Vaginitis and Urethritis (Case 50)

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Vaginitis and Urethritis (Case 50)

Patricia D. Brown MD

Case: A 28-year-old woman presents acutely with complaints of discomfort in the vulvar region of 3 days, accompanied by pain with intercourse (dyspareunia). The patient complains of intense itching and burning in the vulvar area. She has noticed a small amount of thick, whitish-yellow discharge in her underwear; the discharge does not have any odor. She also complains of dysuria but denies urgency, frequency, or hesitancy; she has no lower abdominal pain or fever. The patient has no chronic medical illness and takes no regular medications except oral contraceptives. She was HIV-negative when tested during a routine visit for contraception 1 year ago. She is sexually active with a new (past 3 months) male partner who uses condoms inconsistently; she has had two additional partners in the preceding year. She states that her partner has no symptoms, but she is very concerned about the possibility of an STD. She has never been pregnant; her last menstrual period was 2 weeks ago and was normal.

Differential Diagnosis

Candida vaginitis

Bacterial vaginosis (BV)

Trichomoniasis

Cervicitis/urethritis

 

Speaking Intelligently

When approaching a patient with vaginal complaints, the physician can narrow the differential diagnosis on the basis of the symptoms and characteristics of the discharge (if present). However, a specific etiologic diagnosis cannot be made without a pelvic examination and examination of vaginal secretions that includes measurement of the pH and microscopy. In the absence of symptoms suggestive of bladder irritation that would suggest urinary tract infection (urgency, hesitancy, frequency), women with dysuria may have vaginitis or urethritis; men with isolated dysuria are likely to have urethritis and may also complain of penile discharge.

 

PATIENT CARE

Clinical Thinking

• The differential diagnosis of vaginal symptoms consists mainly of infectious etiologies, although noninfectious causes of vaginal symptoms are also possible.

• Cervicitis can also present with complaints of vaginal discomfort, dyspareunia, and vaginal discharge; the differential diagnosis of cervicitis consists mainly of sexually transmitted pathogens (Neisseria gonorrhoeae and Chlamydia trachomatis); these two pathogens are also the major causes of urethritis in men.

• A focused history (including a detailed sexual history) may allow the clinician to narrow the differential diagnosis; however, as discussed above, accurate diagnosis requires pelvic examination and examination of vaginal secretions.

• The clinician should carefully address the patient’s concerns regarding the possibility of a sexually transmitted infection.

History

• The history should include the specific symptoms (vaginal/vulvar pain, irritation, itching, dysuria, dyspareunia, intermenstrual bleeding) and the characteristics of the vaginal discharge, if present.

• The history must include a detailed gynecologic history (menstrual history, pregnancy history, history of previous infections, contraceptive use) and sexual history (sexual preference, number of partners/recent new partner, symptoms in partners, types of sexual activity).

• Question the patient regarding the use of any products that may cause vaginal irritation (spermicides, lubricants, douches).

• Review the past medical history, particularly any history of diabetes or conditions associated with immunosuppression.

• In men with complaints suggestive of urethritis, obtain a detailed sexual history including history of prior infections and general medical history.

Physical Examination

• Physical examination will focus on a detailed examination of the external genitalia and a careful pelvic examination.

• Examine the external genitalia for the presence of any lesions or erythema; note the presence of inguinal adenopathy.

• Examine the urethral meatus and vaginal mucosa for evidence of erythema or lesions, and describe the appearance of vaginal secretions; take samples of vaginal secretions for pH testing and microscopic examination.

• Examine the cervix for any visible abnormalities, and obtain a sample of cervical secretions if there is evidence of cervicitis.

• Perform a bimanual examination, especially in women with evidence of cervicitis and/or complaints of lower abdominal discomfort.

• In men with symptoms suggestive of urethritis, perform a careful examination of the external genitalia and the inguinal region.

• Palpate the testes, spermatic cords, and epididymis to look for tenderness or masses.

• Often, discharge will be visible at the urethral meatus; obtain a sample for microscopic examination (if available) and further testing. If no discharge is present, the examiner can “milk” the urethra by holding the base of the penis between the thumb (on the ventral surface) and the index finger (on the dorsal surface) and moving the hand slowly down the shaft of the penis to the urethra with gentle pressure. If discharge still cannot be obtained, the examiner can obtain a sample by spreading the urethral meatus.

Tests for Consideration

• In women with evidence on examination of vaginitis, document the pH of the vaginal secretions using commercially available pH paper strips to test a sample of secretions collected from the lateral wall of the vaginal vault with a cotton-tipped applicator. Prepare two slides for microscopic examination (wet mount), one utilizing normal saline and the other 10% KOH; upon adding a drop of KOH to a sample of vaginal secretions, the presence of a fishy odor (positive whiff test) is supportive of a diagnosis of BV.

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• Cultures are generally not utilized in the diagnosis of vaginitis; however, microbiologic confirmation is required in patients with cervicitis and in men with urethritis; non–culture-based (DNA amplification–based) testing is most commonly utilized to confirm the diagnosis of gonorrhea (GC) or chlamydia.

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• Any patient with an STD should be screened for other STDs, including screening for HIV. In light of the recent CDC recommendation that routine HIV screening should be offered to all patients in all health-care settings at least once, screening should be offered even if the final diagnosis is not an STD.

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Candida Vaginitis (Vulvovaginal Candidiasis)

Pφ

Candida species (mainly C. albicans) can be part of the vaginal flora in asymptomatic women. Risk factors for symptomatic infection include antibiotic use, poorly controlled diabetes, and the use of oral contraceptives; however, the majority of women with vulvovaginal candidiasis (VVC) have no predisposing risk factor for infection. VVC is exceedingly common; it is estimated that almost 75% of women will have at least one episode in their lifetime.

TP

The most common complaint of women with VVC is vulvar irritation, burning, and/or pruritus. Patients may complain of dysuria without other urinary tract symptoms, and dyspareunia. Discharge is typically not a prominent complaint; if present, it is typically scant. Examination of the vulvar area and the vaginal mucosa reveals erythema; linear ulcerations (fissures) and excoriations may be seen in the vulvar region. The presence of erythematous papules beyond the area of vulvar erythema (satellite lesions) is characteristic of candidal infection. Thick, clumped (“cottage cheese–like”) discharge that is typically adherent to the vaginal mucosa is characteristic.

Dx

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