VULVOVAGINITIS

Week 63
AuduBon-Bons Prepared by: Holli Jakalow, MD
SDH and .phrase slides by Chloé Altchek, MS4
Bite Sized
Learning for Clinic
Reading Assignment:
ACOG Practice Bulletin #215
Vaginitis in Nonpregnant Patients
 LEARNING OBJECTIVES
• To understand how to perform an evaluation for patients with
symptoms of vaginitis

• To understand how to diagnose bacterial vaginosis, vulvovaginal

candidiasis, and trichomoniasis

• To understand how to treat bacterial vaginosis, vulvovaginal

candidiasis, and trichomoniasis
 CASE VIGNETTE
• Ms. Pica Zon, a 37yo G3P3003 woman presents to clinic with vulvar
redness, itching, and thick white discharge for the past week.
 FOCUSED HISTORY
What elements of the patient’s history are most relevant?
• PMH: HTN, HLD, T2DM
• PSH: CS x3
• POBH: Term CS x3
• PGYNH: Regular menses Q28 days lasting 6 days. Denies history of STIs or
abnormal paps. Up to date on pap. Last STI screening 5 years ago.
Sexually active with mutually monogamous male partner for 10 years.
Denies vulvar or vaginal issues prior to this week. Denies dyspareunia.
• MEDS: Lisinopril, Simvastatin, Metformin
• ALL: NKDA
• FH: T2DM, CAD
• SH: Lives with husband and children. Denies tob, drug, etoh use.
Denies IPV. Works as a teaching assistant. Accepts blood products.
 PERTINENT PHYSICAL EXAM FINDINGS
What elements of the patient’s physical exam are most relevant?
• General: Well appearing woman, VSS
• Vulva: Erythematous external female genitalia. No lesions
• Vagina: Erythematous mucosa. Thick white discharge
• Cervix: No lesions. No CMT
• Uterus: NT. Anteverted. Not enlarged
• Adnexae: NT. No masses palpable
• Clinic Microscopy 10x: Branching and budding pseudohyphae with 10%
potassium hydroxide, lactobacillus present
 CAUSES OF VULVOVAGINITIS

What are the most common causes of vulvovaginitis?

• Bacterial vaginosis 22-50%
• Vulvovaginal candidiasis 17-39%
• Trichomoniasis 4-35%
• Undiagnosed 7-72%

What are other etiologies of vulvovaginitis?

• Vulvar skin diseases, desquamative inflammatory vaginitis, genitourinary
symptoms of menopause
 EVALUATION OF VULVOVAGINITIS

What is the recommended initial evaluation for patients with

symptoms of vulvovaginitis?
• Complete medical history
• Physical examination of the vulva and vagina
• Clinical testing of vaginal discharge
• pH testing, KOH “whiff test,” and microscopy
 BACTERIAL VAGINOSIS
Background: How do you treat bacterial
• Most common cause of abnormal vaginal discharge in patients of vaginosis?
reproductive age
• Not a true infectious or inflammatory state
• Change in normal microbiome of the vagina with an overgrowth
of facultative anerobic organisms and lack of lactobacilli
• Rarely occurs in patients who have not been sexually active

How do you make the diagnosis of bacterial

vaginosis?

Vaginitis in Nonpregnant Patients. ACOG Practice Bulletin No. 215. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e1-17.
 VULVOVAGINAL CANDIDIASIS
Background: How do you treat uncomplicated
• Represents inflammation and infection of the vagina with vulvovaginal candidiasis?
Candida species
• Second most common cause of vaginitis
• 29-49% of females report at least one lifetime episode
• Uncommon in prepubescent and postmenopausal women

How do you make the diagnosis of vulvovaginal

candidiasis?

Vaginitis in Nonpregnant Patients. ACOG Practice Bulletin No. 215. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e1-17.
 VULVOVAGINAL CANDIDIASIS
How do you classify uncomplicated versus complicated vulvovaginal
candidiasis?

• Uncomplicated (presence of ALL the following):

• Sporadic or infrequent episodes
• Mild-to-moderate symptoms or findings
• Immunocompetent patients
• Complicated (presence of ANY of the following):
• Recurrent episodes (four or more per year)
• Severe symptoms or findings
• Non-C albicans candidiasis (suspected or proven)
• Diabetes, immunocompromising conditions, debilitation, or immunosuppressive
therapy
 TRICHOMONIASIS
Background: How do you treat trichomoniasis?
• Caused by an infection with the protozoan parasite Trichomonas
vaginalis
• Most common non-viral STI in the USA
• 3-5 million cases annually
• Douching is modifiable risk factor
• Associated with PID, post-hysterectomy cuff cellulitis, HIV, and other
STIs
• Because asymptomatic carriage can occur for prolonged periods of
time, recent diagnosis not necessarily mean recent acquisition

How do you make the diagnosis of trichomoniasis?

Vaginitis in Nonpregnant Patients. ACOG Practice Bulletin No. 215. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e1-17.
 SOCIAL DETERMINANTS OF HEALTH
DISPARITIES IN TRICHOMONIASIS RATES AND ASSOCIATED RISKS

Disproportionately high rates of Black women have T. vaginalis

(TV) infection (13.3%), compared with White women (1.3%) and
Mexican American women (1.8%)

T vaginalis increases both transmission and acquisition of HIV

among women, and successful treatment for TV can reduce HIV
genital shedding Prevalence of T. vaginalis among black
women, compared with women from all
Disparities are not associated with individual or population-level other racial/ethnic groups, by age group
behavioral differences; rather they result from systemic, societal,
and cultural barriers to STD diagnoses, treatment and preventive
services

Control of T vaginalis may represent an important means of slowing HIV transmission,

particularly among African Americans, in whom higher rates have been observed.
 EPIC .PHRASE
BBonTVaginalis
Description: Trichomoniasis diagnosis/treatment and counseling
Exam and symptoms consistent with trichomoniasis, including ***[yellow to green
frothy vaginal discharge, abnormal vaginal odor, pruritis, irritation, dysuria,
vaginal/cervical-vaginal erythema with petechiae].
***Labs/microscopy/KOH/NAAT/culture confirm diagnosis.
Pt counseled that trichomoniasis is a sexually transmitted disease. Potential
complications include pelvic inflammatory disease, increased risk of getting or
spreading HIV, and preterm delivery in those who are pregnant. Treatment plan
was discussed with the patient including metronidazole 500mg BID for 7 days for
the patient ***[and partner]. Pt was advised that in order to avoid reinfection, all
sex partners should get treated with antibiotics at the same time and the patient
and partners should abstain from sex until pharmacological treatment has been
completed and they have no symptoms. Pt counseled that latex condoms may
lower the risk of getting trichomoniasis. Pt also advised to avoid the consumption of
alcohol while taking metronidazole. All questions were answered.
 CODING AND BILLING
• ICD-10 Code
• N77.1
• Vaginitis, vulvitis, and vulvovaginitis in diseases classified elsewhere
• B37.3
• Candidal vulvovaginitis
• A59.9
• Trichomoniasis, unspecified
• CPT Code
• 99214
• Office or other outpatient visit for the evaluation and management of an established patient,
which requires at least two of these three key components:
• A detailed history; a detailed examination; medical decision making of moderate
complexity.
• Counseling and/or coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the problem(s) and
the patient's and/or family's needs.
• Usually, the presenting problem(s) are of moderate to high severity.
• Typically, 25 minutes are spent face-to-face with the patient and/or family.
 EVIDENCE
1. Diagnosis and management of vulvar skin disorders. ACOG Practice Bulletin No.
93. American College of Obstetricians and Gynecologists. Obstet Gynecol
2008;111:1243–53.
2. Vaginitis in nonpregnant patients. ACOG Practice Bulletin No. 215. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e1-17.
3. Madeline Sutton, Maya Sternberg, Emilia H. Koumans, Geraldine McQuillan,
Stuart Berman, Lauri Markowitz, The Prevalence of Trichomonas
vaginalis Infection among Reproductive-Age Women in the United States,
2001–2004, Clinical Infectious Diseases, Volume 45, Issue 10, 15 November
2007, Pages 1319–1326, https://doi.org/10.1086/522532
4. Kissinger P, Adamski A. Trichomoniasis and HIV interactions: a review. Sex
Transm Infect. 2013 Sep. 89 (6):426-33.
5. Centers for Disease Control and Prevention. Sexually Transmitted Diseases
Treatment Guidelines, 2015. MMWR, 64(RR-3) (2015).