A 24-year-old G0 presents to your office complaining of vulvar discomfort, with intense burning and pain during intercourse. The discomfort occurs at the vaginal introitus, primarily with penile insertion into the vagina. The patient also experiences the same pain with tampon insertion and when the speculum is inserted during a gynecologic examination. The problem has become so severe that she can no longer have intercourse, which is causing problems in her marriage. She is otherwise healthy. She has regular menses without dysmenorrhea. On physical examination, the region of the vulva around the vaginal vestibule has several punctate, erythematous areas of epithelium measuring 3 to 8 mm in diameter. Most of the lesions are located on the skin between the two Bartholin glands. Each inflamed lesion is tender to touch with a cotton swab.
Which of the following is the most likely diagnosis?
Vulvodynia is a syndrome of unknown etiology that is defined as vulvar discomfort in the absence of reliable visible findings or a specific neurologic disorder. It may be provoked (ie, with intercourse), unprovoked, or mixed. To treat vulvodynia, the first step is to avoid tight clothing, tampons, hot tubs, and soaps, which can all act as vulvar irritants. If this fails, topical treatments include lidocaine, estrogen, and steroids. Tricyclic antidepressants and intralesional interferon injections have also been used. For women refractory to medical therapy, surgical excision of the vestibular mucosa may be helpful. Valtrex (valacyclovir) is an antiviral medication used in the treatment of genital herpes and is not indicated for vulvodynia. Contact dermatitis is an inflammation and irritation of the vulvar skin caused by a chemical irritant. The vulvar skin is usually red, swollen, and inflamed, and may become weeping and eczemoid. Women with a contact dermatitis usually experience chronic vulvar tenderness, burning, and itching that can occur even when they are not engaging in intercourse. Atrophic vaginitis is a thinning and ulceration of the vaginal mucosa that occurs as a result of hypoestrogenism; thus this condition is usually seen in postmenopausal women not on hormone replacement therapy. Lichen sclerosus is another atrophic condition of the vulva. It is characterized by diffuse, thin, whitish epithelial areas on the labia majora, minora, clitoris, and perineum. In severe cases, it may be difficult to identify normal anatomic landmarks. The most common symptom of lichen sclerosus is chronic vulvar pruritus. VIN are precancerous lesions of the vulva that are usually HPV related and can progress to cancer. Women with VIN complain of vulvar pruritus, chronic irritation, and raised lesions. These lesions are most commonly located along the posterior vulva and in the perineal body and have a whitish cast and rough texture.
You recommended that she wear loose clothing and cotton underwear and stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved.
Which of the following treatment options is the best next step in treating this patient’s problem?
A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She reports no vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She has no history of sexually transmitted diseases. The only medication she takes are oral contraceptives. Last month, she took a course of amoxicillin for the treatment of sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells.
Bacterial vaginosis (BV) is a condition in which there is an overgrowth of anaerobic bacteria in the vagina, displacing the normal lactobacillus. Women with this type of vaginitis complain of an unpleasant vaginal odor that is described as musky or fishy, and a thin, gray-white vaginal discharge. Vulvar irritation and pruritus are rarely present. To confirm the diagnosis of bacterial vaginosis, a wet prep is performed by mixing with the vaginal discharge, spreading it on a glass slide, and identifying clue cells on microscopy. Clue cells are vaginal epithelial cells with clusters of bacteria adherent to their surfaces. In addition, a whiff test can be performed by mixing potassium hydroxide with the vaginal discharge. In cases of bacterial vaginosis, an amine-like (ie, fishlike) odor will be detected. The treatment of choice for BV is metronidazole (Flagyl) 500 mg given twice daily for 7 days. Pregnant women with symptomatic BV should be treated the same way as nonpregnant women with BV. In cases of a normal or physiologic discharge, vaginal secretions are white and odorless. In addition, normal vaginal secretions do not adhere to the vaginal side walls. In cases of candidiasis, patients commonly complain of vulvar burning, pain, pruritus, and erythema. The vaginal discharge tends to be white, clumpy, and adherent to the vaginal walls. A wet prep with potassium hydroxide can confirm the diagnosis by the identification of hyphae. Treatment of candidiasis can be achieved with the administration of topical imidazoles or triazoles, or the oral medication Diflucan (fluconazole). Trichomonas vaginitis is the most common nonviral, nonchlamydial sexually transmitted disease in women. It is caused by the anaerobic, flagellated protozoan T vaginalis. Women with T vaginitis commonly complain of a copious vaginal discharge that may be white, yellow, green, or gray, and that has an unpleasant odor. Some women complain of vulvar pruritus, which is primarily confined to the vestibule and labia minora. On physical examination, the vulva and vagina frequently appear red and swollen. Only a small percentage of women possess the classically described “strawberry cervix.” The diagnosis of trichomoniasis is confirmed with a wet saline smear. Under the microscope, the Trichomonas organisms can be visualized; these organisms are unicellular protozoans that are spherical in shape with three to five flagella extending from one end. The recommended treatment for trichomoniasis is a one-time dose of metronidazole 2 g orally. C trachomatis is an intracellular parasite that can cause an infection that may be manifested as cervicitis, urethritis, or salpingitis. Patients with chlamydial infections may be asymptomatic. On physical examination, women with chlamydial infections may demonstrate a mucopurulent cervicitis. The diagnosis of chlamydia is suspected on clinical examination and confirmed with cervical cultures. Treatment for a chlamydial cervicitis is with oral azithromycin 1 g or doxycycline 100 mg twice daily for 7 days.
In the patient described earlier, which of the following is the best treatment?
A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency department with a chief complaint of a 24-hour history of increasing pelvic pain. This morning she experienced chills and fever, although she did not take her temperature. She reports no changes in her bladder or bowel habits. She has had nausea or vomiting, and has not been able to tolerate liquids. She reports no medical problems, and her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses without dysmenorrhea. She is currently sexually active with a new sexual partner, and had intercourse with him just prior to her last menstrual period. She reports no history of abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is normal. WBC is 18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished.
The patient is most likely to have PID. Ovarian torsion, appendicitis, and acute salpingitis are all commonly associated with fever, abdominal pain, and elevated white blood cell count. Ruptured ovarian cysts present with acute abdominal pain without fever. Ovarian torsion usually presents as waxing and waning pain that is associated with an adnexal mass. Pain from ruptured ovarian cysts may occur at any time throughout the menstrual cycle but often present around the time of ovulation. Although appendicitis is in the differential diagnosis in any woman presenting with abdominal pain and fever, this patients specific pain history, examination, and associated symptoms are less consistent with appendicitis. In cases of kidney stone, urinalysis usually indicates the presence of blood and there is often flank pain. PID should be managed as an inpatient with intravenous antibiotics in cases where the patient cannot tolerate oral therapy, has not been compliant with oral therapy, has failed oral therapy, or has severe illness with high fever and pain. Outpatient oral therapy may be appropriate for patients with PID who have more mild to moderate symptoms. The decision for inpatient versus outpatient treatment of a patient with PID depends on several factors such as patient compliance, tolerance of oral medications, and certainty of diagnosis. Given this patient’s symptoms, the best treatment for this patient is inpatient intravenous antibiotics. A TOA may form in a patient with untreated PID. A patient with a TOA should also be initially hospitalized and treated with intravenous antibiotics. Patients with TOAs, who do not improve on broadspectrum antibiotics, may require drainage of the abscesses by laparotomy, laparoscopy, or percutaneously under CT guidance.
The recommendation of Centers for Disease Control for inpatient management of PID includes the following:
1. Cefoxitin 2 g IV every 6 hours OR cefotetan 2 g IV every 12 hours PLUS doxycycline 100 mg PO or IV twice daily
OR
2. Clindamycin 900 mg IV every 8 hours PLUS gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3-5mg/kg) may be substituted.
The recommendation of Centers for Disease Control for the outpatient management of PID includes the following:
1. Cefoxitin 2 g IM plus probenecid 1 g PO in a single dose concurrently OR ceftriaxone 250 mg IM PLUS doxycycline 100 mg PO twice daily for 14 days WITH OR WITHOUT metronidazole 500 mg PO twice daily for 14 days.
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