vaginitis--%20trichomoniasis,%20candidiasis,%20bacterial%20vaginosis
VAGINITIS: TRICHOMONIASIS, CANDIDIASIS, BACTERIAL VAGINOSIS

Trichomoniasis is caused by a flagellated protozoan, Trichomonas vaginalis. It is always sexually transmitted.

Bacterial vaginosis is the most common cause of vaginitis, vaginal discharge or malodor. Its prevalence is similar in both pregnant and non-pregnant women.

Vulvovaginal candidiasis is caused by overgrowth of yeasts where 70-90% of cases are secondary to Candida albicans. It most commonly occurs when the vagina is exposed to estrogen (ie, reproductive years, pregnancy) and may be precipitated by antibiotic or corticosteroid use. Immunocompromised and diabetic women are also at risk.

Follow Up

  • Patient follow-up helps to check adherence to therapy, evaluate symptom improvement, confirm if contact tracing was done, and provide further counseling and sexual health education

Trichomoniasis

  • Test of cure after oral Metronidazole therapy is not recommended
    • Perform retesting after 4 weeks if patient remains symptomatic or if treatment of partner is uncertain
  • Re-screening 3 months after initial infection should be considered in sexually active women with trichomoniasis
    • Studies have shown that 17% of women diagnosed with trichomoniasis were reinfected within 3 months
    • No evidence has been shown to support the need to re-screen men infected with T vaginalis
  •  Recurrent T vaginalis infections are usually due to reinfection with untreated partner or decreased susceptibility to Metronidazole
    • 2-5% of cases of T vaginalis infection were identified to have low-level Metronidazole resistance
      • Majority respond to Tinidazole or higher doses of Metronidazole
  • Treatment Failure
    • Rule out possible noncompliance, vomiting of Metronidazole, and re-infection from a new or untreated partner
    • Patients who do not respond to the initial single-dose treatment usually respond to oral Metronidazole using a 7-day regimen
      • If treatment still fails, higher doses of oral Tinidazole or Metronidazole given for 5-7 days should be considered
    • If none of the therapies were effective, patient should be referred to a specialist and susceptibility of T vaginalis to Metronidazole and Tinidazole should be determined

Bacterial Vaginosis

  • Test of cure is not required
  • Patients who become asymptomatic after treatment need not return for a follow-up visit
  • Patient should return for re-evaluation if symptoms recur
  • Patients with first recurrent bacterial vaginosis may be offered a different treatment regimen but may retry same/prior regimen
    • A repeat course of the standard topical regimen may also be done during the early stages of infection
  • Metronidazole gel for 4-6 months have been shown to reduce multiple recurrences, but suppressive effect does not persist after discontinuation
  • Limited studies have shown the use of oral nitroimidazole followed by intravaginal boric acid and suppressive Metronidazole gel or monthly oral Metronidazole plus Fluconazole for women with recurrent bacterial vaginosis

Vulvovaginal Candidiasis

  • Test of cure is not required  
  • Follow-up is needed only if symptoms persist or recur within 2 months of onset of initial symptoms
  • Recurrent vulvovaginal candidiasis occurs in ≤5% of women
    • Should evaluate predisposing factors and treat accordingly
    • Request for culture to confirm the clinical diagnosis and to identify infecting organism, as other non-albicans species (eg C glabrata) may be resistant to conventional antimycotic therapy

Counselling

  • Human immunodeficiency virus counseling and testing is recommended for trichomoniasis patients, unless other risk factors for human immunodeficiency virus infection are identified
    • Vulvovaginal candidiasis occurs more frequently and persistently in women with human immunodeficiency virus but occurrence of recurrent vulvovaginal candidiasis should not be an indication for human immunodeficiency virus testing among women previously tested human immunodeficiency virus negative
    • Bacterial vaginosis and Trichomonas vaginalis are both associated with increased acquisition of human immunodeficiency virus 
  • Consultation allows for an opportunity to discuss patient’s risk factors for sexually transmitted infections and human immunodeficiency virus
  • Determine patient’s risk for human immunodeficiency virus and discuss human immunodeficiency virus testing
  • Testing for human immunodeficiency virus is recommended and should be offered to all persons seeking evaluation and treatment for sexually transmitted infections
    • Pretest and post-test counseling, as well as informed consent are part of the testing procedure
    • Concomitant infection with human immunodeficiency virus may complicate management and control of some sexually transmitted infections

Evaluation and Treatment of Sex Partners

Partners of Patients with Trichomoniasis

  • Sex partners of patients with T vaginalis infection should also be treated with single oral dose of Tinidazole 2 g or 7-day regimen of Metronidazole 500 mg twice a day
    • Partners within the last 60 days must be traced, checked, and treated; if the last sexual contact is >60 days ago, the most recent sex partner should be treated
    • Treatment of sex partners increases cure rates 
  • Patients and their sex partners should avoid sex until they are cured (both partners have completed therapy and are asymptomatic)
  • Patient-delivered partner therapy might be considered in managing partners for trichomoniasis

Partners of Patients with Bacterial Vaginosis

  • Routine screening and treatment of sex partners are not recommended since this has no impact on possible relapse and recurrence of bacterial vaginosis

Partners of Patients with Vulvovaginal Candidiasis

  • Routine treatment of sex partners is not recommended but may be considered in women with recurrent infection
  • Male sex partners who are symptomatic will require treatment; partners with balanitis may benefit from topical antifungal therapy
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