AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

The composition of vaginal flora changes with age, stress, hormonal influence, general health status, and sexual activity. Vaginitis is a diagnosis based on the presence of symptoms of abnormal discharge, vulvovaginal discomfort, or both. Discharge flows from the vagina daily as the body's way of maintaining a healthy environment. Normal discharge is usually clear or milky with no malodor. A change in the amount, color, or smell; irritation; or itching or burning could be due to an imbalance of healthy bacteria in the vagina, leading to vaginitis.

Pathophysiology

Aerobic and anaerobic bacteria can be cultured from the vagina of prepubertal girls, pubertal adolescents, and adult women. The overgrowth of normally present bacteria, infecting bacteria, or viruses can cause symptoms of vaginitis. Chemical irritation also can be a significant factor. Atrophic vaginitis is associated with hypoestrogenism, and symptoms include dyspareunia, dryness, pruritus, and abnormal bleeding.

Frequency

United States

Vaginitis is common in adult women and uncommon in prepubertal girls. Vaginitis is one of the most common reasons for gynecologic consultation consisting of approximately 10 million office visits annually. Bacterial vaginosis accounts for 40-50% of vaginitis cases; candidiasis, 20-25%; and trichomoniasis, 15-20%.

Mortality/Morbidity

The presence of abnormal discharge, vulvovaginal discomfort, or both is required for the diagnosis of vaginitis.

Age

The age of the patient affects the anatomy and physiology of the vagina.

• Prepubertal children have a more alkaline vaginal pH than pubertal and postpubertal adolescents and women. The vaginal mucosa is columnar epithelium, vaginal mucous glands are absent, normal vaginal flora is similar to that of postmenopausal women (eg, gram-positive cocci and anaerobic gram-negatives are more common), and labia are thin with a thin hymen.
• Pubertal and postpubertal adolescents and women have a more acidic vaginal pH, stratified squamous vaginal mucosa, vaginal mucous glands, normal vaginal flora of lactobacilli, thick labia, and hypertrophied hymens and vaginal walls. Loss of vaginal lactobacilli appears to be the primary factor in the changes leading to bacterial vaginosis. Recurrences of vaginitis are associated with a failure to establish a healthy vaginal microflora dominated by lactobacilli.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Adults and children must be questioned regarding specific aspects of the symptoms of vaginitis. Vaginal bleeding in prepubertal females is always abnormal and merits full investigation. Essential information to obtain during the history is the onset of symptoms, previous occurrence, associated abdominal pain, trauma, and urinary or bowel symptoms.

• The most common etiologies in adults resulting in symptoms of vaginitis include Candida albicans, Trichomonas vaginalis, and bacterial vaginosis. Elicit symptoms with attention to these possible causes.
• • Candidiasis is a fungal infection common in women of childbearing age that results in pruritus, with a thick, white vaginal discharge. Patients often have a history of recurrent yeast infections or recent antibiotic treatment. Symptoms of candidiasis often begin just before menses. Precipitating factors include immunosuppression, diabetes mellitus, pregnancy, and hormone replacement therapy. Candidiasis is usually not contracted from a sexual partner. Seventy-five percent of all women have one episode of candidiasis in their lifetime. Recurrent episodes may indicate underlying immunodeficiency or diabetes.
  • Trichomoniasis is associated with risk factors for other sexually transmitted diseases (STDs); elicit a history of multiple sexual partners. The discharge is usually copious and frothy, resulting in local pain and irritation. Pruritus might be present. Symptoms often peak just after menses. Trichomonas vaginalis is the most common nonviral STD in the world. Infection during pregnancy has been associated with preterm deliveries and low birth weight infants.
  • Bacterial vaginosis is asymptomatic in up to 50% of women. If a discharge is present, it is typically a homogeneous grayish white or yellowish white. Bacterial vaginosis is common in pregnant women and is associated with preterm birth. Treating pregnant women that have a history of preterm birth with symptomatic bacterial vaginosis early in pregnancy has been shown to decrease the incidence of preterm birth.
  • In women with chronic vaginitis, atrophic vaginitis and hypoestrogenism must be considered. Elicit an accurate menstrual history.
• Vulvovaginitis has multiple nonvenereal causes in prepubertal children; however, if a vaginal discharge suggests an STD, question all children (and/or their caretakers) regarding possible sexual abuse. Symptoms of vulvovaginitis in prepubertal girls generally include localized pain, dysuria, pruritus, erythema, and discharge.
• • Bacteria that can cause vulvovaginitis include streptococcal species (including group A streptococci), Escherichia coli, and Shigella sonnei. Symptoms (eg, pharyngitis, diarrhea) may result from infections in areas of the body other than the vagina. A Shigella infection may result in a bloody vaginal discharge without symptoms of diarrhea. A patient with group A streptococcal infection may present with itching or painful defecation. Purulent discharge may develop insidiously.
  • Viral infections may cause symptoms of vulvovaginitis. Elicit a history of recent viral infections, including varicella. Herpes simplex viruses (HSVs), particularly HSV-1 transmitted via autoinoculation from the oral mucosa, might be present; elicit a history of recurrent oral herpes or digital herpes in the caretaker of a child in diapers.
  • Consider helminthic infections (eg, Enterobius vermicularis infections) resulting in pruritus of the genital area. Ask about contact with pinworm-infected children, itching (particularly at night), and vaginal pain.
  • Ask questions to exclude the possibility of a foreign body in the vagina, chemical irritation (eg, recent bubble baths, washing hair with shampoo while bathing, douching, feminine hygiene sprays), latex, semen, mechanical irritation, and poor hygiene. Foreign bodies in the vagina result in a persistent, foul-smelling, serosanguineous discharge. Contact dermatitis from unusual exposures may occur; ask about this possibility and about bathing patterns.
  • Obtain a history of recent trauma to the vaginal area and a history of urination and defecation patterns and problems to exclude possible anatomic abnormalities (eg, rectovaginal fistula).
  • Lichen sclerosis et atrophicus may be seen in prepubertal children and in postmenopausal women. Symptoms of chronic fissures, pain, or pruritus are often present. Rectal fissures may lead to chronic constipation in children.
  • If candidal vulvovaginitis is considered (rare in healthy prepubertal girls), the history should include recent antibiotic use, possible diabetes mellitus, immunosuppression, and underlying skin disease. Ask about a family history of mucocutaneous candidiasis.
  • Trichomoniasis is rare in prepubertal children. Sexual abuse should be suspected if symptoms are present. Symptoms include a copious frothy discharge, local pain, irritation, and, occasionally, pruritus.

Physical

The physical examination of pubertal and adult women should include a complete pelvic examination. The Tanner stage of development should be noted. The examination for prepubertal girls should be performed as described in Pediatrics, Child Sexual Abuse.

• Infectious causes of vaginitis may have the following specific physical findings:
• • Candidiasis may present with a well-demarcated erythema of the vulva with satellite lesions surrounding the redness. The vulva, vagina, and surrounding areas may be edematous and erythematous, possibly accompanied by excoriations and fissures. A clumpy adherent discharge may be seen.
  • Physical findings for trichomoniasis include a copious frothy discharge (white to greenish-yellow) and a raised punctate erythema of the cervix and upper portion of the vagina (strawberry cervix).
  • Physical findings in bacterial vaginosis include a homogeneous grayish white to yellowish white vaginal discharge. Typically, no underlying erythema exists. Bacterial vaginosis can be diagnosed if 3 of the 4 Amsel criteria are present: increased vaginal pH (>4.5), grayish white homogenous discharge, an amine smell with or without potassium hydroxide, and clue cells.
  • Physical findings associated with cervicitis from STDs include excessive vaginal discharge, erythema, and edema of the cervix.
  • Cervical ectopy or eversion may cause discharge with no apparent infectious etiology.
  • Physical findings associated with atrophy, dysplasia, and vulvar vestibulitis syndrome include localized atrophy or infection in skin and mucous membranes.
  • Vaginal foreign bodies in adults include forgotten tampons; in children, pieces of toilet tissue typically are found. Findings of foul odor and irritation with a purulent discharge are common.
  • A patient with pinworms may present with few physical findings. Occasionally, there may be erythema and excoriations around the perianal area. In severe cases, eggs and/or dead female nematodes may be seen on examination of the anal area.
  • Perianal streptococcal dermatitis usually results in a beefy red perineal area that is edematous and tender. Fissures, drainage, and hemorrhagic spotting may be present.

Causes

• Causes of vulvovaginitis vary depending on the following:
• • Age
  • Sexual activity (or abuse)
  • Hormonal status
  • Hygiene
  • Immunologic status
  • Anatomy of the genital area
  • Underlying skin diseases

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The workup for patients with vaginitis depends on the risk factors for infection and the age of the patient.
• Test for Candida albicans via a potassium hydroxide (KOH) preparation.
• • As many as 30% of symptomatic candidiasis cases have false-negative KOH results.
  • One drop of vaginal discharge is mixed with 1 drop of 10% KOH solution and covered with a coverslip.
  • Branching hyphae and buds of Candida are visible.
  • Gram stain or culture on Nickerson media and Sabouraud agar may enhance diagnosis.
  • Papanicolaou tests (Pap smears) may have frequent false-positive results for yeast.
• Motile trichomonads may be revealed by wet preparation (1 gtt of isotonic sodium chloride solution with 1 gtt of discharge).
• • With trichomoniasis, more than 10 white blood cells (WBCs) per high power field (HPF) are seen on wet preparation. Diagnostic accuracy may be improved by culture on Diamond medium or Trichosel broth.
  • The beta-tubulin (BTUB) fluorescence resonance energy transfer (FRET) polymerase chain reaction (PCR) system shows an improvement in assay time over other methods. This method offers improved accuracy over traditional PCR assays in urine samples and is comparable to the accuracy of vaginal swabs.
  • Pap smears may reveal trichomonads but have a high false-positive rate.
• Bacterial vaginosis is associated with an intense amine odor with the KOH preparation (the whiff test).
• • On wet preparation, clue cells are seen with a paucity of WBCs.
  • On Gram stain, clue cells are identified as epithelial cells covered by small gram-negative rods.
• Gonorrhea vaginitis usually results in a purulent discharge.
• • Obtain cultures of the vagina (prepubertal), cervix (pubertal, adult), oral pharynx, and rectum if gonococcal vulvovaginitis is suspected.
  • Obtain cultures using a cotton-tipped swab and Thayer-Martin media on chocolate agar, incubated in a carbon dioxide–rich environment (see Pediatrics, Child Sexual Abuse).
• Test for chlamydial vulvovaginitis via culture in prepubertal girls and in patients who show signs of abuse or sexual assault.
• • Indirect rapid antigen testing can be performed as a screen using cervical swabs of pubertal and adult women.
  • Obtain rectal chlamydia swabs (see Pediatrics, Child Sexual Abuse).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Treatment may include sitz baths and instruction regarding proper toilet and hygiene techniques. Many women assume vaginal symptoms are the result of an STD, which is often not the case. A patient's idea of vaginal normalcy may be inaccurate and result in increased or unnecessary treatment seeking.
• If the patient shows no improvement, refer her for further workup of possible STDs and other infectious causes of vulvovaginitis.

Emergency Department Care

Usually, no active treatment is necessary in the ED. However, prepubertal girls with vulvovaginitis caused by a foreign body in the vagina may require sedation for removal of the foreign body.

Consultations

Refer patients with resistant infections or persistent symptoms of vulvovaginitis to a gynecologist.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Drugs used for infectious causes of vaginitis may be applied topically or require oral or parenteral administration.

Drug Category: Antifungal agents

Imidazole derivatives that exert a fungicidal effect by altering the permeability of the fungal cell membrane. Mechanism of action also may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxides toxic to the fungal cell.

Intravaginal and topical therapy with a variety of antifungals (eg, clotrimazole, miconazole, terconazole, tioconazole) is highly effective. Many of these preparations are now available over-the-counter. Various 1-, 3-, and 7-day regimens can be used. Cure rates of 90% are reported with longer courses.

Drug Name	Fluconazole (Diflucan)
Description	PO antifungal agent. While ease of use should be considered, direct cost may be a limiting factor. PO antifungals should not be recommended in pregnancy. Current recommendations are for a 7-d course of antifungal topical therapy. Synthetic, broad-spectrum, bis-triazole antifungal agent; highly selective inhibitor of fungal CYP450 and sterol C-14 alpha-demethylation. The recommended duration of intravaginal therapy is 3-7 d.
Adult Dose	150 mg PO once
Pediatric Dose	3-6 mg/kg/d PO for 14-28 d, depending on severity of infection
Contraindications	Documented hypersensitivity
Interactions	Concomitant use with hydrochlorothiazides may increase concentrations, perhaps due to reduced renal clearance; chronic rifampin administration may decrease half-life; increases phenytoin concentrations when administered concurrently; increases half-life of theophylline; may increase concentrations of tolbutamide, glyburide, and glipizide; significant increases in cyclosporine concentrations have occurred following use
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Monitor patients who develop rashes during treatment and discontinue if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure, including fatalities, especially when a serious underlying medical condition exists (eg, AIDS, malignancy) and in patients taking multiple concomitant medications; weigh convenience and efficacy of single-dose regimen against difficulties resulting from higher incidence of adverse reactions; not recommended in nursing mothers

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. The use of antibiotic combinations usually is recommended for the treatment of serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections, prevents emergence of bacterial subpopulations that may be resistant to one of the antibiotic components, and provides additive or synergistic effects. Antibiotic monotherapy is recommended, however, once organisms and sensitivities are known.

Drug Name	Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Description	Indicated in treatment of infections caused by susceptible strains, including Staphylococcus aureus.
Adult Dose	250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h 1h ac or 500 mg q12h; alternatively, may use 333 mg q8h and increase up to 4 g/d, depending on severity of infection; if bid dosing is desired, recommended dose is 500 mg q12h; bid dosing is not recommended when administering doses > 1 g/d
Pediatric Dose	30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6h; age, weight, and severity of infection determine proper dosage; when bid dosing is desired, half-total daily dose may be taken q12h; for more severe infections, dose may be doubled
Contraindications	Documented hypersensitivity, hepatic impairment
Interactions	May increase toxicity of theophylline and digoxin when used concurrently; may potentiate anticoagulant effects of warfarin
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Discontinue use if malaise, nausea, vomiting, abdominal colic, and/or fever occur

Drug Name	Clindamycin (Cleocin, Clinda-Derm, C/T/S)
Description	Inhibits bacterial protein synthesis by its action at the bacterial ribosome. Binds preferentially to the 50S ribosomal subunit and affects the process of peptide chain initiation. Intravaginal use is not recommended for pregnant women because it has been associated with an increased risk of preterm delivery. Treatment of bacterial vaginosis with oral clindamycin during the second and third trimesters of pregnancy has been shown to reduce the occurrence of preterm birth.
Adult Dose	2% vaginal cream: 5 g qd for 7 d Alternatively, 300 mg PO bid for 7 d if pregnant
Pediatric Dose	Administer as in adults
Contraindications	Documented hypersensitivity, regional enteritis, ulcerative colitis, antibiotic-associated colitis
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Avoid contact with eyes; vaginal cream contains ingredients that cause burning and irritation of the eye; in the event of accidental contact with the eye, rinse eye with copious amounts of cool tap water; may result in overgrowth of nonsusceptible organisms, particularly yeasts, in the vagina

Drug Name	Metronidazole (MetroGel, Flagyl, MetroGel-Vaginal, Noritate Cream)
Description	Active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells; the intermediate metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death. Indicated for treatment of bacterial vaginosis (formerly referred to as Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, or anaerobic vaginosis). Highly effective in treating trichomoniasis with one dose. Topical metronidazole is not effective therapy for trichomoniasis. Treatment of bacterial vaginosis with oral metronidazole during the second and third trimester of pregnancy does not reduce the occurrence of preterm delivery. The numbers of T vaginalis cases with metronidazole resistance are increasing.
Adult Dose	500 mg PO bid for 7 d Alternatively, 5 g intravaginally qd for 7 d of 0.75% vaginal gel 250 mg PO tid for 7 d if pregnant T vaginalis: 2 g PO once
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	May potentiate the anticoagulant effects of warfarin, resulting in prolongation of PT
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Known or previously unrecognized vaginal candidiasis may present more prominent symptoms during metronidazole vaginal-gel therapy; more than 6% of patients have developed symptomatic vaginal candidiasis during or immediately after therapy

Drug Name	Cefoxitin (Mefoxin)
Description	A second-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria that are resistant to some cephalosporins and penicillins respond to cefoxitin.
Adult Dose	1-2 g IV/IM q6-8h
Pediatric Dose	>8 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Probenecid may decrease elimination and increase effects; aminoglycoside nephrotoxicity may potentiate effects in the kidney when used concurrently (monitor renal function closely)
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Bacterial or fungal overgrowth of nonsusceptible organisms may result from prolonged use of antibiotics, possibly leading to secondary infection; take appropriate measures if superinfection occurs

Drug Name	Doxycycline (Doryx, Bio-Tab, Vibramycin)
Description	Inhibits protein synthesis and thus bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria.
Adult Dose	100 mg PO bid for 7 d
Pediatric Dose	<8 years: Not recommended >8 years: 2-5 mg/kg/d PO as single dose or divided bid; not to exceed 200 mg/d
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate can decrease tetracycline bioavailability; can increase hypoprothrombinemic effects of anticoagulants (monitor prothrombin activity in patients taking both medications concurrently); coadministration with PO contraceptives can decrease pharmacologic effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Prolonged exposure to sunlight or tanning equipment can cause a photosensitivity reaction; use lower-than-usual doses in patients with renal impairment; if therapy is prolonged, consider drug serum level determinations; use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; never administer outdated tetracyclines (the degradation products of tetracyclines are highly nephrotoxic and can cause a Fanconilike syndrome)

Drug Name	Triple sulfa (Sulfa-Gyn, Femguard, Sulfa-Trip)
Description	Exerts bacteriostatic action by competitive antagonism of PABA, an essential component of folic acid synthesis. Indicated for treatment of Gardnerella vaginalis vaginitis.
Adult Dose	Tablet: Insert 1 tab intravaginally bid for 10 d and repeat prn Cream: Insert 1 applicatorful intravaginally bid for 4-6 d and 1/4-1/2 of an applicatorful bid thereafter; repeat prn
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; kidney disease; breastfeeding
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Avoid contact of cream with eyes; use vaginal applicators with caution after the seventh month of pregnancy; use of this medication has been associated with Stevens-Johnson syndrome

Drug Name	Azithromycin (Zithromax)
Description	Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. Indicated for chlamydial and gonorrheal infections of the genital tract.
Adult Dose	1 g PO once
Pediatric Dose	Day 1: 10 mg/kg PO once; not to exceed 500 mg/d Days 2-5: 5 mg/kg PO; not to exceed 250 mg/d
Contraindications	Documented hypersensitivity; hepatic impairment
Interactions	May increase theophylline and digoxin concentrations and toxicity when used concurrently; may potentiate anticoagulant effects of warfarin; antacids containing aluminum and magnesium reduce peak serum levels but not absorption; concurrent use of cyclosporine may result in elevated cyclosporine concentrations with increased risk of toxicity (nephrotoxicity, neurotoxicity)
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Local IV site reactions have been reported with the IV administration of azithromycin; bacterial or fungal overgrowth of nonsusceptible organisms may result from prolonged use of antibiotics, possibly leading to a secondary infection; take appropriate measures if superinfection occurs; can cause increases in hepatic enzymes and cholestatic jaundice (caution in patients with impaired hepatic function); not recommended for pneumonia in hospitalized patients or in patients who are elderly or debilitated; caution in patients with prolonged QT intervals

Drug Category: Estrogen

Indicated for atrophic vaginitis resulting from diminished levels of circulating estrogens. A relative lack of estrogen also predisposes the vagina and vulva to infection.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Parenteral treatment of infectious causes for vaginitis is rarely indicated. Complicated cases of certain infections (eg, gonorrhea, chlamydia) may require parenteral treatment.

Further Outpatient Care

• Recommend techniques of proper genital hygiene.
• Refer for sexual abuse evaluation all children in whom vaginitis was caused by an STD (see Pediatrics, Child Sexual Abuse).
• Treat sexual partners of patients with identified STDs.

Complications

• Infectious complications (eg, pelvic inflammatory disease, systemic disease resulting from the spread of gonorrhea) may occur.

Prognosis

• The prognosis for vaginitis is generally very good.

Patient Education

• Discuss further preventive efforts, including proper hygiene and toilet techniques, when appropriate. Remind patients that douching can spread a vaginal or cervical infection into the uterus increasing the likelihood of pelvic inflammatory diseases. Studies have also indicated that douching can be associated with endometritis.
• Educate patients regarding use of topical creams for treatment of vaginitis (eg, candidal vaginitis, bacterial vaginosis) as necessary.
• For excellent patient education resources, visit eMedicine's Yeast and Fungal Infections Center, Women's Health Center, and Parasites and Worms Center. Also, see eMedicine's patient education articles Vaginal Infections, Candidiasis (Yeast Infection), Understanding Vaginal Yeast Infection Medications, Female Sexual Problems, and Trichomoniasis.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• In cases of suspected sexual assault or child sexual abuse, proper documentation may assist with possible subsequent legal action (see Pediatrics, Child Sexual Abuse).
• Prior to treatment with any of the drugs that should not be used during pregnancy, determine possibility of pregnancy, test for pregnancy as appropriate, and maintain proper documentation.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• ACOG Practice Bulletin. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. May 2006;107(5):1195-1206.
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• Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA. Mar 17 2004;291(11):1368-79. [Medline].
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• Hillier SL, Nugent RP, Eschenbach DA, et al. Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. The Vaginal Infections and Prematurity Study Group. N Engl J Med. Dec 28 1995;333(26):1737-42. [Medline].
• Jenny C. Sexually transmitted diseases and child abuse. Pediatr Ann. Aug 1992;21(8):497-503. [Medline].
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• Ryan KJ, Berkowitz RS, Barbieri RL. Gynecologic infections. In: Kistner RW, ed. Kistner's Gynecology: Principles and Practice. 6th ed. Mosby-Year Book;1995:496-531.
• Shapiro RA, Schubert CJ, Siegel RM. Neisseria gonorrhea infections in girls younger than 12 years of age evaluated for vaginitis. Pediatrics. Dec 1999;104(6):e72. [Medline].
• Siegfried EC, Frasier LD. Anogenital skin diseases of childhood. Pediatr Ann. May 1997;26(5):321-31. [Medline].
• Sobel JD, Chaim W, Nagappan V, Leaman D. Treatment of vaginitis caused by Candida glabrata: use of topical boric acid and flucytosine. Am J Obstet Gynecol. Nov 2003;189(5):1297-300. [Medline].
• Straumanis JP, Bocchini JA Jr. Group A beta-hemolytic streptococcal vulvovaginitis in prepubertal girls: a case report and review of the past twenty years. Pediatr Infect Dis J. Nov 1990;9(11):845-8. [Medline].
• Swygard H, Sena AC, Hobbs MM, Cohen MS. Trichomoniasis: clinical manifestations, diagnosis and management. Sex Transm Infect. Apr 2004;80(2):91-5. [Medline].
• Van Kessel K, Assefi N, Marrazzo J, Eckert L. Common complementary and alternative therapies for yeast vaginitis and bacterial vaginosis: a systematic review. Obstet Gynecol Surv. May 2003;58(5):351-8. [Medline].
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Article Last Updated: Jul 13, 2006