A 19-year-old nulligravid healthy woman comes to see you for her annual Pap smear and routine health care maintenance. During your routine pelvic exam, you note that she has a 5-cm cystic, nontender, mobile mass in her left adnexa. Rectovaginal exam confirms this and does not note any abnormalities in the cul-de-sac. Transvaginal ultrasonography results are consistent with pelvic exam findings.
Which of the following is the most appropriate next step?
Correct Answer B:
The most common cause for a cystic enlargement of the ovary in a reproductive age woman is a functional cyst (follicular or corpus luteum). These are thin walled and usually resolve or rupture spontaneously. Any cystic mass 6 cm or less can be followed for two cycles. Some texts recommend using oral contraceptive pills to decrease the gonadotropin stimulation of the ovary during this time, but there is no literature that shows any improvement over simple observation.
-If the mass persists, further evaluation and possible surgical intervention is indicated. Laparoscopic surgery is less invasive and just as successful as laparotomy.
-As most cystic masses in the adnexa are functional cysts that resolve spontaneously, no other workup is indicated at this time.
A 21-year-old woman at 24 weeks’ gestation presents with dysuria, vulvovaginal pruritus and vaginal discharge. A saline wet mount slide shows the following on microscopic exam.
The most likely diagnosis is:
Correct Answer A:
The most common causes of vaginal discharge, odor, pruritus, and/or discomfort are bacterial vaginosis, candida vulvovaginitis, and trichomoniasis. The image shows a direct wet mount prepared from a white vaginal discharge showing pseudohyphae, budding yeast, and human epithelial cells - vulvovaginal candidiasis (choice A). Examination of a fresh vaginal discharge provides the simplest and most rapid diagnostic test in aiding presumptive identification of Candida species.
→ Bacterial vaginosis (choice B) will show clue cells on a wet mount. These epithelial cells demonstrate the classic findings of a clue cell: they have a ground glass appearance with irregular borders due to the large number of bacteria coating their surgance, and with the application of KOH to the wet mount there is a characteristic fishy amine odor. The discharge tends to be gray and clings to the vaginal wall.
→ Trichomoniasis (choice C) discharge is often frothy, and when severe the cervix will appear strawberry red.
→ Often a patient with Chlamydia trachomatis (choice D) is asymptomatic.
→ HPV (choice E) can be associated with increased desquamation of the vaginal walls and cytolysis, but usually this is not curd-like in nature. Most HPV infections are not associated with a vaginal discharge.
A sexually active 24-year-old woman presents with frothy vaginal discharge. You perform a wet mount and it shows Trichomonas vaginalis.
What is the best treatment?
This is a classic wet mount showing the motile trichomonads and their flagella. Treatment of choice for Trichomonas vaginals is metronidazole for both the patient and her sexual partner.
Ceftriaxone is used to treat gonorrhea, doxycycline for chlamydia and antifungals for yeast infections such as candida.
You diagnose Trichomonas vaginitis in a 25-year-old white female, and treat her and her partner with metronidazole (Flagyl), 2 g in a single dose. She returns 1 week later and is still symptomatic, and a saline wet prep again shows Trichomonas.
Which one of the following is the most appropriate treatment at this time?
Correct Answer C:
The preferred treatment for Trichomonas vaginitis is metronidazole, 2 g given in a single oral dose. Certain strains of Trichomonas vaginalis, however, have diminished sensitivity to metronidazole. Patients who fail initial treatment with metronidazole should be retreated with 500 mg orally twice a day for 7 days. If treatment fails again, the patient should be treated with 2 g daily for 3-5 days. Metronidazole gel and clindamycin cream are useful for treating bacterial vaginosis, but are not effective in the treatment of Trichomonas vaginitis. Sulfadiazine and pyrimethamine are used to treat toxoplasmosis.
A 31-year-old married white female complains of vaginal discharge, odor, and itching. Speculum examination reveals a homogeneous yellow discharge, vulvar and vaginal erythema, and a “strawberry” cervix.
Trichomonal vaginitis usually causes a yellowish discharge which sometimes has a frothy appearance. Colpitis macularis (strawberry cervix) is often present. Monilial vaginitis classically causes a cheesy, whitish exudates with associated vaginal itching and burning. There may be a vaginal and vulvar erythema and edema, but colpitis macularis is not a feature. Bacterial vaginosis is characterized by a grayish discharge with few other physical signs or symptoms, if any. Chlamydia may cause a yellowish cervical discharge and symptoms of pelvic inflammatory disease, or alternatively, may be totally asymptomatic. Herpes simplex type 2 causes ulcerations on the vulva and vaginal mucosa which are exquisitely tender, often with marked surrounding erythema and edema.
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