Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.


Gynecologic Disorders

Mary Lou C. Rosenblatt and Meg Moorman

Adrenal gland tumor, 255.9

Hypogonadotropic hypogonadism, 253.4

Amenorrhea, 626

Hypothyroidism, 244.9

Asherman's syndrome, 621.5

Ovarian failure, 620.9

Autoimmune oophoritis, 614.2

Pituitary gland infarct, 253.8

Genital anomaly, external, 752.40

Polycystic ovary syndrome (PCOS), 256.4

Genital anomaly, internal, 752.9

Pregnancy, 633

Hyperthyroidism, 242.90



A. Primary: No episodes of spontaneous uterine bleeding by 16.5 years. Evaluate for delayed puberty if no secondary sex characteristics by 14 years.

B. Secondary: After onset of menarche, absence of uterine bleeding for 6 months or time equal to 3 previous menstrual cycles. Regular monthly cycles not often seen until 1-2 years after menarche. Because evaluation of amenorrhea applies to all amenorrhea, not necessary to categorize workup as primary or secondary.

C. Etiology.

1. External genital anomaly: androgen insensitivity (46, XY).

2. Internal genital anomaly:

a. Vaginal agenesis.

b. Imperforate hymen.

c. Transverse vaginal septum.

d. Agenesis of the cervix.

e. Agenesis of the uterus.

f. Gonadal dysgenesis.

3. Hypogonadotropic hypogonadism:

a. Stress.

b. Weight loss or gain.

• Obesity.

• Eating disorders.

• Competitive athletics.

• Familial (ask ages of menarche for mother, sisters).

• Drugs (phenothiazines, oral contraceptives, medroxyprogesterone acetate (Depo Provera), illicit drugs).

• Environmental changes (such as going away to college).

4. Pregnancy.

5. CNS tumor.

6. Pituitary gland infarct, irradiation, surgery.

7. Adrenal gland tumor, disease.

8. Chronic diseases.

9. Hypo- or hyperthyroidism.

10. Autoimmune oophoritis.

11. Ovarian failure, tumor, irradiation, or surgery.

12. Polycystic ovary syndrome (PCOS).

13. Asherman's syndrome (history of uterine surgery)

D. Occurrence.

1. Primary: 3 out of 1000 girls have menarche after 15.5 years.

2. Secondary: Most common reason is pregnancy. Also consider stress, weight changes, eating disorders.

a. 8–10% of 14–18-year olds report missing 3 consecutive menses in past year.

E. Clinical manifestations.

1. May have no signs or, depending on cause, may be specific signs, such as wide-spaced nipples, web neck, short stature of Turner syndrome, obesity, acanthosis nigricans of PCOS, or wasting of anorexia.

2. Evaluate galactorrhea/amenorrhea for prolactinoma and empty sella syndrome.

F. Physical findings.

1. Physical exam to rule out nonreproductive system problems.

2. Plot height and weight looking for Turner syndrome, obesity, anorexia; explain need for genital exam.

3. On external exam check for patent hymen.

4. A cotton Q-tip can determine the length of the vagina.

5. A one-finger, vaginal–abdominal or rectal–abdominal exam may determine the presence of a cervix and uterus.

6. Estrogenized vaginal mucosa is pink.

7. A pelvic exam for sexually active teens to identify normal organ structure. Clitoromegaly is seen in the presence of excess androgens.

G. Diagnostic tests.

1. Testing indicated in stepwise progression based on history and physical exam.

2. If any concern about sexual activity, obtain pregnancy test. Keep in mind admitting sexual activity may be difficult for some teens.

a. Negative pregnancy test: Follow stepwise progression again, starting with thyroid-stimulating hormone (TSH) and prolactin.

b. Pelvic ultrasound to look at pelvic structures may be needed.

c. Vaginal maturation index can be obtained to evaluate estrogenization of vagina.

d. Progestational challenge checks endogenous estrogen levels and competency of outflow tract.

H. Differential diagnosis.

1. See Etiology.

I. Treatment.

1. Cause of amenorrhea determines treatment.

J. Follow up.

1. Determined by the cause and treatment.

2. Referral may be needed in cases of anatomic or chromosomal abnormality, CNS tumor, eating disorder, or specialized management.

K. Complications.

Infertility, 628.9

1. Infertility may result from some causes of amenorrhea, making it important to listen to patient's questions and concerns and to offer emotional support.

L. Education.

1. Offer information relevant to the cause and treatment of the individual's diagnosis.


Abdominal tenderness, 789.6

  Penile discharge, 788.7


Cervicitis, 616

  Salpingitis, 614.2


Chlamydial infection, 079.98

  Urethritis, 597.8


Epididymitis, 604.9

  Vaginal discharge, 623.5


Hypertrophic cervical ectopy, 622.6


A. Etiology.

1. An obligate intracellular bacterial agent with at least 18 serologic variants.

B. Occurrence.

1. Most common sexually transmitted infection (STI) in United States with high rates among sexually active adolescents.

C. Clinical manifestations.

1. Causes urethritis, cervicitis, epididymitis, salpingitis, perihepatitis, endometritis, reactive arthritis.

2. Can lead to acute and chronic pelvic inflammatory disease (PID).

3. Incubation varies; about 1 week.

D. Physical findings.

1. May be no symptoms for males or females.

2. Females: mucopurulent vaginal discharge, hypertrophic cervical ectopy, abdominal tenderness.

3. Males: penile discharge, abdominal tenderness, testicular tenderness.

E. Diagnostic tests.

1. Tissue culture.

2. Nucleic acid amplification: highly sensitive from cervical, urethral, rectal, vaginal swabs, or urine.

F. Differential diagnosis.

Gonorrhea, 098

1. Other STIs, such as gonorrhea.

G. Treatment.

1. Recommended regimens:

a. Azithromycin 1 g one dose PO, OR

b. Doxycycline 100 mg PO bid for 7 days.

c. See Centers for Disease Control and Prevention (CDC) guidelines (see Bibliography) for alternative regimens or treatment guidelines for PID.

H. Follow up.

1. Rescreen 3–4 months after treatment in high-risk population.

I. Complications.

Chronic pelvic pain, 625.9

Infertility, 628.9

Ectopic pregnancy, 633.9

Pelvic inflammatory disease, 614.9

1. PID.

2. Ectopic pregnancy.

3. Infertility.

4. Chronic pelvic pain.

J. Education.

1. Abstain from sexual intercourse until 7 days after single-dose treatment or completion of 7-day regimen.

2. Sex partner(s) need treatment.

3. Inform about risks associated with untreated infection to motivate completion of treatment.

4. Avoid multiple partners.

5. Educate about safer sex: Use condoms during all intercourse, limit number of sexual partners, carefully screen any potential partner.


Abdominal pain, 789

Headache, 784


Diarrhea, 787.91

Nausea, 787.02


Dizziness, 780.4

Nervousness, 799.2


Dysmenorrhea, 625.3

Pain with menses, 625.3


Fatigue, 780.79

Vomiting, 787.03


A. Primary: pain associated with menstrual cycle without organic source.

B. Secondary: menstrual pain due to organic disease.

C. Etiology.

1. Primary: elevated prostaglandins, prostaglandin levels are higher in women with ovulatory cycles.

2. Secondary: due to pelvic pathology such as infection, structural abnormalities, endometriosis.

D. Occurrence.

1. 60% of teens report pain with menses; 10–14% of those miss school days due to pain.

E. Clinical manifestations.

1. Primary: may begin 6–36 months after menarche.

a. Lower abdominal pain; may radiate to thighs or back.

b. Nausea, vomiting, diarrhea, dizziness, nervousness, headache, fatigue may accompany.

c. Commonly pain starts within 1–4 hours of onset of menses, lasts 1–2 days. Pain may begin before menses and last 2–4 days.

2. Secondary: pain with menses and associated symptoms. History should include sexual history, gastrointestinal and genitourinary systems history.

F. Physical findings.

1. Primary: normal physical exam.

2. Patients with STIs may have purulent cervical discharge, cervical motion tenderness, uterine tenderness, adnexal tenderness. Mass in adnexa could be cyst, ectopic pregnancy, tubo-ovarian abscess. Tender/nodular cul-de-sac may be found with endometriosis.

G. Diagnostic tests.

1. For sexually active teens: pelvic exam to rule out STIs, gonorrhea and chlamydia tests, pregnancy test (if menses are irregular/missed).

2. Urinalysis if urinary symptoms.

H. Differential diagnosis.

Cervicitis inflammatory disease, 616

  Inflammatory bowel disease, 558.9


Chlamydia, 079.98

  Ovarian cysts, 620.2


Constipation, 564

  Pelvic inflammatory disease, 614.9


Cystitis, 595.9

  Postsurgical adhesions, 614


Dyspareunia, 625

  Pyelonephritis, 590.8


Endometriosis, 617.9

  Uterine malformation, 752.3


Gonorrhea, 098


1. Cervicitis or PID caused by agents such as gonorrhea, chlamydia.

2. Cystitis, pyelonephritis.

3. Inflammatory bowel disease.

4. Constipation.

5. Endometriosis: not common in adolescents but may be significant in adolescents with chronic pelvic pain. Pain may occur before and after menses, may include dyspareunia, pain on defecation, abnormal uterine bleeding.

6. Uterine malformation.

7. Ovarian cysts.

8. Postsurgical adhesions.

I. Treatment.

1. Primary: nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptives.

2.  Secondary: treat identified cause.

J. Follow up.

1. If standard treatments such as NSAIDs or oral contraceptives do not relieve pain or if etiology is complex, refer to gynecologist.

2. When infections are the cause, treat and follow up per protocol.

a. PID: inpatient or outpatient therapy, monitor for medication compliance.

b. Gonorrhea or chlamydia: rescreen every 3–4 months.

K. Complications

Dysmenorrhea, 625.3

1. Primary dysmenorrhea should improve with either NSAID or oral contraceptive therapy. If not, consider other causes.

2. Secondary dysmenorrhea: may have complications based on diagnosis (e.g., teens with PID may suffer from infertility, adhesions, or ectopic pregnancy).

L. Education.

1. Take anti-inflammatory agents with food; start as soon as symptoms occur.

2. Hormonal contraception is useful when contraception is needed. Teach sexually active teens about safer sex.

3. When infection is cause, partners need to be treated.


Genital herpes, 054.1

Genitalia lesion, 625.8

A. Etiology.

1. Recurrent lifelong infection, 2 types: herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2).

2. HSV-2 causes most genital HSV infection but increasing numbers of genital HSV are caused by HSV-1.

B. Occurrence.

1. 50 million persons in United States have genital HSV infection.

C. Clinical manifestations.

1. Vesicular or ulcerative lesions of male or female genitalia.

2. Infection can be more severe in immunocompromised individuals.

3. Infections caused by direct contact.

4. Incubation period: 2 days to 2 weeks. Virus persists for life in latent form.

5. Recurrent infections shed virus for 3–4 days rather than 1–2 weeks in primary infection.

D. Physical findings.

1. Vesicular or ulcerative lesions of male or female genitalia.

E. Diagnostic tests.

1. HSV culture provides best sensitivity when lesions are cultured before they begin to heal.

2. Type-specific and nonspecific antibodies to HSV develop in weeks after infection and persist indefinitely, but do not differentiate between genital and orolabial infections. Serologic type-specific glycoprotein G (gG)–based assays can be requested by providers to distinguish HSV-1 and HSV-2.

F. Differential diagnosis.

Candidal inflammation, 112.9

  Syphilis, 091

Excoriation, 919.8

  Warts, 078.1

Folliculitis, 704.8


1. Folliculitis.

2. Chancre of syphilis, warts, candidal inflammation, excoriation.

G. Treatment.

1. Primary infection: Oral acyclovir therapy begun within 6 days of onset of infection can decrease viral shedding by 3–5 days. Subsequent severity/ frequency of recurrences not affected by treatment. Topical antiviral drugs not recommended.

a. Recommended regimens:

• Acyclovir 400 mg PO tid for 7–10 days, OR

• Acyclovir 200 mg PO 5 times per day for 7–10 days, OR

• Famciclovir 250 mg PO tid for 7–10 days, OR

• Valacyclovir 1 g PO bid for 7–10 days.

2. Recurrent infections: Acyclovir therapy started within 2 days of onset of recurrence may shorten clinical course by 1 day. Provide prescription so immediate therapy can begin in case of recurrence.

a. Recommended regimens:

• Acyclovir 400 mg PO tid for 5 days, OR

• Acyclovir 800 mg PO bid for 5 days, OR

• Acyclovir 800 mg PO tid for 2 days, OR

• Famciclovir 125 mg PO bid for 5 days, OR

• Valacyclovir 500 mg PO bid for 3 days, OR

• Valacyclovir 1 g PO once a day for 5 days.

3. Suppressive therapy for recurrent infections (6 episodes per year): can benefit from daily therapy. Acyclovir: safety and effectiveness for 6 years; valacyclovir or famciclovir for 1 year. Because outbreaks diminish in frequency over time, periodic discontinuation of therapy (i.e., yearly) may be helpful in reassessing need for therapy.

a. Recommended regimens:

• Acyclovir 400 mg PO bid, OR

• Famciclovir 250 mg PO bid, OR

• Valacyclovir 500 mg PO daily, OR

• Valacyclovir 1 g PO daily.

H. Follow up.

1. Follow patient's emotional adjustment to having HSV.

2. Test for other STIs.

I. Complications.

Genital HSV, 054.1

Skin-colored lesions, 709.8

Warts, 078.1

1. Daily medication may not suppress recurrent outbreaks.

2. Immune-suppressed patients may have prolonged/severe outbreaks requiring IV therapy.

3. Transmission to neonate from infected mother is highest among women who acquire genital HSV near time of delivery.

J. Education.

1. Psychologic burden may be great. Counseling includes supportive groups, CDC website, written materials. If depression is identified, refer to mental health provider.

2. Latex condoms may reduce transmission if used correctly.

3. Patients should refrain from sexual contact if lesions are present.

4. Sexual partners should be notified by patient.

5. Sexual transmission may occur with asymptomatic viral shedding.

6. Explain risk of neonatal infection to male and female patients; they should inform provider during pregnancy.


Genital warts, 078.19

A. Etiology.

1. Human papilloma viruses (HPVs) are DNA viruses and include 100 types; 30 types can infect genital tract.

2. Types 16, 18, and 45 are associated with cervical cancer.

B. Occurrence.

1. Anogenital HPV occurs in 40% of sexually experienced adolescent females.

2. HPV is etiology of 90% of cervical cancers.

C. Clinical manifestations.

1. May have no symptoms.

2. When present, warts are epithelial tumors of skin/mucous membrane.

3. Immunocompromised individuals may have larger quantity of warts.

4. Incubation unknown; likely ranges from 3 months to several years.

5. May regress spontaneously or may persist for years.

D. Physical findings.

1. Skin-colored lesions with cauliflower-like surface may be several millimeters to several centimeters wide; may be painless or itch, burn, bleed; can be found on vagina, cervix, vulva, penis, anus, perianal area, scrotum.

E. Diagnostic tests.

1. For women younger than 30 years but older than age 20, HPV tests are available to detect (DNA or RNA) viral nucleic acid or capsid protein.

2. Four Food and Drug Administration (FDA)-approved tests are available for use in the United States: Hybrid Capture (HC) II High-Risk HPV test (Qiagen), HC II Low-Risk HPV test (Qiagen), Cervista HPV 16/18 test, and Cervista HPV HR (high risk) test (Hologic).

F. Differential diagnosis.

Condyloma lata, 091.3

Molluscum contagiosum, 078

1. Molluscum contagiosum.

2. Condyloma lata (syphilis).

3. Pink, pearly, penile papules.

G. Treatment.

1. Recommended regimens.

a. Patient applied:

• Podofilox 0.5% solution or gel, OR

• Imiquimod 5% cream, OR

• Sinecatechins 15% ointment.

b. Provider administered:

• Cryotherapy with liquid nitrogen or cryoprobe.

• Podophyllin resin 10–25%.

• Trichloroacetic acid or bichloroacetic acid 80–90%.

• Surgery.

H. Follow up.

1. Females: regular Pap smears to assess for cellular damage.

I. Complications.

1. Recurrences common due to reactivation of virus. May persist for life. Duration of contagiousness unknown.

2. Local treatment can damage normal surrounding skin.

J. Education.

1. Females: regular Pap smears to assess for cellular damage from HPV.

2. Screen for other STIs.

3. Partners should be informed.

4. Teach safer sex.

K. Vaccinations.

1. Cervarix (bivalent) vaccine contains HPV types 16 and 18.

2. Gardasil (quadrivalent) vaccine contains HPV types 6, 11, 16, and 18.

3. Both vaccines protect against 70% of cervical cancers and Gardasil offers protection against 90% of genital warts.

4. Either vaccine can be administered to girls aged 11–12 years and as young as age 9. They can also be administered to women ages 12–26 who have not started or completed the vaccine. It is most beneficial if given before onset of sexual activity. Gardasil can be used in males aged 9–26 to prevent genital warts. Both vaccines are administered in a 3-series injection schedule over a 6-month period. After injection 1 is given, the second is given 1–2 months later, then at 6 months after the first injection for a total of 3 injections. Women should still receive routine cervical cancer screening after receiving the vaccine.


Gonorrhea, 098

A. Etiology.

1. Neisseria gonorrhoeae is Gram-negative, oxidase-positive diplococcus.

B. Occurrence.

1. 650,000 new cases of gonorrhea per year in the United States.

2. 15- to 19-year olds have highest incidence of infection.

3. Co-infection with chlamydia is common.

C. Clinical manifestations.

1. Males tend to have symptomatic infections of urethra.

2. Females may have cervicitis, PID, perihepatitis, bartholinitis.

3. Rectal and pharyngeal infections may be asymptomatic.

4. Disseminated infections occur in up to 3% of untreated persons.

a. Bacteremia causes arthritis-dermatitis syndrome.

b. More common in females infected within 1 week of menstrual period.

5. Incubation is 2–7 days.

D. Physical findings.

1. May be no symptoms.

2. Males may experience penile discharge, dysuria.

3. Females may have vaginal discharge, abdominal pain.

E. Diagnostic tests.

1. Culture is excellent but may require special handling.

2. Nucleic acid amplification is highly sensitive; may be used with mucosal discharge/urine.

3. Gram stain showing Gram-negative intracellular diplococci are most useful in acutely ill patients.

F. Differential diagnosis.

Abdominal pain, 789

  Penile discharge, 788.7

Chlamydia, 079.98

  Vaginal discharge, 623.5

Dysuria, 788.1


1. Chlamydia may cause similar symptoms.

2. Non-gonococcal urethritis (NGU): 40% of cases caused by chlamydia; 20–30% caused by Ureaplasma urealyticum; and 30–40% uncertain but may include HSV, Trichomonas vaginalis, Escherichia coli, and others.

G. Treatment.

1. Dual treatment for chlamydia should be considered in populations where chlamydia is found with 10–30% of gonococcal infections.

2. Recommended regimens for uncomplicated gonococcal infections of cervix, urethra, rectum:

a. Cefixime 400 mg one dose PO, OR

b. Ceftriaxone 125 mg one dose IM, OR

c. Ciprofloxacin 500 mg one dose PO, OR

d. Ofloxacin 400 mg one dose PO, OR

e. Levofloxacin 250 mg one dose PO.

f. PLUS, if chlamydial infection is not ruled out: azithromycin 1 g PO one dose, OR doxycycline 100 mg PO bid for 7 days.

H. Follow up.

1. Test of cure for uncomplicated gonococcal infection not indicated.

2. Persistent infection may be due to reinfected or untreated co-infection with chlamydia.

I. Complications.

Ectopic pregnancy, 633.9

  Pelvic inflammatory disease, 614.9

Infertility, 628.9

  Tubal scarring, 478.9


1. PID.

2. Tubal scarring.

3. Infertility.

4. Ectopic pregnancy.

5. Hematogenous spread causing skin and joint syndrome.

J. Education.

1. Partners need to be evaluated and treated.

2. Encourage use of condom.

3. Screen for other STIs (chlamydia, HIV, syphilis, hepatitis B).


Fever, 780.6

  Papular lesions, 709.9


Headache, 784

  Rash, 781.2


Lymphadenopathy, 785.6

  Syphilis, 097.9


Malaise, 780.79

  Ulcers (chancres), 091


A. Etiology.

1. Person-to-person transmission of spirochete, Treponema pallidum.

2. Incubation is 10–90 days.

B. Occurrence.

1. Rare in much of industrialized world but problem in large U.S. urban areas and the rural South.

C. Clinical manifestations.

1. Primary: painless, indurated ulcers (chancres) at site of inoculation, within 3 weeks of exposure.

2. Secondary: 1–2 months later, generalized maculopapular rash (includes palms and soles), fever, malaise, headache, lymphadenopathy.

3. Hypertrophic, papular lesions (condyloma lata) in moist areas of vulva or anus.

4. Latent: seroreactivity but no clinical manifestations of syphilis, may last years.

a. Early latent: acquired in last year.

b. Late latent: acquired more than 1 year ago or unknown duration.

5. Tertiary: may be many years after acquiring infection; features major organ damage.

6. Neurosyphilis: central nervous system (CNS) disease can occur during any stage of syphilis; examine cerebrospinal fluid in patients with neurologic involvement.

D. Physical findings.

1. Primary: chancre at site of inoculation, painless ulcer.

2. Secondary: maculopapular rash, generalized, including palms/soles, condyloma lata.

3. Neurosyphilis: abnormal neurologic exam.

E. Diagnostic tests.

1. Positive dark-field exam is definitive for syphilis but may not be readily available.

2. Nontreponemal tests (VDRL, RPR) are quantitative, testing activity, treatment response. Same lab should measure subsequent tests to ensure reliability. Tests may become negative 2 years after treatment.

3. Treponemal tests (FTA-ABS, TP-PA) must confirm nontreponemal test.

4. Tests usually positive for life. Other spirochetal disease causes positive test (yaws, pinta, leptospirosis, rat-bite fever, Lyme disease).

F. Differential diagnosis.

Pityriasis rosea, 696.3

1. Rash of secondary syphilis can be confused with pityriasis rosea, making blood evaluation important for sexually active adolescents diagnosed with pityriasis.

G. Treatment.

1. Recommended regimen for adults.

a. Primary, secondary, and early latent:

• Penicillin G benzathine, 2.4 million units IM single dose (preferred), OR

• If penicillin allergic, not pregnant: doxycycline 100 mg PO bid for 14 days, OR tetracycline 500 mg PO qid for 14 days.

b. Late latent, latent of unknown duration, tertiary or neurosyphilis, HIV-positive and pregnant patients refer to CDC guidelines for treatment. Note: Patients allergic to penicillin should be desensitized.

H. Follow up.

1. Evaluate blood tests for early-acquired syphilis at 3, 6, and 12 months.

2. Add 24-month test for persons with syphilis of 1 year duration.

I. Complications.

HIV, V08

  Stillbirth, 779.9


Hydrops fetalis, 752.3

  Syphilis, 097.9


Prematurity, 765.1


1. Untreated syphilis causes damage to most body organs over time, infects partners.

2. Co-infection with HIV, other STIs.

3. Infected pregnant women pass along syphilis to fetus, resulting in stillbirth, hydrops fetalis, or prematurity. Infants may suffer numerous complications.

4. Jarisch-Herxheimer reaction (acute, febrile reaction with headache myalgia) may occur in first 24 hours after treatment (occurs most with patients being treated for early syphilis). Antipyretics may be used but may not prevent this reaction.

J. Education.

1. Sexual partners must be treated. Public health department finds contacts anonymously.

2. HIV status should be checked. If negative, recheck in 3 months.

3. Safer sex counseling.


Trichomoniasis, 131.01


Vaginal discharge, 623.5


A. Etiology.

1. Trichomonas vaginalis is a flagellated protozoan.

B. Occurrence.

1. Primarily sexually transmitted, may coexist with other STIs.

C. Clinical manifestations.

1. Most males have no symptoms.

2. Females may have profuse, pruritic, malodorous, yellow-green vaginal discharge or no symptoms at all.

3. Incubation period: 4–28 days.

D. Physical findings.

1. Females: frothy white, yellow-green vaginal discharge with erythematous vaginal mucosa and friable “strawberry cervix.”

E. Diagnostic tests.

1. On wet mount, trichomonad has jerky motion and lashing flagella.

F. Differential diagnosis.

Chlamydia, 079.98

  Monilia, 112.9


Gonorrhea, 098

  Pruritus, 698.9


1. Other STIs such as gonorrhea and chlamydia could be cause of discharge.

2. Monilia could be cause of pruritus.

G. Treatment.

1. Recommended regimen: metronidazole 2 g dose PO, OR

2. Tinidazole 2 g orally in a single dose, OR

3. Alternative regimen: metronidazole 500 mg PO bid for 7 days.

H. Follow up.

1. None needed unless discharge persists.

I. Complications.

1. If no response to initial treatment, may repeat metronidazole 1 g bid for 7 days OR 2 g daily for 3–5 days. If treatment failure occurs twice with metronidazole 2 g single dose, treat with metronidazole 500 PO bid for 7 days OR or tinidazole 2 g PO for 5 days.

2. In rare cases where infection persists despite treatment of patient and partner, CDC may be helpful in looking at resistance of organism.

J. Education.

1. Treat partners even if no symptoms.

2. Patients should abstain from sex until they and any partners are treated and asymptomatic.

3. Safer sex counseling.

4. Screen for other STIs.

5. No alcohol consumption for 48 hours due to disulfiram-like effects of metronidazole (flushing, pulsating headache, violent vomiting, restlessness).


Vaginal discharge, 623.5


Vulvovaginitis, 616.1


A. Etiology.

1. Bacterial vaginosis is syndrome found in sexually active females caused by changes in vaginal flora. Normal vaginal ecosystem is disrupted by increases in Gardnerella vaginalis, Mycoplasma hominis, Ureaplasmaspecies, anaerobic bacteria, and marked decrease in lactobacillus species.

2. Incubation is unknown.

B. Occurrence.

1. Common, may occur with other infections.

2. Although not proven to be sexually transmitted, it is uncommon in sexually inexperienced females.

C. Clinical manifestations.

1. May have no symptoms.

2. White, homogenous, adherent vaginal discharge with fishy odor.

D. Physical findings.

1. White, malodorous vaginal discharge.

2. Not associated with abdominal pain or pruritus.

E. Diagnostic tests.

1. Three of following four criteria establish diagnosis:

a. Homogenous, white, adherent vaginal discharge.

b. Vaginal fluid pH 4.5.

c. Fishy odor before or after adding 10% KOH (whiff test).

d. Clue cells (squamous vaginal epithelial cells covered with bacteria, causing granular appearance) on microscopic exam.

F. Differential diagnosis.

Edema, 782.3


Erythema, 695.9


Vaginal discharge, 623.5


1. Characterized by white, thick, pruritic discharge with pH 4.5; pseudohyphae are seen under microscope when 10% KOH is added. Candida also causes erythema and edema of vulva-vagina.

2. Rule out other STIs.

G. Treatment.

1. Not necessary in asymptomatic women.

2. Recommended regimens:

a. Metronidazole 500 mg PO bid for 7 days, OR

b. Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days, OR

c. Clindamycin cream 2%, one applicator intravaginally at bedtime for 7 days.

H. Follow up.

1. Recurrence is common.

I. Complications.

HIV, V08

  Postpartum endometritis, 314.9


Pelvic inflammatory disease, 614.9

  Preterm labor, 644.2


1. May be risk factor for PID, HIV, preterm labor, postpartum endometritis.

J. Education.

1. Not clearly sexually transmitted.

2. Partner treatment does not affect recurrence.


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