BENIGN GYN - VULVOVAGINITIS

Question 1

Benign OB: Initial Evaluation

Answer 1

• Medical history
• Obstetric and GYN history
• Women’s physical exam
  o VS, WT/HT
• Breast, thyroid, abdominal, and genital area
  o Pap smear (if indicated)
  o Wet mount (vaginal discharge)
  o GC/chlamydia DNA probe test

Question 2

Vulvovaginitis: 3 Categories

Answer 2

• Bacterial vaginosis
• Vulvovaginal candidiasis
• Trichomoniasis

Question 3

Vulvovaginitis definition?

Answer 3

• The simultaneous inflammation of the vulva and vagina
• Triad of vulvovaginitis symptoms: vaginal itching, burning, and vaginal discharge
• Result of infection
• Noninfectious causes include allergic reactions, foreign body, atrophic or traumatic vaginitis, or collagen vascular disease

Question 4

Vulvovaginitis: Causes

Answer 4

• Infection from bacteria, yeast or parasites
• Gardnerella, which causes bacterial vaginosis (BV), accounts for 50% of all infections
• Diagnosis based on type, amount, color, odor, and pH of discharge
• Physical exam for presence of lesions, discharge, erythema, or atrophy

Question 5

Vulvovaginitis: Differential Diagnosis

Answer 5

• The vaginal environment can be easily altered by numerous internal/external influences
  o Ovulatory mid-cycle mucus production
  o Menstruation
  o Antibiotics
  o Diabetes mellitus or glycosuria
  o Stress
• History with time of symptom onset, description of discharge, and relationship of symptoms to menses, coitus, and use of medications
• Risk for STIs and use of spermicidal preparations, douches, or bubble bath should be addressed as well

Question 6

Vulvovaginitis: Vaginal Hygiene

Answer 6

• What measures help prevent vaginal infections in women?
  o Clothing
  o Soaps, sprays, feminine products (Dove Soap is recommended)
  o Showers, no tub baths
  o Yogurt? Not EBP but might be useful
  o No douching - can change the Ph and conditions in the vaginal vault

Question 7

Vulvovaginitis: Laboratory Testing

Answer 7

• Saline wet mount of vaginal discharge to determine presence of Gardnerella-clue cells=BV, Trichomonas, or atrophic vaginitis
• KOH wet mount for presence of Candida (hyphae)=Candida infection
• BV= POSITIVE whiff test
• Gram stain for presence of gonorrhea
• Urinalysis to rule out UTI

Question 8

Bacterial Vaginosis (BV)

Answer 8

• Caused by increased anaerobic bacteria
• Most prevalent cause of discharge
• May be asymptomatic
• Risk factors
• Diagnosis
• Associated complications
• Treatment
• Management of sex partners (does not pass infection sex partner)

Question 9

Bacterial Vaginosis: Treatment

Answer 9

• If asymptomatic, there is no need to treat
• Flagyl 500mg BID for 7 days (don’t drink etoh with this – nausea)
• Metrogel 0.75%, for 5 nights
  CHRONIC
• Boric acid vaginally for chronic BV
• Clindamycin 500mg BID has shown to help work too for chronic

Question 10

Vulvovaginal Candidiasis

Answer 10

• Caused by C. albicans or other Candida
• Typical symptoms
• Differential diagnosis
• Diagnosed with vaginal microscopy
• What are predisposing factors?
  o Diabetes

Question 11

Vulvovaginal Candidiasis: Treatment

Answer 11

• Treated topically with azoles ie. Clotrimazole, Miconazole, Terconazole
  o Diflucan (Fluconazole) 150 mg po or if recurrent 100-400mg qd for 1 to 5 days
  o Ketoconazole 200mg qd for 5 days (liver function)
• Alternatives therapies: yogurt, boric acid tablets 🡪 (VAGINALLY)