Disorders of the Vulva and Vagina

Question 1

pH ranges in vaginitis

Answer 1

Premenopausal women—pH = 3.5– 4.5
Trichomoniasis—pH = 5.0-6.0
Bacterial vaginosis—pH >4.5
Candidial infection—pH = 4.0 – 4.5
In pregnant women amniotic fluid raises the pH

Question 2

Bacterial Vaginosis

Answer 2

Most common cause of discharge of women of childbearing age (40-50%)
Abnormality of the normal vaginal flora:
Decrease in hydrogen-peroxidase lactobacilli
Increase in primarily gram negative rods

Question 3

Bacterial Vaginosis Findings on exam:

Answer 3

Fishy odor
Clue cells
Thin, white/gray, fishy smelling discharge

Question 4

Amsel criteria for dx of BV

Answer 4

At least 3 of the 4 criteria
Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
Vaginal pH > 4.5
Positive whiff-amine test
Clue cells on saline wet mount, comprising at least 20% of epithelial cells

Question 5

Vulvovaginal Candidiasis

Answer 5

Second most common cause of vaginitis symptoms and accounts for 1/3 of vaginitis cases—not an STI
Primary etiologic agent: Candida albicans, C. glabrata accounts for the remainder
More common in those on OCP’s or DM or immunocompromised
cottage cheese like discharge

Question 6

Vulvovaginal Candidiasis Complicated infection Treatment

Answer 6

Fluconazole
Topical therapy w/ clotrimazole/miconazole/terconazole
Intravaginal boric acid tablets for 2 weeks (FATAL IF SWALLOWED)
Flucytosine cream intavaginally

Question 7

Trichomonas Vaginitis

Answer 7

Most common STI WORLD wide
Flagellated protozoan—Trichomonas vaginalis is the causative organism
Infects both females and males

Question 8

Trichomonas Vaginitis Presentation

Answer 8

Malodorous, thin, green/yellow vaginal discharge (70%) can also be frothy
Burning, dysuria, frequency (urethra commonly involved also)
Pruritus, dyspareunia, pelvic discomfort
Post-coital bleeding
Get “strawberry” cervix

Question 9

Trichomonas Vaginitis Treatment

Answer 9

Tinadazole (Tindamax) or metronidazole (Flagyl)

Question 10

Codylomata acuminata (anogenital warts)

Answer 10

MOST common viral sexually transmitted disease in the U.S.

Etiologic agent: HPV—serotypes 16 & 18

Question 11

Atrophic Vaginitis Clinical manifestations

Answer 11

Vaginal dryness, burning or itching
Decreased lubrication during sex
Dsypareunia
Vulvar or vaginal bleeding (postcoital bleeding)
Vaginal discharge
Pelvic pressure or vaginal bulge
Urinary tract symptoms—frequency, dysuria, hematuria

Question 12

Lichen Sclerosis

Answer 12

Etiology may be linked to genetics, autoimmune
Pathophysiology: Intense inflammatory reaction
Two peaks—prepubertal girls & postmenopausal women
Vulvar pruritus is the hallmark and may be so intense as to interfere with sleep

Question 13

Treatment for lichen sclerosis

Answer 13

clobetasol propionate 0.05% cream for 6-12 weeks (topical steroids)

Question 14

Marsupilization:

Answer 14

Done under local anesthesia
Longer procedure
Reserved for patients who fail 1-2 placements of a Word catheter
Complications: hematoma, scarring, dyspareunia

Question 15

Paget’s Disease

Answer 15

Intraepithelial adenocarcinoma
Extramammary disease may involve genital, perianal and axillary areas
Lesions are brick red, scaly, velvety eczematoid plaque with sharp border
S/S: itching, burning, bleeding
Treatment: excision with > 3 mm border from visible margin