Bacterial
vaginosis
Bacterial vaginosis is caused by
overgrowth of normal vaginal flora. Vaginal odor is the most common symptom and
often the first symptom. Odor may be recognized only after sexual intercourse.
The alkalinity of semen may cause a release of volatile amines from the vaginal
discharge and cause a fishy odor. Increased vaginal discharge is typically mild
to moderate. Vulvar irritation is less common. Dysuria or dyspareunia occur
rarely.
Ask patients about risk factors
that may predispose them to developing bacterial vaginosis. Predisposing
factors include:
- Recent antibiotic use
- Decreased estrogen production
- Smoking
- Douching
- Use of an intrauterine device (IUD)
- Sexual activity that could lead to transmission, as
evidenced by a patient having a new sexual partner, more sexual partners
in the month preceding the onset of symptoms, or having more lifetime
sexual partners,
Vaginal
cancer
Vaginal cancer is uncommon,
especially primary vaginal cancer, as most lesions are metastatic from another
primary site. Metastases typically come from reproductive organs (eg, cervix,
endometrium, ovary); however, they can also come from other sites (eg, colon,
breast, pancreas). The duration of symptoms in vaginal cancer averages 6-12
months before diagnosis, with a range of 0-11 years. Delay in the diagnosis of
vaginal carcinoma is not uncommon; this is partially due to the rarity of the
disease, as well as with delays in relating patient symptoms to a vaginal
origin. As expected, the longer the delay, the more advanced the cancer once
the diagnosis is made, resulting in a poorer outcome.
Painless vaginal bleeding is the
most common symptom, accounting for the vast majority of presentations.
Bleeding is postmenopausal in most patients, which is consistent with the peak
age of 60 years for squamous cell carcinoma, the most common type of vaginal
cancer. Menorrhagia, intermenstrual bleeding, and postcoital bleeding have also
been reported.
Vaginal discharge occurs in about
one third of patients. Some patients report urinary symptoms, which are caused
by an anterior lesion compressing or invading the bladder, the urethra, or
both. This causes bladder pain, dysuria, urgency, and hematuria. Patients may
also have pelvic pain. Posterior lesions compress or invade the rectosigmoid,
which causes tenesmus or constipation.
Few patients report a vaginal
mass or vaginal prolapse. As many as one quarter of patients are asymptomatic;
diagnosis is made during routine pelvic examination. The cancer tends to be
caught at a much earlier stage in these patients than in those who have
symptoms, and their prognosis is much better.
vulvovaginal
candidiasis
Traditionally, vulvovaginal
candidiasis is not considered a sexually transmitted disease because it occurs
in celibate women, and Candida itself is considered part of the normal
vaginal flora; however, it is more common among sexually active women.
In acute vulvovaginal
candidiasis, vulvar pruritus and burning are the main symptoms. Patients
commonly complain of both symptoms after intercourse or upon urination.
Dyspareunia may develop and become severe enough to lead to intolerance of
intercourse. Physical findings in acute vulvovaginal candidiasis include
erythema and edema of the vestibule and of the labia majora and minora. The
rash may extend to the thighs and perineum. Thrush patches are usually found
loosely adherent to the vulva. A thick, white, curd-like vaginal discharge is
usually present.
The clinical picture of chronic,
persistent vulvovaginal candidiasis differs in that it includes marked edema
and lichenification of the vulva with poorly defined margins. Often, a grayish
sheen made up of epithelial cells and organisms covers the area. Symptoms
include severe pruritus, burning, irritation, and pain. Patients with chronic
candidiasis are usually older and obese and often have long-standing diabetes.
A pelvic examination, pH testing,
and other laboratory tests to exclude differential diagnoses are indicated. The
cervix is typically not inflamed in vulvovaginal candidiasis, and no cervical
motion tenderness or abnormal discharge from the cervical os should be
observed. The diagnosis of vulvovaginal candidiasis depends on the
demonstration of a species of Candida — as with a wet-mount test or
potassium hydroxide preparation — and the presence of clinical symptoms.
Vaginal pH usually remains normal in vulvovaginal candidiasis.
Acute vulvovaginal candidiasis is
typically treated with azole antifungals that can be taken orally as a single
dose or applied intravaginally, with many treatments available over the
counter. Patients with recurrent vulvovaginal candidiasis often benefit from
6-month suppressive therapy with weekly oral fluconazole.
Pelvic organ prolapse is the
abnormal descent or herniation of the pelvic organs from their normal attachment
sites or their normal position in the pelvis. The pelvic structures that may be
involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal
prolapse), anterior vagina (cystocele), or posterior vagina (rectocele). Many
parous women may have some degree of prolapse when examined; however, most
prolapses are not clinically bothersome without specific pelvic symptoms, and
they may not require an intervention. Approximately 3% of patients with pelvic
organ prolapse are symptomatic.
PELVIC
ORGAN PROLAPSE
Although signs of pelvic organ
prolapse are frequently observed, the condition seldom causes symptoms.
However, vaginal or uterine descent at or through the introitus can become
symptomatic. Symptoms of pelvic organ prolapse may include:
- A sensation of vaginal fullness or pressure
- Sacral back pain with standing
- Vaginal spotting from ulceration of the protruding
cervix or vagina
- Coital difficulty
- Lower abdominal discomfort
- Voiding and defecatory difficulties (an anatomic
kinking of the urethra may cause obstructive voiding and urinary
retention)
Nonsurgical (conservative)
management of pelvic organ prolapse is recommended by the American College of
Obstetricians and Gynecologists' Committee on Practice Bulletins and should be
attempted before surgery is contemplated. Patients with mild pelvic organ
prolapse do not require surgery because they are usually asymptomatic. Pelvic
muscle exercises and vaginal support devices (pessaries) are the main
nonsurgical treatments for patients with pelvic organ prolapse. Kegel exercises
may help improve incontinence associated with mild pelvic organ prolapse.
Quality-of-life assessment by
standardized questionnaires (eg, Pelvic Floor Distress Inventory Questionnaire
20 (short form), Pelvic Floor Impact Questionnaire 7 (short form), Pelvic Organ
Prolapse/Urinary Incontinence Sexual Function Questionnaire) are helpful in
determining appropriate treatment. A detailed sexual history is crucial, and
focused questions or questionnaires should include quality-of-life measures.
TRICHOMONIASIS
Unlike chlamydia, which has a
peak rate among women aged 19-24 years, the incidence of trichomoniasis is
highest among women aged 40-49 years. Trichomoniasis symptoms in women range
from no symptoms to severe pelvic inflammatory disease. Women with
trichomoniasis frequently report an abnormal vaginal discharge
(yellow/gray-green), which may be purulent, frothy, or bloody. Although frothy
vaginal discharge is thought to be the classic presentation of trichomoniasis,
women with trichomoniasis also commonly report:
- Abnormal vaginal odor (often described as musty)
- Vulvovaginal itching, burning, or soreness
- Dyspareunia (often the major complaint)
- Dysuria
- Postcoital bleeding
- Lower abdominal pain
Given the poor reliability of a
patient's medical history and physical findings, the diagnosis of
trichomoniasis depends on laboratory testing. Tests for trichomoniasis are
quick and can be performed in the medical office. The Centers for Disease
Control and Prevention (CDC) now
recommend molecular diagnostic tests, when available, to evaluate patients
at risk for trichomoniasis.
After a positive diagnosis,
treatment should be instituted immediately and, whenever possible, in
conjunction with all sexual partners. Expedited partner therapy is a safe and
effective means of treating the sexual partners of patients diagnosed with
trichomoniasis and should be practiced whenever possible. Both patient and
partner should abstain from sex until pharmacologic treatment has been
completed and they have no symptoms. For women, the CDC recommends oral
metronidazole (500 mg) twice daily for 7 days. Tinidazole (2 g) orally in a
single dose is an alternative regimen. Metronidazole gel is effective in less than 50% of
patients with trichomoniasis and is not recommended to treat the disease.
