Abstract
Vaginitis is one of the main causes of primary care and gynecological visits in the United States. The most common infectious causes are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis. A physician survey was conducted to measure awareness of vaginitis clinical guidelines and availability of in-office point-of-care (POC) diagnostic tools. Participants were asked to perform a chart review to evaluate diagnostic practices for their symptomatic vaginitis patients. A total of 333 physicians and 984 patient charts were included. Physicians were most familiar with VVC and BV diagnostic guidelines; fewer than half were aware of current trichomoniasis guidelines. Although access to POC tools used to evaluate and diagnose vaginitis varied by practice, there was limited access to all 3 tools (microscope, pH test strips, potassium hydroxide solution) required to perform a full Amsel workup for BV (47% obstetricians/gynecologists vs. 32% primary care physicians, P < .05). Based on guidelines, 66% of patients evaluated for VVC, 45% of patients evaluated for BV, and 17% evaluated for trichomoniasis received an optimal workup. Among trichomoniasis positive patients, 75% received chlamydia/gonorrhea testing, 42% were tested for HIV, partner therapy was noted in 59% of cases, and 47% returned to be retested within 3 months. Limited awareness of recommended diagnostic practices and lack of access to POC tools contributed to broad guideline nonadherence. This study demonstrates that clinicians commonly fall short of current guidelines and suggests the need for lab-based assessments and appropriate insurance coverage to fill the present diagnostic void.
Highlights
The most common gynecologic-related diagnosis[1] in the primary care setting, vaginitis is one of the most widespread causes for patient visits to obstetrician/gynecologists (OBGYN).[2]
Infectious vaginitis is generally caused by bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), or trichomoniasis.[3,4]
Clinical guidelines recommend that BV be diagnosed using Amsel’s criteria,[2,6,7] which are based on presence of 3 or 4 of the following: a homogeneous, thin, white-gray vaginal discharge; a vaginal pH of >4.5; clue cells on saline microscopy; and a positive potassium hydroxide (KOH) whiff test
Summary
The most common gynecologic-related diagnosis[1] in the primary care setting, vaginitis is one of the most widespread causes for patient visits to obstetrician/gynecologists (OBGYN).[2]. Clinical guidelines recommend that BV be diagnosed using Amsel’s criteria,[2,6,7] which are based on presence of 3 or 4 of the following: a homogeneous, thin, white-gray vaginal discharge; a vaginal pH of >4.5; clue cells on saline microscopy; and a positive potassium hydroxide (KOH) whiff test. Nugent criteria, which utilize laboratory examination of the Gram stain, are considered the gold standard for diagnosing BV.[2,7,8] VVC is commonly diagnosed through wet mount (KOH or saline) microscopy or with a positive culture, which is more accurate than wet mount alone.[2,7] It is recommended that trichomoniasis be diagnosed using nucleic acid amplification testing (NAAT), which is far more sensitive at detecting T. vaginalis infections than is saline microscopy.[2,7]
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