I hear trainees express diffidence about the clinical diagnosis of vaginitis in the emergency department. While our bedside diagnostic certainty might be limited, studies suggest that it is limited for the specialists as well. In fact, even after testing for pH, amines, and wet preparation microscopy, 30% of patients remain undiagnosed (Lowe 2009). Thus, judgment is required.
The initial differential diagnosis centers on the three most common conditions, bacterial vaginosis, candidiasis, and trichomoniasis. The treatment for the first and third is the same, metronidazole for 7 days.
Thus, the treatment decisions come down to a decision about antifungals. In general, if the history and physical examination does not give evidence of candidiasis, the patient should be treated with seven days of metronidazole and then referred to the gynecologist for further care. Although candida is commonly recognized by the cottage cheese discharge, keep in mind that severe cases of candidiasis can present with erythema and fissures. Bacterial vaginosis does not (Sobel 2007).
Sometimes the best thing we do for health of the patient is give helpful lifestyle advice. Some patients suffer from recurrent vaginitis because of overutilization of antibiotics for winter colds or other practices whose harm is unperceived to them. Optimal vaginal acidity is maintained by lactobacillus. Women who suffer from recurrent vaginitis need to do all they can to maintain lactobacillus. Preventable disturbances include douching, frequent introduction of alkaline sperm, and overutilization of antibiotics.
There are several other considerations, especially in the patient with chronic disease, but this at least serves as a reminder that emergency physicians can approach this acute presentation with confidence and make a difference for our patients.