vaginal microflora is not understood The high prevalence of the syndrome in sexually active women and in women attending STI clinics suggests that a wide range of epidemiologic and microbiologic factors may contribute to its pathogenesis Clinical Assessment The symptoms of bacterial vaginosis—malodor and discharge—are not distinctive and can resemble those of trichomonal infection A complaint of dysuria or pruritus goes against the diagnosis As many as half of women who have signs of vaginosis are asymptomatic The vaginal discharge is moderate or copious, grayish-white, and homogeneous On examination, the vulva, vagina, and cervix are not inflamed, but concomitant infection with trichomonas or gonococci can complicate this picture Compared with the composite Amsel criteria, the use of single tests (e.g., pH, clue cells, or whiff test alone) produces lower positive and negative predictive values for the diagnosis of bacterial vaginosis When a wet mount of vaginal discharge is examined, clue cells can be seen which are epithelial cells that are studded with large numbers of small bacteria giving them a granular appearance with shaggy borders ( Fig 92.2 ) The ratio of epithelial cells to polymorphonuclear leukocytes in the discharge is or higher Lactobacilli (long rods) are sparse Gram stain can be used to confirm the presence of clue cells and the scarcity of long gram-positive rods (lactobacilli) Because 35% to 55% of women without bacterial vaginosis have positive cultures for G vaginalis, culture is not a useful diagnostic test In addition, a rapid, antigen-based test has been developed to assess for bacterial vaginosis using a vaginal swab sample, similar to the rapid antigen test for T vaginalis This test has improved sensitivity and specificity over Gram stain but may not be widely available Trichomonal infection is the major diagnostic alternative for patients suspected of having bacterial vaginosis FIGURE 92.2 A clue cell The vaginal epithelial cell on the right has shaggy borders obscured by coccobacilli (×100 magnification) Management The standard treatment of bacterial vaginosis is oral metronidazole, 500 mg twice daily for days Treatment of patients’ sexual partners does not reduce the recurrence rate and is not recommended Common side effects of metronidazole include GI upset, headache, and a metallic taste Patients should abstain from alcohol during treatment and for 24 hours after treatment with metronidazole to avoid the disulfiram reaction Metronidazole in standard doses is not a human teratogen; however, some clinicians prefer to postpone treatment of pregnant women until the second trimester Intravaginal clindamycin cream (2%, g) and metronidazole gel (0.75%, g) are alternative treatment options for nonpregnant women Oral clindamycin (300 mg twice a day for days) is an alternative treatment regimen for pregnant patients with bacterial vaginosis NONSPECIFIC VAGINITIS Clinical Considerations Clinical Recognition The term nonspecific vaginitis, referring to a disorder of prepubertal girls, encompasses a variety of genitourinary symptoms and signs that are sometimes caused by poor perineal hygiene but that in other cases have no readily identifiable cause Genital discomfort, discharge, itchiness, and dysuria are relatively common childhood complaints In a reported series of premenarcheal girls with vaginitis who have been systematically evaluated, between 25% and 75% are ultimately categorized as having nonspecific vaginitis The diagnosis should not be made until other entities have been excluded through examination and testing if indicated Clinical Assessment When a prepubertal girl with vaginitis symptoms has either a normal vulva and vagina or only mild vulvar inflammation on physical examination, a specific vaginal infection is unlikely, and other possible explanations for the complaint— smegma, pinworms, urinary tract infection, a local chemical irritant, or sexual abuse, for example—should be sought with appropriate questions and laboratory tests (It should be noted that commercially available bubble bath is not often the culprit.) If, however, a vaginal discharge is present on physical examination, the specific vaginal infections discussed in this chapter are diagnostic possibilities and cultures or other specific testing should be obtained Management General measures to promote cleanliness and comfort should be initiated for the girl with nonspecific vaginitis Daily soaking in a bath of warm water, either plain or with some baking soda added, gentle perineal cleaning with a soft washcloth, and the use of cotton underwear can be recommended The girl should be taught to wipe toilet paper anteroposteriorly Using these suggestions, most girls with perineal irritation will show improvement within weeks The remaining patients should be reevaluated to exclude any specific but previously unrecognized disorder If none is found, these girls may benefit from a brief course of topical estrogen cream (a small amount dabbed onto the vulva nightly for to weeks) to stimulate thickening of the vaginal mucosa so that it is more resistant to local irritation Parents should be cautioned that estrogen cream is capable of producing breast growth and tenderness if it is used for a prolonged period of time CERVICITIS Goals of Treatment To identify the causative agent and treat with antibiotics or removal of offending agent as appropriate, patients should also be screened for other sexually transmitted infections, evaluated for pelvic inflammatory disease (PID), and counseled on safe sexual practices CLINICAL PEARLS AND PITFALLS The most common etiology of acute cervicitis is infectious Cervicitis may be diagnosed incidentally in asymptomatic women Sexually active women with cervicitis should be treated empirically for gonorrhea and chlamydia while test results are pending Current Evidence Cervicitis, or inflammation of the cervix, can be acute or chronic in nature The etiology of acute cervicitis is most often an infectious etiology (including Neisseria gonorrhoeae and Chlamydia trachomatis and potentially Mycoplasma genitalium ) Many of the cases of acute cervicitis will not have a specific infectious etiology identified Other etiologies of acute cervicitis include mechanical irritation (e.g., tampon, IUD, sexual intercourse) and chemical irritation (e.g., contraceptive cream, douche) Chronic cervicitis is more often due to a noninfectious etiology If untreated, infections can ascend the genitourinary tract and cause PID which may lead to infertility, chronic pelvic pain, and increased risk of ectopic pregnancy In addition, cervical infections can be transmitted to sexual partners and increases the risk of acquiring HIV infections if exposed Clinical Considerations Clinical Recognition Patients with cervicitis may be asymptomatic Symptomatic patients with cervicitis present with variable and nonspecific symptoms including purulent vaginal discharge, intermenstrual bleeding, postcoital bleeding, and dyspareunia Less frequently, patients will present with urinary symptoms such as dysuria and urinary frequency due to a concomitant urethritis Patients with isolated cervicitis are unlikely to have fever or significant pain The presence of these should signal other conditions such as PID or a herpes simplex virus infection (HSV) Clinical Assessment On physical examination, patients with acute cervicitis will have purulent (or mucopurulent) discharge from the cervix on speculum examination The clinician may also notice that the cervix tends to bleed easily after minor trauma from a