Candidal vaginitis is characterized by a thick, curdy, white discharge and vulvar discomfort. Intense vulvar erythema, pruritus, or burning is often present. A microscopic slide prepared with 10% potassium hydroxide yielding characteristic branch chain hyphae and spores establishes the diagnosis (Fig. 25.13). The pH of the discharge is less than 4.5. Predisposing factors that should be considered include oral contraceptive, anti biotic, or corticosteroid use; pregnancy; and diabetes. Sexually transmitted diseases are not usually associated with isolated candidal vaginitis.
Trichomonas vaginitis presents as a persistent, thin, copious discharge that is often frothy, green, or foul-smelling. The pH of these secretions is greater than 4.5. The amount of vaginal and cervical erythema and inflammation varies considerably; thus the diagnosis depends on the presence of motile flagellates on normal saline wet-mount microscopy. Occasionally, multiple petechiae on the vaginal wall (strawberry spots) or cervix (strawberry cervix) are seen.
Bacterial vaginosis (previously termed Haemophilus or Gardnerella vaginitis) is characterized by a malodorous, homogeneous discharge with a pH greater than 4.5 and a transient amine (fishy) odor when mixed with a drop of KOH solution (positive sniff test). The presence of clue cells on normal saline wet mount establishes the diagnosis (Fig. 25.14). Other associated vaginal or abdominal complaints are minimal and, if significant, may represent another disease process.
Vaginal foreign bodies, particularly in children, atrophic vaginitis, and contact dermatitis, should all be considered in the differential diagnosis.
Emergency Department Treatment and Disposition
For candidal vaginitis, various regimens of topical antifungal agents are the mainstay of treatment (clotrimazole 1% cream, one applicatorful inserted high into the vaginal vault for 7 nights, clotrimazole, two 100-mg vaginal tablets for 3 nights, or one 500-mg vaginal tablet for single-dose treatment). Oral fluconazole (Diflucan, 150 mg as a single dose) is also effective.
For Trichomonas vaginitis, a single, one-time dose of metronidazole (2 g) is generally curative but is contraindicated in pregnancy and is associated with an Antabuse-like reaction when taken with alcohol. For the pregnant patient, clotrimazole (100-mg vaginal suppositories daily for 7 to 14 days) may provide symptomatic relief.
For bacterial vaginosis, metronidazole (500 mg twice daily for 7 days) is recommended in the nonpregnant patient. Treatment for asymptomatic infection or for male sexual partners is not generally recommended.
Candidal Vaginitis. Thick, curdy white discharge secondary to candidal vaginitis. (Photo contributor: Kevin J. Knoop, MD, MS.)
Trichomonas Vaginitis. Thin vaginal discharge suggestive of Trichomonas vaginitis. (Photo contributor: H. Hunter Handsfield. Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)