Disorders of the Vagina and Vulva Flashcards
Normal pH of vagina is what?
<4.5 (very acidic)
A vaginal pH 4.5 or higher is indicative of what?
infection (makes vagina alkaline)
What is the predominant normal vaginal flora?
Lactobacillus predominates
What does Lactobacillus produce?
produces hydrogen peroxide
Which vaginal infection is described below?
Gram negative obligate intracellular bacteria that lack the ability to
make it’s own ATP
Infects columnar epithelium
If untreated, up to 40% may develop pelvic inflammatory disease
(PID)
Chlamydia
C. trachomatis serotypes L1, L2, L3 cause this
Presents as inguinal or femoral lymphadenopathy in women
A self-limiting vesicle or papule sometimes forms
This is a systemic infection that, if untreated, can cause secondary
infection of the rectal or anal lesions which can lead to abscesses or fistulas
Lymphogranuloma Verereum
Which vaginal infection is described below?
Frequently asymptomatic
Mucopurulent cervicitis – angry, red congested cervix
Discharge indistinguishable from gonorrhea
Irregular bleeding (post coital)
Dysuria
Chlamydia
Is a test of cure required for chlamydia?
Unless erythromycin is used, test for cure is not recommended unless symptoms remain or
reinfection is suspected
Which vaginal infection is described below?
Gram negative intracellular diplococcus
Found in 20% of PID cases
Risk of transmission after one exposure is 70%
Emergence of antimicrobial resistant strains
Gonorrhea
What are the multiple methods that can be used to diagnose chlamydia?
Culture
Direct fluorescent antibody
Enzyme immunoassay (EIA)
Gen probe – swab
Nucleic acid hybridiziation testing
Nucleic acid amplification testing
(NAAT)
Urine screening
What is the treatment of choice for chlamydia?
Azithromycin 1 gm PO once
What is the treatment of choice for chlamydia in pregnant patients?
Azithromycin 1 gm PO once
There are concerns that gonorrhea may facilitate transmission of what?
HIV
Risk of transmission of gonorrhea after one exposure is what percentage?
70%
Which vaginal infection is described below?
Appear within 3-5 days of infection
Copious mucopurulent vaginal discharge in women, may be greenish-yellow
Cervix is inflamed and edematous with discharge from the os
May have purulent anal discharge
Gonorrhea
What are the multiple methods that can be used to diagnose gonorrhea?
Genital culture
Gen probe
Gram stain
Testing may be added to many liquid based pap smears
What percentage of gonorrhea cases have a co-infection of chlamydia?
30%
What is the treatment of choice for gonorrhea?
Aggressive therapy for suspected or confirmed
Ceftriaxone (Rocephin) 250mg IM once
Which vaginal infection is described below?
Vulvar erythema and edema
Itching
White, curdy discharge (cottage cheese)
Candidiasis
What organisms are responsible for vaginal candidiasis?
Candida albicans
Candida glabrata
What are the risk factors for candidiasis?
Antibiotic use
Pregnancy
OCP use
Consider screening for diabetes if recurrent
What is the gold standard of diagnosing candidiasis?
Vaginal culture
What is the treatment for vaginal candidiasis?
Fluconazole (Diflucan) 150mg PO x 1 dose, may repeat in 3 days if
symptoms persist
Which vaginal infection is described below?
Unicellular flagellate protozoan
Colonizes the urethra, vagina, Skene ducts
Non-sexual transmission is infrequent because large numbers of organisms are required to produce infection
Trichomonas
What is Trichomonas associated with?
Increased incidence of HIV
PID
Endometritis
Preterm birth/low birth weight
Premature rupture of the membranes
Which vaginal infection is described in the presentation below?
Profuse vaginal discharge - Frothy, green-ish in color, foul smelling at times
Swollen and tender labia minora
Dysuria
Dyspareunia
Vaginal itching
Vaginal and cervical erythema with multiple small petechiae
Trichomonas
What sign in a Trichomonas infection is found in 10% of cases?
Strawberry cervix
What is the gold standard for diagnosing Trichomonas?
Culture
What is the only FDA approved treatment for Trichomonas?
Metronidazole
Which vaginal infection is described below?
Common viral infection capable of causing superficial oral and vulvar
ulcerations or necrotic mass of the cervix leading to profuse vaginal
discharge
Herpes Simplex Virus
Which type of herpes infection is described below?
Causes most genital lesions
Genital recurrence likely
After primary infection - 1 outbreak – 90% within 1 year, 6 outbreaks – 38%, >10 outbreaks – 20%
HSV-2
Which type of herpes infection is described below?
Oral cold sores
Responsible for 10-15% of genital (80% of new genital infections)
Increasing among adolescents and young adults
Genital recurrence not likely
HSV-1
HSV virus may be shed up to how long after lesions appear?
up to 3 weeks
What are not effective at eliminating transmission of HSV?
Condoms
What is a definitive test for HSV?
PCR testing
Pregnant patients with known HSV-2 should be offered suppressive therapy started at how many weeks?
36 weeks
In pregnant patients, what is recommended if herpetic lesions are identified at the time of labor, regardless of whether it is primary or recurrent?
C section
Which vaginal infection is described below?
Caused by Treponema pallidum – spirochete
Spirochetes pass through intact mucous membranes and abraded skin
10-90 days later, a primary lesion or chancre appears
Syphilis
Transplacental spread of syphilis may occur when during pregnancy?
at any time
indurated, firm, painless ulcer with rolled borders
Chancre- - seen in primary syphilis
How long does it take for chancre to heal in primary syphilis?
Heals spontaneously within 3-6 weeks
Secondary syphilis develops in what time frame following untreated primary syphilis?
4-8 weeks
Secondary syphilis resolves spontaneously in what time frame?
2-6 weeks
Which stage of syphilis is described below?
Diffuse systemic spread hematogenously
Viral syndrome with diffuse lymphadenopathy - Fever, HA, fatigue, weight loss, muscle aches, patchy hair loss
Skin rash - Rough, red or brown lesions on palms and soles
Condyloma lata - Moist appearing patches, Highly infective, Broad-based and flat
Secondary syphilis
Which stage of syphilis is described below?
Chancre- indurated, firm, painless ulcer with rolled borders, 10-60 days after infection
Penis, vulva, vagina, cervix, anus, lips, nose, nipple can be affected
Heals spontaneously within 3-6 weeks
Painless, rubbery, regional lymphadenopathy
Primary syphilis
Which stage of syphilis is described below?
2-6 weeks following untreated secondary syphilis
No signs or symptoms of disease
Transmission during this stage unlikely except through blood or placental transfusion
Latent Syphilis
Which stage of syphilis is described below?
Develops in 1/3 of untreated cases
Cardiac manifestations
Ophthalmic and auditory lesions
Gummas – lesions of bone and skin
Neurologic manifestations
Tertiary Syphilis
Due to high risk of false positives, what is the preferred way to diagnose syphilis?
Must have two positive tests due to possible false-positives with the
non-treponemal tests (RPR and VDRL)
Common to screen with RPR and confirm with one of the other treponemal-specific tests
What is the follow up schedule for patients treated for syphilis?
Quantitative VDRL titers and exams at 3,6 and 12 months
Abstain from sexual intercourse until all lesions are completely healed
What is the DOC for treating syphilis?
Benzathin penicillin G 2.4 million units IM once
Which vaginal infection is described below?
This is not an STD – can be due to a change in vaginal pH
Caused by polymicrobial change in vaginal flora
Anything that changes the pH of the vaginal
Bacterial Vaginosis
What is the most common organism responsible for bacterial vaginosis?
Gardnerella vaginalis
What are the Amsel criteria in gardnerella vaginalis?
Abnormal grey discharge
pH greater than 4.5 (normal is 3.2 to 4.5)
Positive “whiff” test
Presence of clue cells on saline wet mount (epithelial cells stippled with
bacteria)
Which vaginal infection is described below?
Fishy vaginal odor especially after intercourse
Creamy grey-white or yellow vaginal discharge
Little or no vaginal irritation
Recurrence very common
Bacterial Vaginosis
What factors can help prevent the recurrence of bacterial vaginosis?
Condoms
Longer treatment length
Prophylactic treatment
Acidify the vagina
Note: Treating partrer does not decrease recurrence
Condition of the vulva involving thinning, dryness, and irritation of the mucosa
Tissue is dry, whitish, non-elastic
Found in situations of low estrogen
Vaginal Atrophy
Vaginal epithelium is thin and more susceptible to what in atrophic state?
infection and trauma
What are some signs and symptoms of vaginal atrophy?
Vaginal mucosa is thin with few or absent vaginal folds
Vaginal dryness
Dyspareunia (Lack of elasticity and dryness)
Vaginal wall defects may result from what?
Childbirth and resulting injury to cardinal ligaments (main support structures of the uterus)
Weakening of pelvic structures with aging
Increased intra-abdominal pressure (obesity, repeated heavy lifting, chronic cough, etc)
What is the most common cause of vaginal wall defects?
Childbirth
What are the four types of vaginal wall defects?
Uterine
Anterior vaginal wall (Cystocele, Cystourethrocele)
Posterior vaginal wall (Rectocele, Enterocele (rectum + bowel)
Vaginal vault (post-hysterectomy)
Uterus protrudes into the vagina
Uterine Prolapse
Relaxation and descent of bladder into vagina due to weakening or
injury (childbirth) to pelvic fascia
Cystocele
What are some signs/symptoms of a cystocele?
“something is bulging or falling out”
Incontinence
Frequent UTIs due to incomplete bladder emptying
May be asymptomatic
Relaxation and descent of rectum posteriorly into vagina resulting
from injury and/or weakness of pelvic fascia
Rectocele
What is the most common symptom seen with rectoceles?
constipation
What are some signs/symptoms of a rectocele?
Most common symptom is constipation
“something is bulging or falling out”
Splinting - Patient will use thumb or toilet paper to apply pressure to posterior vaginal wall to help initiate defecation
Posterior vaginal wall herniation at Pouch of Douglas (posterior culdosack)
Likely to contain loops of bowel (Can present as a bowel obstruction)
Typically high in vaginal vault - May be able to differentiate
this from high rectocele with rectovaginal exam
Enterocele
Uncommon cancer
Accounts for only 5% of gynecological cancers
Primarily a disease of postmenopausal women
Vulvar Cancer
What is strongly associated in women of younger ages, but not older
women with vulvar cancer?
HPV
In cases of vulvar cancer, what is the presenting symptom in >50% of cases?
Pruritis
What are the types of vulvar cancer?
Squamous Cell carcinoma
What is the most common type of vulvar cancer?
Squamous Cell carcinoma
Malignant melanoma
Basal cell carcinoma
Carcinoma of Bartholin’s gland
In vulvar cancer, what percentage of squamous cell cancers arise from labia minora or majora?
65%
In vulvar cancer, what percentage of squamous cell cancers arise from clitoris or
perineum?
25%
What is the second most common type of vulvar cancer?
Malignant melanoma
~2-6% of vulvar cancers
Most commonly arise on labia minor or clitoris with a tendency
to spread toward the urethra and vagina
Raised, irritated, pruritic, pigmented lesion
Malignant melanoma
Account for ~1% of vulvar cancers
Most are small elevated lesions with an ulcerated center and rolled edges
Found almost exclusively on labia majora
Basal cell carcinoma
Account for ~1% of vulvar cancers
Because it is difficult to clinically differentiate a tumor of the
Bartholin gland from a benign Bartholin cyst, any woman >40
years old should undergo biopsy
Recurrence common
5 year survival rate is 65%
Carcinoma of Bartholin’s gland
