These materials were developed by the Program and Training Branch



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ready-to-use std curriculum for clinical educators vaginitis module target audience - faculty in clinical education programs, including those programs that train advanced practice nurses, physician assistants, and physicians contents - the following resources are provided in this module -faculty notes (microsoft word and adobe acrobat formats) - includes notes that correspond to the slide presentation, a case study with discussion points, and test questions with answers. -slide presentation (microsoft word and adobe acrobat formats) -student handouts --case study (microsoft word format) --test questions (microsoft word format) --slides handout (adobe acrobat format) --resources (microsoft word format) suggested time allowance - the approximate time needed to present this module is 60-90 minutes.

These materials were developed by the

Program and Training Branch,

Division of STD Prevention, CDC. They are

Based on the curriculum developed by the

National Network of STD/HIV Prevention

Training Centers (NNPTC) which includes

recommendations from the 2010 CDC STD

Treatment Guidelines




Information on the NNPTC can be accessed at:
www.nnptc.org
The 2010 CDC STD Treatment Guidelines

can be accessed or ordered online at:


www.cdc.gov/std/treatment/2010


July 2013
hhs logo april 2008 centers for disease control and prevention division of std prevention program and training branch

STDTraining@cdc.gov


[Slide 1]

Vaginitis

This module provides an overview of normal vaginal flora, common causes of vaginitis, and general information on the diagnosis and evaluation of vaginitis. The module covers



  • Bacterial Vaginosis (BV)

  • Vulvovaginal Candidiasis (VVC)

  • Trichomoniasis

[Slide 2]



Vaginal Environment

    • The vagina is a dynamic ecosystem that normally contains approximately 109 bacterial colony-forming units per gram of vaginal fluid.

    • The normal vaginal discharge is clear to white, odorless, and of high viscosity.

    • The normal bacterial flora is dominated by lactobacilli, but a variety of other organisms, including some potential pathogens, are also present at lower levels.

    • Lactobacilli convert glycogen to lactic acid.

    • Lactic acid helps to maintain a normal acidic vaginal pH of 3.8 to 4.2.

    • The acidic environment and other host immune factors inhibit the overgrowth of bacteria and other organisms with pathogenic potential.

    • Some lactobacilli also produce hydrogen peroxide (H2O2), a potent microbicide that kills bacteria and viruses.

[Slide 3]



Vaginitis

    • Vaginitis can be characterized by any of the following—vaginal discharge, vulvar itching, vulvar irritation, vaginal odor, dyspareunia, and dysuria.

    • The three most common types of vaginitis are—bacterial vaginosis (40%–45%), and vulvovaginal candidiasis (20%–25%), trichomoniasis (15%–20%). In some cases the etiology may be mixed, and there may be more than one disease present.

[Slide 4]



Causes of Vaginitis

Causes of vaginal discharge or irritation may include



  • Normal physiologic variation

  • Allergic reactions, e.g., spermicides, deodorants

  • Herpes Simplex Virus (HSV)

  • Mucopurulent cervicitis—may be related to Chlamydia trachomatis or Neisseria gonorrhoeae infection

  • Atrophic vaginitis—found in lactating and post-menopausal women and related to a lack of estrogen

  • Vulvar vestibulitis, lichen simplex chronicus, and lichen sclerosis (especially pruritis)

  • Foreign bodies, e.g., retained tampons

  • Desquamative inflammatory vaginitis

[Slide 5]



Diagnosis of Vaginitis

      • Patient history

      • Visual inspection of the external genitalia, vagina, and cervix

      • Appearance of vaginal discharge: color, viscosity, adherence to vaginal walls, odor

[Slide 6]



Preparation and Evaluation of Specimen

      • Collect specimen—collect discharge from the lateral wall of the vagina with a swab

  • Prepare specimen slide (wet mount)

  • With a drop of .9% warm saline and a drop of discharge; place cover slip on slide and examine microscopically at low and high power for clue cells and motile trichomonads.

  • Alternately—Place swab with discharge in 0.5 mL .9% warm saline; touch the swab to a slide and place cover slip on slide and examine microscopically at low and high power.

      • In addition to wet mount, the following diagnostic steps can be helpful in the diagnosis of vaginitis.

        • KOH (wet mount)—microscopic examination of discharge for pseudohyphae or yeast with 10% KOH

        • Whiff test—assessment of a fishy odor after application of 10% KOH to wet mount

        • Vaginal pH—determine vaginal pH with narrow-range pH paper

[Slide 7]



Wet Prep: Common Characteristics

Image: Note squamous epithelial cell, polymorphonuclear (PMN) leukocyte, red blood cells (RBCs).



wet prep: common characteristics

[Slide 8]



Wet Prep: Lactobacilli and Epithelial Cells

Image: Saline: 40x objective. Note lactobacilli and squamous epithelial cells.



wet prep: lactobacilli and epithelial cells
[Slide 9]

Other Diagnostic Aids for Vaginitis Evaluation

      • Culture—Available for both T. vaginalis and Candida spp. Culture may be useful in the management of persistent or recurrent vulvovaginal candidiasis. Culture for T. vaginalis is more sensitive than wet mount. Culture for bacterial vaginosis is not recommended.

      • DNA probe—(BD, Affirm VP III) for Trichomonas vaginalis, Candida albicans, and Gardnerella vaginalis is available. Sensitivity, specificity, and clinical utility are higher than wet mount but lower than culture.

      • Rapid antigen test—(OSOM TV, Genzyme Diagonostics, Inc.) for T. vaginalis is an available point-of-care test. Sensitivity higher than wet mount, but similar to culture.

      • Nucleic acid amplification tests (NAAT)—The Trichomonas APTIMA test (GenProbe) is approved by the U.S. FDA for the diagnosis of vaginal trichomoniasis. This test is highly sensitive and specific and can be performed on self-collected or clinician-collected vaginal swab, urine, or liquid endocervical cytology media. This test is considerably more sensitive than culture.

      • Other commercially available diagnostic tests

        • PIP activity (Proline aminopeptidase ) for BV

        • BV-Blue® (Genzyme Diagnostics, Inc.) detects sialidase produced by G. vaginalis and other species for BV

        • PCR assay—(Amplicor, Roche Diagnostic Corp.) for N. gonorrhoeae, C. trachomatis and T. vaginalis

[Slide 10]



Vaginitis Differentiation

Table—useful criteria for diagnosing vaginitis


Vaginitis: Differentiating BV, Candidiasis, and Trichomoniasis




Normal

Bacterial Vaginosis

Candidiasis

Trichomoniasis

Symptoms

presentation




Odor, discharge, itch

Itch, discomfort, dysuria, thick discharge

Itch, discharge, ~70% asymptomatic



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