Vulvar/Vaginal Complaints - Differential Diagnosis ...

Vulvar/Vaginal Complaints - Differential Diagnosis and Management

Presentation: vaginal discharge, odor, pain, pruritus

Infectious vaginitis: more likely to present acutely

 • Bacterial vaginosis (BV): malodorous discharge, most common and most pts asymptomatic, high prevalence in WSW

    - Dx: 3/4 Amsel criteria (homogenous/thin/grey-white discharge smoothly coating vaginal walls, clue cells, fishy smell on KOH, pH >4.5 (less reliable if post-menopause) → order “Genital culture female” in Epic, collected with rayon swab, gram stain assesses for clue cells (0-3 consistent with normal flora, 7-10 consistent with BV)

    - Tx: Flagyl 500mg BID x7d, clinda 300mg BID x 7d, or secnidazole 2gm x 1; can opt not to tx if not pregnant

 • Candida: curd-like discharge, pruritus

    - Dx: pH nl, order “Genital culture female” in Epic, collected with rayon swab, add on anti-fungal sens. if recurrent

    - Tx: Monistat 7 (vaginal miconazole 2% 5g daily x 7d) OTC, fluconazole 150mg PO x1 requires Rx (cheaper)

 • Trichomonas: purulent malodorous discharge, inflammation on exam (DDx includes gonorrhea and chlamydia)

    - Dx: pH >5-6, trichomonads on microscopy, order “Trichomonas vaginalis antigen” collected with rayon swab

    - Tx: Flagyl 2gm x1 for patient and sexual partners

Dermatoses: more likely to present chronically, often require GYN referral and biopsy

 • Contact dermatitis: erythema, swelling, fissures, erosions → r/o Candida, remove offending agent

 • Vulvar atrophy: 50% postmenopausal ♀ 2/2 decreased vaginal secretions, Δ vaginal flora → moisturizers, topical estradiol

 • Lichen simplex chronicus: intense pruritis + lichenified plaque i/s/o atopic dermatitis hx → antihistamines, steroids

 • Lichen sclerosis: onset 50-60s, cigarette paper skin + porcelain white papules i/s/o autoimmune dz, may lead to labia minora fusion, clitoral hood phimosis, fissures, perianal dz, 5% incidence of malignancy → high potency steroids x4 wks

 • Lichen planus: “purple, papular, pruritic,” white lacy Wickham striae → high potency steroids, monitor for SCC

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