Vulvar and Vaginal Diseases
Guy I. Benrubi
Vaginitis is the most common reason for visits to the offices of obstetrics and gynecology physicians as well as constitutes a very large component of visits to primary care providers.
Vulvovaginal discomfort does not usually create in a patient a sense of urgency, therefore, most of these patients are not going to present either to emergency departments or to urgent care centers or call physician offices for emergency consultations. However, with the effects of the Great Recession in the United States and with the increasing loss by patients of coverage for health care, there has been an increase in the number of patients presenting with these symptoms to urgent settings. Therefore, this chapter will briefly discuss some of the overall aspects of care of patients presenting with these conditions as well as the most common causes for these symptoms.In the medical literature, the three most common causes identified as c reating vulvovaginal discomfort are bacterial vaginosis, candidiasis, and trichomoniasis (1). Though these three conditions have been so described for quite a long time, currently, the most common cause of vulvovaginal discomfort in the United States is mucosal atrophy secondary to insufficient estrogen (2). This particular diagnosis will be seen increasingly in the next few years as the population of women in this country ages. Additionally, the result of the publication of the Women’s Health Initiative in 2002 lead to a 70% decline in the use of hormone replacement therapy in US postmenopausal women.
In approaching this problem, it should be understood that the term “itis” in vaginitis is probably a misnomer. “Itis” refers to inflammation. Very frequently, what is causing the symptoms in the patient’s vulvovaginal area is not an inflammation but a colonization or an abnormality in the bacterial flora of the vagina.
Another concept that should be understood is that a lot of the symptoms are not arising in the vagina but in the vulva. The vulva in addition to being part of the urogenital system is also part of the integumentary system. Vulva is skin and any condition which can arise in the skin can also arise on the vulva.One of the most common presentations of vulvovaginal atrophy due to estrogen deficiency is urethral meatal irritation, which the patient interprets as a urinary tract infection. Frequently, when these patients arrive at the care area, urine culture and urinalysis are negative. Other symptoms of estrogen lack are nonspecific sense of irritation as well as occasionally mild burning and some dyspareunia both intromissional as well as post coital. In the emergent setting, the patient should be reassured and a determination should be made as to whether the patient wants to be placed on systemic hormone replacement therapy or to be on localized therapy. There are multiple options for localized therapy (3-5). Estradiol vaginal tablets (Vagifem®) can be inserted vaginally twice weekly and can deliver 50 μg of estradiol per week. Another option is an estradiol vaginal ring (Estring®) which is inserted in the vagina and stays in place for 90 days and delivers 52 μ g of estradiol each week. Other options are to use estradiol creams with an applicator which allows the patient to use a small amount on a weekly basis.
Bacterial vaginosis is the term that is now used to describe a whole host of conditions that have had multiple other names prior to 1984 when the current term was adopted. It is important to note that “vaginosis” implies a colonization and not an inflammatory process. Vaginosis is a condition where the normal lactobacillus bacteria in the vagina have decreased in number and the vagina becomes colonized with anaerobic bacteria. These bacteria come from the rectum. This is due to proximity and not hygiene deficiency. The patient presents with a complaint of a profuse smooth vanilla yogurt-like discharge as well as possibly a “fishy” odor which is most profound after partner ejaculation during intercourse.
On examination, the most notable aspect will be the profuse white discharge which is frequently found in the introitus even before a speculum is inserted. On wet prep, the diagnostic sign will be the clue cells which are squamous cells covered by anaerobic bacteria clinging to their surface. The presence of clue cells in conjunction with a profuse smooth white discharge is diagnostic 99% of the time for bacterial vaginosis. The other important sign is that there is no evidence of inflammation, that is, no redness of the vaginal or vulvar tissues and no white blood cells in the wet prep. This condition is treated efficaciously with metronidazole or clindamycin. These medications can be given systemically or topically (6). A high incidence of this disease is seen in lesbian couples. This may be due to the use of sexual toys. If the patient keeps reappearing in the urgent care area and the patient does not go to her primary physician, a discussion should be carried out with her as to sexual practices. Although this is not, strictly speaking, a sexually transmitted disease, it is a disease which may be impacted by the patient’s type of sexual practice.The next frequently seen etiology for vulvovaginal discomfort is a yeast infection. Most yeast infections in this country are candida albicans. There are some that are candida tropicalis, and also there is an increasing incidence of candida glabrata. Most yeast infections at the time the patient presents to the physician are not inflammatory in nature but are colonizations of the vagina with yeast. If the patient has delayed care, then a yeast infection may in fact become inflammatory. The patient will frequently describe, in addition to a discharge, a pruritic sensation. This pruritus is secondary to an IgA reaction on the tissues and is similar to a contact dermatitis or an allergic dermatitis. On wet prep, the squamous cells will appear normal. There may be some white blood cells, and the diagnostic sign would be yeast forms, either budding yeast forms or mycelial forms.
One frequent cause of a yeast infection is the use of antibiotics by the patient prior to the start of the yeast colonization problem (7). The antibiotics knock out the lactobacilli, and this results in an overgrowth of yeast. These i nfec- tions are invariably treated with azoles whether it is fluconazole, butoconazole, terconazole, etc (8). Therapy can be either oral or by insertion of vaginal ovules or cream depending on the preference of the patient.Trichomoniasis is the true inflammatory infection of the vagina. Once the patient contracts a vaginal trichomonal infection, the infection will spread to the draining lymph nodes in the obturator as well as the hypogastric area of the pelvis. The patient therefore will present not only with a discharge but also with pelvic pain because of the lymphatic involvement. The diagnosis is made by looking at a wet prep which shows not only a profuse number of white blood cells but also the trichomonads which are swimming against Brownian motion. Once the diagnosis is made, the patient is most efficaciously treated with metronidazole. This should be given systemically not topically because the metronidazole must get into the pelvic lymph nodes; otherwise, the infection will recur (9,10). One of the problems that trichomoniasis presents is that the patient’s partner also needs to be treated, and the partner must be referred to the appropriate physician for the appropriate therapy.
The above are the most common conditions which would necessitate a patient to seek care in an urgent or semi-urgent manner. There is a whole host of other conditions of the vagina that one must consider which may cause symptoms but in fact are not applicable to treatment in the urgent care area. These include inflammatory conditions such as desquamative inflammatory vaginitis, lichen planus, lichen sclerosus, vulvar hypertrophy, as well as vulvar intraepithelial neoplasia. The reader is referred to the appropriate literature and texts for these conditions as it would be unlikely that the urgent care physician would have to provide definitive therapy.
The physician, however, must be aware that these conditions occur because if the patient presents with symptoms and none of the four conditions described above are obvious, then the patient must be told about other possibilities and must be referred for appropriate care.References
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