What are the treatment guidelines for common illnesses affecting the penis, scrotum, and vagina?

Treatment Guidelines for Common Genital Illnesses

For optimal patient outcomes, treatment of common penile, scrotal, and vaginal illnesses should follow evidence-based protocols that target the specific causative organisms while preventing complications and recurrence. 1

Epididymitis

Diagnosis

• Clinical presentation: Unilateral testicular pain and tenderness with palpable swelling of epididymis
• Diagnostic evaluation:
  • Gram-stained smear of urethral exudate (≥5 PMNs per oil immersion field)
  • Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis
  • First-void urine examination for leukocytes if urethral Gram stain is negative
  • Syphilis serology and HIV testing

Treatment Algorithm

1. For sexually transmitted epididymitis (age <35 years):

   • Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days 1

2. For epididymitis likely caused by enteric organisms (age >35 years) or in patients with cephalosporin/tetracycline allergies:

   • Ofloxacin 300 mg orally twice daily for 10 days OR Levofloxacin 500 mg orally once daily for 10 days 1

3. Adjunctive measures:

   • Bed rest
   • Scrotal elevation
   • Analgesics until fever and inflammation subside

Follow-Up

• Reevaluate if no improvement within 3 days
• Consider alternative diagnoses if swelling/tenderness persists after treatment:
  • Tumor
  • Abscess
  • Testicular infarction
  • Testicular cancer
  • Tuberculous or fungal epididymitis

Partner Management

• Refer sex partners for evaluation and treatment if contact occurred within 60 days of symptom onset
• Abstain from sexual intercourse until both patient and partner(s) complete treatment and are asymptomatic

Fournier's Gangrene

Clinical Features

• Necrotizing soft tissue infection of scrotum and penis or vulva
• Usually occurs from perianal/retroperitoneal infection spreading along fascial planes
• May present with fever, pain, erythema, swelling, cutaneous necrosis, and crepitus

Treatment

• Prompt, aggressive surgical debridement of all necrotic tissue is necessary 1
• Empiric antimicrobial therapy to cover S. aureus, Pseudomonas, and mixed aerobic/anaerobic flora
• Consider hospitalization for severe cases

Vaginal Infections

1. Bacterial Vaginosis

Diagnosis

• Clinical (Amsel's) criteria:
  • Vaginal pH >4.5
  • Positive whiff test (fishy odor)
  • Thin, white discharge
  • Clue cells on microscopy
• Or laboratory criteria (Gram stain with objective scoring)

Treatment

• Metronidazole 500 mg orally twice daily for 7 days 2
• Alternatives:
  • Vaginal metronidazole gel
  • Oral or vaginal clindamycin cream

Recurrent Bacterial Vaginosis

• Longer courses of therapy recommended 2
• Consider vaginal products containing Lactobacillus crispatus 3

2. Vulvovaginal Candidiasis

Diagnosis

• Symptoms: Itching, burning, white discharge, vulvar/vaginal erythema
• Microscopic examination: Yeast forms in 10% KOH solution
• Normal vaginal pH (4.0-4.5)

Treatment

• Topical or oral antifungal azole medications (equally effective) 2
• For symptomatic cases: Longer courses of topical azoles may be required 2

Recurrent Vulvovaginal Candidiasis (≥4 episodes/year)

• Initial therapy followed by maintenance with weekly oral fluconazole for up to 6 months 2
• Alternative: Vaginal boric acid for cases not responding to first-line agents 3

3. Trichomoniasis

Diagnosis

• Best detected by antigen testing using vaginal swabs (immunoassay or nucleic acid amplification)
• Features: Trichomonads in saline, more leukocytes than epithelial cells, positive whiff test, vaginal pH >5.4

Treatment

• Metronidazole 2 g orally as single dose OR 500 mg twice daily for 7 days 2
• Higher-dose therapy for treatment-resistant cases 2
• Partner treatment recommended even without screening 2
• Test of cure not recommended 2

Pregnancy Considerations

• Treatment with oral metronidazole warranted for prevention of preterm birth 2

Special Considerations

HIV Infection

• Patients with uncomplicated epididymitis and HIV should receive the same treatment regimen as HIV-negative patients
• Be aware that fungi and mycobacteria are more likely to cause epididymitis in immunosuppressed patients 1

Penile Swelling in Pediatrics

• Consider emergency conditions such as penile fracture, priapism, and paraphimosis 4
• Ultrasound with Doppler is valuable for assessing blood flow and distinguishing between inflammatory conditions and torsion 4

Common Pitfalls and Caveats

1. Failure to consider testicular torsion in cases of acute scrotal pain (surgical emergency)
2. Inadequate partner treatment in sexually transmitted infections
3. Not extending treatment duration for recurrent vaginal infections
4. Overlooking mixed infections (e.g., concurrent BV and candidiasis)
5. Treating trichomoniasis with single-dose therapy when 7-day course is more effective for complicated cases

By following these evidence-based guidelines, clinicians can effectively manage common genital illnesses while minimizing complications and recurrence.