Vaginal Infections in the Backcountry

0:00This is AWLS, podcasts on wilderness medicine, from the University of Utah School of Medicine. Welcome back to AWLS, I'm Laila Risen and I'm excited to be joining you as a guest host. Today we're tackling a topic that doesn't get enough attention in wilderness medicine, gynecologic infections in the field. Whether you're on a week-long backpacking trip, working a remote field season, or guiding expeditions, yeast infections, bacterial vaginosis, and UTIs can range from uncomfortable annoyances to trip-ending medical concerns. You might have heard advice about managing these infections in wilderness courses, guidebooks, or from experienced outdoors people, and while that practical wisdom is incredibly valuable, what we're missing is formal, peer-reviewed research, specifically studying these

1:04infections in remote environments. The evidence we do have comes from clinical studies. So in this episode, we'll be looking at what the medical literature tells us and then thinking critically about how to apply that knowledge when your day is away from the nearest clinic. There are two most common vaginal infections that you might encounter on a long trip. First, bacterial vaginosis, BV, which accounts for about 40-50% of vaginitis cases. This isn't caused by a single bacteria, but rather an imbalance in the vaginal microbiome. The hallmark symptom is thin, grayish discharge with a distinctive fishy odor, especially after intercourse. Treatment requires prescription antibiotics. Second, is vulvovaginal-candiditisis, commonly known as a yeast infection, which represents 20-25% of cases. The classic presentation of this fungal infection is thick white cottage cheese-like discharge with intense itching.

2:06This is the only condition we'll talk about today for which over-the-counter treatment exists, although the more powerful anti-fungals are prescription only. It's worth mentioning that sexually transmitted infections, including trichomonitisis, chlamydia, and gonorrhea, can also cause vaginal discharge and symptoms. These require prescription treatment, and if there's been recent sexual activity and you're developing symptoms, should be on your differential diagnosis. But for this episode, we're focusing on BV and yeast infections, since the most common in wilderness medicine. And we can't have this conversation without mentioning urinary tract infections, UTIs. While not technically vaginal infections, they're incredibly common outdoors, and share many of the same risk factors. UTI symptoms are burning with urination, urgency, frequency, and possibly lower abdominal pain or blood in the urine. But if symptoms include fever, back pain, or feeling systemically ill, that could be pile in a fritis, a kidney infection, which is a much more serious problem.

3:08So why do these infections happen more often in the wilderness environment? Moisture and friction are probably the biggest culprits. When you're hiking long days with a heavy pack, wearing wet clothes from river crossings or sweat, you're creating an environment where both bacteria and yeast can thrive. While the evidence of synthetic versus natural fabrics is actually pretty limited, one study found no increased risk of yeast infections with non-caught and underwear, what matters more is moisture retention. Wet layers that don't breathe trap moisture against the skin. Limited access to washing, both your body and your clothes, creates additional challenges. Limited water, no showers, infrequent clothing changes, all of these can disrupt normal vaginal pH, which typically sits between 4 and 4.5. One particularly relevant finding from research on menstrual hygiene and resource limited areas showed that women using reusable materials that weren't adequately dried had higher rates of both bevy and yeast infections. The key factor wasn't the material itself,

4:11but inadequate drying. For UTIs specifically, the wilderness adds unique challenges. Holding urine because there's no convenient place to pee, dehydration from exertion and altitude, difficulty with adequate post bowel movement hygiene, all of these increase UTI risk. So what can you do to prevent these infections? Keep it dry. This is your most important prevention strategy. Change out of wet clothes as soon as possible. If you cross a stream and get your base layer wet, change it. Don't wait until camp. Hang damp clothing to dry thoroughly before wearing again. Consider bringing an extra base layer specifically for sleeping in dry gear and choose breathable layers. While the evidence doesn't strongly favor one fabric over another, moisture wicking fabrics that dry quickly make more sense than cotton, which stays wet. Maintain basic external cleanliness. Avoid harsh soaps, which disrupt normal vaginal pH. Plain water is great for cleansing. Uncented gentle soap can be used externally, but only a few

5:15must and don't use it internally. For UTI prevention, stay hydrated and don't hold your urine, wipe front to back. And if you're prone to UTIs, the CDC yellow book specifically mentions carrying prescribed antibiotics for empiric treatment. And a note on what doesn't work because there's a lot of misinformation out there. The American College of Obstetricians and Gynecologists has stated clearly that probiotics, whether oral or vaginal, are not recommended for preventing vaginitis, yeast infection, or otherwise. So despite what you might hear from friends, these aren't evidence-based strategies. Now, what do you do if someone develops symptoms on a trip? For yeast infections, over-the-counter antifungals achieve greater than 90% symptom relief when used appropriately for uncomplicated infections. The challenge is the qualifier when used appropriately. If you're treating what you think is a yeast infection, but it's actually BV, you won't get better. One study found that self-diagnosis of yeast infections is incorrect

6:15about half the time. This is where pre-trip planning becomes crucial. If you have a history of recurrent yeast infections and can reliably identify your symptoms, consider carrying over-the-counter antifungals. But be honest with yourself about whether you can truly distinguish your yeast infection from other causes of vaginitis. For BV, you need prescription medications. This means your options are prevention, suffering through it, or evacuation. Some people prone to recurrent BV do get prescriptions from their health care providers to carry just in case. For UTIs, empiric antibiotic treatment is more commonly accepted in travel medicine. If you're prone to UTIs, talk to your provider about carrying a prescription. Most vaginal infections are uncomfortable, but not immediately dangerous. However, certain red flags should prompt serious consideration of evacuation. Fever suggests systemic infection. For UTI symptoms with fever, think pylinephritis, which can lead to sepsis if untreated. For vaginal symptoms with fever and abdominal pain,

7:16consider pelvic inflammatory disease, especially if there's been recent sexual activity. Severe pain, whether pelvic, abdominal, or back pain with UTI symptoms, needs medical evaluation. Or if you've been treating a presumed yeast infection for 48 to 72 hours, and symptoms are the same or worse, you probably don't have a yeast infection. And finally, inability to continue the trip. Even if it's not medically dangerous, if someone is so uncomfortable that they can't function, that's a valid reason to change plans. Like all areas of wilderness medicine, pre-trip planning is essential. For longer trips or remote expeditions, schedule a visit with your health care provider beforehand. Be honest about your history. If you get yeast infections every time you take antibiotics, if you have recurrent BV, if you're prone to UTIs, share that information with them. Your provider can prescribe appropriate medications to carry. Also, pack appropriately. Bring extra base layers for staying dry. Pack unscented soap or just plan to use water. Include any prescribed medications.

8:22And consider your trip duration and remoteness. A weekend backpacking trip is very different from a month-long expedition in the Arctic. Scale your preparation to the level of remoteness and the difficulty of evacuation. And finally, let's normalize talking about gynecologic health. The more we discuss these topics openly, the better prepared will be to handle them in the field. As always, this information is for educational purposes and doesn't replace individualized medical advice. Talk to your health care provider about your specific situation and travel plans. Thanks for listening to this episode of AWLS.