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N825 > Abnormal Vaginal Discharge and Vaginal Health > Flashcards

Abnormal Vaginal Discharge and Vaginal Health Flashcards

1
Q

Vaginal Environment

A
  • ~10 to the 9th bacterial CFUs
  • NL discharge is clear-to-white, odorless, and high viscosity
  • NL flora is dominated by lactobacilli
  • Lactic acid helps maintain a NL pH of 3.8-4.2 to inhibit bacterial overgrowth
  • Some lactobacilli produce H2O2
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2
Q

Key features of Vaginal Acidic Environment and Lactobacilli

A
  • NL pH <4.7
    • Maintained by lactobacilli producing lactic acid
    • Favor growth of lactobacilli and inhibits growth of others
  • Human lactobacilli
    • Major species: L. crispatus & L. jensenii
    • Need to produce H2O2 for maximum benefit
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3
Q

Vaginitis: S/S (general)

A
  • Vaginal discharge
  • Vulvar itching
  • Irritation
  • Odor
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4
Q

Vaginitis: Common Types

A
  • Bacterial vaginosis (40-45%)
  • Vulvovaginal candidiasis (20-25%)
  • Trichomoniasis (15-20%)
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5
Q

Vaginitis: Other Causes

A
  • NL physiologic variation
  • Allergic reaction
  • HSV
  • Mucopurulent cervicitis
  • Atrophic vaginitis
  • Vulvar vaginitis
  • Foreign bodies
  • Desquamative inflammatory vaginitis
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6
Q

Vaginitis: Dx

A
  • Hx
  • Visual inspection of internal/external genitalia
  • Appearance of d/c
  • Collection of specimen
  • Preparation and examination of specimen slide
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7
Q

Vaginitis: S/S (BV)

A
  • Odor
  • D/C
  • Itch
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8
Q

Vaginitis: Discharge (BV)

A
  • Homogenous, adherent, thin, milky white

- Malaodorous

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9
Q

Vaginitis: pH (BV)

A

> 4.5

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10
Q

Vaginitis: “Whiff” Test (BV)

A

Positive

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11
Q

Vaginitis: Wet mount (BV)

A
  • Clue cells (>20%)

- No-to-few WBC

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12
Q

Vaginitis: S/S (Candidiasis)

A
  • Itch
  • Discomfort
  • Dysuria
  • Thick d/c
  • “Fishy” Odor
  • Reported more commonly after intercourse or after completion of period
  • S/S may remit spontaneously
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13
Q

Vaginitis: Discharge (candidiasis)

A
  • Thick
  • Clumpy
  • White
  • “Cottage Cheese”
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14
Q

Vaginitis: Clinical Findings (Candidiasis)

A

Inflammation and erythema

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15
Q

Vaginitis: pH (Candidiasis)

A

Usually < or = 4.5

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16
Q

Vaginitis: “Whiff” Test (Candidiasis)

A

Negative

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17
Q

Vaginitis: Wet Mount/KOH (Candidiasis)

A
  • Few WBCs on wet mount

- Pseudohyphae or spores if non-albicans species on KOH

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18
Q

Vaginitis: S/S (Trich)

A
  • Itch
  • D/C
  • ~50% ASymptomatic
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19
Q

Vaginitis: Discharge (Trich)

A
  • Frothy
  • Gray or yellow-green
  • Malodorous
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20
Q

Vaginitis: Clinical Findings (Trich)

A
  • Cervical petechiae

- Strawberry cervix

21
Q

Vaginitis: pH (Trich)

A

> 4.5

22
Q

Vaginitis: “Whiff” Test (Trich)

A

Often positive

23
Q

Vaginitis: Wet Mount (Trich)

A
  • Mobile, flagellated protozoa

- Many WBC

24
Q

Bacterial Vaginosis (BV): Facts

A
  • Most common cause of vaginitis
  • Overgrowth of commensal anaerobic flora in relation to H2O2 lactobacilli
  • Low pH maintained by H2O2, which inhibits bacteria growth
  • Not considered an STI, but r/t sexual activity
25
Q

BV Links

A
  • Premature rupture of membranes
  • Premature delivery
  • Low birth weight
  • Acquisition of HIV
  • Development of PID
  • Post-op infections after GYN procedures
26
Q

BV Risks

A
  • African-Americans
  • 2+ sex partners in previous 6mo/new sex partner
  • Douching
  • Lack of barrier protection
  • Absence or decrease of lactobacilli
  • Lack of H2O2 producing lactobacilli
27
Q

H2O2-Producing Lactobacilli Facts

A
  • All lactobacilli produce lactic acid
  • Some also produce H2O2, which is a natural microbicide
  • Present in 42-74%
  • In vitro, H2O2 is toxic to viruses such as HIV as well as bacteria
28
Q

Vaginal Biofilms

A
  • Visualized as slime
  • Vagina is optimal environment for biofilms
  • Prevents ABX from getting to organisms
29
Q

BV Diagnosis: Amsel Criteria

A

Amsel Criteria: Must have 3+ of the following

  • pH >4.5
  • Presence of >20% per HPF of “clue cells” on wet mount examination
  • (+) amine “Whiff”test
  • Homogenous, non-viscous, milky-white D/C adherent to the vaginal walls
30
Q

Other Diagnostic Tools: BV

A
  • Vaginal Gram stain (Nugent or Speigel criteria)
  • Culture
  • DNA probe
  • PIP Activity
  • Sialidase tests
31
Q

BV: Treatment

A
  • 1st Line
    • Metronidazole 500mg PO BID x 7d
    • Metronidazole 0.75% gel intravaginally q day x 5d
    • Clindamycin 2% cream intravaginally qhs x7d
  • 2nd Line
    • Clindamycin 300mg PO BID x7d
    • Clindamycin Ovules 100g intravaginally qhs x3d
  • Chronic
    • Metronidazole gel twice weekly for 6mo
32
Q

BV: Treatment in Pregnancy

A 
Symptomatic
- Metronidazole 500mg BID for 7d
- Metronidazole 250mg TID for 7d
- Clindamycin 300mg BID for 7d
Asymptomatic high-risk women (those who have had previous pre-term birth)
- Screening and treatment at NOB visit
- F/U 1mo after treatment
33
Q

Screening & Treatment in Asymptomatic Non-Pregnant Patients

A
  • Male partners of women with BV do NOT need to be treated
  • Female partners of women with BV SHOULD be examined and treated
  • Screen and treat prior to hysterectomy or surgical abortion
34
Q

BV: Recurrence

A
  • Rate is ~20-40% 1mo after therapy
  • may be r/t persistence of BV-associated organisms and failure of lactobacillus flora to recolonize
  • Yogurt and exogenous lactobacillus supplements NOT proven to be helpful
  • Vaginal suppositories w/human lactobacillus strains being investigated
  • Twice weekly metronidazole gel for 6mo may reduce recurrence
35
Q

BV: Patient Education

A
  • Association w/sexual activity
  • High concordance in lesbian partnerships
  • Correct and consistent condom use
  • Avoid douching
  • Limit number of sex partners
36
Q

Vulvo-Vaginal Candidiasis (VVC): Facts

A
  • Affects most females during their life
  • Most caused by C. albicans
  • 2nd most common cause of vaginitis
  • NOT sexually transmitted pathogens
  • Yeast can grow as oval budding cells of chains of cells (pseudohyphae)
37
Q

Candidiasis: S/S

A
  • Vulvar pruritus is most common symptom
  • Thick, white, curd-like vaginal discharge
  • Erythema, irritaion, occasional erythematous satellite lesion
  • External dysuria and dyspareunia
38
Q

Candidiasis: Dx

A
  • Hx of recent ABX, S/S
  • Visualization of pseudohyphae (mycelia) and/or budding yeast (conida) on KOH or saline wet prep
  • pH NL (4-4.5)
    • If pH >4.5, consider concurrent BV or trich
  • Cultures NOT useful
39
Q

Classification: Uncomplicated VVC

A 
- Sporadic/infrequent VVC
OR
- Mild-to-moderate VVC
OR
- Likely to be C. albicans
OR
- Non-immunocompromised women
40
Q

Classification: Complicated VVC

A 
- Recurrent VVC (4+/yr
OR
- Severe VVC (edema/excoriation)
OR
- Non-albicans candidiasis
OR
- Women with uncontrolled DM, debilitation, or immunosuppression
OR
- Pregnancy
41
Q

Uncomplicated VVC: Treatment

A

Intravaginal agents:
Butoconazole 2% cream, 5 g intravaginally for 3 days†
Butoconazole 2% sustained release cream, 5 g single intravaginally application
Clotrimazole 1% cream 5 g intravaginally for 7-14 days†
Clotrimazole 100 mg vaginal tablet for 7 days
Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days
Miconazole 2% cream 5 g intravaginally for 7 days†
Miconazole 100 mg vaginal suppository, 1 suppository for 7 days†
Miconazole 200 mg vaginal suppository, 1 suppository for 3 days†
Miconazole 1,200 mg vaginal suppository, one suppository for 1 day
Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days †
Tioconazole 6.5% ointment 5 g intravaginally in a single application†
Terconazole 0.4% cream 5 g intravaginally for 7 days
Terconazole 0.8% cream 5 g intravaginally for 3 days
Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
Oral agent:
Fluconazole 150 mg oral tablet, 1 tablet in a single dose

42
Q

Complicated VVC: Treatment

A 
Recurrent VVC
- 7-14d of topical therapy, OR
- 100, 150, 0r 200mg oral dose of fluconazole (repeated 3d later) AND
- Maintenance regimens
Severe VVC
- 7-14d of topical therapy
- 150mg oral dose fluconazole (repeat 3d later
Non-albicans
- 7-14d non-fluconazole therapy
- 600mg boric acid in gel capsule vaginally qd x14d
Compromised Host
- 7-14d topical therapy
Pregnancy
- Fluconazole is CONTRAINDICATED
- 7d topical agents receommended
43
Q

Trichomoniasis: Facts

A
  • Most common treatable STD
  • Risks: Multiple sex partners; Lower socioeconomic status; Hx of STD; Lack of condom use
  • Sexually transmitted
  • Females and males may be asymptomatic
  • Caused by trichomonas vaginalis (flagellated anaerobic protozoa)
  • Associated w/pre-term rupture of membranes/delivery; increased risk of HIV
44
Q

Trich: S/S

A
  • May be asymptomatic or vagintitis
  • Frothy gray or yellow-green vaginal D/C
  • Pruritus
  • Cervical petechiae (“Strawberry cervix”)
  • May also infect Skene’s glands or urethra (not susceptible to topical therapy in these locations)
45
Q

Trich: In Males

A
  • May cause non-gonococcal urethritis

- Associated with increased shedding of HIV virus

46
Q

Trich: Dx (Females)

A
  • Motile trichomonads seen on wet mount
  • Vaginal pH often >4.5
  • Culture is the gold standard
  • Pap smear has low S&S
  • DNA probe
  • Rapid test
47
Q

Trich: Dx (Males)

A
  • 1st void urine concentrated
    • Examine for motile trichomonads
    • Culture
  • Urethral swab culture
48
Q

Trich: Tx

A 
1st Line
- Metronidazole 2g PO x 1 dose OR
- Tinidazole 2g PO x 1 dose
2nd Line
- Metronidazole 500mg BID PO x 7d
Pregnancy
- Metronidazole 2g PO x 1dose
49
Q

Trich: Tx Failure

A
  • Reinfection is most common reason for failure
    • Treat partners and avoid intercourse until both Tx are completed
  • If failure occurs w/single dose of metronidazole, use single dose tinidazole or metronidazole x7d
  • If failure occurs with either of these regimens, use tinidazole of metronidazole 2g PO x5d
  • If repeated Tx fails call CDC (Division of STD prevention)

N825 (16 decks)

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