Vaginitis, Sexually Transmitted Infections, Pelvic Inflammatory Disease

In this section, we provide an overview of the following:

• Vaginitis

• Sexually Transmitted Infections

• Pelvic Inflammatory Disease

Vaginitis

• Presentation: Vaginitis is a common complaint in the primary care setting. When a woman presents with vaginal irritation and discharge, it is critical to identify the etiology in order to prescribe the appropriate therapy and quickly alleviate symptoms.

• Causes: The most common causes of vaginitis are bacterial vaginosis (BV; usually caused by Gardnerella vaginalis), vulvovaginal candidiasis, and trichomoniasis.

• Diagnosis: The gold-standard test to differentiate between these common etiologies is wet mount microscopy to look for clue cells (BV), hyphae, or Trichomonas. Some point-of-care diagnostic tests are available for diagnosing BV and trichomoniasis, but these are not available in typical primary care offices.

Sexually Transmitted Infections (STIs)

The following organizations provide summaries of screening, diagnosis, and treatment recommendations for STIs:

• Centers for Disease Control (CDC)

• World Health Organization (WHO)

• U.S. Preventive Services Task Force (USPSTF)

The CDC Sexually Transmitted Infections Treatment Guidelines, 2021 is the most comprehensive resource for screening, diagnosis, and treatment of sexually transmitted infections and includes recommendations for STIs not covered in this rotation guide (including hepatitis C, hepatitis B, genital herpes simplex virus, lymphogranuloma venereum, Mycoplasma genitalium, and viral hepatitis). See also the Summary of CDC STI Treatment Guidelines, 2021.

Screening

For otherwise healthy women, STI screening recommendations are as follows:

• Chlamydia and gonorrhea: Screen women in the following groups annually:

  • all sexually active women aged <25 years

  • all sexually active women aged ≥25 years at increased risk, including those with:

    • a new sex partner

    • more than one sex partner

    • a sex partner with concurrent partners

    • a sex partner who has an STI

  • Note: A pelvic exam is not required for testing. USPSTF guidelines recommend nucleic acid amplification testing (NAAT) from urine, vaginal, or cervical specimens.

• Syphilis: There is no recommendation for routine screening for healthy nonpregnant women at average risk. Pregnant women, women with risky sexual behaviors, men who have sex with men (MSM), and patients with HIV should be screened. See USPSTF guidelines.

• HIV: Testing should be offered at least once to all patients ages 13-64 years on an opt-out basis. See the section on HIV/AIDS in the Resident 360 Infectious Diseases rotation guide for more information about screening.

Note: The screening recommendations listed above do not apply to patients who have symptoms (discharge, dysuria, dyspareunia, abnormal bleeding, or any other new symptoms), are pregnant, or have HIV or other immunodeficiency.

Expedited partner therapy (EPT): EPT is the practice of simultaneously treating patients and their sex partners by providing prescriptions or medications for the patient to take to his or her partner. EPT is important in the treatment of patients with chlamydia or gonorrhea, considered a “useful option” according to the CDC, and is legal in most states.

Treatment

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) occurs when the female upper reproductive tract (endometrium, fallopian tubes, ovaries) becomes infected, usually with sexually transmitted organisms. PID can lead to infertility, ectopic pregnancy, and chronic pelvic pain.

Diagnosis

• Who’s at risk? PID is most commonly seen in sexually active adolescents and young women, who present with pelvic or lower abdominal pain, discharge, bleeding, and dyspareunia (pain with sex).

• Clinical diagnosis: Clinical diagnosis is based on signs of upper genitourinary tract involvement (cervical motion tenderness, adnexal tenderness) on exam. You may also note evidence of lower genitourinary tract involvement (cervical purulence and/or cervical friability or easy bleeding, or white blood cells on wet mount microscopy).

(Source: Pelvic Inflammatory Disease. N Eng J Med 2015.)

• Testing: All patients with suspected PID should undergo:

  • testing for Neisseria gonorrhoeaeand Chlamydia trachomatis (with NAAT from cervical or vaginal samples)

  • pregnancy test to rule out ectopic pregnancy

  • HIV testing (presence of HIV increases the risk of tubo-ovarian abscess), and syphilis testing if community prevalence rates are high

Treatment

Abbreviation: IV, intravenously (Source: Pelvic Inflammatory Disease (PID). Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for Disease Control and Prevention 2021.)

• Antibiotics: According to the CDC, all regimens used to treat PID should also be effective against N gonorrhoeae and C. trachomatis because negative endocervical screening for these organisms does not rule out upper reproductive tract infection. Therapy always involves at least two antibiotics (usually a third-generation cephalosporin and doxycycline) given at the same time, even if the woman was recently treated for chlamydia. In a recent study, the addition of metronidazole to treatment regimens for PID resulted in a reduction in anaerobes and pelvic pain at 30 days, compared with regimens without metronidazole.

• Expedited partner therapy: EPT is the practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications for the patient to take to his or her partner.

• Treatment of PID in women with an IUD: If a woman has an intrauterine device (IUD), it does not need to be removed when she is diagnosed with PID. Most infections can be treated through the IUD to maintain placement of the highly effective contraception. If there is no clinical improvement within 48 hours and/or if you suspect complicated infections (e.g., tubo-ovarian abscess or perforation), recommend urgent referral to an OB/GYN specialist.

• Retesting: All women who have received a diagnosis of chlamydial or gonococcal PID should be retested 3 months after treatment, regardless of whether their sex partners have been treated. If retesting at 3 months is not possible, these women should be retested whenever they next seek medical care <12 months after treatment.