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Causes of vulvovaginitis include infections, irritants, allergies, reaction to foreign bodies, and atrophy. The normal vaginal flora helps maintain an acidic pH between 3.8 and 4.5, which decreases pathogen growth.

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Bacterial vaginosis (BV) is the most common cause of malodorous vaginal discharge. However, many infected women are asymptomatic. BV occurs when vaginal lactobacilli are replaced by anaerobes, Gardnerella vaginalis, and Mycoplasma hominis.

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Clinical Features

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The most common symptom is malodorous or “fishy smelling” vaginal discharge. Vaginal irritation, excoriation, and fissures are less common. Examination findings range from mild vaginal redness to a frothy gray-white or yellow discharge.

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Diagnosis and Differential

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The diagnosis can be made if 3 of the following 4 criteria are present: (a) vaginal discharge, (b) vaginal pH greater than 4.5, (c) positive amine test (fishy odor when 10% KOH is added to the discharge), (d) clue cells seen on saline wet preparation. Often, the diagnosis of BV is suspected from the history.

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Emergency Department Care and Disposition

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Treat with metronidazole 500 milligrams PO twice daily for 7 days. Clindamycin 300 milligrams PO twice daily for 7 days is an alternative. Treatment is not recommended for male partners or asymptomatic women. All patients treated with metronidazole should refrain from alcohol use during treatment and for 24 hours after ending treatment, to avoid a disulfram-like reaction.

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Pregnant women at high risk of preterm labor should be considered for treatment, and all symptomatic pregnant women should be treated. The recommended treatment in pregnancy is metronidazole 250 milligrams PO twice daily for 7 days. Routine treatment of asymptomatic pregnant women with BV is not recommended.

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Candida albicans is a common cause of vaginitis. Conditions that promote Candida vaginitis include systemic antibiotics, diabetes, pregnancy, and birth control pills. Incidence is decreased in postmenopausal patients. Candidiasis is not considered a sexually transmitted disease, though it can be transmitted sexually.

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Clinical Features

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The most common symptom of Candida vaginitis is pruritus. Other symptoms include vaginal discharge, external dysuria, and dyspareunia. Signs include vulvar and vaginal edema, erythema, and a thick “cottage cheese” discharge.

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Diagnosis and Differential

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Examine vaginal secretions microscopically in a few drops of saline solution or make a KOH preparation. Ten percent KOH dissolves vaginal epithelial cells, leaving yeast buds and pseudohyphae intact and easier to see. The sensitivity of the KOH technique is 80%, with a specificity approaching 100%.

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Emergency Department Care and Disposition

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Almost all topically applied azoles are equally efficacious. Treatment options include clotrimazole 100 milligram intravaginal tablet (2 tablets for 3 days), butoconazole 2% cream 1 vaginal applicator daily for 3 days, miconazole 200 milligrams vaginal suppository for 3 days. Pregnant patients are treated with intravaginal agents for 7 days. Single-dose treatment with ...

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