Urinary Tract Infections (UTIs)
Acute uncomplicated cystitis, also known as a simple UTI, can present with urinary frequency and urgency (urinating more often and suddenly), dysuria (pain while urinary), hematuria (blood in urine), suprapubic tenderness (pelvic pain), and dyspareunia (pain during intercourse). Escherichia coli is the most common causative bacterial pathogen. UTIs are often treated with nitrofurantoin or trimethoprim/sulfamethoxazole (also known as Bactrim). The diagnosis is clinical; however, urinalysis is used when the diagnosis is unclear.
Vaginal Discharge and Vaginal Health
Physiologic leukorrhea (normal discharge) in women is a white odorless vaginal discharge that consists of normal vaginal flora, squamous epithelial cells (skin cells), and cervical mucus. It is commonly evident mid-cycle, 10-14 days after the end of menses. Signs that it is more than psychological leukorrhea and may be an infection include pruritus (itchiness) and a malodorous vaginal discharge.
Bacterial vaginosis is an alteration of normal vaginal bacteria from lactobacilli predominance to anaerobes and facultative aerobes. It presents with an off-white or gray, thin vaginal discharge with a foul-smelling fish-like odor after sexual intercourse. The first-line treatment options include vaginal or oral metronidazole or clindamycin.
Sexually Transmitted Infections (STIs) and Other Complications
Acute cervicitis, inflammation of the cervix, is typically the result of an STI. It presents with foul-smelling mucopurulent discharge, postcoital spotting (bleeding after sexual intercourse), vulvar or vaginal irritation, dysuria, and dyspareunia; however, many patients do not have any symptoms. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common causative agents. Treatment is based on the clinical diagnosis, and testing is only used for confirmation (usually with nucleic acid amplification testing). Because coinfection is common, antibiotics are chosen that can treat both chlamydia and gonorrhea (i.e., doxycycline and ceftriaxone).
Cervicitis can also be caused by Trichomonas vaginalis (trichomoniasis), a sexually transmitted protozoal infection. The clinical presentation in women can range from an asymptomatic carrier state to an acute, severe pelvic inflammatory disease. It presents with green-yellow purulent, frothy malodorous vaginal discharge with irritative symptoms. It also presents with punctate hemorrhages on the cervix (known as a strawberry cervix) that can be seen by a physician performing a pelvic speculum exam and erythema (redness) of the vulva and vagina. It can be diagnosed via wet mount microscopy showing motile trichomonads (motile flagellated unicellular organisms) or by positive nucleic acid amplification testing. The treatment is typically oral metronidazole 500 mg twice daily for 7 days.
Condyloma acuminate (anogenital warts) appear as fleshy, exophytic (outward growing) lesions on or near the genitalia and are caused by certain types of human papillomavirus (HPV). Treatment depends on the extent of the disease: local limited disease is treated medically, and extensive disease is treated surgically. Surgical options for condyloma acuminata include cryotherapy (which involves the local application of liquid nitrogen), surgical excision, and laser ablation, the preferred therapy, particularly in patients who have vaginal involvement.
Candida vulvovaginitis (vulvovaginal candidiasis) occurs when Candida species overgrows, penetrates the superficial cells of the vulva and vagina, and causes inflammation. Common features include vulvar pruritus, thick white vaginal discharge, vulvar or vaginal erythema, and beefy red scaly plaques with small pustules (blisters). Wet mount microscopy would show the presence of yeast. Dysuria can occur due to contact between acidic urine and the inflamed vulvovaginal epithelium.
Bartholin glands are glands that are located in the labia minora and produce mucus to keep the vaginal area moist. Obstruction of Bartholin glands can lead to cysts or abscesses. A Bartholin gland cyst can present as a soft painless cystic mobile mass that is flesh-colored in the posterolateral vaginal introitus or labia (at the base of the labia majora). They occur at the 4 and 8 o’clock positions. They have clear or white fluid and average 1 to 3 cm. Small cysts are generally asymptomatic and are detected only during routine physical examination, while larger ones (> 3 cm) may present with discomfort during sexual activity, sitting, or ambulation. Small cysts (< 3 cm) are initially managed with warm compresses and sitz baths. Asymptomatic masses do not require management while incision and drainage are indicated for painful lesions. Abscesses result from primary gland infection or an infected cyst. People with abscesses may have acute, rapidly progressive severe vulvar pain and swelling. Patients often find it difficult to walk, sit, or have sexual intercourse.
Cysts can also be found elsewhere. Gartner duct cysts are located at the lateral aspect of the upper anterior vagina. Skene gland cysts are located lateral to the urethral meatus.