Diagnose Vaginitis by Exam, Not by Phone : Symptoms are often misleading, and relatively few women can accurately self-diagnose candidiasis.


HOUSTON — Telephone consultations for vaginitis often result in misdiagnosis, Dale Brown Jr., M.D., warned at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Patients think it is a drag to come in to be evaluated, and many health care professionals think it is a drag to have to treat vaginitis all the time,” said Dr. Brown, chairman of clinical affairs in the obstetrics and gynecology department at Baylor.

Nonetheless, thorough office examinations are necessary, even for what appear to be repeated fungal infections, according to Dr. Brown. He maintained that symptoms are often misleading, and studies have found relatively few women can accurately self-diagnose vulvovaginal candidiasis.

“Patients are spending a lot of money over the counter and then they have to come in to be treated again. They don't know what they are treating,” Dr. Brown said, contending that availability of over-the-counter antifungal treatments for candidiasis has not lived up to expectations of reduced health care costs. Instead, he said, many women are seeking a physician's help only after trying two or three different medications that did not relieve their symptoms.

Candida albicans was confirmed in only 33% of cases for which over-the-counter medications were purchased in one report cited by Dr. Brown (J. Fam. Pract. 1996;42:595-600).

He noted that women with a history of diagnosed fungal infections were even more likely to misdiagnose a repeat infection.

In another study at a vaginitis referral center, he said only 28% of cases of candidiasis were clinically confirmed (Obstet. Gynecol. 1997;90:50-3).

A third investigation cited by Dr. Brown involved the collection of vaginal swabs every 4 months from 1,248 women. He said the study, presented at a meeting of the Infectious Diseases Society for Obstetrics and Gynecology in 2002, found 24% of women who were never colonized by yeast used antifungal drugs at least once.

At least half the women who are diagnosed with candidiasis actually have another condition, according to Dr. Brown. Although frequently suspected, candidiasis accounts for only 20%-25% of vaginitis; bacteria are responsible for 40%-50% of cases and trichomoniasis for 15%-20%.

Dr. Brown urged consideration of other noninfectious causes and less common infections. He gave a long list of possible diagnoses that included atrophic vaginitis, a foreign body, allergic hypersensitivity and contact dermatitis, trauma, desquamative inflammatory vaginitis, erosive lichen planus, lactobacilli vaginosis, cytolytic vaginosis, streptococcal group A infection, ulcerative vaginitis with Staphylococcus aureus, and idiopathic ulceration associated with human immunodeficiency virus.

When examining women for vaginitis, physicians should have patients use a magnifying glass to identify the exact location of the itch.

He recommended collecting a specimen from the lateral midsection of the vagina and looking for systemic diseases that can present as a vulvovaginal symptom. He singled out erythrasma and tinea cruris as two conditions that can be mistaken for candidiasis.

“Most common vaginitis is not hard to treat, but too often we make a diagnosis that is not the correct diagnosis and we get failure of our treatment,” he said.

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