Improving the Diagnosis of Vulvovaginitis: Perspectives to Align Practice, Guidelines, and Awareness

Haywood Brown, Madeline Drexler, Haywood Brown, Madeline Drexler

Abstract

Vulvovaginitis is a frequent reason for women to see a health care provider and has been linked to adverse reproductive and psychosocial consequences. Accurate diagnosis is a cornerstone of effective treatment, yet misdiagnosis of this condition approaches 50%, raising the risk of recurrence. The past 3 decades have seen few improvements over the traditional means of diagnosing the 3 main causes of vaginitis: bacterial vaginosis, Candida infections, and trichomoniasis. Newer molecular tests, which are both more sensitive and specific, have introduced the potential to transform the diagnosis of vaginitis-ensuring more accurate diagnoses and timely interventions, while reducing health care costs and enhancing patients' quality of life. Clinical approaches and professional guidelines should be updated to reflect advances in molecular testing and improve the diagnosis and management of acute and recurrent vulvovaginitis.

Keywords: Candida infections; adverse reproductive consequences; bacterial vaginosis; guidelines; interventions; trichomoniasis; vulvovaginitis.

Conflict of interest statement

Dr. Brown is a past president of the American College of Obstetricians and Gynecologists and has served as a consultant to Hologic, Inc. He did not receive compensation for his contributions to this work.

Ms. Drexler is employed by the Harvard T.H. Chan School of Public Health and received financial support from Mary Ann Liebert, Inc., publishers, to review the literature, consult with designated experts, and develop and write this article.

Figures

FIG. 1.
FIG. 1.
Practice Guidelines for Diagnosing Vaginitis.

References

    1. Egan ME, Lipsky MS. Diagnosis of vaginitis. Am Fam Physician 2000;62:1095–1104
    1. Zhu YX, Li T, Fran SR, Liu XP, Liang YH, Liu P. Health-related quality of life as measured with the short-form 36 (SF-36) questionnaire in patients with recurrent vulvovaginal candidiasis. Health Qual Life Outcomes 2016;14:65.
    1. ACOG. Vaginitis in nonpregnant patients: ACOG practice bulletin number 215. Obstet Gynecol 2020;135:e1–e17
    1. Sobel JD. Vaginal infections in adult women. Med Clin North Am 1990;74:1563–1602
    1. Koumans EH, Sternberg M, Bruce C, et al. . The prevalence of bacterial vaginosis in the United States, 2001–2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis 2007;34:864–869
    1. Granato PA. Vaginitis: clinical and laboratory aspects for diagnosis. Clin Microbiol Newslett 2010:32:111–116
    1. Peebles K, Velloza J, Balkus J, McClelland RS, Barnabas R. High global burden and costs of bacterial vaginosis: a systematic review and meta-analysis. Sex Transm Dis 2019;45:304–311
    1. Powell AM, Nyirjesy P. Recurrent vulvovaginitis. Best Pract Res Clin Obstet Gynaecol 2014;28:967–76
    1. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. [published erratum appears in MMWR Recomm Rep. 2015; 64:924]. MMWR Recomm Rep 2015;64(RR-03):1–137
    1. Onderdonk AB, Delaney ML, Fichorova RN. The human microbiome during bacterial vaginosis. Clin Microbiol Rev 2016;29:223–238
    1. Brotman RM, Klebanoff MA, Nansel TR, et al. . Bacterial vaginosis assessed by gram stain and diminished colonization resistance to incident gonococcal, chlamydial, and trichonomal genital infection. J Infec Dis 2010;202:1907–1915
    1. Laxmi U, Agrawal S, Raghunandan C, et al. . Association of bacterial vaginosis with adverse fetomaternal outcome in women with spontaneous preterm labor: a prospective cohort study. J Maternal Fetal Neonatal Med 2012;25:64–67
    1. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2016. Atlanta: U.S. Department of Health and Human Services, 2017.
    1. Allsworth JE, Peipert JF. Prevalence of bacterial vaginosis: 2001–2004 National Health and Nutrition Examination Survey data. Obstet Gynecol 2007;109:114–120
    1. Sobel JD. Vulvovaginal candidosis. Lancet 2007;369:1961–1971
    1. Satterwhite C, Torrone E, Meites E, et al. . Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40:187–193
    1. Sutton M, Sternberg M, Koumans EH, McQuillan G, Berman S, Markowitz L.. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001–2004. Clin Infect Dis 2007. 45:1319–1326
    1. Flagg EW, Meites E, Phillips C, et al. . Prevalence of Trichomonas vaginalis among males and females aged 14–59 years: United States, 2013–2016. Sex Transm Dis 2019 DOI: 10.1097/olq.0000000000001013
    1. Schwebke JR, Taylor SN, Ackerman R, et al. . Clinical validation of the Aptima bacterial vaginosis and Aptima candida/Trichomonas vaginitis assays: results from a prospective multicenter clinical study. J Clin Microbiol 2020;58:e01643-19
    1. Van Der Pol B, Daniel G, Kodsi S, Paradis S, Cooper C. Molecular-based testing for sexually transmitted infections using samples previously collected for vaginitis diagnosis. Clin Inf Dis 2019;68:375–381
    1. Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med 1983;74:14–22
    1. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by standardized method of gram stain interpretation. J Clin Micro 1991;29:297–301
    1. Gutman RE, Peipert JF, Weitzen S, Blume J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005;105:551–556
    1. Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, Litaker MS. Over-the-counter antifungal drug misuse associated with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol 2002;99:419–425
    1. Marchaim D, Lemanek L, Bheemreddy S, Kaye KS, Sobel JD. Fluconazole-resistant Candida albicans vulvovaginitis. Obstet Gynecol 2012;120:1407–1414
    1. Nye MB, Schwebke JR, Body BA. Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women. Am J Obstet Gynecol 2009;200:188..e1–188.e7.
    1. Landers DV, Wiesenfeld HC, Heine RP, et al. . Predictive value of the clinical diagnosis of lower genital tract infection in women. Am J Obstet Gynecol 2004;190:1004–1010
    1. Sobel J. Approach to females with symptoms of vaginitis. UpToDate. Accessed September19, 2020
    1. Schwebke JR, Gaydos CA, Nyirjesy P, Paradis S, Kodsi S, Cooper CK. Diagnostic performance of a molecular test versus clinician assessment of vaginitis. J Clin Microbiol 2018;56:e00252-18
    1. Gaydos CA, Beqaj S, Schwebke JR, et al. . Clinical validation of a test for the diagnosis of vaginitis. Obstet Gynecol 2017;130:181–189
    1. Cartwright CP, Pherson AJ, Harris AB, Clancey MS, Nye MB. Multicenter study establishing the clinical validity of a nucleic-acid amplification-based assay for the diagnosis of bacterial vaginosis. Diagn Microbiol Infect Dis 2018;92:173–178
    1. Ackerman S, Knight T, Wahl P, Cartwright C. Health care utilization and costs following amplified versus non-amplified molecular probe testing for symptomatic patients with suspected vulvovaginitis: a US commercial payer population. Clinicoecon Outcomes Res 2019;11:179–189
    1. Centers for Medicare and Medicaid Service. Provider performed microscopy (PPM) procedures, 42.493.19. Washington, DC: Department of Health and Human Services, 2016
    1. Paladine HL, Desai UA. Vaginitis: diagnosis and treatment. Am Fam Physician 2018;97:321–329
    1. Sobel JD, Subramanian C, Foxman B, Fairfax M, Gygax SE. Mixed vaginitis—more than coinfection and with therapeutic implications. Curr Infect Dis Rep 2013;15:104–108
    1. Bradshaw CS, Morton AN, Garland SM, Horvath LB, Kuzevska I, Fairley CK. Evaluation of a point-of-care test, BVBlue, and clinical and laboratory criteria for diagnosis of bacterial vaginosis. J Clin Microbiol 2005;43:1304–1308
    1. Foxman B, Muraglia R, Dietz JP, Sobel JD, Wagner J. Prevalence of recurrent vulvovaginal candidiasis in 5 European countries and the Unites States: results from an internet panel survey. J Low Genit Tract Dis 2013;17:340–345
    1. Green KA, Zarek SM, Catherino WH. Gynecologic health and disease in relation to the microbiome of the female reproductive tract. Fertil Steril 2015;104:1351–1357
    1. Brown HL, Fuller DA, Davis TE, Schwebke JR, Hillier SL. Evaluation of the affirm ambient temperature transport system for the detection and identification of Trichomonas vaginalis, Gardnerella vaginalis, and Candida species from vaginal fluid specimens. J Clin Microbiol 2001:39;9:3197–3199
    1. Powell AM, Gracely E, Nyirjesy P. Non-albicans candida vulvovaginitis: treatment experience at a tertiary care vaginitis center. J Low Genit Tract Dis 2016;20:85–99
    1. Kim T, Young M, Goggins E, et al. . Trichomonas vaginalis in pregnancy: patterns and predictors of testing, infection, and treatment. Obstet Gynecol 2020;35:1136–1144
    1. Hollman D, Coupey SM, Fox AS, et al. . Screening for Trichomonas vaginalis in high-risk adolescent females with a new transcription-mediated nucleic acid amplification test (NAAT): associations with ethnicity, symptoms, and prior and current STIs. J Pediatr Adolescent Gynecol 2010;23:312–316
    1. Roth AM, Williams JA, Ly R, et al. . Changing sexually transmitted infection screening protocol will result in improved case finding for Trichomonas vaginalis among high-risk female populations. Sex Transm Dis 2011;38:398–400
    1. Schwebke JR, Hobbs MM, Taylor SN, et al. . Molecular testing for Trichomonas vaginalis in women: results from a prospective U.S. clinical trial. J Clin Microbiol 2011;49:4106–4011
    1. Belley-Montfort L, Lebed J, Smith B, et al. . Sensitivity of the Amsel's criteria compared to the nugent score in absence and in presence of Trichomonas vaginalis (TV) and/or Candida spp among women with symptomatic vaginitis/vaginosis. Sex Transm Infect 2015:91;A97 [Poster presentation]
    1. Nyirjesy P. Management of persistent vaginitis. Obstet Gynecol 2014;124:1135–1146
    1. Prendez JY. Case report: efficient and cost-effective diagnosis of vaginitis. Am Fam Physician 2019;99:344.
    1. Bilardi JE, Walker S, Temple-Smith M, et al. . The burden of bacterial vaginosis: women's experience of the physical, emotional, sexual and social impact of living with recurrent bacterial vaginosis. PLoS One 2013;8:e74378.
    1. Aballéa S, Guelfucci F, Wagner J, et al. . Subjective health status and health-related quality of life among women with recurrent vulvovaginal candidosis (RVVC) in Europe and the USA. Health Qual Life Outcomes 2013;11:169.
    1. Chavoustie S, Eder S, Koltun W, et al. . Experts explore the state of bacterial vaginosis and the unmet needs facing women and providers. Int J Gynaecol Obstet 2017;137:107–109
    1. Nyirjesy P, Troeger K, Banker W, Bonus T. Physician awareness and adherence to clinical practice guidelines in the diagnosis of vaginitis patients: a retrospective chart review. Popul Health Manage 2020;23:S2 (In Press).
    1. Hillier SL, Austin M, Macio I, Meyn LA, Badway D, Beigi R.. Diagnosis and treatment of vaginal discharge syndromes in community practice settings. Clin Infect Dis 2020. DOI: 10.1093/cid/ciaa26053
    1. Van Der Pol B. Diagnosing vaginal infections: it's time to join the 21st century. Curr Infect Dis Rep 2010;12:225–230
    1. Miller J, Binnicker M, Campbell S, et al. . A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis 2018;67:e1–e94

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi