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Candidiasis a common vulvovaginitis
Taking a thorough history is critical. Smears help make the diagnosis.
MIAMI BEACH, Fla.—Adolescents who suffer from infectious vulvovaginitis may be distressed and confused about their condition. The onus, therefore, is on the pediatrician to handle the history and clinical examination with care and consideration.
George D. Comerci, MD, discussed some of the more common and unusual presentations of vulvovaginitis here at the Fifth Annual Masters of Pediatrics meeting.
"First, physicians should look for candidiasis, because it is the a frequent cause of vaginal infection in adolescents," which is an easy diagnosis to make, according to Comerci, President, American Academy of Pediatrics.
The vaginal pH is 4.5 or lower, and effective treatment includes miconazole or clotrimazole. In young non-sexually active girls, it is important, however, to rule out diabetes mellitus.
Trichomoniasis is a common parasitic infection, with a high incidence in the sexually active adolescent population. The vaginal pH is usually 4.7 or higher.
Bacterial vaginosis was traditionally known as Gardnerella vaginalis vaginitis or non-specific vaginitis.
"This bacterial infection is not necessarily sexually transmitted, so you may see it in any patient. It is believed to be the result of a combination action of anaerobic organisms as well as the Gardnerella vaginalis organism," he said.
Mechanism of action
Essentially, amino acids in the vaginal vault are acted on by anaerobic organisms and produce some of the symptoms that are so characteristic. One in particularly is the amine (or "fishy") smell of the discharge. Also, the increase in vaginal pH seen in these two trichomoniasis and bacterial vaginosis, is very distinctive.
"Bacterial vaginosis has a frothy discharge due to CO2 production and has with an offensive odor. When potassium hydroxide is added to the slide, you get what is referred to as a "positive whiff test." This finding is very characteristic and is one of the things that helps the physician make the diagnosis," he said.
Another is the presence of clue cells. These are vaginal epithelial cells that are coated with coccobacillary organisms. The cells have a granular appearance and are usually seen in bacterial vaginosis.
"You'll find you can't shake the bacteria off by tapping the slide when you look at them under the microscope," he said.
All of these characteristics: the vaginal pH, the presence of clue cells and amines leads to increased growth of Gardnerella and, "this provides the substrates for the anaerobic bacteria to increase and continue this vicious circle," he said.
The interruption of this vicious circle depends on the use of a very effective drug, oral metronidazole. Comerci suggests a 10- to 14-day regimen, rather than the 2-g dose prescribed for trichomoniasis.
Cervicitis and urethritis
Chlamydia is the most common cause of cervicitis and urethritis, Comerci noted. This infection is effectively treated with doxycycline and azithromycin with alternate regimens for those who are pregnant.
The conditions, in adolescents, may also be caused by a herpes simplex virus.
"Usually this is the primary infection, and can be treated with acyclovir," he said.
Gonorrhea is also seen in adolescents. Ceftriaxone or cipro are effective, Comerci said, "It is important that doxycycline or azithromycin be added to cover for chlamydia."
Other causes
If the patient presents with a foul vaginal odor and or blood staining, the physician should suspect the presence of a foreign body, such as a tampon or tissue, he said. Recurrent genital herpes infection may also be seen and can be controlled with acyclovir.
Physicians should be aware that pelvic inflammatory disease is seen in adolescents and should be treated aggressively. Another unusual presentation, clitoral abscess, may be caused by a strand of hair acting as a clitoral tourniquet.
Human papillomavirus may also be seen in the adolescent population. – by Leslie Sabbagh
Presented at the Fifth Annual Masters of Pediatric meeting in Miami Beach, Fla, held Jan 25-29, 1996.