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calculate GFR) is also an important point, but not as important as addressing
the respiratory status. Rather than simply fluid overload, another potential
problem is acute myocardial infarction, so an electrocardiogram and cardiac
enzyme values are also indicated.
21.2 C. Optimal control of high blood pressure, acidosis, volume depletion, and
cholesterol is important to prevent worsening renal function. Diabetes is a
leading cause of ESRD. Tight glycemic control can prevent the microvascular
complications of diabetes, such as diabetic nephropathy, though it has not
been shown to decrease significantly the occurrence of macrovascular complications of diabetes, such as coronary artery disease or peripheral vascular disease. Treating secondary hyperparathyroidism prevents complications such
as renal osteodystrophy. The patient’s weight (answer D) does not impact
renal function substantially. Smoking (answer A) has numerous health risks
but does not tend to impact kidney function directly; nevertheless, its effect
on the cardiovascular system may impact the kidneys. Answer B (triglyceride
control) is not as important as hypertension and diabetes control; also, the
LDL cholesterol more closely correlates to cardiovascular events. Answer E
(dietary sodium intake) can help to avoid fluid overload, but it is control
of protein in the diet that is more important in slowing the progression of
kidney disease.
21.3 D. This patient has an enlarged prostate that has caused urinary obstruction
and potentially reversible renal failure, depending on when the obstruction
is resolved. Placing the Foley catheter usually allows for significant reversal
of an elevated Cr. Following catheter placement, the urine output needs to
be carefully monitored and evaluation of the Cr repeated later. Another clue
to the diagnosis of urinary obstruction is the tense lower abdomen, which is
caused by a very enlarged bladder. When evaluating for a cause, it is especially
important to rely on clinical examination skills in elderly patients who have
less-than-optimal communication skills as a consequence of dementia or who
have a history of stroke. Importantly, when there is relief of postobstructive
kidney insufficiency, profuse diuresis is common. Answer A (intravenous fluids) would be indicated in a prerenal situation, where the patient is volume
depleted, but intravenous fluids would only make the distended bladder even
more distended in this case. Answer B (perform renal ultrasound in the emergency department) is something that should be done at some time in the
next 24 hours, but it is not as important as relieving the urinary obstruction.
Answer C (maintain control of blood pressure) is important in preserving
kidney function on a chronic basis.
21.4 A. ACE inhibitors would help in hypertension treatment and protect renal
function in this patient. Both diabetes and CKD are known to be cardiovascular risk equivalents. Other factors, such as uncontrolled blood pressure and
cholesterol, add to the patient’s high risk, which is why it is so important for
all diabetics and CKD patients to improve all modifiable risk factors. The
goals become much more stringent when looking at these two groups of
patients. Answer B (hydralazine) will not help with cardiac risk and will not
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protect the kidneys. Answer C (oral nitrate) may help with occasional chest
pain but will not affect survival. The patient should have a cardiac stress test
to evaluate the chest pain. Answer D (thiazide diuretic) may possibly worsen
the renal insufficiency, worsen the diabetes, and not protect the kidneys.
CLINICAL PEARLS
» Small kidneys on imaging usually reflect irreversible disease. Small
kidneys should rarely be biopsied since the result of the biopsy usually
will not alter the treatment or prognosis of the condition.
» Calculation of the estimated GFR using the Cockcroft-Gault formula is an
important process because, especially in older persons, a seemingly normal serum Cr could reflect a significant reduction in GFR and could affect
dosing of medications.
» Volume status is assessed clinically by skin turgor, mucous membranes,
specific gravity in the urinalysis, and orthostatic blood pressure.
» The most common etiologies of CKD are diabetes, hypertension, and
glomerulonephritis.
» Patients with a GFR < 30 mg/dL, difficult-to-control comorbidities, sig-
nificant proteinuria, or sudden worsening of renal function should be
referred to a nephrologist for evaluation and preparation for possible
dialysis.
REFERENCES
ADVANCE Collaborative Group; Patel A, MacMahon S, et al. Intensive blood glucose control and
vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358(24):2560-2572.
Bargman JM, Skorecki KL. Chronic kidney disease. In: Jameson J, Fauci AS, Kasper DL, Hauser SL,
Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 20th ed. New York, NY:
McGraw Hill; 2018: Chap. 305. http://accessmedicine.mhmedical.com/content.aspx?bookid=212
9§ionid=186950702. Accessed May 3, 2019.
Fowler M. Microvascular and macrovascular complications of diabetes. Clin Diabetes. 2008;26:2. http://
clinical.diabetesjournals.org/content/26/2/77.full.pdf+html. Accessed May 3, 2019.
Gaitonde DY, Cook DL, Rivera IM. Chronic kidney disease: detection and evaluation. Am Fam
Physician. 2017;96(12):776-783.
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high
blood pressure in adults: report from the panel members appointed to the Eighth Joint National
Committee (JNC 8). JAMA. 2014;311(5):507-520.
Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group. KDIGO clinical practice
guideline for lipid management in chronic kidney disease. Kidney Int. 2013;3(suppl):259-305.
Kliger AS, Foley RN, Goldfarb DS, et al. KDOQI US commentary on the 2012 KDIGO clinical
practice guideline for anemia in CKD. Am J Kidney Dis. 2013;62(5):849-859.
National Kidney Foundation. KDOQI clinical practice guideline for diabetes and CKD: 2012 update.
Am J Kidney Dis. 2012;60(5):850-886.
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CASE 22
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A 25-year-old woman presents to the office with 1 week of vaginal discharge. She
describes this as green-yellow in color with a bad odor. She has never had this
before. She says the symptoms started along with vaginal soreness after she had
sexual intercourse. She denies any itching, abdominal pain, nausea, vomiting,
fever, or chills. She is sexually active and prevents pregnancy with an intrauterine
device (IUD). She has been with one male partner for the past 3 months, and he has
no symptoms. She states she first had intercourse at age 15 and has had multiple
sexual partners. She had a chlamydial infection 2 years ago that was treated with
oral antibiotics. Her last menstrual period was 2 weeks ago and was normal. She
denies any recent antibiotic treatment. On examination, she is afebrile, has normal
vital signs, and is well appearing. Her general physical examination is normal. On
pelvic examination, she has normal external genitalia. She has a small amount
of frothy, homogenous green-gray discharge at the introitus. The cervix has a
“strawberry”-red appearance with a slight amount of discharge noted coming
from the os. The IUD string is in place. Chlamydia and gonorrhea specimens are
obtained from the cervical os, and a sample of the vaginal discharge is collected
for microscopic evaluation. Bimanual examination shows no cervical motion
tenderness and a normal uterus and adnexa.
▶ What organism is the most likely cause of her symptoms?
▶ What would you expect to see on microscopic examination of the vaginal
discharge?
▶ What is the recommended treatment for this infection?
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ANSWERS TO CASE 22:
Vaginitis and Other Vaginal Infections
Summary: A 25-year-old woman presents with
A foul-smelling vaginal discharge and vaginal soreness after sexual intercourse
Greenish, frothy discharge and a “strawberry cervix” noted on examination
Denial of any itching, abdominal pain, nausea, vomiting, fever or chills, or recent anti-
biotic use
Sexual history includes one male partner (with no symptoms) for the past 3 months,
first intercourse at age 15, and multiple sexual partners in the past
An IUD with string in place and last menstrual cycle 2 weeks ago
Chlamydial infection 2 years ago that was treated with oral antibiotics
Normal bimanual examination
Organism most likely to cause this infection: Trichomonas vaginalis.
Expected microscopic examination findings: Motile, flagellated trichomonads and
many white blood cells.
Recommended treatment: Metronidazole 2 g by mouth in a single dose for both the
patient and her sexual partner. Metronidazole 500 mg twice a day for a week is an
alternate regimen.
ANALYSIS
Objectives
1. Be able to create a differential for common presentations of vaginitis on the
basis of clinical information and laboratory testing. (EPA 1, 2)
2. Describe the diagnostic strategy for vaginal infections. (EPA 1, 2, 3)
3. Be able to state current recommendations for treatment of the various etiologies of vaginitis. (EPA 4)
Considerations
Women with vaginitis may present with a variety of symptoms, including vaginal
discharge, itching, odor, and dysuria. There are many potential causes of vaginal
discharge, including sexually transmitted pathogens and overgrowth of the normal
vaginal flora.
Certain historical information may lead a clinician to suspect a specific cause of
vaginitis in a given patient. For example, a history of recent antibiotic use may predispose to a Candida vaginitis, as the antibiotic may alter the normal vaginal flora
and allow the overgrowth of a fungal organism. Women with diabetes mellitus are
also more predisposed to developing yeast infections. A history of multiple sexual
partners may raise the likelihood of a sexually transmitted infection (STI), such as
trichomonas vaginitis (trichomoniasis).
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The patient’s symptoms and signs may also suggest a specific organism as the
cause of her vaginitis. Fungal infections tend to have thick discharge and cause
significant pruritus. The discharge of bacterial vaginosis (BV) is often thinner and
patients complain of a “fishy” odor. Trichomoniasis produces a discharge that is
usually frothy, and the patient’s cervix is frequently very erythematous.
The key test to determining the cause of vaginal discharge, which guides the
specific treatment, is microscopic examination of the discharge. A sample of the
discharge is examined both as a “wet mount” (ie, mixed with a small amount of normal saline) and as a “KOH prep” (ie, mixed with a small amount of 10% potassium
hydroxide). On wet mount, the examiner can evaluate the normal epithelial cells
and look for white blood cells, red blood cells, clue cells, and motile trichomonads.
The hyphae or pseudohyphae of Candida are best seen on KOH prep.
APPROACH TO:
Vaginal Infections
DEFINITIONS
BACTERIAL VAGINOSIS: Condition of excessive anaerobic bacteria in the
vagina, leading to a discharge that is alkaline.
CANDIDA VULVOVAGINITIS: Vaginal and/or vulvar infection caused by
Candida species, usually with heterogeneous discharge and inflammation.
TRICHOMONAS VAGINITIS: Infection of the vagina caused by the protozoa
T. vaginalis, usually associated with a frothy yellow/green discharge and intense
inflammatory response.
CLINICAL APPROACH
Vulvovaginal Candidiasis
A vulvovaginal candidiasis infection is typically caused by C. albicans, although
other species are occasionally identified. More than 75% of women have at least
one episode during their lifetime. The presenting symptom is a thick, sometimes
curd-like, whitish discharge that has no odor. The patient usually complains of
significant pruritus of the external and internal genitalia. On physical examination, the vaginal area can be edematous with erythema present. The discharge
has a pH between 4.0 and 5.0. The diagnosis is confirmed by wet mount or
KOH preparation showing budding yeast or pseudohyphae. Fungal cultures are
not needed to confirm the diagnosis, but they are useful if the infection recurs
or is unresponsive to treatment. Numerous treatment options are available for
patients with vulvovaginal candidiasis, including over-the-counter and prescription medications. Uncomplicated candidiasis can be treated effectively with
short-term intravaginal preparations (creams or vaginal suppositories) or singledose oral therapies (fluconazole 150 mg). Treatment of complicated or recurrent
infection should begin with an intensive regimen for 10 to 14 days followed by
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6 months of maintenance therapy to reduce the likelihood of recurrence. Treatment of sexual partners is not indicated unless they are symptomatic (eg, male
partners with balanitis).
Trichomoniasis
Trichomoniasis infection is caused by the protozoan T. vaginalis and is sexually
transmitted. The incubation period is 3 to 21 days after exposure. Certain factors
predispose to infection, such as multiple sexual partners, pregnancy, and menopause.
The presenting complaint is copious amounts of a thin, frothy, green-yellow or gray,
malodorous vaginal discharge. Women can also have vaginal soreness or dyspareunia. Symptoms may start or be exacerbated during the time of their menses. Vaginal examination may reveal that the cervix has a “strawberry” appearance (red and
inflamed with punctations) or that redness of the vagina and perineum is present.
Microscopically, the wet mount preparation can demonstrate motile trichomonads
and many white blood cells, although cultures or polymerase chain reaction (PCR)
may be necessary because of the significant number of false-negative results. The
recommended treatment for trichomoniasis is a single 2-g oral dose of metronidazole or 1-week regimen of 500 mg twice a day for the patient and her sexual
partner. It is important to screen for other STIs and to remember to treat the partner
to ensure better cure rates.
Bacterial Vaginosis
Bacterial vaginosis arises when normal vaginal bacteria are replaced with an
overgrowth of anaerobic bacteria and Gardnerella vaginalis. Although not sexually transmitted, it is associated with having multiple sexual partners. Diagnosis
can be based on the presence of three of four clinical criteria: (1) a thin, homogenous vaginal discharge; (2) a vaginal pH more than 4.5; (3) a positive KOH
“whiff” test (a fishy odor present after the addition of 10% KOH to a sample
of the discharge); and (4) the presence of clue cells in a wet mount preparation
(Figure 22–1). Culture is generally not needed. Treatment options include both
oral and topical vaginal preparations of metronidazole or clindamycin. There are
no advantages to any of these regimens with regard to cure rates or recurrence,
although patients do report more satisfaction with the vaginal preparations.
Treatment of BV in pregnant women may reduce the incidence of miscarriage and
postpartum endometritis. Treatment of sexual partners is not necessary and does
not reduce the risk of recurrent infection.
Chlamydia trachomatis and Neisseria gonorrhea
Approximately 50% of gonococcal infections and 70% of chlamydial infections are
asymptomatic in women. For this reason, the US Preventive Services Task Force
recommends screening for these infections in sexually active women < 25 years old
and in older women if at higher risk. The Centers for Disease Control and Preven-
tion (CDC) recommends nucleic acid amplification tests (NAAT) as the test of choice,
which can be done with either urine or cervical specimens. Symptomatic women may
present with mucopurulent cervicitis or vaginal discharge. As it may take a few days
to get a test result, empiric treatment should be considered in symptomatic women
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A
B
Figure 22–1. Bacterial vaginosis (A) Clue cells, (B) Normal epithelium. (Reproduced with permission,
from Kasper DL, Braunwald E, Fauci A, et al. Harrison’s Principles of Internal Medicine, 16th ed. 2005.
Copyright © McGraw Hill LLC. All rights reserved.)
with higher risk and if follow-up is unlikely. The first-line treatment recommendation for gonorrhea is dual antibiotic treatment with ceftriaxone 250 mg intramuscularly and a 1 g oral dose of azithromycin. Per CDC guidelines, all patients
with a positive gonorrhea test should be treated for chlamydia as well regardless
of chlamydia test results. The recommended treatment for Chlamydia infections is
azithromycin in a single 1 g oral dose or doxycycline 100 mg orally twice daily for
7 days. Recent sex partners should be treated, and follow-up testing for reinfection
in 4 to 6 months can be considered. In pregnancy, a test of cure should be obtained
4 to 6 weeks after treatment.
Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is inflammation of the upper genital tract,
including pelvic peritonitis, endometritis, salpingitis, and tubo-ovarian abscess,
caused by infection with gonorrhea, Chlamydia, or vaginal and bowel flora.
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Table 22–1 • TREATMENT REGIMENS FOR PELVIC
INFLAMMATORY DISEASE
Oral and Intramuscular
• Ceftriaxone 250 mg IM single dose or cefoxitin 2 g IM with probenecid 1 g orally
given concurrently
• Plus doxycycline 100 mg orally twice daily for 14 days
• With or without metronidazole 500 mg orally twice daily for 14 days
Parenteral
Regimen A
• Cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours
• Plus doxycycline 100 mg orally or IV every 12 hours
Regimen B
• Clindamycin 900 mg IV every 8 hours
• Plus gentamicin 2 mg/kg loading dose (IV or IM) followed by 1.5 mg/kg IV every 8 hours
Single daily dosing (3-5 mg/kg) can be substituted
The presence of lower abdominal tenderness with both adnexal and cervical motion
tenderness, without other explanation of illness, is enough to diagnose PID. Other
criteria that enhance the specificity of the diagnosis include temperature more
than 101°F, abnormal cervical or vaginal discharge, elevated sedimentation rate or
C-reactive protein, and cervical infection with gonorrhea or Chlamydia. Because
of the clinical similarity between PID and ectopic pregnancy, a serum pregnancy test
should be performed on all patients suspected of having PID.
Determination of appropriate treatment should consider pregnancy status,
severity of illness, and compliance. Less severe disease can generally be treated on
an outpatient basis. Women who are pregnant, have HIV, or have severe disease
generally require inpatient therapy and treatment with parenteral antibiotics.
Table 22–1 lists PID treatment regimens.
Patients who have PID need to be aware of potential complications, including
the potential for recurrence of disease, the development of tubo-ovarian abscess,
chronic abdominal pain, development of pelvic adhesions, infertility, and the
increased risk of ectopic pregnancy. All patients with STIs or who are at risk for
developing STIs should be counseled on safe sexual practices.
CASE CORRELATION
See also Case 11 (Adult Female Health Maintenance), Case 16 (Male
Genitourinary Conditions), and Case 45 (HIV, AIDS, and Other Sexually
Transmitted Infections).
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COMPREHENSION QUESTIONS
22.1 A 24-year-old nulliparous woman is noted to have a bothersome vaginal discharge. On examination, she is found to have a homogenous discharge with
a fishy odor. Which of the following characteristics is most likely to be noted
on examination?
A. Evidence of excoriation of the vulva
B. Vulvar erythema
C. Budding hyphae on KOH examination
D. Many white blood cells on a saline “wet prep”
E. A vaginal pH > 4.5
22.2 A 38-year-old woman complains of new-onset vaginal discharge and irritation. She notes having had a urinary tract infection 10 days previously, with
subsequent resolution of her symptoms following treatment. Which of the
following is the best empiric therapy for her condition?
A. Oral metronidazole
B. Vaginal metronidazole
C. Oral fluconazole
D. Oral clindamycin
E. Oral estrogen and progestin therapy
22.3 A 24-year-old woman is noted to have lower abdominal tenderness, cervical motion tenderness, and a vaginal discharge. She has a low-grade fever of
100.5°F (38°C). Which of the following is the best therapy for her condition?
A. Ceftriaxone intramuscularly and doxycycline orally
B. Ampicillin orally and azithromycin orally
C. Metronidazole orally as a single dose
D. Ciprofloxacin orally as a single dose
ANSWERS
22.1 E. This homogenous discharge with a fishy odor is most likely BV associated
with an alkaline pH. Partner treatment is not necessary for BV. Oral metronidazole is one treatment. Lower pH, excoriation, inflammation, and budding yeast (answers A, B, and C) and itching are more likely with Candida.
AnswerD (many white blood cells on the slide) is indicative of an inflammatory condition such as trichomoniasis; BV usually does not present with
many white blood cells.
22.2 C. This patient most likely has Candida vulvovaginitis since her discharge
appeared after her cystitis, which was likely treated with antibiotics. Treatment for this includes oral fluconazole or topical azole agents such as miconazole. The other answer choices (answer A, oral metronidazole; answer B,
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