今日の臨床サポート

外陰掻痒、帯下増加

著者: 金井誠 信州大学 保健学科

監修: 小林裕明 鹿児島大学大学院医歯学総合研究科生殖病態生理学

著者校正/監修レビュー済:2021/02/10
参考ガイドライン:
  1. 日本産科婦人科学会:産婦人科診療ガイドライン-婦人科外来編2020
患者向け説明資料

概要・推奨   

  1. カンジダ外陰腟炎の診断は、腟分泌物または外陰皮膚の直接検鏡による菌体の確認、または培養によりカンジダの存在を確認し、臨床症状と併せて診断する。治療は抗真菌薬の局所または内服投与を行い、外陰部にはクリームまたは軟膏を用いる。ただし内服薬は妊婦・授乳婦に禁忌である(推奨度1)。
  1. トリコモナス腟炎の診断は、腟分泌物の鏡検にて、腟トリコモナス原虫を確認するが、鏡検法で原虫が確認できない場合には培養法を行う。治療には尿路への感染も考慮して経口薬による全身投与を原則とし、メトロニダゾールもしくはチニダゾールを用いる。パートナーにも同時期に同様の治療(内服)を行う。ただし両薬の日本の添付文書には、妊娠中は有益性投与で妊娠3カ月以内は投与しないことと記載されている(推奨度2)。
  1. 細菌性腟症(BV)は、帯下のグラム染色標本を用いたNugent score、または帯下生食標本を用いたLactobacillus grade、またはAmsel の診断基準のいずれかで診断し、治療の基本は局所療法または内服療法で、メトロニダゾールを使用する(推奨度2)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
金井誠 : 特に申告事項無し[2021年]
監修:小林裕明 : 講演料(中外製薬株式会社,アストラゼネカ株式会社),奨学(奨励)寄付など(中外製薬株式会社)[2021年]

改訂のポイント:
  1. 産婦人科診療ガイドライン-婦人科外来編の改訂、および評価・治療例(オーダーセット)の掲載中止に基づき、確認と修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 外陰掻痒と帯下増加は、産婦人科外来で日常的に診療する症状であり、多くの女性が訴える症状である[1]
  1. 外陰掻痒は、外陰の炎症に起因するが、その原因となる疾患はさまざまである。
  1. 帯下とは子宮・腟・外陰などから生じる分泌物であり、性周期において生理的に増加することもあり得る。しかし病的に増加した場合には炎症に起因することが多い。
  1. 外陰掻痒と帯下増加の原因のほとんどは、子宮頸部、腟、外陰の局所的な炎症であるが、全身性の病変に起因する場合もあり、軽視せずに対応することが重要で、代表的な疾患については熟知しておくことが望ましい。
問診・診察のポイント  
 
 
  1. 女性ホルモン分泌状況は、初経前の学童期、初経後の性成熟期、閉経後で著しく異なり、腟へ感染する微生物の傾向も変化する。したがって月経の情報は、いかなる年齢においても確認する[1]
  1. 学童期で腟内の診察が困難な場合、綿棒のみで腟内の分泌物を採取する。ただしまれに異物の混入が外陰掻痒や帯下増加の原因となることもあり、性行為や自慰行為の有無を知ることも必要となる場合がある[1]
  1. 学童期でも初経を迎えるか性行為の経験があれば、性成熟期と同様疾患の想定が必要となる[1]
  1. 外陰炎の原因として接触皮膚炎や尿・糞便による汚染もあり得る。したがって、下着の種類や生活習慣(肛門清拭や入浴など)の把握も重要である[1]
  1. 性成熟期には細菌性腟症やカンジダ外陰・腟炎に加えて、性感染症を念頭に置く[1]
  1. 全身性疾患である糖尿病、肝・腎機能異常、精神的疾患などの潜在や、腫瘍性病変の可能性も想定する。

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文献 

著者: Centers for Disease Control and Prevention, Kimberly A Workowski, Stuart M Berman
雑誌名: MMWR Recomm Rep. 2006 Aug 4;55(RR-11):1-94.
Abstract/Text These guidelines for the treatment of persons who have sexually transmitted diseases (STDs) were developed by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta, Georgia, during April 19-21, 2005. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2002 (MMWR 2002;51[No. RR-6]). Included in these updated guidelines are an expanded diagnostic evaluation for cervicitis and trichomoniasis; new antimicrobial recommendations for trichomoniasis; additional data on the clinical efficacy of azithromycin for chlamydial infections in pregnancy; discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; emergence of lymphogranuloma venereum protocolitis among men who have sex with men (MSM); expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis; the emergence of azithromycin- resistant Treponema pallidum; increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM; revised discussion concerning the sexual transmission of hepatitis C; postexposure prophylaxis after sexual assault; and an expanded discussion of STD prevention approaches.

PMID 16888612  MMWR Recomm Rep. 2006 Aug 4;55(RR-11):1-94.
著者: B H Tidwell, W B Lushbaugh, M D Laughlin, J D Cleary, R W Finley
雑誌名: J Infect Dis. 1994 Jul;170(1):242-6. doi: 10.1093/infdis/170.1.242.
Abstract/Text Since metronidazole is a mutagen in vitro, there is concern about the widespread systemic use of this drug in women with trichomoniasis, particularly those who are pregnant. A randomized, double-blind, placebo-controlled trial compared a single 2-g intravaginal dose of metronidazole cream with a single 2-g oral dose of metronidazole in patients with a culture positive for Trichomonas organisms. Of the 302 preenrollment cultures completed, 94 (31%) were positive. Sixty-one patients were enrolled in the study. Each received either oral placebo and intravaginal metronidazole or intravaginal placebo and oral metronidazole. Follow-up cultures were done on posttreatment day 3-5. Of the 53 evaluatable patients, 14 (50%) of 28 in the intravaginal group and 22 (88%) of 25 in the oral group were microbiologically cured (P = .0037). Single-dose intravaginal metronidazole is inferior to single-dose oral metronidazole and cannot be relied on as an alternative therapy.

PMID 8014510  J Infect Dis. 1994 Jul;170(1):242-6. doi: 10.1093/infdi・・・
著者: R P Nugent, M A Krohn, S L Hillier
雑誌名: J Clin Microbiol. 1991 Feb;29(2):297-301.
Abstract/Text The purpose of the study was to examine intercenter variability in the interpretation of Gram-stained vaginal smears from pregnant women. The intercenter reliability of individual morphotypes identified on the vaginal smear was evaluated by comparing them with those obtained at a standard center. A new scoring system that uses the most reliable morphotypes from the vaginal smear was proposed for diagnosing bacterial vaginosis. This scoring system was compared with the Spiegel criteria for diagnosing bacterial vaginosis. The scoring system (0 to 10) was described as a weighted combination of the following morphotypes: lactobacilli, Gardnerella vaginalis or bacteroides (small gram-variable rods or gram-negative rods), and curved gram-variable rods. By using the Spearman rank correlation to determine intercenter variability, gram-positive cocci had poor agreement (0.23); lactobacilli (0.65), G. vaginalis (0.69), and bacteroides (0.57) had moderate agreement; and small (0.74) and curved (0.85) gram-variable rods had good agreement. The reliability of the 0 to 10 scoring system was maximized by not using gram-positive cocci, combining G. vaginalis and bacteroides morphotypes, and weighting more heavily curved gram-variable rods. For comparison with the Spiegel criteria, a score of 7 or higher was considered indicative of bacterial vaginosis. The standardized score had improved intercenter reliability (r = 0.82) compared with the Spiegel criteria (r = 0.61). The standardized score also facilitates future research concerning bacterial vaginosis because it provides gradations of the disturbance of vaginal flora which may be associated with different levels of risk for pregnancy complications.

PMID 1706728  J Clin Microbiol. 1991 Feb;29(2):297-301.
著者: G G Donders, A Vereecken, A Dekeersmaecker, B Van Bulck, B Spitz
雑誌名: J Clin Pathol. 2000 Apr;53(4):308-13.
Abstract/Text AIM: The status of vaginal lacto-bacillary flora, an indicator of possible genital infection and pregnancy complications, can be assessed on wet mount or Gram stained specimens. The former is quick, the latter more routine. The accuracy of the two preparative techniques to detect normal vaginal lacto-bacillary microflora was compared for 646 patients. The effect of delay in transport medium before Gram staining was also investigated.
METHODS: Patients presented with infectious vaginitis or for a routine prenatal visit. After placement of a speculum, duplicate smears were taken from the upper vaginal vault and examined fresh or after Gram staining. Lacto-bacillary grades from both methods were compared with lactate concentration in vaginal rinses. In a subgroup of 238 patients, Gram staining was performed both on fresh smears and those that had been transported in Stuart's growth medium.
RESULTS: Higher lacto-bacillary grades (more disrupted flora) were diagnosed 2.9 times more frequently on Gram stained specimens than on wet mounts (p < 0.0001), a difference even more pronounced after transport in Stuart's medium (relative risk, 4.2; p < 0.0001). Lacto-bacillary grades assessed on wet mounts correlated better with vaginal lactate concentration than those assessed on Gram stains.
CONCLUSIONS: Easier recognition of lacto-bacillary morphotypes on wet mounts than on Gram stains might result from the loss of lactobacilli by the process of fixation or Gram staining. Wet mount microscopy of vaginal smears for assessment of lacto-bacillary grades, rather than Gram staining, is strongly recommended.

PMID 10823128  J Clin Pathol. 2000 Apr;53(4):308-13.
著者: R Amsel, P A Totten, C A Spiegel, K C Chen, D Eschenbach, K K Holmes
雑誌名: Am J Med. 1983 Jan;74(1):14-22.
Abstract/Text Numerous previous studies of nonspecific vaginitis have yielded contradictory results regarding its cause and clinical manifestations, due to a lack of uniform case definition and laboratory methods. We studied 397 consecutive unselected female university students and applied sets of well defined criteria to distinguish nonspecific vaginitis from other forms of vaginitis and from normal findings. Using such criteria, we diagnosed nonspecific vaginitis in up to 25 percent of our study population; asymptomatic disease was recognized in more than 50 percent of those with nonspecific vaginitis. A clinical diagnosis of nonspecific vaginitis, based on simple office procedures, was correlated with both the presence and the concentration of Gardnerella vaginalis (Hemophilus vaginalis) in vaginal discharge, and with characteristic biochemical findings in vaginal discharge. Nonspecific vaginitis was also correlated with a history of sexual activity, a history of previous trichomoniasis, current use of nonbarrier contraceptive methods, and, particularly, use of an intrauterine device. G. vaginalis was isolated from 51.3 percent of the total population using a highly selective medium that detected the organism in lower concentration in vaginal discharge than did previously used media. Practical diagnostic criteria for standard clinical use are proposed. Application of such criteria should assist in clinical management of nonspecific vaginitis and in further study of the microbiologic and biochemical correlates and the pathogenesis of this mild but quite prevalent disease.

PMID 6600371  Am J Med. 1983 Jan;74(1):14-22.
著者: Hiroshige Mikamo, Mochiyoshi Ninomiya, Teruhiko Tamaya
雑誌名: J Infect Chemother. 2003 Sep;9(3):282-3. doi: 10.1007/s10156-003-0253-7.
Abstract/Text The detection and eradication of pharyngeal Chlamydia trachomatis in patients with chlamydial uterine cervicitis (commercial sex workers and others) were investigated. Pharyngeal C. trachomatis was detected in 75.0% of the commercial sex workers and in 21.9% of the other subjects. All the pharyngeal C. trachomatis-positive patients had a past history of orogenital contact. Chlamydial infection was treated with clarithromycin for 7 or 14 days. The presence of C. trachomatis was determined by polymerase chain reaction (PCR) on days 8, 15, and 22 after completion of the treatment. In the 7-day treatment group, the eradication rate of pharyngeal C. trachomatis was 53.3%, 56.7%, and 60.0% on days 8, 15, and 22, respectively, after completion of the treatment, while the eradication rate of cervical C. trachomatis was 83.3%, 96.7%, and 100% on days 8, 15, and 22, respectively. The eradication rate of pharyngeal C. trachomatis in the 7-day treatment was significantly lower than that of cervical C. trachomatis, while there was no significant difference in the 14-day treatment. The eradication rate of pharyngeal C. trachomatis in the 14-day treatment was significantly higher than that in the 7-day treatment. Since the DNA of dead organisms may be detected because of high PCR sensitivity, appropriate therapeutic judgment by PCR could be done around day 22 after completion of the treatment.

PMID 14513403  J Infect Chemother. 2003 Sep;9(3):282-3. doi: 10.1007/s・・・
著者: N K Veien, P Olholm Larsen, K Thestrup-Pedersen, G Schou
雑誌名: Br J Dermatol. 1999 May;140(5):882-6.
Abstract/Text Chronic hand eczema can be incapacitating, and there is little knowledge of the efficacy and safety of long-term treatment with topical corticosteroids. We compared the efficacy and safety of two different schedules for the treatment of chronic hand eczema with a potent topical corticosteroid, mometasone furoate. In a prospective, open, randomized trial, 120 patients with chronic hand eczema were treated daily with mometasone furoate fatty cream until the dermatitis cleared or for a maximum of 9 weeks. Those who cleared were randomized to treatment for up to 36 weeks with mometasone furoate on Sunday, Tuesday and Thursday (group A), mometasone furoate on Saturday and Sunday (group B) or no further corticosteroid treatment (group C). In the event of relapse, patients were permitted daily treatment with mometasone furoate for 3 weeks on two separate occasions. For 50 of 106 randomized patients, daily treatment for 3 weeks controlled their dermatitis; 29 needed 6 weeks and 27 needed 9 weeks of treatment. During the maintenance phase, 29 of 35 (83%) in group A, 25 of 37 (68%) in group B and nine of 34 (26%) in group C had no recurrences (P = 0.001, chi2-test). Side-effects were minimal. It is concluded that long-term, intermittent treatment of chronic hand eczema with mometasone furoate fatty cream is effective and safe.

PMID 10354026  Br J Dermatol. 1999 May;140(5):882-6.
著者: J Bourke, I Coulson, J English, British Association of Dermatologists
雑誌名: Br J Dermatol. 2001 Dec;145(6):877-85.
Abstract/Text These guidelines for the management of contact dermatitis have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, including details of relevant epidemiological aspects, diagnosis and investigation.

PMID 11899139  Br J Dermatol. 2001 Dec;145(6):877-85.

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