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gynaecology > 62. Diseases of vulva and vagina > Flashcards

62. Diseases of vulva and vagina Flashcards

1
Q

what is the normal physiology of and microbiology of the vagina?

A

THE NEWBORN`S VAGINAL EPITHELIUM IS STRONGLY ESTROGENIZED AND RICH IN GLYCOGEN, OF LACTIC ACID-PRODUCING LACTOBACILLI. THIS RESULTS IN A LOW PH (≤ 4.7), WHICH PROMOTES FURTHER GROWTH OF ACIDOPHILIC- PROTECTIVE MICROFLORA.

WITHIN DAYS OF BIRTH, ESTROGEN DECREASES, AND THE VAGINAL EPITHELIUM BECOMES THIN, ATROPHIC, AND LARGELY DEVOID OF GLYCOGEN. IN THIS ENVIRONMENT, THE PH RISES. AS A CONSEQUENCE, THE PREDOMINANT VAGINAL MICROFLORA BECOMES DIVERSE GRAM-POSITIVE COCCI AND BACILLI

THE ONSET OF PUBERTY AND OVARIAN STEROIDOGENESIS, THE VAGINA AGAIN BECOMES ESTROGENIZED, AND THE GLYCOGEN CONTENT INCREASES. LACTIC ACID-AND HYDROGEN PEROXIDE (H2O2) – PRODUCING LACTOBACILLI AGAIN PREDOMINATE, RESULTING IN SELF-SUSTAINING VAGINAL PH OF BETWEEN 3.8 AND 4.5.

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2
Q

what can alter the protective vaginal flora

A

ANTIBIOTICS

spraying WITH WATER OR NONBUFFERED SOLUTIONS MAY TRANSIENTLY ALTER THE PH

SEXUAL INTERCOURSE WITH INTRODUCTION OF SEMEN RAISES THE PH TO 7.2 FOR 6 TO 8 HOURS, MAKING THE VAGINA RECEPTIVE TO STI PATHOGENS

THE PRESENCE OF A FOREIGN BODY (FORGOTTEN DIAPHRAGM OR TAMPON IN ADULTS OR VARIOUS SMALL OBJECTS IN CHILDREN) DRAMATICALLY DISRUPTS NORMAL VAGINAL CLEANSING MECHANISMS AND MAY LEAD TO SECONDARY INFECTION

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3
Q

PHYSIOLOGIC INCREASES IN VAGINAL AND ENDOCERVICAL FLUID OCCUR?

A

DURING PREGNANCY, AT MID MENSTRUAL CYCLE, AND DURING INTERCOURSE

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4
Q

what are the vaginal diseases ?

A

bacterial vaginosis

vulvovaginal candiasis

trichomoniasis

others :
STI

mucopurulent cervicitis caused by chlamydia , neisseria and gonorrhoea lead to vaginal irritation

less common - atrophic vaginitis

foriegn body vaginitis

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5
Q

what can mimic infectious vaginitis ?

A

irritation from sexual activity and allergen containing substance

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6
Q

pathoetiology of bacterial vaginosis

A

due to disruption of the vaginal flora - lactobacillus jeneseni and lactobacillus crispatus

causes Bv complex micro-organism to invade

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7
Q

what are the bv complex micro-organisms ?

A

gardnerella vaginalis

genital mycoplasma

vaginal anaerobic bacteria

prevotella

bactericides

mobiluncus

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8
Q

what increases the risk of BV ?

A

new sexual partner , smoking , intrauterine device and frequent douching , antibiotic use

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9
Q

what are the signs and symptoms of BV ?

A

may be asymptomatic

a profuse , milky , discharge - fishy smelling

no dyspareunia

burn with urination

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10
Q

what are the complications of having BV

A

doubles the risk of having other sexually transmitted diseases such as HIV

also causes PROM if regnant

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11
Q

how do we diagnose bacterial vaginosis ?

A

a profuse , milky , discharge
amine or fishy odour after alkalisation with a drop of KOH (positive whiff test)

ph of the vagina goes more alkaline going over 4.5

vaginal wall normal

wet mound microscopy
clue cells - epithelia cells with bacteria attached to them - they are found from the vaginal discharge and sodium chloride is added and put under microscope

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12
Q

what is the organism which causes vulvovaginal candiasis ?

A

candida albicans

Cabinda glabrata less often

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13
Q

candida infection is more common in whom?

A

VVC is more common in women after menarche and less common after menopause

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14
Q

why is Vvc more common in women who have menarche ?

A

because candida growth is favourable in estrogenated tissues

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15
Q

what increases the risk of VVC ?

A

oral contraceptives

diaphragm use with spermicide

immunosuppression - HIV / antibiotics / steroid

diabetes mellitus

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16
Q

what are the symptoms of VVC ?

A

vaginal and vulvar itching - pruritus

burning with urination

dyspareunia

odourless cottage cheese like vaginal discharge

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17
Q

what is the diagnosis of VVC ?

A

vaginal wall erythema and edema

ph less than 4.5

whiff test is negative

vaginal wet mound microscopy - Budding yeast, pseudohypha

microbial culturing

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18
Q

what is trichomoniasis caused by ?

A

protozoan T vaginalis (it is an STI)

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19
Q

what are the symptoms in trichomoniasis?

A

half of the time asymptomatic

genital itching

bad smelling yellow green purulent discharge

dysuria

dyspareunia

strawberry cervix

burning sensation

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20
Q

what are the complication of trichomoniasis ?

A

increases risk of getting HIV and aids

also PROM

21
Q

how to diagnose vaginal trichomoniasis ?

A

vaginal wall is erythema

vaginal ph more than 5

wife test -positive

vaginal wet mound microscopy - flagellated protozoa

or microbial culturing

nucleic acid amplification tests (NAATs)

22
Q

what is the treatment for trichomoniais?

A

pregnant and non pregnant women - metronidazole

23
Q

what causes atrophic vaginitis

A

tissue thinning bacuse of not enough estrogen causing a secondary infection -premenarchal and after menopause

decreased ovarian function - radiation and chemotherapy or oophorectomy

medication with antiestrogen properties - tamoxifen

smoking

breast feeding

24
Q

what is the signs and symptoms of atrophic vaginitis ?

A

vaginal dryness
- dyspareunia

dysuria

vulvuar pruruitis

discharge which may be clear or purulent, yellow, and occasionally with blood
malodorous

vulvar erythem

25
Q

what is the diagnosis of atrophic vaginitis ?

A

indication lower estrogen levels: little pubic hair,
loss of the labial fat pad, thinning and resorption of the labia minora,
narrowing of the vaginal opening.

Pale, smooth or shiny vaginal epithelium; loss of elasticity or turgor of skin;

internal exam will reveal the presence of low vaginal muscle tone,
the lining of the vagina appears smooth, shiny, pale with loss of folds.

the ph is higher than 4.5

serum oestrogen levels

cytological examinations of vaginal smear / papanicolaou of vagina
immature basal cells and increased proportion of parabasal cells replacicing superficial epithelial cells which are diminishing

26
Q

what is the treatment for atrophic vaginitis ?

A

topical estrogen

vaginal moisturisers

27
Q

what is the cause of foreign body vaginitis ?

A

sexual abuse

forgotten or lost tampons

condoms

28
Q

how is genital herpes transmitted ?

A

genital herpes - HSV 2

sexually

29
Q

what is the complication of genital herpes in pregnancy ? and no in pregnancy ?

A

high risk at first trim
increase fetal mortality- miscarriage
PROM
cause microcephaly , microopthalmia ,

if occurs in second trim - not bad ?

go into labour less than 6 weeks after a first episode of genital herpes, your immune system won’t have had time to produce antibodies to protect your baby. There is thus a high chance of passing the virus to your baby if you have a vaginal

CNS disease
Meningoencephalitis (manifesting with fever, lethargy, irritability)

Skin, eye, and mouth disease
Vesicular skin lesions

trouble breathing -grunting,
blue appearance (cyanosis),
rapid breathing
short periods of no breathing

dessimentaed - sepsis
jaundice
=========

there is reoccurrence as it resides in the nerve ganglion until it is triggered again

30
Q

what is the signs and symptoms of genital herpes simplex?

A

can appear on the vulva, perineum, buttocks, anal area, cervix, and inside of the vagin

Most patients are asymptomatic

multiple , bilateral , painful red bumps or white vesicles
the vesicles can burst to ulcerate

unusual vaginal discharge

pruritus

Painful lymphadenopathy in the groin area

fever

myalgia

Recurrence is common.

31
Q

diagnosis of genital herpes simplex ?

A

Light microscopy findings on a Tzanck smear
does not differentiate from hsv1 and 2
and vriella zzoter virus

PCR

viral culture

specific serum antibodies

32
Q

what is the treatment for genital herpes ?

A

there is no cure

but symptomatic treatment and prevention of reoccurrence with acyclovir

33
Q

what are the symptoms of HPV16 and 18 (31/33)?

A

90 parent of cases no symtoms and resolves spontaneously

but in some HPV persists and presents as warts (mostly vulva , cervix and anus)

precancerous lesions

but transmission to fetus is rare

34
Q

nearly all cervical cancer is caused by ?

A

HPV16 and 18

35
Q

what is the prevention of HPV 16 and 18 ?

A

gardasil - HPV like particle vaccine

36
Q

what is the treatment of HPV ?

A

should not be used in pregnancy :

doctor applied medication - podophylin resin

patient applied medication -podofilox

cryotherapy , surgical , laser ablation excision

37
Q

what is is vulvitis ?

A

inflammation of the vulva including - labio maoris and minors ,introits

38
Q

different vulval diseases ?

A 
PYOGENIC 
all caused by staph areas 
pyogenic -
 vulval cellulitis 
folliculitis

======

viral
genital herpes

Condylomata accuminata

=====

bartholinitis - Escherichia coli, Staphylococcus, Streptococcus

bartholin cyst

39
Q

describe the clinical manifestation of the pyogenic vulva infection

A

vulval cellulitis -
limited, in majority, upto the labiocrural fold.

The vulva is swollen, red, and tender.

purulent discharge

dysuria

pruitis

40
Q

treatmnet of pyogenic vulval infections ?

A

vulval cellulitis- systemic antibiotics
local hot compress
analgesics

folliculitis / furunculosis -furunculosis -bath containing potassium permanganate
loca and systemic antibiotics

41
Q

clinical feature of bartholinitits

A

local pain and discomfort even to the extent of difficulty in walking or sitting.

tenderness and induration of the posterior half of the labia when palpated between thumb outside and the index finger inside the vagina

purulent secretion from duct

pain during intercourse

The infection may resolute completely or an abscess is formed.

In others, the infection subsides only to recur in future. In such cases, the gland becomes fibrotic. Too often, the duct lumen heals by fibrosis with closure of the orifice → pent up secretion of the gland → formation of bartholin cyst

42
Q

treatment for bartholinitis ?

A

Hot compress
area and analgesics to relieve pain are instituted.

Systemic antibiotic like ampicillin

if abcess -Abscess should be drained at the earliest opportunity

43
Q

treatment for bartholin cyst ?

A

Marsupialization is the

An incision is made on the inner aspect of the labium minus just outside the hymenal ring

includes the vaginal wall and the cyst wall. The cut margins of the either side are to be trimmed off to make the opening an elliptical shape

The edges of the vaginal and cyst wall are sutured by interrupted catgut - free drainage

44
Q

what causes genital warts or condyloma acuminate ?

A

Human Papilloma Virus (HPV) usually type 6 and 11

sexually transmitted

45
Q

clinical signs and symptoms of condyloma accuminata

A

multiple papillary lesion
grow in clusters along a narrow stalk giving it a cauliflower appearance

anogenital HPV infection is: Cervix 70%, Vulva 25%, Vagina 10%

46
Q

treatment of condyloma accuminata

A

local cytostatic treatment (e.g., 5-FU, trichloroacetic acid, podophyllin,

or immune response modifiers (e.g., imiquimod, interferon alpha)

Cryotherapy: freezing external warts with CO2, N2O, or N2

In case of numerous warts: curettage, laser surgery, or electrocoagulation

preventive 
HPV vaccine (Types 6 and 11) can prevent
47
Q

treatment of bacterial vaginosis ?

A

internal gel that regulates the vaginal ph back to normal

metronidazole gel / clindamycin cream

48
Q

vulvovaginal candiasis ?

A

fluconazole tablet

butoconozole cream

gynaecology (21 decks)

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