62. Diseases of vulva and vagina Flashcards
what is the normal physiology of and microbiology of the vagina?
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.
what can alter the protective vaginal flora
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
PHYSIOLOGIC INCREASES IN VAGINAL AND ENDOCERVICAL FLUID OCCUR?
DURING PREGNANCY, AT MID MENSTRUAL CYCLE, AND DURING INTERCOURSE
what are the vaginal diseases ?
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
what can mimic infectious vaginitis ?
irritation from sexual activity and allergen containing substance
pathoetiology of bacterial vaginosis
due to disruption of the vaginal flora - lactobacillus jeneseni and lactobacillus crispatus
causes Bv complex micro-organism to invade
what are the bv complex micro-organisms ?
gardnerella vaginalis
genital mycoplasma
vaginal anaerobic bacteria
prevotella
bactericides
mobiluncus
what increases the risk of BV ?
new sexual partner , smoking , intrauterine device and frequent douching , antibiotic use
what are the signs and symptoms of BV ?
may be asymptomatic
a profuse , milky , discharge - fishy smelling
no dyspareunia
burn with urination
what are the complications of having BV
doubles the risk of having other sexually transmitted diseases such as HIV
also causes PROM if regnant
how do we diagnose bacterial vaginosis ?
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
what is the organism which causes vulvovaginal candiasis ?
candida albicans
Cabinda glabrata less often
candida infection is more common in whom?
VVC is more common in women after menarche and less common after menopause
why is Vvc more common in women who have menarche ?
because candida growth is favourable in estrogenated tissues
what increases the risk of VVC ?
oral contraceptives
diaphragm use with spermicide
immunosuppression - HIV / antibiotics / steroid
diabetes mellitus
what are the symptoms of VVC ?
vaginal and vulvar itching - pruritus
burning with urination
dyspareunia
odourless cottage cheese like vaginal discharge
what is the diagnosis of VVC ?
vaginal wall erythema and edema
ph less than 4.5
whiff test is negative
vaginal wet mound microscopy - Budding yeast, pseudohypha
microbial culturing
what is trichomoniasis caused by ?
protozoan T vaginalis (it is an STI)
what are the symptoms in trichomoniasis?
half of the time asymptomatic
genital itching
bad smelling yellow green purulent discharge
dysuria
dyspareunia
strawberry cervix
burning sensation
what are the complication of trichomoniasis ?
increases risk of getting HIV and aids
also PROM
how to diagnose vaginal trichomoniasis ?
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)
what is the treatment for trichomoniais?
pregnant and non pregnant women - metronidazole
what causes atrophic vaginitis
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
what is the signs and symptoms of atrophic vaginitis ?
vaginal dryness
- dyspareunia
dysuria
vulvuar pruruitis
discharge which may be clear or purulent, yellow, and occasionally with blood
malodorous
vulvar erythem
what is the diagnosis of atrophic vaginitis ?
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
what is the treatment for atrophic vaginitis ?
topical estrogen
vaginal moisturisers
what is the cause of foreign body vaginitis ?
sexual abuse
forgotten or lost tampons
condoms
how is genital herpes transmitted ?
genital herpes - HSV 2
sexually
what is the complication of genital herpes in pregnancy ? and no in pregnancy ?
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
what is the signs and symptoms of genital herpes simplex?
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.
diagnosis of genital herpes simplex ?
Light microscopy findings on a Tzanck smear
does not differentiate from hsv1 and 2
and vriella zzoter virus
PCR
viral culture
specific serum antibodies
what is the treatment for genital herpes ?
there is no cure
but symptomatic treatment and prevention of reoccurrence with acyclovir
what are the symptoms of HPV16 and 18 (31/33)?
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
nearly all cervical cancer is caused by ?
HPV16 and 18
what is the prevention of HPV 16 and 18 ?
gardasil - HPV like particle vaccine
what is the treatment of HPV ?
should not be used in pregnancy :
doctor applied medication - podophylin resin
patient applied medication -podofilox
cryotherapy , surgical , laser ablation excision
what is is vulvitis ?
inflammation of the vulva including - labio maoris and minors ,introits
different vulval diseases ?
PYOGENIC all caused by staph areas pyogenic - vulval cellulitis folliculitis
======
viral
genital herpes
Condylomata accuminata
=====
bartholinitis - Escherichia coli, Staphylococcus, Streptococcus
bartholin cyst
describe the clinical manifestation of the pyogenic vulva infection
vulval cellulitis -
limited, in majority, upto the labiocrural fold.
The vulva is swollen, red, and tender.
purulent discharge
dysuria
pruitis
treatmnet of pyogenic vulval infections ?
vulval cellulitis- systemic antibiotics
local hot compress
analgesics
folliculitis / furunculosis -furunculosis -bath containing potassium permanganate
loca and systemic antibiotics
clinical feature of bartholinitits
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
treatment for bartholinitis ?
Hot compress
area and analgesics to relieve pain are instituted.
Systemic antibiotic like ampicillin
if abcess -Abscess should be drained at the earliest opportunity
treatment for bartholin cyst ?
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
what causes genital warts or condyloma acuminate ?
Human Papilloma Virus (HPV) usually type 6 and 11
sexually transmitted
clinical signs and symptoms of condyloma accuminata
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%
treatment of condyloma accuminata
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
treatment of bacterial vaginosis ?
internal gel that regulates the vaginal ph back to normal
metronidazole gel / clindamycin cream
vulvovaginal candiasis ?
fluconazole tablet
butoconozole cream
