At least three of the following Metronidazole, clindamycin four criteria: (1) thin, homogeneous vaginal discharge; (2) vaginal pH ≥4.5; (3) a fishy odor of volatile amines on the addition of a drop of 10% potassium hydroxide to a drop of vaginal discharge (the whiff test); and (4) the presence of clue cells on a saline wet mount of vaginal discharge (Gardnerella vaginalis and anaerobes)
Sarcoptes scabiei infection Nocturnal pruritus, pruritic Mites; ova black, dots of feces 5% permethrin (scabies) vesicles, pustules in runs (microscopic)
Foreign body Foul-smelling vaginal discharge, Foreign body on physical Removal of foreign body sometimes bloody examination vulvovaginal candidiasis. Douching or vaginal irrigation is PREVENTION not beneficial and is not recommended. There are no recognized prophylactic measures for bacterial vaginosis or nonspecific vaginitis. Douching is not protective and reduces normal vaginal flora, which are protective against
COMPLICATIONS AND PROGNOSIS pathogenic organisms. Complications are rare. The prognosis is excellent.
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Adolescents have the highest rates of sexually transmitted infections (STIs). Compared with adults, sexually active adolescents are more likely to believe they will not contract an STI, more likely to come into contact with an infected sexual partner, less likely to receive health care when an STI develops, and less likely to be compliant with treatment for an STI.
Although numerous organisms cause STIs, the diseases can be grouped by the characteristic clinical presentation. Urethritis and endocervicitis (Table 116-1) are characteristic of Neisseria gonorrhoeae and C. trachomatis and are the most common STIs. Note that more than 70% of genital chlamydial infections in women are asymptomatic. Genital ulcers (Table 116-2) are characteristic of syphilis (Treponema pallidum), genital herpes simplex virus (HSV) infections, chancroid (Haemophilus ducreyi), and granuloma inguinale, also known as donovanosis (Klebsiella granulomatis). Vaginal discharge (Table 116-3) is a symptom of trichomoniasis (Trichomonas vaginalis) and is part of the spectrum of vulvovaginitis (see Chapter 115), which is not always associated with sexual activity. Human papillomavirus (HPV) causes condylomata acuminata, or genital warts (Table 116-4), and is the major risk factor for cervical, vulvar, and vaginal cancers.
STIs are associated with significant physiologic and psychological morbidity. Early diagnosis and treatment are important
Table 116-1 Features of Sexually Transmitted Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae* FEATURE C. TRACHOMATIS N. GONORRHOEAE Incubation period 5–12 days 3–14 days Possible presentations Pharyngitis, conjunctivitis (including neonatal conjunctivitis), disseminated disease (arthritis, dermatitis, endocarditis, meningitis)
Signs/symptoms of common syndromes
Mucopurulent cervicitis Cervical erythema, friability, with thick creamy discharge >10 PMNs/hpf Mild cervical tenderness Gram-negative intracellular diplococci
Pelvic inflammatory disease Onset of symptoms day 3–10 of menstrual cycle
Adnexal tenderness, mass (95%)
Nausea, vomiting (variable)
Weakness, syncope, dizziness (variable)