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Abstract: A 25-year-old female presented with vulvar pruritus, burning sensation in the vulva, vaginal discharge, and increased odorous discharge. The clinical diagnosis was bacterial vaginitis, and she was given cleansing lotion and compound metronidazole suppositories for anti-infection treatment. After local douching and topical vaginal medication, the patient’s discomfort was cured and her symptoms were significantly relieved, and the indicators were normal in the later examination.
Basic information】Female, 25 years old
Type of disease】Bacterial vaginitis
Hospital】Guangzhou Huadu District People’s Hospital
Date of consultation】January 21, 2020
Treatment plan】Medication (Jieer Yin lotion + compound metronidazole suppository)
Treatment Period】15 days of outpatient treatment
Effectiveness】Significant relief of symptoms has been achieved
I. Initial consultation
On January 21, 2020, she came to the hospital with itchy vulva, odorous discharge and localized burning and painful sensation in the vagina for 3 days. 3 days ago, after high-risk sex, the above symptoms appeared in the vagina, and the symptoms were not relieved by washing with saline, and the symptoms were not relieved by taking cefuroxime tablets orally for 1 day, so she came to the hospital. g0p0, i.e., not pregnant, nor had she given birth, unmarried, but had a history of sexual intercourse, last menstrual period January 8, 2020. Usually regular menstruation but multiple sexual partners, no history of vaginal douching or episodes of medication in the last 3 days. Normal development in appearance, no abnormal heart and lung auscultation, flat and soft abdomen, no pressure pain in the lower abdomen without palpation of liver and spleen, normal development of vulva, local flushing, mild edema, vaginal patency, large amount of yellow discharge in the vagina and odor, local congestion in the cervix but no obvious discharge, normal size of uterus with no abnormality palpated in the bilateral adnexal area. She was diagnosed with bacterial vaginitis after a cervical cancer screening test six months ago with normal results.
II. Treatment history
As the patient was not planning to get pregnant, she was given routine vaginitis treatment. She was given a daily vaginal douche with a cleansing lotion, which was administered continuously. After douching, a compound metronidazole suppository was inserted into the vagina. After the clinical symptoms had completely disappeared, the patient was rechecked 2 days after stopping the medication and was given a cleanliness of II degree in the routine leucorrhoea. In order to consolidate the treatment and reduce the chance of reoccurrence of infection. The patient was advised to abstain from eating spicy and acidic foods and to prohibit alcohol consumption during the treatment period.
III. Treatment effect
In order to achieve complete cure, the patient was instructed to continue to use the medicine for 7 days. The patient felt that the clinical symptoms had completely disappeared, and there was no burning sensation, itching, odor of vaginal discharge, or other uncomfortable symptoms.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment, but the patient still needs to pay attention to some matters in life: 1.
1. Keep the vulva locally clean every day, insist on changing underwear regularly, and also strengthen the local care of vulva during menstruation. In addition, after washing underwear, it is recommended that they be scalded with boiling water and then dried in the sun.
2. It is recommended to have regular gynecological checkups to rule out the possibility of vaginitis, cervicitis and pelvic inflammatory disease, and to have regular cervical cancer screening to find out whether there are lesions in the cervical epithelium and whether there is high-risk HPV virus infection.
3. avoid intercourse during vaginitis treatment.
4. Once there is an increase in discharge, odorous discharge or bloody discharge, go to the hospital promptly.
V. Personal insight
Although vaginitis is one of the common inflammatory diseases in gynecology, it can affect the patient’s daily work and life and cause a lot of pain. In this case, the patient was initially treated privately and the treatment was not effective, but the patient was younger and had better resistance, so the recovery time after regular treatment was relatively short. It is recommended that women pay attention to vulva hygiene and eliminate the history of high-risk sex to reduce inflammation and STD production.