Articles
Year 2019
July 2019
09 July 2019

A Refresher on Common Vaginal infections

Most common causes of vaginal discharge or odour with or without pruritus ( more than 90% ) can be attributed to 3 common vaginal infections:

  • Bacterial vaginosis
  • Candida vulvovaginitis
  • Trichomoniasis

VULVOVAGINAL CANDIDIASIS (VVC or Thrush)

Clinical features

10-20% of reproductive age women are asymptomatic.

Symptoms arise  when the natural environment is upset, for example due to chronic use of broad spectrum antibiotics, immunosuppressive states such as steroid use, HIV, diabetes mellitus or vaginal douching.

The woman commonly presents with ‘cottage cheese’ discharge with vulva itching.

Additional Investigations

If  predisposing conditions are suspected, additional tests can be performed such as a fasting glucose level or a HIV test.

Management  

There is no need to treat asymptomatic women incidentally diagnosed (for example on a pap smear).

General rules:

  • Avoid contact with soap, shampoo and bubble baths
  • Simple emollients for example aqueous cream can be used as a soap substitute
  • Avoid tight fitting garments
  • Avoid use of spermicidally lubricated condoms
  • Avoid overvigorous vaginal douching

Local treatment is generally preferred over systemic treatment:

Topical treatments work more quickly and have fewer side effects (such as irritation) compared to oral treatment ( of which side effects may include gastrointestinal intolerance and transient liver function abnormalities).

Treatment options include:

  • Isoconazole (gynotravogen pessary) single dose
  • Clotrimazole (canestan) pessary ( 500mg once or 100mg nightly  for 7 days )
  • Tioconazole (gynotrosyd) pessary nightly  for 3 doses
  • Nystatin pessary 100, 000 units daily for 14 days
  • If vaginal treatment fails or oral treatment is preferred: a single dose of fluconazole 150mg or Intraconazole (sporanox) 200mg twice daily for 1 day or 200mg daily for 3 days

Complementary therapies

There is no evidence from randomized trials that tea tree oil, yogurt (or other products containing live Lactobacillus species) or douching is effective.

Pregnant or breastfeeding women

Only topical azole therapies for 7 days, are recommended. Avoid oral regimens due to potential teratogenicity.

Treatment of sexual partners is not needed unless symptomatic.

BACTERIAL VAGINOSIS (BV)

Normally, about 60% of the lactobacilli in the vagina produce hydrogen peroxidase but in BV, only 6% do. The rise in vaginal pH causes an overgrowth of predominantly anaerobic organisms like Gardnerella vaginalis, Mycoplasma hominis. Pregnant women with BV are at higher risk of preterm labour.

Clinical Features

About half of women with BV are asymptomatic. The commonest symptoms are an offensive, fishy discharge which can be white or grey, thin and watery. It does not usually cause vaginal itching or soreness.

Additional Investigations are generally not needed

Treatment

There is no need to treat asymptomatic women incidentally diagnosed.

Treatment

  • Oral Metronidazole 500mg 12 hourly for 5 to 7 days.
  • Vaginal Flagystatin pessaries  (Metronidazole and Nystatin): 1 pessary nightly for 5 to 7 nights
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
  • Oral Clindamycin 300 mg bd for 7 days

For oral or vaginal metronidazole, advised patient to avoid alcohol while on treatment and 24 hours after the last dose.

Pregnancy

Symptomatic pregnant women can be treated with either of the oral or vaginal regimens recommended for nonpregnant women. Single stat doses should be avoided.

Some clinicians avoid use of metronidazole in the first trimester because of a potential for teratogenicity. However, meta-analysis has not found any relationship between metronidazole exposure during the first trimester of pregnancy and birth defects.

Breastfeeding

Although several reported case series found no evidence of metronidazole-associated adverse effects in breastfed infants, some clinicians advise deferring breastfeeding for 12 to 24 hours following maternal treatment with a single 2 gram dose of metronidazole. Lower doses are compatible with breastfeeding.

Treatment of sexual partners has not shown to reduce the recurrence rates

TRICHOMONAS INFECTION (TI)

This is a sexually transmitted infection caused by the flagellated protozoon parasite Trichomonas vaginalis. This infection is associated with increased risk of preterm labour and low birthweight infants.

Transmission is almost always by unprotected sexual intercourse.

Clinical features

Up to half of women are asymptomatic.

The patient may have a yellowish-green vaginal discharge which may be thick, thin or frothy. This is sometimes accompanied by an unpleasant smell, soreness or itching.

The classical appearance of  a “strawberry cervix” due to punctate haemorrhages is found in 2% of cases.

Additional Investigations

When reported incidentally on cervical cytology, a vaginal swab should be sent off for confirmation as the sensitivity of cytology-detected infection is lower.

Management

STD (sexually transmitted disease) screening should be offered.

Specific Treatment

Systemic antibiotic therapy is required for permanent cure. Intravaginal treatment is not recommended as cure rates are unacceptably low.

  • Metronidazole 2g orally in a single dose
  • Metronidazole 500mg twice daily for 5 to 7 days

Contact tracing & treatment

Current partners and any partner(s) within 4 weeks prior to presentation should be offered STD screening and treated irrespective of the results.

Advise patient to avoid sexual intercourse until they and their partner(s) have completed treatment and follow-up.

Retesting for T. vaginalis is recommended for sexually active women within 3 months following initial treatment regardless of whether they believe their sex partners were treated.

When to refer to a Gynaecologist?

  • Recurrent infections
  • Severe infections
  • High risk of STDs: screen for chlamydia and gonorrhea
  • Suspicion of Upper reproductive tract infection: the patient may present with abdominal pain or fever
  • Brownish discharge in a menopausal patient
  • If in doubt

References

CDC 2015 Sexually Transmitted Diseases Treatment Guidelines
https://www.uptodate.com

A Specialist’s Point of View – Written by Dr Clara Ong

Dr Ong is a fully qualified Obstetrician and Gynaecologist with the Specialist Accreditation Board of the Ministry of Health, Singapore. She is a Fellow of the Academy of Medicine, Singapore. She is also an accredited Colposcopist with the Society for Colposcopy & Cervical Pathology of Singapore. Married for more than ten years with 3 children, she can relate to other young mothers and is a strong breastfeeding advocate. She is very much willing to hold the hands of mothers through their journey from conception to delivery to postpartum care. Besides general obstetrics and gynecology, she promotes sexual and reproductive health and contraception. She supports natural birth and women centred care.

Clinic details: 

SOG – Clara Ong Clinic for Women
Gleneagles Medical Centre
6 Napier Road #08-15-16
Singapore 258499

Contact:
Tel: +65 6254 1741
Email: claraongclinic@sog.com.sg

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