Vulvovaginitis - Hyperexcision

Last updated: November 11, 2024

Table Of Contents

Overview
Trichomoniasis
Candida Vaginitis
Bacterial Vaginosis

Overview

Investigations for vaginal discharge/irritation
- Speculum exam
- Vaginal swab
  - Vaginal pH
  - Vaginal KOH prep
  - Wet mount (of vaginal secretions)
  - Whiff test
  - NAAT for chlamydia and gonorrhea

	Trichomoniasis	Candida vaginitis	Bacterial vaginosis
Physical Exam	Erythema and irritation	Erythema and irritation	Unremarkable
Discharge	Yellow-green, malodorous	“Cottage-cheese” like	Gray/White, “fishy
Wet mount	“Motile, flagellated protozoa	Nothing	Clue cells
KOH prep	Nothing	Pseudohyphae, spores	+ whiff test
pH	Elevated (> 4.5)	Normal (4.0 – 4.5)	Elevated (> 4.5)
Treatment (non-pregnant)	Metronidazole	Topical or PO antifungal	Metronidazole
Treatment (pregnant)	Metronidazole	Topical antifungal	Metronidazole
Complications	Preterm birth, Low Birth Weight, PROM	None	Preterm birth, Low Birth Weight, PROM

**normal vaginal discharge (**white, mucoid)

Trichomoniasis

Trichomoniasis is the most prevalent non-viral STD. Trichomonas has a predilection for epithelial cells. Most cases are asymptomatic. Men carry Trichomonads (upto 70% who have female partners with trichomoniasis) but are not affected. Trichomoniasis is a clinical marker for high-risk sexual activity and has a high co-incidence of infection with other STDs. Vertical transmission is posisble but rare

Signs and symptoms
- Foul, thin yellow-green discharge
- Dysuria
- Dyspareunia
- Vulvar itching and burning
- Cervicitis may be present (can mimic chlamydial or gonococcal infection)
Physical examination
- Erythematous, edematous vulva
- Excoriation
- “Strawbery spots”
Investigation
- Saline prep: Motile trichomonads
- Vaginal pH: Elevated (> 4.5)
- Rapid Antigen Detection Tests
Treatment
- Metronidazole
- Test for other STDs
- Refer sexual contacts for Metronidazole

Candida Vaginitis

Candida vaginitis is not an STD but risk increases with sexual contact. C. albicans is the most implicated pathogens but other Candida species can cause it.

Risk factors
- Diabetes mellitus
- Immunosuppression
- Recent antibiotic use
- Pregnancy
Signs and symptoms
- Cottage-cheese-like or “curdy”discharge
- Vulvar/vaginal itching and burning
Physical examination
- Erythematous, edematous vulva
- Excoriation
Investigations
- 10% KOH prep: buds and hyphae
- Vaginal pH: normal (4.0 – 4.5)
Criteria for complicated candida vaginitis
- Recurrent (≥ 4 cases per year)
- Severe
- Non-albicans infection
- Diabetic, Immunosuppressed, Debilitated or Pregnant
Treatment of uncomplicated candida vaginitis
- Topical azole (Miconazole, Clotrimazole)
Treatment of complicated candida vaginitis
- Recurrent: Prolonged PO Fluconazole
- Pregnant: Nystatin vaginal tablets
- Non-albicans: Boric acid vaginal capsules

Cottage-cheese like discharge in candida vaginitis

Bacterial Vaginosis

Bacterial vaginosis is a disturbance in the normal vaginal flora. It is a disturbance, not inflammatory, and not an STD**.**

Risk factors
- Vaginal douching
- Oral sex
- Sex during menses
- New or multiple sex partners
- Early sexual debut
- Sexual activity with other women
- IUD placement
- Smoking
Signs and symptoms
- “Fishy” grey vaginal discharge without vaginal discomfort
Physical exam
- Unremarkable
- Adherent gray discharge
Investigations
- Saline prep: “Clue cells”
- Positive amine “whiff”” test (after adding KOH to the discharge sample)
- Elevated vaginal pH
Treatment
- Metronidazole

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Overview

Trichomoniasis

Candida Vaginitis

Bacterial Vaginosis

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