Case Studies

Case 2: Vaginitis

Beth is a 33-year-old single woman who has been in your practice for several years and left a message with your nurse that she has a pruritic vaginal discharge that has persisted for 2 weeks despite her attempts at using an over-the-counter yeast cream.

• 1. Is it ever appropriate to treat without an examination?

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  Correct answer: Very frequently, women will attempt to self-diagnose their vaginitis and self-treat with any number of readily available topical or oral agents. The benefits of using a non-prescription antifungal include convenience, the potential to avoid the cost of a physician visit, and, most importantly, the ability to quickly initiate effective treatment. However, the accuracy of self-diagnosis is often worse than is widely assumed. Given the non-specific nature of vulvovaginal symptoms, patients requesting treatment by telephone should be asked to come in for evaluation, particularly – as in this patient – if she has treated herself with a non-prescription antifungal without success. However, in a reasonably compliant woman with multiple confirmed episodes and similar symptoms, a short course of treatment may be initiated over the phone. In these cases, she should be asked to come in for evaluation only if symptoms persist.

• 2. What are the other disadvantages of using non-prescription antifungal agents?

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  Correct answer: A patient with a simple, straightforward case of vulvovaginal candidiasis who uses an over-the-counter non-prescription product should respond to therapy. Failure to respond should prompt clinical evaluation. Side effects consist primarily of localized burning and irritation in 5% of women. Mainly, it leads to a delay in accurate diagnosis and appropriate treatment. Although such delay may have minimal effect on vulvovaginal symptoms, such as pruritis, odor, or discharge, it may be of greater concern if she ends up being diagnosed with pelvic inflammatory disease (see Chapter 8), sexually transmitted infection, or a urinary tract infection.

• 3. What else should be considered in the differential diagnosis?

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  Correct answer: Vaginitis is a general term that refers to a spectrum of conditions causing vulvovaginal burning, itching, irritation, and/or abnormal discharge. The differential diagnosis is extensive. Bacterial vaginosis is the most common cause, followed by candidiasis and trichomoniasis. Many cases will remain undiagnosed or end up attributed to atrophic vaginitis or various vulvar dystrophies.

• 4. How should Beth be evaluated?

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  Correct answer: The first step is to obtain a focused history to understand the extent of symptoms, including any recent changes and whether she has been experiencing associated dyspareunia and/or dysuria. Questions about the duration of symptoms, relation to menstrual cycle, prior attempts at treatment, and a sexual history also may yield important insights into the etiology.

  The pertinent parts of the physical examination include careful inspection of the vulva. During speculum examination, samples should be obtained for vaginal pH, the “whiff” test, and slide preparations for a saline (wet mount) and 10% KOH microscopy. Importantly, the pH swab should be obtained from the mid-portion of the vaginal side wall to avoid false elevation from cervical mucus, blood, semen, or previous intravaginal medications.

• 5. On examination the vaginal pH is high, but microscopic findings are equivocal. How should this patient be managed?

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  Correct answer: Usually when the pH is elevated in a symptomatic patient, microscopic findings will quickly confirm the diagnosis (eg, trichomonads, clue cells). However, recent intercourse, menses, sampling of cervical mucus, or recent intravaginal therapy can also elevate the pH of the vagina.

  Although light microscopy is a standard part of the diagnostic evaluation, it misses a large percentage of patients with symptomatic vulvovaginal candidiasis. As in this patient, self-treatment before evaluation may also make it more difficult to visualize yeast.

  Vaginal cultures are not obtained routinely because of their cost, the delay in obtaining results, and the fact that many women may be asymptomatically colonized with group B streptococci or lactobacilli. However, cultures should be obtained in cases of recurrent vulvovaginal candidiasis, possible non-albicans candida infection (eg, persistent yeast symptoms after antifungal therapy), or symptomatic women with negative microscopic findings. Therefore, this symptomatic patient should be treated in a manner similar to other women with vaginitis where the diagnosis is unclear and cultures may be helpful.

• 6. How do you confirm the diagnosis of candidiasis? What is the treatment?

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  The diagnosis may be suggested on the basis of history and physical examination, but confirmation requires either (1) visualization of branched and budding hyphae on KOH wet mount or (2) a positive culture in a symptomatic woman. Uncomplicated patients may be treated with either topical clotrimazole or oral fluconazole. Occasionally, in more severe cases, a second dose or repeated doses of fluconazole will be required. Although much less common than Candida albicans, candidiasis caused by non-albicans Candida species are less likely to respond to “azole” antifungal therapy. Therapy with vaginal boric acid, 600 mg capsules daily for at least 2 weeks, may be effective.