Vaginitis and PID – The Basics

Wanda Ronner, M.D.

Vaginitis

• Disruption in the normal vaginal ecosystem

• Alteration of vaginal pH

• A decrease in lactobacilli

• Growth of other bacteria

Normal physiologic discharge

• Cervical mucus

• Endometrial fluid

• Fluid from Skene’s and Bartholin’s glands

• Exfoliated squamous cells

• Normal pH: 3.5 – 4.5 during reproductive years; 6 – 8 after menopause

Common Causes of Vaginitis

• Bacterial Vaginosis: 15 - 50% of cases; all ages; anaerobic bacteria and Gardnerella vaginalis

• Trichomonas: 15 - 20% of cases; 20-45years; protozoan Trichomonas vaginalis

• Candida: 33% of cases; premenopausal women: 90% caused by Candida albicans

Common Treatments

• Yeast: oral fluconazole 150mg single dose, or clotrimazole, miconazole, or terconazole.

• Trichomonas: oral metronidazole 2 grams in a single dose or 500mg bid for 7 days.

• Bacterial Vaginosis: oral metronidazole 500mg bid for 7 days, or vaginal clindamycin cream or metronidazole gel.

Atrophic Vaginitis

• 40% of postmenopausal women• Caused by estrogen deficiency• Symptoms: dryness, itching, burning,

dyspareunia, pelvic pressure, yellowish-green malodorous discharge

• Findings: pH > 5, decreased superficial cells, WBCs

• Treatment: vaginal or oral estrogen

67 yr. old with vulvar/vaginal atrophy

Pelvic Inflammatory Disease

• Inflammatory disorders of the upper female genital tract – endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis

• Organisms responsible: mainly Gonorrhea and Chlamydia; anaerobes, G. vaginalis, Haemophilus, enteric Gram-negative rods, Streptococcus agalactiae.

PID – a public health concern

• Most common gyn reason for ER visits: 350,000/year.

• 70,000 hospitalizations/year.

• Most common serious infection of women age 16 – 25.

• One in four women have significant medical or reproductive complications.

Diagnosis of PID• Cervical motion tenderness• Uterine tenderness• Adnexal tenderness• Temp > 101º F• Mucopurulent discharge• Abundant WBCs on wet mount• Elevated ESR, elevated C-reactive protein• GC or Chlamydia

Differential Diagnosis

• Ectopic pregnancy

• Acute appendicitis

• Functional pain (e.g. pain with ovulation)

• Dysmenorrhea

• Endometriosis

• UTI/Pyelonephritis

• Bowel disorders

Treatment of PID

• Need to provide empiric, broad spectrum coverage of likely pathogens

• Must include treatment for GC and Chlamydia

• See handout for April 2007 CDC treatment regimens

CDC Recommended Regimens• Parenteral: Cefotetan (2g IV every 6 hrs)

OR Cefoxitin (2g IV every 6 hrs) PLUS Doxycycline (100 mg orally or or IV) every 12 hrs.

• Oral: Ceftriaxone (250mg IM in a single dose) PLUS Doxycycline 100mg orally twice a day for 14 days with or without Metronidazole 500mg orally twice a day for 14 days

Why do we treat aggressively?• Even mild cases may result in severe

damage: infertility, ectopic pregnancy, and chronic pelvic pain.

Follow Up

• Improvement should be seen within 3 days on oral meds – defervescence, reduction in abdominal tenderness, uterine, adnexal and cervical motion tenderness – if not – HOSPITALIZE

• In no improvement after 3 days on parenteral meds consider laparoscopy