and culture, PAP smear for cervical carcinoma and Herpes.

Vaginal Irritant. Irritation from spermicide, feminine powders, deodorants, douche, tampon , or non-cotton underclothing are common causes of vaginitis.

Atrophic Vaginitis Seen in older individuals from estrogen deficiency.

Gonococcus. Gram stain shows gram negative intracellular diplococci. Must be confirmed by culture in females. Look for signs of disseminated disease such as heart murmur in endocarditis, skin lesions and rash, tender cervix and adnexal structures in acute salpingitis.

Trichomonas. Wet prep shows mobile, pear-shaped organisms.

Candida. Wet prep shows budding yeast forms with or without pseudohyphae.

Gardnerella. Malodorous discharge with fishy smell after adding 10% KOH. Clue cells, clumps of bacteria overlying epithelial cells, on wet prep.

Chlamydia. Vaginitis/urethritis/salpingitis with a negative work-up is the basis for a presumed diagnosis. Diagnosis by direct immunofluorescence test for chlamydia specific antigens.

Genital Herpes Simplex Virus. Characteristic painful, vesicular lesions on vulva, labia lips, or cervix. Characteristic inclusions on pap smear.

General Management Measures All patients with proven sexually transmitted infections should have serological tests for syphilis and HIV. Partners should be tested and treated as appropriate. Use of cotton underwear and no intercourse until treatment is completed are recommended. All spermicide, douche, tampons, and feminine deodorants should be avoided until symptoms resolve.

Vaginal Irritant. General measures are sufficient.

Atrophic Vaginitis Estrogen cream.

Gonococcus. Uncomplicated infections are treated with Ceftriaxone 125 or 250 mg IM. Individuals with beta-lactam sensitivity are treated with spectinomycin 2 gm IM or ciprofloxacin 500 mg PO. All receive doxycycline 100 mg PO bid or erythromycin 500 mg PO qid for 7 days. Pregnant patients should receive erythromycin.

Trichomonas. Metronidazole 2 gm PO for patients and all partners. No alcohol.

Candida. Miconazole or clotrimazole suppositories 200 mg q HS for three days or 100 mg q HS for 7 days. Oral fluconazole 150 mg x1 dose can be used in resistant or recurrent cases.

Gardnerella. Metronidazole 500 mg PO bid for 7 days with warning about use of alcohol. Clindamycin 300mg PO bid for 7 days is also effective.- Chlamydia. Doxycycline 100 mg PO bid for 7 days in non-pregnant females. Erythromycin ethylsuccinate 400 mg. qid for 7 days with monitoring for hepatotoxicity should be used during pregnancy. Amoxicillin 500 mg tid for 7 days is an alternative during pregnancy.

Genital Herpes Simplex Virus. Primary infections may benefit from Acyclovir 200 mg PO 5 times a day for 7-10 days. Those with frequent flairs may benefit from Acyclovir 400 - 800 mg per day divided into two or three doses. Long-term safety is unclear.

Nursing Considerations

? Use universal precautions when handling specimens and sending to the lab (lesions/mucous membranes, exudate are infectious).

 Administer medication to patient to take as prescribed - Early treatment can prevent complications.

 Counsel patient to return for follow up appointments.

 Monitor body temperature and other symptoms. Early detection of infections and treatments may prevent dissemination of the pathogen, severe disease which may cause fertility problems.

 Educate patient on proper hygiene and cleanliness. Encourage use of loose fitting cotton underwear that allows for ventilation.

 Provide education on sexually transmitted diseases and use of condoms.

 Teach patients not to reuse contaminated douche equipment and that chronic douching can alter vaginal ph.

Primary prevention involves limiting sexual partners and using condoms for protection. Proper cotton underwear will decrease vaginal irritation. Limiting use of antibiotics will decrease candida infections. Proper evaluation of sexual partners with cultures and treatment is appropriate. Follow-up testing to assure cure is important.

Patients must understand which of the diseases are sexually transmitted and which are not. Treatment of partners must be stressed for those that have sexual transmission. Limiting sexual exposure is part of the education of all sexually active individuals.

Stone KM, Grimes DA, Magder LS. Personal protection against sexually transmitted diseases. Amer. J. Obstet. Gynecol. 155:180-188, 1986.

Treatment of sexually transmitted diseases. Med. Letter on Drugs and Therap. 30:5-10, 1988.

Condoms for prevention of sexually transmitted diseases. MMWR 37:133-137, 1988.

Lossick JG. Treatment of sexually transmitted vaginosis/vaginitis. Rev. Infect. Dis. 12:S665-S681, 1990.

Moran JS, Zenilman JM. Therapy for gonococcal infections: Options in 1989. Rev. Infect. Dis. 12:S633-S644, 1990.

Toomey KE, Barnes RC. Treatment of Chlamydia trachomatis genital infection. Rev. Infect. Dis. 12:S645-S655, 1990.

Stone KM, Whittington WL. Treatment of genital herpes. Rev. Infect. Dis. 12:S610-S619, 1990.

Haefner HK, Current evaluation and management of vulvovaginitis. Clinical Obtetrics and Gynecology. 42:184-195, 1999.

Sobel JD. Vaginitis. NEJM. 337:1896-1903, 1997.

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Copyright © 1997 Sickle Cell Information Center
Last modified: October 08, 2000