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Patient Story

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An 18-year-old female presented to her physician with vulvar and vaginal itching associated with a vaginal discharge. On examination, the patient is noted to have redness and excoriations on her vulva (Figure 74-1). She also had a thick white discharge was seen covering cervix and vaginal sidewallson speculum exam. The pH of the discharge was 4.2, and <10 percent of the epithelial cells on her wet prep were clue cells (Figure 74-2), but yeast and hyphae were noted. She was diagnosed with candida vulvovaginitis and was treated with oral fluconazole.

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FIGURE 74-1

Candida vulvovaginitis in an 18-year-old female who complained of severe vaginal and vulvar itching. Her vulva demonstrated redness with excoriations. Note the satellite lesions near the borders of the inflamed areas. She was diagnosed with candida vulvovaginitis. (Used with permission from E.J. Mayeaux, Jr., MD.)

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FIGURE 74-2

Clue cells on a wet mount of vaginal discharge in saline under high-power light microscopy. Note the presence of vaginal epithelial cells, smaller white blood cells (polymorphonucleocytes), and bacteria. The bacteria are the coccobacilli of Gardnerella vaginalis covering the cell membranes of the two vaginal epithelial cells near the lower end of the field. These are clue cells seen in patients with bacterial vaginosis. (Used with permission from Richard P. Usatine, MD.)

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Introduction

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Vaginal discharge is a frequent presenting complaint in primary care. The three most common causes in adolescents and adults are bacterial vaginosis, candidiasis, and trichomoniasis. Providers must refrain from “diagnosing” a vaginitis based solely on the color and consistency of the discharge, as this may lead to misdiagnosis and may miss concomitant infections.1

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Vulvovaginal complaints in prepubertal children may be result from infection, congenital abnormalities, trauma, or dermatologic conditions. Vaginitis is the most commont gynecologic problem in prepubertal girls, often presenting with symptoms including vaginal discharge, erythema, soreness, pruritus, dysuria, or bleeding.2

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Adolescence is a developmental period with rapid changes in physical characteristics, sexual development, emotional development, and sexual activity. These changes may result in potential increased risk for acquiring sexually transmitted diseases.

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Epidemiology

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The reported rates of chlamydia and gonorrhea are highest among females ages 15 to 19 years. Adolescents are at greater risk for sexually transmitted diseases (STDs) because they frequently have unprotected intercourse, are biologically more susceptible to infection, are often engaged in partnerships of limited duration, and face multiple obstacles to utilization of health care.1

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Cross-sectional data from the 2003 to 2004 US National Health and Nutrition Examination Survey (NHANES) shows 24 percent of female adolescents (aged 14 to 19 years) had laboratory evidence of infection with human papillomavirus (HPV, 18%), Chlamydia trachomatis (4%), Trichomonas vaginalis (3%), herpes simplex virus type 2 (HSV-2, 2%), or ...

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