Vaginitis and PID

Wanda Ronner, M.D.

Vaginitis

Disruption in the normal vaginal ecosystem

Alteration of vaginal pH
A decrease in lactobacilli
Growth of other bacteria

Normal physiologic discharge

Cervical mucus
Endometrial fluid
Fluid from Skenes and Bartholins glands
Exfoliated squamous cells
Normal pH: 3.5 4.5 during reproductive
years; 6 8 after menopause

Common Causes of Vaginitis

Bacterial Vaginosis: 15 - 50% of cases; all
ages; anaerobic bacteria and Gardnerella
vaginalis
Trichomonas: 15 - 20% of cases; 20-45
years; protozoan Trichomonas vaginalis
Candida: 33% of cases; premenopausal
women: 90% caused by Candida albicans

Common Treatments
Yeast: oral fluconazole 150mg single dose, or
intravaginal clotrimazole, miconazole, or
terconazole.
Trichomonas: oral metronidazole 2 grams in
a single dose or 500mg bid for 7 days.
Bacterial Vaginosis: oral metronidazole
500mg bid for 7 days, or intravaginal
clindamycin cream or metronidazole gel.

Atrophic Vaginitis
Affects 40% of postmenopausal women
Caused by estrogen deficiency
Symptoms: dryness, itching, burning,
dyspareunia, pelvic pressure, yellowishgreen malodorous discharge
Findings: pH > 5, decreased superficial
cells, WBCs
Treatment: vaginal or oral estrogen

67 yr. old with vulvar/vaginal atrophy

Pelvic Inflammatory Disease

Inflammatory disorders of the upper female
genital tract endometritis, salpingitis,
tubo-ovarian abscess, pelvic peritonitis
Organisms responsible: mainly Gonorrhea
and Chlamydia; anaerobes, G. vaginalis,
Haemophilus, enteric Gram-negative rods,
Streptococcus agalactiae.

PID a public health concern

Most common gyn reason for ER visits:
350,000/year.
70,000 hospitalizations/year.
Most common serious infection of women
age 16 25.
One in four women have significant
medical or reproductive complications.

Diagnosis of PID
Cervical motion tenderness or Uterine
tenderness or Adnexal tenderness
Temp > 101 F
Mucopurulent discharge
Abundant WBCs on wet mount
GC or Chlamydia

Differential Diagnosis

Ectopic pregnancy
Acute appendicitis
Functional pain (e.g. pain with ovulation)
Dysmenorrhea
Endometriosis
UTI/Pyelonephritis
Bowel disorders

Treatment of PID
Need to provide empiric, broad spectrum coverage
of likely pathogens
Must include treatment for GC and Chlamydia
Cefotetan/Cefoxitin plus Doxycycline
Clindamycin plus Gentamicin
Ampicillin/Sulbactam plus Doxycycline
ORAL TREATMENT: Ceftriaxone IM plus
Doxycycline with or without Metronidazole

Err on the side of caution

Empiric treatment of PID should be
initiated in sexually active young women
and other women at risk for STDs if they
are experiencing pelvic or lower abdominal
pain if no other cause for the symptoms
can be identified.

Why do we treat aggressively?

Even mild cases may result in severe
damage: infertility, ectopic pregnancy, and
chronic pelvic pain.

Follow Up
Improvement should be seen within 3 days
on oral meds defervescence, reduction in
abdominal tenderness, uterine, adnexal and
cervical motion tenderness if not
HOSPITALIZE
In no improvement after 3 days on
parenteral meds consider laparoscopy