The treatment of vulvovaginal candidiasis (VVC) due to Candida glabrata is challenging, with limited therapeutic options. Unexplained disappointing clinical efficacy has been reported with systemic and topical azole antifungal agents in spite of in vitro susceptibility. Given that the vaginal pH of patients with VVC is unchanged at 4 to 4.5, we studied the effect of pH on the in vitro activity of 11 antifungal agents against 40 C. glabrata isolates and compared activity against 15 fluconazole-sensitive and 10 reduced-fluconazole-susceptibility C. albicans strains. In vitro susceptibility to flucytosine, fluconazole, voriconazole, posaconazole, itraconazole, ketoconazole, clotrimazole, miconazole, ciclopirox olamine, amphotericin B, and caspofungin was determined using the CLSI method for yeast susceptibility testing. Test media were buffered to pHs of 7, 6, 5, and 4. Under conditions of reduced pH, C. glabrata isolates remained susceptible to caspofungin and flucytosine; however, there was a dramatic increase in the MIC 90 for amphotericin B and every azole drug tested. Although susceptible to other azole drugs tested at pH 7, C. albicans strains with reduced fluconazole susceptibility also demonstrated reduced susceptibility to amphotericin B and all azoles at pH 4. In contrast, fluconazole-sensitive C. albicans isolates remained susceptible at low pH to azoles, in keeping with clinical observations. In selecting agents for treatment of recurrent C. glabrata vaginitis, clinicians should recognize the limitations of in vitro susceptibility testing utilizing pH 7.0.

Vulvar pain is a common problem, affecting up to 16% of women. The pain and discomfort seriously impacts their quality of life, and is compounded by the increasing frustration encountered in their search for appropriate medical advice. Their pain can be localized or generalized, constant or intermittent, with or without visible changes. For practitioners, the correct diagnosis and treatment of vulvar pain is a challenge. There is an extensive differential diagnosis, from problems that are simple and immediately visible to those that are much more complex and truly invisible. This review provides an approach to the diagnosis of vulvar pain. It outlines the wide range of etiologies for vulvar pain, and provides details of the most vexing in a comprehensive look at vulvodynia, including definition, theory, diagnosis, and therapy.

Background Screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in men who have sex with men (MSM) is risk-based. Despite high frequencies of oral and receptive anal intercourse (RAI) among women, extragenital screening is not recommended. Methods Women (n=175) and MSM (n=224) primarily recruited from a sexually transmitted infections clinic reporting a lifetime history of RAI completed a structured questionnaire and clinician collected swab samples from the rectum, pharynx, vagina (women) and urine (men). CT and GC were detected using two commercial nucleic acid amplified tests (Aptima Combo 2, Hologic, Inc., Bedford, MA; Xpert CT/NG, Cepheid Innovation, Sunnyvale, CA). Results The median age of the population was 26 years, 62% were Caucasian, and 88% were enrolled from a Sexually Transmitted Diseases clinic. Men were more likely than women to have GC (22.8% vs. 3.4%) and CT (21.9% vs. 12.6%). In men vs. women, GC was detected in 16.5% vs. 2.3% of pharyngeal swabs, 11.6% vs. 2.3% of rectal swabs and 5.4% vs. 2.9% of urine samples or vaginal swabs. CT was detected in 2.2% vs. 1.7% of pharyngeal swabs, 17.4% vs. 11.4% of rectal swabs, and 4.5% vs 10.3% for urogenital sites in men vs. women. Overall 79.6% of CT and 76.5% of GC in men and 18.2% of CT and 16.7% of GC in women were detected only in the pharynx or rectum. Conclusion Reliance on urogenital screening alone misses the majority of GC and CT in men and more than 15% of infections in women reporting RAI.

Nucleic acid amplification testing (NAAT) is the preferred method to detect Chlamydia trachomatis and Neisseria gonorrhoeae, but no commercial tests are cleared by the U.S. Food and Drug Administration for use with extragenital swab samples. This study evaluated the performance of the Gen-Probe Aptima Combo2 assay (Aptima) and the Cepheid Xpert CT/NG assay (Xpert) to detect C. trachomatis and N. gonorrhoeae in rectal and pharyngeal samples from 224 men and 175 women reporting a history of anal receptive sexual intercourse. Discordant results between the NAATs were repeated using the assays APTIMA CT or APTIMA GC, which target alternate primers, as the confirmatory tests. C. trachomatis was detected from 59 rectal swabs and 8 pharyngeal samples, with 97.7% and 99.5% agreement between the two test systems, respectively. For C. trachomatis, Xpert was 95% sensitive (95% CI, 86 to 99%) and Aptima was 92% sensitive (95% CI, 81 to 97%) from rectal swabs, while both systems were 100% sensitive from pharyngeal samples. N. gonorrhoeae was detected from 30 rectal and 40 pharyngeal samples, with 99.5% and 97.5% agreement between the two test systems. The sensitivity of Xpert for N. gonorrhoeae from rectal swabs was 100% (95% CI, 88 to 100%) versus 93% (95% CI, 78 to 99%) for Aptima. From pharyngeal swab samples, Xpert was 98% sensitive (95% CI, 87 to 99.9%) versus 93% (95% CI, 80 to 98%) for Aptima. For C. trachomatis, neither system was Ͼ95% sensitive from the rectum, though both were Ͼ99.5% specific. For N. gonorrhoeae, Xpert had higher sensitivity than Aptima, but with more false positives from pharyngeal samples.

Objective The aim of the study was to evaluate the performance of nucleic acid amplification testing (NAAT) for the diagnosis of vulvovaginal candidiasis (VVC), bacterial vaginosis, and Trichomonas vaginalis. Methods A cross-sectional analysis of women with (n = 200) and without (n = 100) vulvovaginal symptoms was enrolled from outpatient gynecology offices and a vulvovaginal referral clinic. Vaginal swabs were analyzed by wet mount microscopy, yeast culture, Gram stain, T. vaginalis culture, and NAAT. Sensitivity and specificity analyses were performed. Results Among symptomatic women, the sensitivity of microscopy was 48.5% for VVC and 75% for T. vaginalis. Sensitivities of NAAT and culture for diagnosing VVC were 92.4% and 83.3%, respectively, whereas these methods were 100% and 93.8% for T. vaginalis. The sensitivity for bacterial vaginosis diagnosis by clinical criteria (“Amsel criteria”), Gram stain, and NAAT were 98.7%, 82.7%, and 78.7%, respectively. Test concordance rates were high between culture and NAAT for Candida species (91%) and between Gram stain and NAAT for the detection of bacterial vaginosis (88%). Among asymptomatic women, 20%–21% tested positive for bacterial vaginosis by Gram stain or NAAT, and 8%–13% were colonized with Candida species based on culture or NAAT. Conclusions Given the limitations of wet mount sensitivity for VVC and T. vaginalis, culture or NAAT testing should be considered when evaluating women with symptoms of vaginitis who test negative by microscopy. Although Amsel criteria accurately diagnosed bacterial vaginosis, NAAT is preferred for detection of T. vaginalis and performed similarly to culture for the diagnosis of VVC.