Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
The diagnosis of vaginitis is made by pH and microscopic examination of fresh
samples of the discharge. The pH of vaginal secretions should be determined by using
narrow-range pH paper. Normal pH is <4.5 and is related to the presence of
lactobacilli. An elevated pH, i.e., >4.5, is typical of bacterial vaginosis or
trichomoniasis. One way to examine the discharge is to dilute a sample in 1-2 drops of
0.9% normal saline solution on one slide and 10% KOH solution on a second slide. An amine
odor detected immediately after applying KOH suggests either BV or trichomoniasis. A cover
slip is placed on each slide and they are examined under a microscope at low- and high-dry
power. The motile T. vaginalis or the clue cells of BV are usually easily identified in
the saline specimen. The yeast or pseudo hyphae of Candida species are more easily
identified in the KOH specimen. The presence of objective signs of vulvar inflammation in
the absence of vaginal pathogens, along with a minimal amount of discharge, suggests the
possibility of mechanical or chemical irritation of the vulva.
Answer 2a
- Metronidazole, 500 mg orally 2 times a day for 7 days, OR clindamycin cream 2%,
one full applicator (5g) intra vaginally at bedtime for 7 days, OR metronidazole gel
0.75%, one full applicator (5g) intra vaginally twice a day for 5 days.
- Alternative regimens are metronidazole 2 grams orally in a single dose OR
clindamycin 300 mg orally twice a day for 7 days.
Answer 2b
- Metronidazole, 500 mg orally 2 times a day for 7 days, OR clindamycin cream 2%,
one full applicator (5g) intra vaginally at bedtime for 7 days, OR metronidazole gel
0.75%, one full applicator (5g) intra vaginally twice a day for 5 days.
- Alternative regimens are metronidazole 2 grams orally in a single dose OR
clindamycin 300 mg orally twice a day for 7 days.
Answer 2c
- Metronidazole, 2 g orally in a single dose.
- Alternative regimen is metronidazole 500 mg twice a day for 7 days.
Answer 2d
Intravaginal agents:
- Butoconazole 2% cream 5 g intra vaginally for three days (OTC)
- Clotrimazole 1% cream 5 g intra vaginally for 7-14 days (OTC)
- Clotrimazole 100 mg vaginal tablet for 7 days
- Clotrimazole 100 mg vaginal tablet, two tablets for three days
- Clotrimazole 500 mg vaginal tablet, one tablet in a single application
- Miconazole 2% cream 5 g intra vaginally for 7 days (OTC)
- Miconazole 200 mg vaginal suppository, one suppository for 3 days
- Miconazole 100 mg vaginal suppository, one suppository for 7 days
- Nystatin 100,000-unit vaginal tablet, one tablet for 14 days
- Tioconazole 6.5% ointment 5 g intra vaginally in a single application (OTC)
- Terconazole 0.4% cream 5 g intra vaginally for 7 days
- Terconazole 0.8% cream 5 g intra vaginally for 3 days
- Terconazole 80 mg vaginal suppository, one suppository for 3 days
- Floconazole 150 mg oral tablet, one tablet in a single dose