Trichomonas  vaginalis organisms may be noted in a fresh wet preparation made by diluting the secretions with normal saline and examining the preparation  under  a  microscope. TREATMENT—Flagyl ^®(metronidazole)    is administered in 250-mg doses 3 times a day for 1 week. However, this drug is contraindicated in pregnancy   and   should,   therefore,   not   be administered until pregnancy has been ruled out. A  vinegar  douche  (2  tablespoons  of  vinegar  to 1 quart of warm water) administered once or twice a  week  may  prove  beneficial. . Monilia  Vaginitis—This   inflammation   is the  result  of  an  overgrowth  of  the   Candida albicans yeast, History may show a recent period of  antibiotic  therapy.  Yeast  infections  are  more common  in  warm,  moist  climates.  Patients  with persistent or recurrent monilial infections should be  investigated  for  possible  diabetes. SYMPTOMS—The   discharge   is   most   often thick,  curdlike,  white  in  color,  and  may  have  a musty  order.  This  discharge  is  not  usually  as profuse as the discharge of  Trichomonas.  Visual examination may reveal a red, inflamed vaginal mucosa, with   white   or   grayish   patches   of discharge.  When  these  patches  are  scraped  off, there  is  frequently  a  small  amount  of  bleeding. Vulvar  irritation,  itching,  vaginismus,  and dyspareunia  are  common.  Preparation  of  a  wet smear  with  15  percent  potassium  hydroxide added will help to visualize the Candida hyphae and  spores. TREATMENT—MONISTAT^® 7   vaginal cream  (miconazole  nitrate  2  percent)  administered once daily over a 2-week period is the treatment of choice. Hydrocortisone 1 percent cream applied locally   to   the   vulva   3   times   a   day   will help   to   relieve   local   irritation   and   itching. Mycostatin^® vaginal  tablets  taken  once  daily  at bedtime  for  15  days  may  also  be  used. .   Bacterial   Vaginitis—The   etiologic   agent may  range  from   Haemophilus   vaginitis   to Neisseria  gonorrhea  and  a  wide  range  of  other bacteria. SYMPTOMS—The  discharge  in  this  form  of vaginitis may range from scanty to profuse, may have a foul or musty odor, maybe viscid to watery in  consistency,  and  the  color  may  range  from greenish-yellow,  brown,  pink,  gray,  or  milky white.  The  vaginal  mucosa  may  be  red  and swollen,  but  this  is  not  always  true.  Vulvitis, urethritis, and   ulceration   of   the   cervix   are commonly   accompanying   symptoms.   Infections of   the   Bartholin’s   and   Skene’s   glands   are common,  especially  in  gonorrhea  infections.  A purulent  discharge  is  often  seen  exuding  from  the cervical  OS,  and  pain  and  swelling  of  the  cervix itself  is  often  noted.  The  only  definitive  method of   determining   the   specific   etiologic   agent   is through  a  culture. TREATMENT—General  measures  consist  of perineal  and  vulvar  hygiene  to  control  pruritus and   local   itching.    Specific   measures   include vaginal application of sulfa creams once daily for 2  weeks.  Ampicillin  taken  orally  may  also  be beneficial. When   the   causative   agent   is   unknown,   a broad-spectrum  drug  such  as  Betadine^® vaginal gel may prove effective in treating any of the more commonly   encountered   types   of   vaginitis.   A culture for Neisseria gonorrhea should always be considered  in  sexually-active  women. Vulvitis This is an inflammation of the vulvar region. The   causes   include   mechanical   and   chemical irritation;  hygiene  neglect;  urinary,  fecal,  or vaginal   contamination;   allergic   reactions   to detergents   or   drugs;   parasitic   infestations (pediculosis   pubis);   herpes   simplex;   psoriasis; condylomata  acuminata;  and  folliculitis. SYMPTOMS—They  include  burning,  severe pain,   pruritus,    redness,   swelling,   ulceration, pustular formation, edema, and vesicular itching. Areas  of  irritation  may  extend  to  the  perineal region  and  the  inner  areas  of  the  thighs. TREATMENT—When   a   specific   infection exists,  treat  the  cause.  Symptomatic  relief  may  be obtained by the use of cool compresses of Burow’s solution  or  tepid  sitz  baths.  The  area  should  be kept as clean and dry as possible, and the use of soaps and other harsh cleansing agents should be avoided,  as  they  tend  to  dry  the  tissues  and increase  irritation.  If  an  allergic  reaction  is  the suspected  cause,  oral  antihistamines  may  prove beneficial.   Hydrocortisone   1   percent   cream   is often helpful. Chronic or intractable cases should be  referred  to  a  medical  treatment  facility  as  soon as  possible. 2-37