Vaginitis cases
Barbara S. Apgar, MD, MS
Professor of Family Medicine
Michigan Medicine
Ann Arbor, Michigan
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4. Wet prep with increased parabasal cells and leukocytes. Vaginal gram stain, urogenital culture and PCR for trich. Women with atrophy may have leukocytes on ...
Typology: Exercises
2022/2023
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Vaginitis cases
Barbara S. Apgar, MD, MS Professor of Family Medicine Michigan Medicine Ann Arbor, Michigan
New patient
29 year old G0 with increased vaginal
discharge; no odor, itching, pain.
Has had 2 new partners in last year.
Last Pap 4 years ago; negative
Using OCPs for contraception, no
condoms
Wet Prep
Wet prep reveals > 10 leukocytes/HPF
No motile trich, hyphae/buds, clues
pH 5.
Empiric treatment?
Further testing?
What is the etiology of increased
leukocytes on wet prep?
Trichomoniasis Diagnosis
Nye MB, et al. Am J Obstet Gynecol. 2009 Feb;200(2):188.e1-7. Wet mount 54% sensitive for trich UM current test
Trichomonas vaginalis
Diagnostic testing (NAAT). BD Probe DNA Assay (UM lab). Urine, vagina, endocervix in women. Urine, urethra in men. Can use same swab for Trich, GC CT. Molecular test-resolved algorithm (neg wet prep followed by NAAT). Retest 3 months after treatment.
Recurrent or Persistent Trich
High rate of reinfections (17% reinfected in 3 months). NAAT 2 weeks after tx. All patients should be rescreened 3 months after initial treatment. Is reinfection from having sex with untreated partner? (> 50%) Or metronidazole resistance (4-10%) Or tinidazole resistance (1%)
Treatment failure after 2gm metronidazole
If reinfection excluded. Treat with metronidazole 500 mg po bid for 7 days (patient and partner). If fails, treat with tinidazole or metronidazole 2gm orally for 7 days. If fails, consult CDC. No other topical microbicide is effective. (Cochrane 2012;6:CD 007961)
Speculum exam
No unusual discharge, no odor Normal appearing vaginal mucosa.
Wet prep
No trich, hyphae/buds Clue cells > 30% of squamous cells No lactobacilli 2 leucocytes/HPF pH 5. DIAGNOSIS?
What is Bacterial Vaginosis?
No single organism is a disease marker.
Polymicrobial condition (Gardnerella,
Bacteroides, anaerobic gram-positive cocci,
Mobiluncus).
Shift in the vaginal ecosystem (Lactobacilli
are absent or markedly decreased. pH of vagina increases. Replaced by anaerobic bacteria.
Decrease in lactobacilli Increase in Anaerobes Bacterial Vaginosis