Resistant or recurrent cases

1. Recurrent infections always should be reevaluated. Repeating topical therapy for a 14-21-day course may be effective. Oral regimens have the potential for eradicating rectal reservoirs.

2. Cultures are helpful in determining whether a non-candidal and difficult-to-treat species is present. Patients with recalcitrant disease should be evaluated for diabetes and HIV.

VI. Trichomonas vaginalis

A. Trichomonas, a flagellated anaerobic protozoan, is a sexually transmitted disease with a high transmission rate. Non-sexual transmission is possible because the organism can survive for a few hours in a moist environment.

B. A copious, yellow-gray or green homogeneous discharge is present. A foul odor, vulvovaginal irritation, and, occasionally, dysuria is common. The pH level is usually greater than 4.5.

C. The diagnosis of trichomonal infection is made by examining a wet-mount preparation for mobile, flagellated organisms and an abundance of leukocytes.

D. Occasionally the diagnosis is reported on a Pap test and treatment is recommended.

E. Treatment of Trichomonas vaginalis

1. Metronidazole (Flagyl), 2 g PO in a single dose for both the patient and sexual partner, or 500 mg PO bid for 7 days.

2. Topical therapy with topical metronidazole is not recommended because the organism may persist in the urethra and Skene's glands after local therapy.

3. Screening for coexisting sexually transmitted diseases should be completed.

4. Recurrent or recalcitrant infections a. If patients are compliant but develop recurrent infections, treatment of their sexual partners should be confirmed.

b. Cultures should be performed. In patients with persistent infection, a resistant trichomonad strain may require high dosages of metronidazole 2.5 g/d, often combined with intravaginal metronidazole for 10 days.

VII. Other diagnoses causing vaginal symptoms

A. One-third of patients with vaginal symptoms will not have laboratory evidence of bacterial vaginosis, Candida, or Trichomonas.

B. Other causes of the vaginal symptoms include cervicitis, allergic reactions, and vulvodynia.

C. Atrophic vaginitis should be considered in postmenopausal patients if the mucosa appears pale and thin and wet-mount findings are negative.

1. Oral estrogen (Premarin) 0.625 mg qd should provide relief.

2. Estradiol vaginal cream 0.01% may be effective as 2-4 g daily for 1-2 weeks, then 1 g one to three times weekly.

3. Conjugated estrogen vaginal cream may be effective as 2-4 g daily (3 weeks on, 1 week off) for 3-6 months.

D. Allergy and chemical irritation

1. Patients should be questioned about use of substances that cause allergic or chemical irritation, such as deodorant soaps, laundry detergent, vaginal contraceptives, bath oils, perfumed or dyed toilet paper, hot tub or swimming pool chemicals, and synthetic clothing.

2. Topical steroids and systemic antihistamines can help alleviate the symptoms until the irritant can be identified.

References: See page 195.

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