Vaginitis and PID

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; 20-45 years; protozoan Trichomonas vaginalis

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

Common Treatments

• Yeast: oral fluconazole 150mg single dose, or intravaginal 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 intravaginal clindamycin cream or metronidazole gel.

Atrophic Vaginitis

• Affects 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 or Uterine tenderness or Adnexal tenderness

• Temp > 101º F

• Mucopurulent discharge

• Abundant WBCs on wet mount

• 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• Cefotetan/Cefoxitin plus Doxycycline• Clindamycin plus Gentamicin• Ampicillin/Sulbactam plus Doxycycline

ORAL TREATMENT: Ceftriaxone IM plus Doxycycline with or without Metronidazole

Err on the side of caution

• Empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain if no other cause for the symptoms can be identified.

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