Intended for healthcare professionals

Overview of genital candidiasis, bacterial vaginosis, and trichomoniasis

Overview of genital candidiasis, bacterial vaginosis, and trichomoniasis

Genital candidiasis

Cause

Candida albicans in 80-95% of cases; C glabrata in about 5%

Associated conditions

Diabetes mellitus, pregnancy, antibiotic use, and immunosuppression

Transmission

Mostly non-sexual

Site of infection

Vulva, vagina, glans, prepuce, and rectum

Symptoms in women

Vulvar pruritus, white curdy discharge with "cottage cheese" appearance and sour milk odour, external dysuria, and superficial dyspareunia

Symptoms in men

Soreness, pruritus, redness, and fissuring of glans and prepuce

Examination findings in women

Redness, fissuring, excoriation of vulva, swelling of labia, intertrigo, and lichenification

Thick, white, adherent discharge with vaginal wall erythema

Examination findings in men

Dry, dull, red, glazed plaques and papules on glans and prepuce

Main methods of detection

Fungal hyphae and budding yeasts in smears and culture

Recommended treatments for women*

Treatment regimens offer 80-95% clinical and mycological cure rates in acute vulvovaginal candidiasis in non-pregnant women

Vaginal:

  • Butoconazole 2% cream 5 g for one to three days (C)
  • Clotrimazole pessary 500 mg single dose (C, E, U, W), 200 mg for three days (C, E, W), or 100 mg for six to seven days (C, U, W)
  • Econazole pessary 150 mg for one to three days (U)
  • Miconazole ovule 1.2 g single dose (E, U)
  • Nystatin vaginal pessary 1-200 000 units for two weeks (C, U) or fluconazole 100 mg per week (see recurrent vaginal Candida)
  • Fluconazole 150 mg single dose (C, E, U, W)
  • Itraconazole 200 mg twice daily for one day (E, U)
  • Clotrimazole 1% cream
  • Miconazole nitrate 2%
  • Clotrimazole 1% with 1% hydrocortisone
  • Vaginal pH 4.5
  • Homogeneous grey vaginal discharge
  • 10% potassium hydroxide produces fishy odour "whiff test"
  • Clue cells present on wet mount
  • Nugent’s diagnostic criteria
  • Metronidazole 2 g single dose (C (2), E (2), U, W (2))
  • Metronidazole 400 mg twice daily for five to seven days (C, E, U, W)
  • Metronidazole 0.75% gel daily for five days (C, E, U, W (2))
  • Clindamycin 2% cream 5 g daily for seven days (C, E, U, W (2))
  • Clindamycin ovules 100 mg daily for three days (C)
  • Clindamycin 300 mg orally twice daily for seven days (C, E, W (2))
  • Prophylaxis for surgical interventions: rectal metronidazole 1 g or intravenous metronidazole 500 mg
  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

Recurrent infection:

  • Nystatin vaginal pessary 1-200 000 units for two weeks (C, U) or fluconazole 100 mg per week (see recurrent vaginal Candida)
  • Fluconazole 150 mg single dose (C, E, U, W)
  • Itraconazole 200 mg twice daily for one day (E, U)
  • Clotrimazole 1% cream
  • Miconazole nitrate 2%
  • Clotrimazole 1% with 1% hydrocortisone
  • Vaginal pH 4.5
  • Homogeneous grey vaginal discharge
  • 10% potassium hydroxide produces fishy odour "whiff test"
  • Clue cells present on wet mount
  • Nugent’s diagnostic criteria
  • Metronidazole 2 g single dose (C (2), E (2), U, W (2))
  • Metronidazole 400 mg twice daily for five to seven days (C, E, U, W)
  • Metronidazole 0.75% gel daily for five days (C, E, U, W (2))
  • Clindamycin 2% cream 5 g daily for seven days (C, E, U, W (2))
  • Clindamycin ovules 100 mg daily for three days (C)
  • Clindamycin 300 mg orally twice daily for seven days (C, E, W (2))
  • Prophylaxis for surgical interventions: rectal metronidazole 1 g or intravenous metronidazole 500 mg
  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

Oral therapies:

  • Fluconazole 150 mg single dose (C, E, U, W)
  • Itraconazole 200 mg twice daily for one day (E, U)
  • Clotrimazole 1% cream
  • Miconazole nitrate 2%
  • Clotrimazole 1% with 1% hydrocortisone
  • Vaginal pH 4.5
  • Homogeneous grey vaginal discharge
  • 10% potassium hydroxide produces fishy odour "whiff test"
  • Clue cells present on wet mount
  • Nugent’s diagnostic criteria
  • Metronidazole 2 g single dose (C (2), E (2), U, W (2))
  • Metronidazole 400 mg twice daily for five to seven days (C, E, U, W)
  • Metronidazole 0.75% gel daily for five days (C, E, U, W (2))
  • Clindamycin 2% cream 5 g daily for seven days (C, E, U, W (2))
  • Clindamycin ovules 100 mg daily for three days (C)
  • Clindamycin 300 mg orally twice daily for seven days (C, E, W (2))
  • Prophylaxis for surgical interventions: rectal metronidazole 1 g or intravenous metronidazole 500 mg
  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

Topical symptomatic relief suitable for both sexes:

  • Clotrimazole 1% cream
  • Miconazole nitrate 2%
  • Clotrimazole 1% with 1% hydrocortisone
  • Vaginal pH 4.5
  • Homogeneous grey vaginal discharge
  • 10% potassium hydroxide produces fishy odour "whiff test"
  • Clue cells present on wet mount
  • Nugent’s diagnostic criteria
  • Metronidazole 2 g single dose (C (2), E (2), U, W (2))
  • Metronidazole 400 mg twice daily for five to seven days (C, E, U, W)
  • Metronidazole 0.75% gel daily for five days (C, E, U, W (2))
  • Clindamycin 2% cream 5 g daily for seven days (C, E, U, W (2))
  • Clindamycin ovules 100 mg daily for three days (C)
  • Clindamycin 300 mg orally twice daily for seven days (C, E, W (2))
  • Prophylaxis for surgical interventions: rectal metronidazole 1 g or intravenous metronidazole 500 mg
  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

A large number of other preparations are available

Bacterial vaginosis

Cause

Bacterial vaginosis has a polymicrobial aetiology. Organisms involved in the aetiology of bacterial vaginosis include anaerobes Mobiluncus sp. and Prevotella sp., Gardnerella vaginalis, and Mycoplasma hominis

Main symptoms

Vaginal discharge with fishy odour that increases after unprotected sexual intercourse and with menstruation

Main methods of diagnosis

Amsel’s diagnostic criteria (three out of four of these criteria need to be present to diagnose bacterial vaginosis):

  • Vaginal pH 4.5
  • Homogeneous grey vaginal discharge
  • 10% potassium hydroxide produces fishy odour "whiff test"
  • Clue cells present on wet mount
  • Nugent’s diagnostic criteria
  • Metronidazole 2 g single dose (C (2), E (2), U, W (2))
  • Metronidazole 400 mg twice daily for five to seven days (C, E, U, W)
  • Metronidazole 0.75% gel daily for five days (C, E, U, W (2))
  • Clindamycin 2% cream 5 g daily for seven days (C, E, U, W (2))
  • Clindamycin ovules 100 mg daily for three days (C)
  • Clindamycin 300 mg orally twice daily for seven days (C, E, W (2))
  • Prophylaxis for surgical interventions: rectal metronidazole 1 g or intravenous metronidazole 500 mg
  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

Note that culture for Gardnerella is no longer a recommended approach to diagnosis

Recommended treatments*

Treatment regimens have similar cure rates of 70-80% after four weeks. Compliance with therapy may result in a symptomatic cure but not a microbiological cure, so relapse after single dose metronidazole (2 g) treatment is common; 60% of women relapse in three months. Clindamycin is effective but also kills lactobacilli, and topical treatment may predispose patient to vulvovaginal candidiasis. Intravaginal clindamycin can cause condom failure

  • Metronidazole 2 g single dose (C (2), E (2), U, W (2))
  • Metronidazole 400 mg twice daily for five to seven days (C, E, U, W)
  • Metronidazole 0.75% gel daily for five days (C, E, U, W (2))
  • Clindamycin 2% cream 5 g daily for seven days (C, E, U, W (2))
  • Clindamycin ovules 100 mg daily for three days (C)
  • Clindamycin 300 mg orally twice daily for seven days (C, E, W (2))
  • Prophylaxis for surgical interventions: rectal metronidazole 1 g or intravenous metronidazole 500 mg
  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

 

Trichomoniasis

Cause

Trichomonas vaginalis, a flagellated protozoon

Incubation period

Usually seven days (range 3-21 days)

Transmission

Usually sexual. Trichomonas may be acquired perinatally. Infection in pre-pubescent girls is unusual, and the possibility of sexual abuse should always be considered

Symptoms in women

Can be asymptomatic. Classically, profuse, frothy, yellow vaginal discharge but also can be scant and watery. Associated symptoms include marked vulvar irritation or soreness (or both), external dysuria, and superficial dyspareunia

Symptoms in men

T vaginalis can cause relapsing non-gonococcal urethritis. T vaginalis in men can be asymptomatic and has a spontaneous cure rate of about 20-25%, which results in a low rate of isolation in male contacts of about 30-40%

Examination findings

External genital examination may be normal in men and women

Vulvar and vaginal wall erythema may be present; the "strawberry cervix" appearance caused by inflammatory punctate haemorrhage is uncommon

Main methods of diagnosis

Direct microscopy of discharge and culture

Recommended treatments*

Patients should be advised to abstain from sexual intercourse during treatment and until their sexual partner has been seen. Cure rates are 95%.

  • Metronidazole 2 g orally stat dose (C, E (2), U, W)
  • Tinidazole 2 g orally single dose (W)
  • Metronidazole 400 mg orally twice daily for five to seven days (C, E, U, W (2))
  • Tinidazole 500 mg orally twice daily for five days (W (2))

World Health Organization recommends five days’ treatment in preference to single doses for men. Compliance can be a problem with the longer regimen because of the nausea and metallic taste in the mouth associated with metronidazole treatment. In cases of allergy, no effective alternative to imidazole compounds exists

Follow up

A test of cure should be done at one week with microscopy and culture

Management of contacts

Sexual contacts should be offered a screen for T vaginalis and other STIs and given epidemiological treatment with metronidazole 2 g oral stat dose

Treatment failure

Recalcitrant trichomoniasis can result from poor compliance with treatment, reinfection, and poor absorption of treatment—for example, because of vomiting

Longer courses of oral metronidazole or higher dose regimens 2 g a day for three to five days may be effective. Unusually imidazole resistant strains may be responsible.

No standard effective treatments are available for recalcitrant T vaginalis infection. haemolytic streptococci in the vagina may contribute to metronidazole treatment failure and empirical treatment with amoxicillin or erythromycin before retreatment should be considered in such cases

*C=Centers for Disease Control, USA; E=European STI guidelines; U=UK National Guidelines; W=World Health Organization; 2=second line recommendation.