Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

or burning, and a whitish or “cheesy” vaginal discharge. There may also be tingling or burning as urine irritates inflamed tissues, causing some confusion with UTI. The practitioner will need to ask specific questions about the presence of discharge and the location of discomfort to make the distinction. Many women presenting with yeast vaginitis will have a previous history of similar symptoms and will recognize the problem and know the treatment. New onset cases with no previous history should be taken more seriously. Even if an uncomplicated yeast infection is suspected, medical evaluation is indicated. Bacterial vaginitis also causes itching and burn- ing, but the discharge is typically yellow or brown and malodorous. A lost tampon is a common cause. Medication use, diabetes, and other sys- temic problems can also contribute. Vaginitis becomes an emergency when it migrates into the uterus and fallopian tubes causing the infection known as pelvic inflamma- tory disease (PID). The symptoms include the easily recognized signs and symptoms of serious abdominal pain. A strong suspicion of sexually transmitted disease should also be considered a serious condition. Treatment of Vaginitis Simple yeast vaginitis may respond to nonpre- scription treatment in the field. Medications like miconazole (Monistat) suppositories are available over the counter and should be carried on expedi- tion. The manufacturers warn against relying on this treatment unless the patient is certain of the diagnosis through past experience. Because yeast and bacteria grow well in a warm and moist environment, the situation can also be improved by staying dry and cool. This means wearing loose-fitting clothing and spending less time in a bathing or wet suit. Good hygiene is also important. Bacterial vaginitis is best evaluated and treated in a medical facility. Practitioners will want to rule out sexually transmitted disease and treat with antibiotics. Evacuation need not be an emergency

if symptoms are not progressing and no fever or pain is noted.

Vaginitis

General Principles

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Signs and Symptoms: • Yeast - white, cheesy discharge

• Bacterial - yellow/brown, malodorous discharge • Itchy, burning sensation on contact with urine Serious: • Associated with red flags for abdominal pain • Pregnancy “Many women presenting with yeast vaginitis will have a previous history of similar symptoms, and will recognize the problem and know the treatment.”

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When eva cuation or definitive treatment is not available, a reduction of symptoms or complete field cure may be achieved by using a douche of dilute povidone iodine or vinegar and water. Add 15 cc of povidone iodine solution or vinegar to a liter of water and instruct your patient to douche once a day for several days. This will be most effec- tive when your patient can spend several hours supine after treatment.

Vaginitis

General Principles

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Treatment: • Yeast Infection:

- oral antifungal (fluconazole, Rx) - topical antifungal (miconazole, OTC) - 1% PI douche x 3 days • Bacterial Vaginitis: - oral or vaginal antibiotics - 1% PI douche x 3 days - evacuation for medical evaluation

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Douching is not a high-tech operation. It can be accomplished using a regular hydration system or 60 cc catheter tip syringe and nasopharyngeal airway. Anything similar will work, but fluid should not be forced into the vagina under pres- sure. Gravity feed is sufficient. A douche should not be used by a pregnant patient or if trauma is suspected.