Cause Of Vaginitis Research Articles

The role of physical examination in diagnosing common causes of vaginitis: a prospective study

ObjectiveWe evaluated agreement in diagnoses for bacterial vaginosis (BV), Trichomonas vaginalis (TV) and vulvovaginal candidiasis (VVC) between clinicians examining the patient and performing diagnostic tests versus a clinician with access...

Interpreting the epidemiology and natural history of bacterial vaginosis: Are we still confused?

Bacterial vaginosis (BV) is a common cause of vaginitis and increases women’s risk of pelvic inflammatory disease, adverse pregnancy outcomes, and risk of STD/HIV acquisition. The etiology of BV is unclear, though it is believed to involve loss of vaginal hydrogen peroxide-producing lactobacilli and acquisition of complex bacterial communities that include many fastidious BV-associated bacteria (BVAB) that have recently been detected using PCR methods. Treatment failure (persistence) is common, and may be facilitated by unprotected sex. Potential contributions to BV and BV persistence include (1) sexual partners as a reservoir for BVAB; (2) specific sexual practices, including male partners’ condom use; and (3) the composition of the vaginal microbiota involved in BV. Specific BVAB in the Clostridiales order may predict BV persistence when detected pre-treatment, and have been detected in men whose female partners have BV. BVAB may be associated with unprotected sexual behavior and failure of BV to resolve in women, supporting the hypothesis that BVAB colonization of male genitalia may serve as a reservoir for re-infection of female partners. Moreover, specific sexual practices may favor vaginal colonization with certain BVAB that have been associated with persistence. This review provides background on BV, and discusses the epidemiologic and microbiologic data to support a role for acquisition of BVAB and how this process might differ among subsets of women.

Group A streptococcal vaginitis: an unrecognized cause of vaginal symptoms in adult women

Vaginal infection with group A streptococci (GAS) is an established cause of vaginitis amongst prepubescent girls, but largely unrecognized in adult women and therefore often misdiagnosed as vulvovaginal candidosis. We sought to give an overview of the epidemiology, risk factors, symptoms, signs, and treatment of GAS vaginitis in adult women. Systematic literature search. We identified nine case reports covering 12 patients with documented GAS vulvovaginitis. GAS vulvovaginitis in adult women is often associated with a predisposing factor: (1) household or personal history of dermal or respiratory infection due to GAS, (2) sexual contact, and (3) lactational or menopausal vaginal atrophy. Symptoms of GAS vulvovaginitis in adult women may include vaginal and/or vulvar pain, dyspareunia, burning sensation or irritation, and pruritus. In most cases, there is also profuse or copious vaginal discharge which may be watery, yellow, or even purulent. Whilst there are neither clinical trials nor treatment guidelines, treatment with oral penicillin or with vaginal clindamycin cream has been reported to result in rapid cure. In breast-feeding and postmenopausal women with vaginal atrophy, additional treatment with local estriol may be necessary to prevent recurrence. Finally, in case of recurrent GAS vulvovaginitis it will be necessary to assess the patients' asymptomatic household members for pharyngeal and anal carriage and to treat them accordingly. Vaginal infection with GAS in adult women is a clearly defined entity and should be considered a diagnosis when more common causes of vaginitis have been ruled out.

Risk factors for vaginal candidiasis among women attending primary health care centers in Jos, Nigeria

Vaginal candidiasis is a common complaint among women of different age groups in any society whether or not they are sexually active. Although it is both treatable and mild, when left untreated, is a possible risk for acquisition of HIV/AIDS as well as other complications. The study was set to detect Candida organisms in female genital discharge in order to improve treatment of vaginal candidiasis in current syndromic management of abnormal vaginal discharge. A prospective study of female genital swabs collected from Primary Health Care Centers, Jos, and analysed for microscopy, culture and sensitivity in Jos University Teaching Hospital, December 2006 to December 2007. Data on epidemiologic indices were collected from the patients, using structured interviewer- administered questionnaires. Four hundred and twenty Candida species were detected, constituting 60% (n = 420) of 700 female genital discharge samples of microbial etiology in a total of 1000 female genital samples received. The distribution of vaginal candidiasis according to age was highest in young adults aged 21 to 30 years with 43% (n = 180) of the total 420 cases. Pregnant women presented with vaginal candidiasis constituted 40% (n = 168) of the total 420 cases. Other risk groups included the immune-suppressed with 24% (n = 101); group on hormonal therapy 15% (n = 63) and broad spectrum antibiotics users 16%(n = 67). The result shows that Candida species has assumed the role of the most common cause of vaginitis, with Candida albicans as the most prevalent species. Vulvo-vaginal candidiasis was common in the young adults of age range 21 to 30 years, pregnant mothers, immune-suppressed, contraceptive and broad spectrum antibiotic users. We therefore recommend prevention, early diagnosis and prompt treatment of vulvo-vaginal candidiasis especially among the risk groups in order to avert its complications and reduce HIV transmission. Key words: Vaginal candidiasis, risk factors, microscopy, culture, sensitivity.

A study of female genital swabs in a Nigerian Tertiary Hospital

Objective To detect some common microbial agents of vaginal discharge and improve the current syndromic management of abnormal vaginal discharge. Methods A prospective study of female genital swabs collected from obstetrics and gynecology units of Aminu Kano Teaching Hospital, Kano, Nigeria and an analysed of microscopy, culture and sensitivity in the medical microbiology and parasitology laboratory of this hospital were conducted from December 2007 to December 2008. Data on epidemiologic indices were collected from the patients, using structured interviewer-administered questionnaires. Results Eight hundred and forty Candida species were detected, constituting 60% ( n=840) of 1 400 female genital discharge samples of microbial etiology in a total of 2 000 female genital samples received. The distribution of vaginal candidiasis was the highest in young adults aged 21 to 30 years with 43%( n=360) of the total 840 cases. Pregnant women that presented with vaginal candidiasis constituted 40% ( n=360) of the total 840 cases. Other risk groups included the immuno-suppression with 24% ( n=202), group on hormonal therapy with 15% ( n=126) and broad spectrum antibiotics users with 16% ( n=134). Conclusions The results show that Candida is the most common cause of vaginitis and vulvo-vaginal candidiasis followed by C. albicans in the young adults aged 21 to 30 years, pregnant mothers, immuno-suppression, contraceptive and broad spectrum antibiotic users. Proper management of vaginal candidiasis and vulvo-vaginal candidiasis is recommended especially among the risk groups in order to avoid complications and reduce HIV transmission.

Diagnostic techniques for bacterial vaginosis and vulvovaginal candidiasis – requirement for a simple differential test

Vulvovaginal candidiasis (VVC) and bacterial vaginosis (BV) account for ∼ 90% of infectious cases of vaginitis in women. Differentiating between these two conditions based on clinical features can be difficult owing to the wide variety of signs and symptoms observed. Current diagnostic techniques in the clinical setting are inadequate, and even trained physicians frequently fail to make a correct diagnosis. New techniques for the diagnosis of VVC and BV are being developed, but almost all require specialised equipment, with expensive reagents, and are laborious and time-consuming. Furthermore, many women prefer to self-diagnose their condition, but are more likely to assume they have VVC, having little awareness of BV. The reader will be introduced to the specific diagnostic techniques for VVC and BV. Following this, recent advances and new approaches in diagnosis will be discussed. Misdiagnosis may result in delay of correct treatment with resulting sequelae, particularly for BV. There is a need for a simple, rapid, unequivocal and economic diagnostic test that can differentiate between BV and VVC. This would be of use both to physicians and to women who wish to self-diagnose and self-medicate, and would also help educate women about the possible alternative causes of vaginitis and vulvovaginal symptoms.

Prevalence and Risks for Bacterial Vaginosis in Women Who Have Sex With Women

Bacterial vaginosis (BV) is a common cause of vaginitis and, for unknown reasons, is common in lesbian and bisexual women. We defined risks for prevalent BV in lesbian and bisexual women with attention to detailed sexual risk history. Women 16 to 35 years reporting sex with > or = 1 woman in prior year underwent computer-assisted self-interview with extensive sexual and medical history. BV was defined by Amsel criteria, and associations with subject characteristics were estimated by Poisson regression and generalized estimating equation to adjust for potential coenrollment of current sexual partners. Of 335 participants (median age, 25 years; 22% nonwhite race), 6% reported douching, 24% sex with men, and 91% any sex in the prior 3 months. 96 (29%) had BV, 40% of whom reported corresponding symptoms. BV was associated with reporting a partner with BV (39% vs. 12%; multivariate relative risk [MRR], 4.53 [2.59 -7.93]), vaginal lubricant use (59% vs. 21%; MRR, 1.86 [0.94 -3.68]), or sharing vaginal sex toys in prior 3 months (33% vs. 21%; MRR, 1.70 [0.96 -3.01]). No association was seen for age, race, smoking, hormone use, douching, vaginal, anal or oral sex, or numbers of new partners. Lubricant use and shared vaginal toys were correlated (Spearman 0.29). BV is associated with practices that efficiently transmit vaginal fluid and with use of vaginal lubricant; since these are correlated, assessing independent effects will require further analysis. More research is required to understand relationships between role of transmission of BV-associated bacteria and vaginal lubricant on BV pathogenesis.

An epidemiological survey of bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis in the Tibetan area of Sichuan Province, China

Objective To determine the prevalence and risk factors of vaginitis in the Tibetan area of Sichuan Province in China. Study design Between September and October 2007, 397 women were surveyed with a questionnaire and diagnosed with bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomoniasis by Gram stain and microscopy of vaginal swabs. Results The prevalence of BV, VVC, and trichomoniasis was 51.6%, 6.5%, and 2.5%, respectively. Multivariate logistic modeling showed that risk factors associated with having vaginitis due to any of the three infections were older age and Tibetan ethnicity. Conclusion BV appears to be the predominant cause of vaginitis, followed by VVC, and trichomoniasis. Risk factors for vaginitis include being more than 49 years old and of Tibetan ethnicity.

Don't Reinfect the Messenger: Partner-Delivered Therapy and Trichomoniasis Prevention

Trichomoniasis is a common cause of vaginitis that has been linked to adverse pregnancy outcomes and excess risk for HIV acquisition. Men are usually asymptomatic and therefore are not tested or treated for trichomoniasis, contributing to high rates of recurrent infection among women. Investigators enrolled 484 women (mean age, 29; 95% black) with diagnoses of trichomoniasis who were treated …

The effects of antimicrobial therapy on bacterial vaginosis in non-pregnant women

Bacterial vaginosis (BV) is a very common cause of vaginitis that has been associated with a high incidence of obstetric and gynaecologic complications and increased risk of HIV-1 transmission. This has led to renewed research interest in its treatment. To assess the effects of antimicrobial agents on BV in non-pregnant women. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, LILACS, and African Healthline (December 2007); and proceedings of relevant international conferences (from 1981 to date). Randomised controlled trials comparing any two or more antimicrobial agents, or antimicrobial agents with placebo or no treatment, in women with clinical or Gram-stain criteria of BV. Two authors independently assessed trial quality and extracted data from the original publications while the third author cross checked the data. Twenty-four trials involving 4422 participants were reviewed. Most examined symptomatic women only. Only seven trials analysed results by intention to treat; we re-analysed the remainder.Compared with placebo, clindamycin showed a lower rate of treatment failure (relative risk (RR) 0.25, 95% confidence interval (CI) 0.16 to 0.37). Clindamycin and metronidazole showed identical rates of treatment failure, irrespective of regimen type, at two and four-week follow up (RR 1.01, 95% CI 0.69 to 1.46; RR 0.91, 95% CI 0.70 to 1.18, respectively). Clindamycin tended to cause a lower rate of adverse events (RR 0.75, 95% CI 0.56 to 1.02); metallic taste, and nausea and vomiting were more common in the metronidazole group (RR 0.08, 95% CI 0.1 to 0.59; RR 0.23, 95% CI 0.10 to 0.51, respectively). Given intravaginally as gelatin tablets, lactobacillus was more effective than oral metronidazole (RR 0.20, 95% CI 0.05 to 0.08). Similarly, oral lactobacillus combined with metronidazole was more effective than metronidazole alone (RR 0.33, 95% CI 0.14 to 0.77). Clindamycin showed a lower rate of clinical failure than triple sulfonamide cream (RR 0.46, 95% CI 0.29 to 0.72). Hydrogen peroxide douche showed a higher rate of clinical failure (RR 1.75, 95% CI 1.02 to 3.00) and adverse events (RR 2.33, 95% CI 1.21 to 4.52) than a single 2 g dose of metronidazole. Clindamycin preparations, oral metronidazole, and oral and intravaginal tablets of lactobacillus were effective for bacterial vaginosis. Hydrogen peroxide douche and triple sulphonamide cream were ineffective. Metronidazole caused metallic taste, nausea and vomiting. We need better-designed trials with larger sample sizes to test the effectiveness of promising drugs.

Refractory urinary tract and vulvovaginal infection caused by Candida krusei

Candida krusei is an uncommon cause of vaginitis and cystitis but is unique because of the management challenge it poses due to intrinsic resistance to fluconazole and flucytosine. We report a case of C. krusei vaginitis and cystitis successfully managed with topical vaginal and intravesical amphotericin B. The challenges in managing C. krusei cystitis and the role of amphotericin B bladder irrigation in the management of fungal urinary tract infections are discussed.

Efficacy and tolerance of metronidazole and miconazole nitrate in treatment of vaginitis

Objective To evaluate the efficacy and tolerability of a vaginal pessary containing 750 mg of metronidazole and 200 mg of miconazole nitrate used daily for 7 days in the treatment of vaginitis. Methods Ninety-two women with vaginitis participated in this phase 3 study using one vaginal pessary daily for 7 days. Gynecological and microbiological evaluations were carried out prior to and following treatment. Results Reductions occurred in symptoms and signs of vaginitis. Clinical cure rate was 87.7%, while the cure rates according to microscopy and Candida albicans culture were 81.8% and 73.9%, respectively. The cure rate for bacterial vaginosis was 75% and culture of Gardnerella vaginalis turned negative in 63.6% of cases following treatment. The medication was well tolerated. Conclusion Use of a combination of 750 mg of metronidazole and 200 mg of miconazole in a single daily application was found to be effective in the treatment of the most common causes of vaginitis.

An update onTrichomonas vaginalis

<i>Trichomonas vaginalis</i> is a parasitic protozoan that is the cause of trichomoniasis, a sexually transmitted disease (STD) of worldwide importance. Recent data have shown that the annual incidence of trichomoniasis is more than 170 million cases worldwide. In fact, the World Health Organization (WHO) has estimated that this infection accounts for almost half of all curable sexually transmitted infections. The actual burden of the disease remains unknown in India. As per the published literature, the prevalence of <i> T. vaginalis</i> ranges from 0.4-27.4% in women and 0.0-5.6% in men. Although <i> T. vaginalis</i> is the most common cause of nonviral STD, the exact mechanism of its pathogenesis has not been clearly elucidated. Standard teaching is that trichomoniasis is an important cause of vaginitis in women. The prevalence and spectrum of disease in males are less well characterized; the infection appears to usually be asymptomatic, but it has been suggested as an increasingly important cause of nongonococcal urethritis. The laboratory plays a key role in the diagnosis of this infection. The time-honored approach has been microscopic evaluation by wet mount method. The broth culture method is the 'gold standard' for diagnosis of trichomoniasis and detects twice as many infections as the wet mount method. The drug of choice is metronidazole or tinidazole. For long it has been considered a 'minor' STD. Recent literature documents that women infected during pregnancy are predisposed to premature rupture of membranes, premature labor, and low-birth-weight infants. Further, it may amplify HIV transmission. Therefore, the identification of this common treatable sexually transmitted infections offers a precious and much needed additional strategy for AIDS prevention.

Prevalence of Trichomoniasis, Bacterial Vaginosis and Candidiasis in Women Attending a Sexual Transmitted Infections and Gynaecologic Clinic using an Immunologic Latex Agglutination Test

Objectives: Validation of a simple and rapid test for diagnosis of vaginitis diagnosis and to evaluate its performance in a population sample of women attending gynecologic and STIs clinic in the diagnosis of Candida albicans, Trichomonas vaginalis and Gardnerella vaginalis. Methods: Clinical sensitivity and specificity were determined for Gardnerella vaginalis with 459 vaginal secretions samples obtained from a Gynecological Clinic of Havana, using Gram staining as reference method. Prevalence study was carried out in a total of 113 non-pregnant women attending a gynecology and STIs clinic that were screened for STIs (VIH/AIDS, Gonorrhea, Hepatitis B, Syphilis, Condyloma, and Genital Herpes) and for vaginitis by of Trichomonas vaginalis, Gardnerella vaginalis and Candida albicans by an immunological method. Risk factors were surveyed among attended women. Prevalence, confidence intervals (with 5% error) and oOdds ratios were calculated. Results: In the case of Gardnerella vaginalis 24 (5.2%) of the clinical samples reacted with the negative control and were classified as inconclusive. Clinical sensitivity and specificity determined in the 435 remaining samples were 91% and 97% respectively. Diagnosed STIs were 3 women with Gonorrhea and 1 woman with Condyloma. Prevalence of trichomoniasis, bacterial vaginosis (gardnerellosis) and candidiasis were 43.36%, 31.86% and 13.27% respectively. From the declared risk factors and diagnosis was possible to observed a significant odds ratio >6 between trichomoniasis and promiscuous behavior confirming Trichomonas vaginalis STI condition. This was not the same for Gardnerella vaginalis where no relation was observed with STI risk factors., Ccandidiasis was not possible to correlate because of small number of cases diagnosed. The frequency of vaginitis symptoms and signs is shown in figure 2. Vaginal discharge was the most common symptom in women with any kind of vaginitis; the other more frequent symptoms or signs were colpitis, vulvar pruritus, abdominal pain, bleeding cervix and dyspareunia with no relation with the diagnosis. Conclusion: The kit validation showed results as other more sophisticated techniques as DNA hybridization test and its performance was as expected detecting Ttrichomoniasis wasas the most frequent cause of vaginitis in this sample and hadwith significant relation with promiscuous behavior confirming the STI condition of this infection. This study was financed by a grant from the Ministry of Public Health of the Republic of Cuba

Bacterial Vaginosis: Do High Recurrence Rates Suggest Sexual Transmission?

Bacterial vaginosis (BV) is the most common cause of vaginitis, yet we understand little about its etiology and epidemiology (see Journal Watch

Bacterial vaginosis in women of low socioeconomic status living in slum areas in Chennai, India

Bacterial vaginosis (BV) is a common cause of vaginitis among women of childbearing age. This study was performed to investigate the prevalence of BV and its association with sexually transmitted infections among 487 women of low socioeconomic status. Blood, vaginal and endocervical swabs were tested for HIV, herpes simplex virus-2 (HSV-2), Treponema pallidum, BV, Chlamydia trachomatis, Neisseria gonorrhoea and Trichomonas vaginalis. Of the women screened for BV, 120 (25, 95% CI 20.8-28.4) were positive and 40 (8.2, 95% CI 5.8-10.6) were intermediate. Bacterial vaginosis was significantly associated with age >25 (P = 0.014) and sexual experience (P = 0.085). Bacterial vaginosis was also related to concurrent infections with T. vaginalis (relative risk (RR) = 6.6, 95% CI 2.8-15.5, P = 0.000) and HSV-2 (RR = 2, 95% CI 1.3-2.9; P = 0.0031). The role of other possible risk factors needs to be explored.

Evaluating vaginitis

Vaginal complaints are extremely common, accounting for approximately 10 million office visits each year.1 Current research has important limitations. Vaginal symptoms and signs inaccurately predict the etiologic agent. Microbial identification from vaginal secretions does not prove causation. About 30% of women with vaginal complaints remain undiagnosed despite extensive testing.2 In this issue of the Journal of General Internal Medicine, Carr et al.3 present a cost-effectiveness analysis which concludes that a “shotgun” approach to undiagnosed vaginitis costs less than sequential testing. This study underscores the challenge physicians have in choosing the best (most complete and least expensive) strategy for testing and treating these complaints. The “shotgun” approach assessed by Carr et al. included: pH testing; yeast culture; DNA probes for Gonorrhea and Chlamydia; and Gram's stain and Trichomonas culture when the vaginal pH is greater than 4.9. Adhering to this approach would save $8 to $76 and lessen symptoms by up to 1.3 days. Because rigorous cost-effectiveness analyses are difficult to perform with the results dependent on correct assumptions,4 we are concerned that several assumptions used in this analysis are oversimplified, limiting the applicability of the study's results. This strategy may work for undifferentiated patients, but general internal medicine patients are differentiated. Previous studies have documented that causes of vaginitis vary depending on a woman's menopausal status and age. Candidiasis, bacterial vaginosis, and trichomoniasis represent the most common causes of vaginitis in premenopausal women.2 In contrast, up to 40% of postmenopausal women have vaginal symptoms because of atrophic vaginitis, which can mimic the vaginal discharge of infectious etiologies.5 The prevalence of Gonorrhea and Chlamydia are highest in women aged 15 to 19 years, and African-American women in this age group have rates eight times higher than white women.6 We can further risk stratify patients with certain comorbidities (diabetes mellitus and immunosuppression), recent antibiotic use, or steroid use. In these patients, the pretest probability of Candida as the etiologic agent, with targeted testing and potential empiric therapy, would likely dominate strategies incorporating DNA probes for Gonorrhea and Chlamydia. Likewise, if a patient already self-medicated with an over-the-counter antifungal therapy without symptom improvement, the pretest probability for Candida would decrease in favor of other etiologic microbes.7 We also question the major utility assumptions in this analysis. When considering adverse outcomes, the authors assumed that treatment side effects and vaginitis symptoms would cause similar decreases in quality of life. Yet, fluconazole is safe and well tolerated with a low (2.8%) incidence of significant adverse side effects or laboratory abnormalities leading to discontinuation of the drug.8 We wonder whether women would consider gastrointestinal symptoms from fluconazole as equal to symptoms of vaginitis, especially as vaginitis can cause extreme anxiety and severe social and sexual dysfunction in addition to the physical discomfort.9 The authors did a very nice job of considering further evaluation costs with follow-up office visits and possible referral to specialists. However, nurse practitioners often evaluate acute vaginal complaints, and phone triage of vaginitis is common.10 In the age of physician extenders, phone triage, and e-medicine, this analysis may overestimate the cost of traditional follow-up office visits. This would be difficult to account for in any model but may alter the results of the analysis. This cost-effectiveness analysis—demonstrating that a “shotgun” approach to undiagnosed vaginitis is less expensive than sequential testing—does a great service in helping us understand a very complicated problem. Further refinements of the model should address differentiated patients, incorporating age, sexual risk factors, and comorbidities. Symptom severity and medication side effects are likely not equivalent for all women, thus limiting generalizability. Finally, in our changing world of health care access, prior trials of self-medication and physician extenders will add more uncertainty. This common problem deserves further study and we applaud the authors for advancing the work in managing this complex symptom.

Evaluation of vaginal complaints.

Vaginal symptoms are one of the most common reasons for gynecological consultation. Clinicians have traditionally diagnosed vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis using some combination of physical examination, pH, the wet mount, and the whiff test. To evaluate the role of the clinical examination and determine the positive and negative likelihood ratios (LRs) for the diagnosis of vaginal candidiasis, bacterial vaginosis, and vaginal trichomoniasis. Using a structured literature review, we abstracted information on sensitivity and specificity for symptoms, signs, and office laboratory procedures. We chose published (1966 to April 2003) articles that appeared in the MEDLINE database and were indexed under the combined search terms of diagnosis with vaginitis, vaginal discharge, candidiasis, bacterial vaginosis, and trichomoniasis. Included studies of symptomatic premenopausal women seen in primary care settings. Tests were evaluated only if they would provide diagnostic information during the office visit and were compared with an acceptable criterion standard. All 3 authors extracted the data and computed sensitivity and specificity from each article independently. The absence of standard definitions for symptoms and signs made it impossible to combine results across studies. Symptoms alone do not allow clinicians to distinguish confidently between the causes of vaginitis. However, a patient's lack of itching makes candidiasis less likely (range of LRs, 0.18 [95% confidence interval [CI], 0.05-0.70] to 0.79 [95% CI, 0.72-0.87]) and lack of perceived odor makes bacterial vaginosis unlikely (LR, 0.07 [95% CI, 0.01-0.51]). Similarly, physical examination signs are limited in their diagnostic power. The presence of inflammatory signs is associated with candidiasis (range of LRs, 2.1 [95% CI, 1.5-2.8] to 8.4 [95% CI, 2.3-31]). Presence of a "high cheese" odor on examination is predictive of bacterial vaginosis (LR, 3.2 [95% CI, 2.1-4.7]) while lack of odor is associated with candidiasis (LR, 2.9 [95% CI, 2.4-5.0]). Office laboratory tests, particularly microscopy of vaginal discharge, are the most useful way of diagnosing these 3 conditions. The cause of vaginal complaints may be easily diagnosed when typical findings appear in microscopy. However, the poor performance of individual symptoms, signs, and office laboratory tests often makes it problematic to identify the cause of vaginal symptoms.

Antibiotic-associated vulvovaginal candidiasis

Vulvovaginal candidiasis (VVC) is one of the most common causes of vaginitis, and its incidence has increased markedly during the past three decades. The widespread overuse of antibiotics has been suggested as one of the major factors contributing to the increasing incidence of VVC. However, evidence supporting this association has been limited because few studies with rigorous scientific methodology have been conducted. Moreover, existing data regarding the risk for developing VVC after antibiotic use are conflicting. This review examines the available information in the literature regarding antibiotic-associated VVC, its incidence, and its potential mechanisms. Implications for clinical practice and research are also discussed.

Trichomonas Vaginalis Orchitis With Associated Severe Oligoasthenoteratospermia and Hypogonadism

Trichomonas vaginalis is a fairly common cause of vaginitis in the sexually active woman. It is an important consideration in the differential diagnosis of the at risk man with urethral symptoms. We report a novel case of T. vaginalis orchitis detected during evaluation for severe oligoasthenoteratospermia and hypogonadism. CASE REPORT A 35-year-old male presented for infertility evaluation after he and his wife had practiced unprotected intercourse for 1 year without success. He had undergone 3 previous semen analyses, which revealed severely low sperm concentration and 0% motility. His wife was 37 years old and had normal menses and a normal hysterosalpingogram. Neither had previously achieved a pregnancy. Medical and surgical history were unremarkable. Physical examination was notable only for bilaterally soft, atrophic testes measuring 1.5 cc on the right and 4 cc on the left side. Penis, epididymides, vasa deferentia and bilateral cord structures were normal. Laboratory analysis was notable for an initial testosterone of 1.8 ng/ml (normal 2 to 8). Follicle-stimulating hormone, luteinizing hormone and prolactin were normal, as was the initial urinalysis. Semen analysis showed a sperm concentration of less than 100,000/ml with 0% motility, 0% normal forms and no pyospermia detected. Transrectal ultrasound demonstrated no evidence of ejaculatory duct obstruction. Cystic fibrosis testing revealed the presence of 1 copy of the 5T variant but was otherwise unremarkable. The patient had a normal 46,XY karyotype. Y chromosome testing was unremarkable. Four weeks later the patient underwent testicular sperm extraction. Right testis wet preparation showed rare nonmotile but normal appearing sperm (fig. 1) and motile flagellates (fig. 2). Left testis wet preparation demonstrated no flagellates and occasional nonmotile sperm. Immediate postoperative urinalysis revealed Trichomonas. Final pathological analysis confirmed the diagnosis of right T vaginalis orchitis. The patient and his wife were treated with oral metronidazole. Repeat urinalysis 2 weeks later was normal. Semen analysis at 6 months showed 20% motile forms with the concentration still at less than 100,000/ml.