Vaginitis is a common medical condition among women in the reproductive age group and is responsible for numerous visits to healthcare facilities and much distress due to its capacity to negatively impact the overall quality of life (Guedou et al., 2013). Although vaginitis is basically the most common gynecologic diagnosis encountered by health care professionals who provide medical services to women, achieving an accurate diagnosis of the genitourinary disorder can be elusive due to its many variants (Egan & Lipsky, 2002). This paper reviews a case study based on one of the variants of vaginitis known as bacterial vaginosis.
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The main symptoms presented by the 28-year-old female patient include burning and pain upon urination, elevated lower abdominal pain, history of urinary tract infections (UTIs), and brown foul-smelling vaginal discharge after engaging in unprotected sex. It is also clear that the patient has experienced three UTIs in one year and has also been infected with gonorrhea (two times in one year) and Chlamydia (one time). She underwent tubal ligation two years ago and did her last pap smear six months ago, which turned out positive for dark-looking urine. She has a history of multiple male sexual partners and she has been on medication for UTIs.
Her blood pressure (100/80) is indicative of prehypertension, though her heart rate (80) appears to be within the normal range. Other physical examinations (RR 16; T 99.7F; Wt 120; Ht 5’ 0”; HEENT WNL; Chest WNL; Rectal WNL; and Cardio) appear unremarkable except for the softness and tenderness of the abdominal area, cervical motion softness, adnexal tenderness, as well as foul smelling vaginal discharge. Laboratory results are as follows: “Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2%”; “UA: Straw colored. Sp gr 1.015, pH 8.0, Protein neg, Glocuse neg, Ketones neg, Bacteria – many, Lkcs 10-15, RBC 0-1”; “Urine gram stain – gram negative rods”; “Vaginal discharge culture – Gram negative diplococci, Nesisseria gonorrhoeae, sensitivities pending”, and “Positive monoclonal AB for Chlamydia, KOH preparation, Wet preparation, and VDRL negative” (Class Case Study).
The three priority diagnoses arising from the subjective and objective data include the variants of vaginitis known as Trichomonas, cervicitis, and bacterial vaginosis. The reason for choosing Trichomonas Vaginalis is because of the high pH, the presence of smelly vaginal discharge, genital burning, as well as pain during urination and sexual intercourse (Nenadic & Pavlovic, 2015).
Similarly, the reason for choosing cervicitis is because of the purulent vaginal discharge, the high pH, and the gram stain test revealing gram negative diplococci with the presence of Nesisseria gonorrhea (Guedou et al., 2013). Lastly, the reason for making a diagnosis for bacterial vaginosis is because of the smelly vaginal discharge, pain during sexual intercourse and/or urination, pH greater than 4.5, and the gram stain test revealing gram negative diplococci indicative of Nesisseria gonorrhoeae (Nenadic & Pavlovic, 2015).
Plan of Care
The preferred treatments for bacterial vaginosis include “metronidazole 500 mg orally twice a day for 7 days, metronidazole gel intravaginally once a day for 5 days, or clindamycin cream intravaginally at bedtime for 7 days” (Campos-Outcalt, 2011, p. 143). It is also important to educate and counsel the patient not to douche and to minimize the utilization of shower gel, antiseptic agents or shampoo in the bath (Williams, 2005), not to prolong the use of topical vaginal gels as they can contribute to a sustained duration of vaginal symptoms and potential damage to the vulvar epithelium (Theroux, 2005), and not to self-treat the symptoms but to seek medical assistance in case of recurrence (Nenadic & Pavlovic, 2015).
Evaluation of Priority Diagnosis
The most likely diagnosis is bacterial vaginosis as the following criteria for the disorder has been satisfied; pH of more than 4.5; clue cells more than 20%; homogenous vaginal discharge; and positive whiff test (amine odor with addition of KOH) (Alfonsi, Shlay, & Parker, 2004).The disease lowers the quality of life of patients due to the discomfort it causes and the smelly vaginal discharge (Guedou et al., 2013). The patient should avoid having sexual intercourse when applying the vaginal treatment gels because of the annoying vaginal symptoms.
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Furthermore, it is important to share the knowledge that the disorder “is associated with increased risks of more serious conditions such as pelvic inflammatory disease (PID), postoperative infections, and pregnancy-related complications including prematurity” (French, Horton, & Matousek, 2004, p. 806). Lastly, it is important to discuss with the patient the importance of using protection during sexual intercourse because the disorder increases the probability of acquiring HIV once a woman is exposed to the virus. An interdisciplinary team comprising a nurse (to provide education and information), a social worker (to monitor medication adherence and lifestyle change), and a counselor (to provide advice of sexual choices) can provide the needed care to achieve optimum disorder management and outcomes.
Facilitators and Barriers
In facilitators, the patient needs to follow the treatment regimen and develop alternative strategies to douching. In barriers, the patient should know that it is impossible to achieve optimal disorder management if she continues having multiple sexual partners and if she continues experiencing recurrent UTIs (Nenadic & Pavlovic, 2015). The condition can also be worsened by cigarette smoking, use of intrauterine device, having sex with another woman, and failure to use a condom during sexual intercourse (Alfonsi et al., 2004).
This paper has reviewed a clinical case study based on one of the variants of vaginitis known as bacterial vaginosis. From the discussion and analysis, it is clear that there exists a need for patients to visit qualified healthcare professionals so that a correct diagnosis is made due to similar symptoms in a number of genitourinary disorders under vaginitis.
Alfonsi, G.A., Shlay, J.C., & Parker, S. (2004). What is the best approach for managing recurrent bacterial vaginosis? Journal of Family Practice, 53(8), 650-652.
Campos-Outcalt, D. (2011). CDC update: Guidelines for treating STDs. Journal of Family Practice, 60(3), 143-146.
Egan, M., & Lipsky, M.S. (2002). Vaginitis: Case reports and brief review. AIDS Patient Care and STDs, 16(8), 367-373. doi: 10.1089/10872910260196396
French, L., Horton, J., & Matousek, M. (2004). Abnormal vaginal discharge: Using office diagnostic testing more effectively. Journal of Family Practice, 53(10), 805-814.
Guedou, F.A., Van Damme, L., Deese, J., Crucitti, T., Becker, M., Mirembe, F.,…Alary, M. (2013). Behavioral and medical predictors of bacterial vaginosis recurrence among female sex workers: Longitudinal analysis from a randomized controlled trial. BMC Infectious Diseases, 13(1), 1-11. doi: 10.1186/1471-2334-13-208
Nenadic, D., & Pavlovic, M.D. (2015). Value of bacterial culture of vaginal swabs in diagnosis of vaginal infections. Military Medical & Pharmaceutical Journal of Serbia, 72(6), 523-528. doi: 10.2298/VSP140602061N
Theroux, R. (2005). Factors influencing women’s decision to self-treat vaginal symptoms. Journal of the American Academy of Nurse Practitioners, 17(4), 156-162. doi: 10.1111/j.1041-2972.2005.0024.x
Williams, O. (2005). Bacterial vaginosis: Don’t miss the most common cause of vaginal discharge. Pulse, 65(24), 72-76.