Diagnosis and Management of Vulvovaginitis

Diagnosis and Management of VulvovaginitisDiagnosis and Management of Vulvovaginitis

Diagnosis and Management of Vulvovaginitis – Introduction

Vulvovaginitis is a fairly common condition in gynecological consults. It is defined as inflammation of the vulva and vagina, usually secondary to infectious agents in reproductive-aged women. The most frequent symptoms include discomfort, pruritus, and vaginal discharge. Patients should be initially evaluated by detailed anamnesis, gynecological examination, and if available, microscopy. Some patients require more detailed evaluation and further studies to arrive at a correct diagnosis. Empiric treatment should be avoided due to the risk of an incorrect diagnosis. (1)

This article emphasizes the most important aspects of each possible etiology and the different treatment options to consider.

Definition

Vulvovaginitis is defined as the inflammation of the vulva and vagina that can be caused by infectious or non-infectious etiology. It’s characterized by vaginal discharge, inflammation, pruritus, odor, burning sensation, dyspareunia, spotting, and possible abrasions, among others, and usually impact the quality of life. (2)

Epidemiology

It is estimated that the majority of females will experience a vaginal infection during their lifetime. Vaginitis is responsible for more than 10 million consults in the US yearly. More than 90% of infectious vaginitis are caused by bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis. (3) Treatment for bacterial vaginosis, which is the most common form, represents $1.3 billion/year. (4) Vaginitis caused by Trichomonas Vaginalis is the most prevalent non-viral sexually transmitted infection (STI), affecting 3.7 million people annually in the US. (2)

Infectious vaginitis is not out of the regular course in postmenopausal women but, in this group of patients, other etiologies must be considered. Genitourinary syndrome of menopause is due to vulvovaginal atrophy and affects 27 to 84% of postmenopausal women. Symptoms include vaginal dryness, burning, irritation, and urinary symptoms, such as dysuria and recurrent infections. (5)

General Management

To begin with, it is necessary to have a clear idea of the patient’s medical history: clinical conditions, medical treatments, contraceptive methods, menses, vaginal hygiene practices (e.g., douching), sexual behaviors, allergies, and if there was self-treatment with over-the-counter medication.  It is essential to draw out information about the symptoms’ location, description, and duration.

After a complete anamnesis, it is essential to examine the patient correctly. The gynecologic examination should start with inspecting the vulva, pelvis, and perine, and continue with palpation seeking inguinal adenopathies. Later, speculoscopy should be careful to evaluate cervical anatomy and detect any bleeding or lesions; vaginal discharge must be assessed, looking at the following characteristics: color, smell, aspect, consistency, and quantity. Finally, and if it is possible, a sample of vaginal discharge must be collected with a cotton swab and tested for pH and microscopy. (6)

Clinicians should not rely on symptoms entirely to distinguish confidently between the causes of vaginitis because it can result in inaccurate or incomplete diagnoses and elevated recurrence rates. (4) FDA-approved molecular tests have shown higher specificity and sensitivity and have been recommended if available. (3)

Classification

Infectious Non-infectious
-Bacterial Vaginosis (BV)

-Candida Vulvovaginitis (CVV)

-STIs: Trichomonas Vaginalis (TV), Neisseria Gonorrhoeae, Chlamydia Trachomatis

-Allergic and Irritative Vaginosis

-Desquamative Inflammatory Vaginitis

-Genitourinary Syndrome

-Cytolytic Vaginosis

Infectious Vaginitis 

Bacterial Vaginosis

It is the principal cause of vulvovaginitis worldwide and the most common cause of abnormal vaginal discharge in patients of reproductive age. Prevalence is higher in African-American and Hispanic women. (6-8)

The reason for this condition is a change in the vaginal microbiota generated by the loss of hydrogen peroxide produced by Lactobacillus species toward more diverse bacterial species, including Gardnerella Vaginalis, a gram variable rod, Prevotella species, Mobiluncus species, and others. (9,10)

Some of the most frequently associated risk factors, in addition to ethnicity are reproductive age, lack of condom use, (11) HSV-2 seropositivity, (12) vaginal douching (13,14), and pregnancy. (15,16) BV prevalence has been reported to be higher among women with copper-containing IUDs. (17,18) On the other hand, hormonal contraception (19,20) and male circumcision might protect against BV development. (21) It is essential to know that although BV is linked to hetero and homosexual activity (22) and rarely occurs in patients who have never been sexually active, it is not considered a sexually transmitted disease, so treatment for the partner is not recommended. (23-29)

Many patients with BV are asymptomatic; those who present symptoms usually report abnormal watery, white-gray vaginal discharge, often with a fishy odor. Symptoms usually appear during menses. (30,31)

The diagnosis is based on Amsel clinical criteria or Gram stain with Nugent scoring. (32,33) In research settings, Gram stain with Nugent scoring is considered standard criteria for BV diagnosis; however, it is not practical; therefore, Amsel criteria typically are used for the diagnosis. (33)

Amsel Criteria: 3 of the 4 criteria are required (33)
1 Thin, homogeneous gray-white or yellow discharge that adheres to the vaginal walls
2 Clue cells identified on wet mount preparation
3 Vaginal pH > 4.5
4 Positive Whiff test (fishy odor)

The presence of bacterial vaginitis is associated with an increased risk of sexually transmitted infections, consequently, the patient must be tested for HIV and other STIs. Pregnant women have a higher risk of preterm delivery, premature rupture of membranes, spontaneous abortion, intra-amniotic infection, and postpartum endometritis. (34-36) At any rate, there is no recommendation for routine screening for BV among asymptomatic pregnant women. (37)

Recommended regimen based on CDC 2021 guidelines: (38)

Recommended regimen Alternative regimen
-Metronidazole 500 mg orally 2 times/day for 7 days.

-Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5 days

-Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days

-Clindamycin 300 mg orally 2 times/day for 7 days

-Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days *

-Secnidazole 2 g oral granules in a single dose**

-Tinidazole 2 g orally once daily for 2 days

-Tinidazole 1 g orally once daily for 5 days

* Clindamycin ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and diaphragms). Use of such products within 5 days after treatment with clindamycin ovules is not recommended.
** Oral granules should be sprinkled onto unsweetened applesauce, yogurt, or pudding before ingestion. A glass of water can be taken after administration to aid in swallowing.

Refraining from alcohol use while taking metronidazole (or tinidazole) is unnecessary. (39) The warning against the simultaneous use of alcohol and metronidazole was based on laboratory experiments and individual case histories in which the reported reactions were equally likely to have been caused by alcohol alone or by adverse effects of metronidazole.

In addition, it is a good medical practice to advise women to refrain from sexual activity or to use condoms consistently and correctly during the BV treatment regimen. (38)

Vulvovaginal Candidiasis (VVC)

It is the second most common cause representing 17–39% of vulvovaginitis; statistics show that 29 – 49% of female patients report at least one-lifetime episode. (40)

Among the risk factors are medications (antibiotics, steroids, immunosuppressive therapies), pregnancy, excessive moisture, smoking cigarettes, diabetes mellitus, and some congenital pathologies (AIRE gene mutation). (6) The most common clinical features are erythematous vulva and vagina, dyspareunia, external dysuria, and intense pruritus with vaginal burning sensation, fissures, and abrasions. Characteristic vaginal discharge is white, thick, odorless, and has a “cottage cheese” appearance. (38)

Candidiasis infection can be classified as uncomplicated or complicated.

Uncomplicated VVC Complicated VVC
All of the followings:

-Sporadic or infrequent VVC

-Mild-to-moderate VVC

-Likely to be Candida Albicans

-Non Immunocompromised women.

Any of the following

-Recurrent VVC

-Severe VVC

-Non-albicans candidiasis

-Diabetes, immunocompromising conditions, underlying immunodeficiency, or immunosuppressive therapy

The diagnosis of VVC is based on clinical signs and symptoms and a wet preparation (saline, 10% KOH) of vaginal discharge demonstrating budding yeast, hyphae or pseudohyphae, or positive mycological culture. VVC is associated with normal vaginal pH (< 4.5). If candida cultures cannot be done, or the results of the wet mount are negative with existing signs and symptoms, empiric treatment should be prescribed. (38)

Recommended treatment for uncomplicated VVC is based on short-course topical formulations (i.e., single dose and regimens of 1–3 days). Medications recommended by CDC are: (38)

Over-the-Counter Agents Prescription Agents
  • Clotrimazole 1% cream 5 g intravaginally daily for 7-14 days
  • Clotrimazole 2% cream 5 g intravaginally daily for 3 days
  • Miconazole 2% cream 5 g intravaginally daily for 7 days
  • Miconazole 2% cream 5 g intravaginally daily for 7 days
  • Miconazole 4% cream 5 g intravaginally daily for 3 days
  • Miconazole 100 mg vaginal suppository one suppository daily for 7 days
  • Miconazole 200 mg vaginal suppository one suppository daily for 3 days
  • Miconazole 1200 mg vaginal suppository one suppository for 1 day
  • Tioconazole 6,5% ointment 5 g intravaginally in a single application
  • Butoconazole 2 % cream 5 g intravaginally in a single application
  • Terconazole 0.4% cream 5 g intravaginally daily for 7 days
  • Terconazole 0.8% cream 5 g intravaginally daily for 3 days
  • Terconazole 80 mg vaginal suppository daily for 3 days
  • Oral agent: fluconazole 150 mg orally in a single dose.

Regarding complicated VVC, there are some specific considerations to mention.

Recurrent is defined as three or more episodes of symptomatic VVC in less than a year. (41) Most of these are caused by Candida Albicans and respond well to a short-term duration of oral or topical azole therapy. In any case, a longer duration of initial therapy and a maintenance antifungal regimen is recommended. Some of the most useful initial regimens are 7–14 days of topical therapy or a 100 mg, 150 mg, or 200 mg oral fluconazole every third day for 3 doses (days 1, 4, and 7). For a maintenance regimen, oral fluconazole (100mg, 150 mg, or 200 mg) weekly for 6 months is prescribed. If this regimen is not feasible, topical treatments used intermittently can also be considered.

Severe VVC is based on the severity of the symptoms, such as extensive vulvar erythema, edema, excoriations, or fissure. In this case, 7–14 days of topical azole or 150 mg of fluconazole are recommended in two sequential oral doses (the second dose 72 hours after the initial dose). (38)

The optimal treatment of non-albicans VVC remains unknown; however, a longer duration of therapy for 7 or 14 days with a non-fluconazole azole regimen (oral or topical) is recommended. If recurrence occurs, 600 mg of boric acid in a gelatin capsule administered vaginally once daily for 3 weeks is prescribed. This regimen has clinical and mycologic eradication rates of approximately 70%. If symptoms recur, a referral to a specialist is advised. (42)

Trichomona Vaginalis (TV)

Even though it is one of the most prevalent STIs in the United States, more than 50% of patients have minimal or no genital symptoms; for that reason, it can last as an untreated infection for the long term. The danger of untreated Trichomonas is preterm birth, premature rupture of membranes, and a higher risk of HIV acquisition. When a diagnosis is performed, it is vital to evaluate other STIs and test and treat sexual partners. (6, 43)

Symptomatic patients report abnormal vaginal discharge, itching, burning, or postcoital bleeding. The discharge usually is abundant, purulent, and odorous. It is associated with an elevated pH level. Vulvar inspection shows erythema, edema, and significant inflammation.

To confirm the diagnosis, microscopy reveals flagellated and undulating Trichomonas and increased white blood cells with a sensitivity of 50 to 60%. A higher sensitive and specific test, such as nucleic acid amplification, is preferred. Alternative diagnostic options include FDA-approved commercial tests or vaginal culture, which should take five days. In practice, the most used method might be the microscopic evaluation of wet preparations of genital secretions due to its low cost. However, the absence of trichomonas in samples does not rule out a TV infection. (4,6,41)

CDC recommended treatment is metronidazole 500 mg orally twice a day for 7 days or tinidazole 2 g orally in a single dose. A single dose of 2 g by mouth is recommended in male partners. In refractory disease tinidazole 2 g by mouth daily for 7 days. (41)

Desquamative Inflammatory Vaginitis

It is a chronic inflammation of the vulva and vagina without identifying a specific pathogen. The vaginal microbiome has nearly absent Lactobacilli with facultative anaerobes (such as Enterococcus Faecalis, Streptococcus Agalactiae, and Escherichia Coli). (44,45)

Clinically patients refer vaginal discharge and irritative vulvovaginal symptoms. (44)

Required diagnostic criteria: (44, 45)

Symptoms: abundant purulent and odorless vaginal discharge, dyspareunia, pruritus, burning or irritation
Clinical Signs: vaginal inflammation characterized by ecchymosis, petechiae, erythema, or erosions.
Vaginal pH > 4.5
Microscopy: increase of parabasal and inflammatory cells, leukocyte-to-epithelial cell ratio greater than 1:1, and exclusion of other germs (VB, TV, Chlamydia, Gonococcus)

It is more frequent in perimenopausal women and has been associated with an increased risk of urinary tract infections, premature rupture of membranes, chorioamnionitis, and miscarriage. (44)

Treatment is not entirely defined due to the lack of randomized trials. The recommendation is to use antibiotics, such as topic clindamycin (2% vaginal cream daily for 3 weeks and then biweekly), to treat anaerobic bacteria and anti-inflammatory agents like vaginal hydrocortisone (300-500 mg/day for 3 weeks and then biweekly for 6 months). Vaginal estrogen might help reduce the duration of inflammatory symptoms. (44,46)

Genitourinary Syndrome of Menopause

It is defined as symptoms and signs resulting from estrogen deficit in the female genitourinary tract. It is highly prevalent in postmenopausal women. Genital symptoms include dryness, burning, and irritation, as well as vaginal dryness and dyspareunia. Urinary symptoms involve dysuria, urgency, and recurrent urinary tract infections. All of these, generally, are progressive without effective therapy.

During the examination, vulvar atrophy, vaginal dryness, introital stenosis, and clitoral atrophy are visible. After a while, the vulvar and vaginal epithelium can result in friable and hypopigmentation. (5, 47)

First-line therapies include non-hormone vulvar and vaginal lubricants for sexual activity and long-acting vaginal moisturizers used regularly. There is no evidence that products with hyaluronic acid have a more significant benefit than non-hyaluronic acid lubricants or moisturizers.

Even though there are no sufficient clinical trials, the North American Menopause Society recommends regular, gentle vaginal stretching exercises. (5)

Hormonal therapy with low-dose vaginal estrogens is widely recommended. Subjective results may take 4 to 12 months, and continued therapy is generally required because symptoms are likely to recur on cessation of treatment. There are multiple forms of vaginal estrogen treatment, but Cochrane concluded they had similar efficacy after reviewing 19 trials. (23) Usually, vaginal therapy provides sufficient estrogen to the genitourinary system. A Cochrane review determined that vaginal estrogens improve incontinence and urinary symptoms. (48)

Oral hormonal therapy is exclusively recommended with concomitant vasomotor symptoms. (5)

Cytolytic Vaginosis

Its name is given due to the lysis of vaginal epithelial cells caused by the abundant growth of Lactobacilli. It is also known as Lactobacilli overgrowth syndrome or Doderlein’s cytolysis. (49)

The etiology is poorly understood. Patients complain of intense pruritus and copious white vaginal discharge, which may simulate a VVC. The diagnosis is confirmed by abundant Lactobacilli covering the fragmented epithelial cells that may be confused with the “clue cells” of BV, these are therefore called “false clue cells”. It is confirmed by the absence of Trichomonas Vaginalis, Gardnerella, or Candida on wet smears.

Treatment consists in reducing Lactobacilli by douching with a sodium bicarbonate solution. Douches are carried out twice weekly with 30 to 60 grams of baking soda every two weeks.

Disclosures

The author does not report any conflict of interest.

Disclaimer

This information is for educational purposes and is not intended to treat disease or supplant professional medical judgment. Physicians should follow local policy regarding the diagnosis and management of medical conditions.

References

  1.    Zemouri C, Wi TE, Kiarie J, Seuc A, Mogasale V, Latif A, Broutet N. The Performance of the Vaginal Discharge Syndromic Management in Treating Vaginal and Cervical Infection: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(10):e0163365. Epub 2016 Oct 5.
  2.   Marnach M, Wygant J, Casey P. Evaluation and Management of Vaginitis Mayo Clin Proc. Feb 2022;97(2):347-358
  3.   Schwebke JR, Taylor SN, Ackerman R, Schlaberg R, Quigley NB, Gaydos CA, et al. 2020. Clinical validation of the Aptima bacterial vaginosis and Aptima Candida/Trichomonas vaginitis assays: results from a prospective multicenter clinical study. J Clin  Microbiol. 2020 Feb; Vol 58 Issue 2: 1643-58.
  4.   Brown H, Drexler M. Improving the Diagnosis of Vulvovaginitis: Perspectives to Align Practice, Guidelines, and Awareness. Population Helath Managment. 2020; Vol 23, Supplement 1, Mary Ann Liebert, Inc.
  5.   The North American Menopause Society. The 2020 genitourinary syndrome of menopause position statement. 2020; J North Ame Menop Soc. Vol. 27, No. 9, pp. 976-992.
  6. Vaginitis in nonpregnant patients. ACOG Practice Bulletin No. 215. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e1–17.
  7. Ravel J, Gajer P, Abdo Z, Schneider GM, Koenig SS, McCulle SL, et al. Vaginal microbiome of reproductive- age women. Proc Natl Acad Sci U S A 2011;108(suppl 1): 4680–7.
  8. Allsworth JE, Peipert JF. Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data. Obstet Gynecol 2007;109:114–20.
  9. Powell AM, Nyirjesy P. Recurrent vulvovaginitis. Best Pract Res Clin Obstet Gynaecol 2014;28:967–76.
  10. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002;100:765–72.
  11. Sanchez S, Garcia PJ, Thomas KK, Catlin M, Holmes KK. Intravaginal metronidazole gel versus metronidazole plus nystatin ovules for bacterial vaginosis: a randomized controlled trial. Am J Obstet Gynecol 2004;191:1898–906. PMID:15592270 https://doi.org/10.1016/j. ajog.2004.06.089
  12. Abbai NS, Reddy T, Ramjee G. Prevalent bacterial vaginosis infection—a risk factor for incident sexually transmitted infections in women in Durban, South Africa. Int J STD AIDS 2016;27:1283–8. PMID:26538552 https://doi.org/10.1177/0956462415616038
  13. Ness RB, Soper DE, Holley RL, et al.; PID Evaluation and Clinical Health (PEACH) Study Investigators. Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis 2001;28:240–5. PMID:11318257 https://doi. org/10.1097/00007435-200104000-00010
  14. Gondwe T, Ness R, Totten PA, et al. Novel bacterial vaginosis-associated organisms mediate the relationship between vaginal douching and pelvic inflammatory disease. Sex Transm Infect 2020;96:439–44. PMID:31810995 https://doi.org/10.1136/sextrans-2019-054191
  15. Koumans EH, Sternberg M, Bruce C, McQuillan G, Kendrick J, Sutton M, et al. The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis 2007;34:864–9.
  16. Ravel J, Gajer P, Abdo Z, Schneider GM, Koenig SS, McCulle SL, et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A 2011;108(suppl 1): 4680–7.
  17. Peebles K, Velloza J, Balkus JE, McClelland RS, Barnabas RV. High global burden and costs of bacterial vaginosis: a systematic review and meta-analysis. Sex Transm Dis 2019;46:304–11. PMID:30624309
  18. Achilles SL, Austin MN, Meyn LA, Mhlanga F, Chirenje ZM, Hillier SL. Impact of contraceptive initiation on vaginal microbiota. Am J Obstet Gynecol 2018;218:622.e1–10. PMID:29505773 https://doi. org/10.1016/j.ajog.2018.02.017
  19. Vodstrcil LA, Plummer ME, Fairley CK, et al. Combined oral contraceptive pill-exposure alone does not reduce the risk of bacterial vaginosis recurrence in a pilot randomized controlled trial. Sci Rep 2019;9:3555. PMID:30837554 https://doi.org/10.1038/ s41598-019-39879-8
  20. Brooks JP, Edwards DJ, Blithe DL, et al. Effects of combined oral contraceptives, depot medroxyprogesterone acetate and the levonorgestrel-releasing intrauterine system on the vaginal microbiome. Contraception 2017;95:405–13. PMID:27913230 https://doi. org/10.1016/j.contraception.2016.11.006
  21. Morris BJ, Hankins CA, Banerjee J, et al. Does male circumcision reduce women’s risk of sexually transmitted infections, cervical cancer, and associated conditions? Front Public Health 2019;7:4. PMID:30766863 https://doi.org/10.3389/fpubh.2019.00004
  22. Kenyon CR, Buyze J, Klebanoff M, Brotman RM. Association between bacterial vaginosis and partner concurrency: a longitudinal study. Sex Transm Infect 2018;94:75–7. PMID:27645157 https://doi. org/10.1136/sextrans-2016-052652
  23. Mehta SD. Systematic review of randomized trials of treatment of male sexual partners for improved bacteria vaginosis outcomes in women. SexTransmDis 2012;39:822–30.PMID:23007709https:// doi.org/10.1097/OLQ.0b013e3182631d89
  24. Hawes SE, Hillier SL, Benedetti J, Stevens CE, Koutsky LA, Wolner-Hanssen P, et al. Hydrogen peroxide- producing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996;174:1058–63.
  25. Fethers KA, Fairley CK, Hocking JS, Gurrin LC, Brad- shaw CS. Sexual risk factors and bacterial vaginosis: a systematic review and meta-analysis. Clin Infect Dis 2008; 47:1426–35.
  26. Marrazzo JM, Koutsky LA, Eschenbach DA, Agnew K, Stine K, Hillier SL. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002;185:1307–13.
  27. Fethers KA, Fairley CK, Morton A, Hocking JS, Hopkins C, Kennedy LJ, et al. Early sexual experiences and risk factors for bacterial vaginosis. J Infect Dis 2009;200: 1662–70.
  28. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. Centers for Disease Control and Prevention [published erratum appears in MMWR Recomm Rep. 2015;64:924]. MMWR Recomm Rep 2015;64(RR-03):1–137.
  29. Nyirjesy P. Management of Persistent Vaginitis: A Clinical Expert Series. Obstet Gynecol 2014; 124:1135–46; and Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. Centers for Disease Control and Prevention [published erratum appears in MMWR Recomm Rep 2015;64:924].MMWR Recomm Rep 2015;64(RR-03):1–137.
  30. Srinivasan S, Liu C, Mitchell CM, et al. Temporal variability of human vaginal bacteria and relationship with bacterial vaginosis. PLoS One 2010;5:e10197. PMID:20419168 https://doi.org/10.1371/journal.pone.0010197
  31. Gajer P, Brotman RM, Bai G, et al. Temporal dynamics of the human vaginal microbiota. Sci Transl Med 2012;4:132ra52. PMID:22553250 https://doi.org/10.1126/scitranslmed.3003605
  32. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J Clin Microbiol 1991;29:297–301.
  33. Amsel R, Totten PA, Spiegel CA, Chen KCS, Eschenbach D, Holmes KK. Nonspecific vaginitis. Am J Med .1983; 74(1): p.14-22.doi: 10.1016/0002-9343(83)91112-9.
  34. Laxmi U, Agrawal S, Raghunandan C, Randhawa VS, Saili A. Association of bacterial vaginosis with adverse fetomaternal outcome in women with spontaneous preterm labor: a prospective cohort study. J Matern Fetal Neonatal Med 2012;25:64–7. PMID:21557693 https://doi.org/10.3109/14767058.2011.565390
  35. Nelson DB, Hanlon A, Hassan S, et al. Preterm labor and bacterial vaginosis-associated bacteria among urban women. J Perinat Med 2009;37:130–4. PMID:18999913 https://doi.org/10.1515/ JPM.2009.026
  36. Koumans EH, Kendrick JS; CDC Bacterial Vaginosis Working Group. Preventing adverse sequelae of bacterial vaginosis: a public health program and research agenda. Sex Transm Dis 2001;28:292–7. PMID:11354269 https://doi. org/10.1097/00007435-200105000-00011
  37. Subtil D, Brabant G, Tilloy E, et al. Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA): a multicentre, double-blind, randomized controlled trial. Lancet 2018;392:2171–9. PMID:30322724 https://doi.org/10.1016/S0140-6736(18)31617-9
  38. Workowski KA; Bachmann LH; Chan PA.; Johnston, CM; Muzny, CA; Park, I; et al. Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for disease control and prevention. MMWR. Jul 2021. vol.70/No. 4
  39. Fjeld H, Raknes G. Is combining metronidazole and alcohol really hazardous? [Norwegian]. Tidsskr Nor Laegeforen 2014;134:1661–3. PMID:25223673 https://doi.org/10.4045/tidsskr.14.0081
  40. Ness RB, Hillier SL, Richter HE, Soper DE, Stamm C, McGregor J, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002;100:765–72.
  41. Denning DW, Kneale M, Sobel JD, Rautemaa-Richardson R. Global burden of recurrent vulvovaginal candidiasis: a systematic review. Lancet Infect Dis 2018;18:e339–47. PMID:30078662 https://doi. org/10.1016/S1473-3099(18)30103-8.
  42. 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 2003;189:1297–300. PMID:14634557 https:// doi.org/10.1067/S0002-9378(03)00726-9
  43. Workowski K, Bachmann L. Centers for Disease Control and Prevention’s Sexually Transmitted Diseases Infection Guidelines. 2022;74(S2):S89–94 Published by Oxford University Press for the Infectious Diseases Society of America 2022.
  44. Paavonen J, Brunham R. Bacterial Vaginosis and Desquamative Inflammatory Vaginitis. N Engl J Med 2018;379:2246-54.
  45. Donders G, Bellen G, Grinceviciene S, Ruban K, Vieira-Baptista P. Aerobic vaginitis: no longer a stranger. Dec 2017; Research in Microbiology 168. 845-858.
  46. Moyal-Barracco M, Wendling J. Vulvar Dermatosis. 2014; Best Practice & Research Clinical Obstetrics and Gynaecology 28. 946-958.
  47. Lethaby A, AyelekeRO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev 2016.
  48. Suresh A, Rajesh A, Bhat RM, Rai Y. Cytolytic vaginosis: A review. Indian J Sex Transm Dis 2009;30:48-50
  49. Ramírez-Santos A, Pereiro M, Toribio J. Recurrent vulvovaginitis: diagnostic assessment and therapeutic management. Actas Dermo-Sifiliográficas; Apr 2008.Vol. 99. Núm. 3; 190-198.

See Also

Diagnosis and Management of Anaphylaxis in Adults

Acute Uncomplicated Pyelonephritis in Adults

Initial Management of Hip Fractures in Adults

Community Acquired Pneumonia in Adults

About the Author

Paula Barrera
Paula Barrera was born in Buenos Aires, Argentina and is a graduate with honors of CEMIC University. Her residency was at Bernardo Houssay Hospital, and she completed her training with fellowships in Breast Pathology at the same hospital with credits by the Argentine Breast Society. In addition to her surgical practice, she is part of the teaching programs of Bernardo Houssay gynecological residents. She is a board-certified member of the Argentine Breast Society.

Follow us

Leave a comment

Your email address will not be published.


*