Vulvovaginitis and Bacterial Vaginosis

Chapter 71 Vulvovaginitis and Bacterial Vaginosis




Clinical Case Problem 1 A 21-Year-Old Woman with Vaginal Itching and Discharge


A 21-year-old woman comes to your office complaining of severe vulvovaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3   months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) test results have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test result is negative, the wet mount (saline-prepared slide) reveals no evidence of clue cells or trichomonads, and the potassium hydroxide (KOH) slide preparation reveals several pseudohyphae.





Select the best answer to the following questions




1. What is the most likely diagnosis in this patient?


a. physiologic discharge

b. bacterial vaginosis (BV)

c. vulvovaginal candidiasis (VVC)

d. trichomoniasis

e. an allergic vaginitis secondary to latex condoms

2. You treat the patient accordingly and her symptoms resolve. She returns 6   months later for her routine Pap smear. The Pap smear results return as “satisfactory for evaluation, negative for intraepithelial lesion or malignancy, fungal organisms morphologically consistent with Candida species.” The patient is asymptomatic, and speculum and pelvic examination findings are normal. What is the next most appropriate step?


a. treat the patient for VVC only if her wet prep is positive for pseudohyphae

b. treat the patient for VVC only if a vaginal culture is positive for Candida albicans

c. treat the patient for VVC only if both a wet prep and vaginal culture are positive for yeast

d. no intervention is required at this time

e. repeat the Pap smear

3. Which of the following has not been shown to increase the risk for recurrence of this condition?


a. high-carbohydrate diets

b. diabetes mellitus

c. oral contraceptives

d. frequent or prolonged antibiotic use

e. immunodeficiency

4. Which of the following is an appropriate treatment for this patient?


a. metronidazole (500   mg orally twice a day for 7   days)

b. tinidazole (2   g orally in a single dose)

c. yogurt with live Lactobacillus acidophilus cultures (8 ounces orally or 1 tablespoon intravaginally, four times daily for 7   days)

d. boric acid tablets (600   mg intravaginally daily for 2   weeks)

e. fluconazole (one dose of 150   mg orally)

5. This patient returns 2   weeks later stating that she has not responded to the treatment you prescribed. What should you do next?


a. repeat the same treatment, but double the dose

b. repeat the same treatment, but double the duration of use

c. reconsider the diagnosis, and reevaluate the patient

d. apply topical metronidazole gel to her vulvar and vaginal areas

e. reassure the patient that it often takes several weeks for symptoms to resolve

6. Which of the following therapies has been shown to be useful in this patient if this condition is recurrent?


a. a high-potency topical steroid cream applied intravaginally

b. oral steroids

c. boric acid

d. minocycline (100   mg orally twice daily for 1   month)

e. vinegar and water douches

7. Which of the following statements regarding VVC is true?


a. C. albicans is the most common cause of VVC

b. Candida glabrata is not associated with chronic or recurrent VVC

c. all Candida species are equally sensitive to imidazole antifungal agents

d. Pap tests are diagnostic for candidiasis

e. intestinal Candida is the major source of recurrent VVC

8. Which of the following is not included in the classification for uncomplicated VVC as defined by the Centers for Disease Control and Prevention (CDC)?


a. sporadic and infrequent episodes

b. mild to moderate signs and symptoms

c. vaginal candidiasis occurring in pregnant women

d. infection with C. albicans

e. vaginal candidiasis occurring in nonimmunocompromised individuals

9. Which of the following statements regarding prophylactic antifungal therapy for recurrent VVC is true?


a. there is no evidence to support that prophylactic antifungal therapy for recurrent VVC reduces the risk of recurrence

b. prophylactic therapy for recurrent VCC is not necessary for nonimmunocompromised patients because their symptoms are not severe

c. prophylactic therapy for recurrent VCC is effective indefinitely, even after therapy has been discontinued

d. oral fluconazole therapy (150   mg orally once every 3   days for 2   weeks, followed by 150   mg orally each week for 6   months) has been shown to decrease the number of VVC episodes in women suffering from recurrent VVC

e. prophylactic therapy for recurrent VCC should be initiated in all HIV-infected women, even in the absence of symptoms


Clinical Case Problem 2: A 29-Year-Old Woman with a Malodorous Vaginal Discharge


A 29-year-old woman comes to your office with a 2-week history of a persistent, malodorous vaginal discharge. The unpleasant “fishy” odor appears to worsen after sex. She denies any vaginal itching, urinary symptoms, or other complaints. She is in a long-standing monogamous relationship with her husband, who is asymptomatic. She has no history of sexually transmitted infections (STIs) or abnormal Pap test results. She has been douching weekly for the past several months. On examination, there is a thin, milky, off-white discharge present at the introitus without any evidence of vulvar irritation. On speculum examination, the discharge is homogeneous and pooling on the floor of the vagina with no signs of vaginal or cervical inflammation. You perform a gross and microscopic examination of the vaginal discharge. The pH is 6, the whiff test result is strongly positive, the wet mount slide reveals the presence of several clue cells but no trichomonads or polymorphonuclear/white blood cells (WBCs), and the KOH slide reveals no evidence of pseudohyphae or budding yeast cells.



10. What is the most likely diagnosis in this patient?


a. physiologic discharge

b. trichomoniasis

c. candidiasis

d. atrophic vaginitis

e. BV

11. Which of the following statements regarding this patient’s condition is true?


a. it is considered a sexually transmitted infection

b. treating the partner will prevent recurrence

c. it has no association with preterm labor

d. it has no association with postpartum endometritis

e. it is the result of a reduction of lactobacilli in the vagina

12. Which of the following is no longer an acceptable treatment of this patient’s condition, according to the CDC?


a. metronidazole (500   mg orally twice a day for 7   days)

b. metronidazole (2   g orally for a single dose)

c. metronidazole gel 0.75% (5   g intravaginally at bedtime for 5   days)

d. clindamycin (300   mg orally twice a day for 7   days)

e. clindamycin cream 2% (5   g intravaginally at bedtime for 7   days)

13. What is the most common class of organisms associated with this patient’s condition?


a. aerobic bacteria

b. anaerobic bacteria

c. virus

d. fungi/yeast

e. protozoa

14. Treatment for BV is indicated for all of the following patients except


a. all nonpregnant women who have signs and symptoms of BV

b. women who have evidence of BV based on Pap smear

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Vulvovaginitis and Bacterial Vaginosis

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