TEACHING CASE 34

Vulvar and Vaginal Disease

Student Handout

Clinical Case:

A 20-year-old female college student G2P2 comes to see you because of a persistent
vaginal discharge and also seeking contraceptive advice. She and her boyfriend have

interested in using something with a lower failure rate for birth control. She has
regular menses and no significant past medical or gynecologic history. She describes
the discharge as yellowish and also notes mild vulvar irritation. On physical exam, she
has normal external female genitalia without lesions or erythema, a gray/yellow
discharge on the vaginal walls and pooled in the posterior fornix. Her cervix is grossly
normal but bleeds easily with manipulation. The bimanual exam is unremarkable.

Laboratory testing reveals Vaginal fluid pH = 7 and vaginal wet prep positive for mobile
flagellated organisms.

Discussion Questions:

1. What is your differential diagnosis?

2. What is the most likely diagnosis?

3. What is your management plan for this patient?

4. What are the additional issues you would want to discuss with this patient?

5. What contraceptive options would be appropriate for this patient?

6. Would you recommend screening for additional sexually transmitted infections

in this patient and if so, how?

References:

Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 27 Vulvitis and Vaginitis. Pages 265-
272.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 23 Pelvic
Infections. Pages 296-308.
 Vulvar and Vaginal Disease
Preceptor Handout

Vaginal and vulvar symptoms are frequent patient concerns. In order to provide
appropriate care, the physician must understand the common etiologies of these
problems, as well as appropriate diagnostic and management options.

The APGO Educational Objectives related to this topic are the following:

A. Diagnose and manage a patient with vaginitis*

B. Interpret a wet mount microscopic examination*
C. Describe dermatologic disorders of the vulva*
D. Evaluate a patient with vulvar symptoms*

*Designated as Priority One in the APGO Medical Student Educational Objectives, 8th
Edition
 Vulvar and Vaginal Disease
Preceptor Handout

Clinical Case:

A 20-year-old female college student G2P2 comes to see you because of a persistent
vaginal discharge and also seeking contraceptive advice. She and her boyfriend have

interested in using something with a lower failure rate for birth control. She has regular
menses and no significant past medical or gynecologic history. She describes the
discharge as yellowish and also notes mild vulvar irritation. On physical exam, she has
normal external female genitalia without lesions or erythema, a gray/yellow discharge
on the vaginal walls and pooled in the posterior fornix . Her cervix is grossly normal but
bleeds easily with manipulation. The bimanual exam is unremarkable.

Laboratory testing reveals Vaginal fluid pH = 7 and vaginal wet prep positive for mobile
flagellated organisms.

Discussion Questions:

1. What is your differential diagnosis?

BV
Trichomonas
GC
Chlamydia

2. What is the most likely diagnosis?

Trichomonas

3. What is your management plan for this patient?

Treatment with a 2 gram single oral dose of metronidazole or 500 mg
oral metronidazole twice daily for 7 days
Sexual partner must be treated simultaneously and treatment of both
partners should be completed before resumption of sexual activity
Side effects of metronidazole treatment including a disulfiram-like
reaction should be discussed with the patient and patient should be
encouraged to abstain from alcohol during and for 3 days after treatment
with metronidazole.

4. What are the additional issues you would want to discuss with this patient?
STI protection
contraception
 5. What contraceptive options would be appropriate for this patient?
A variety of contraceptive methods may be appropriate to achieve
effective contraception in this patient including oral contraceptives,
patches, ring or injection.
She is not a good candidate for sterilization (due to age), IUD (due to STI
history) and condom/diaphragm/spermicide (due to non-compliance).
The effectiveness, precautions, contraindications and method
administration should be discussed with the patient so that she can make
an informed choice.
It is important for the student to realize that a patient may have more
than one clinical issue to discuss.

6. Would you recommend screening for additional sexually transmitted infections in

this patient and if so, how?
Yes; with serologic testing for Hepatitis B, Syphilis, HIV and cervical
cultures for Gonorrhea and Chlamydia.
She should also have cervical cytology if not done recently.

References:

Obstetrics and Gynecology by Beckmann 5th Edition, 2006; Chapter 27 Vulvitis and Vaginitis. Pages 265-
272.
Essentials of Obstetrics and Gynecology by Hacker and Moore 4th Edition, 2004; Chapter 23 Pelvic
Infections. Pages 296-308.