Disorders of the Vulva and Vagina Flashcards
What components make up the vulva? 5
Occasionally contains what?
- Keratinized squamous epithelium,
- hair follicles,
- sebaceous glands,
- sweat glands,
- apocrine glands
- Occasionally contains breast tissue – may swell and become tender after delivery
- What kind of tissue makes up the vagina?
- Vaginal pH os what?
- Vaginal flora is made up of what? 3
- Nonkeratinized squamous epithelium
- Vaginal pH is 4.0- 4.5 in premenopausal women
- Vaginal flora –
- lactobacillus and other
- aerobic and
- anaerobic bacteria
Symptoms of vaginitis?
8
- A change in the volume, color, or odor of vaginal discharge
- Pruritus
- Burning
- Dyspareunia
- Dysuria
- Spotting
- Erythema
- Pelvic discomfort
Vaginitis
1. What is it important to document about veginitis?
- One CANNOT determine etiology from _________ alone and may mistreat the condition
- etiology of the vaginitis
2. history and PE
Careful external examination of the vulva:
1. In bacterial vaginitis the vulva appears how?
- What may suggest a dermatitis of the vulva? 3
- In bacterial vaginitis the vulva appears normal
- Erythema,
- lesions or
- fissures may suggest a dermatitis of the vulva
What things should we do in the exam for vaginitis?
5
- May detect a foreign body
- Note characteristics of vaginal discharge even though classic examples are not always the case
- Check the cervix for erythema and discharge
- Check for vaginal trauma
- Bimanual exam to check for cervical motion tenderness and uterine tenderness
- swab with a pH swab or dry swab the ______ of the vagina, not pooled secretions
- Use __________ pH paper or swab
- Premenopausal women—pH = ?
- Trichomoniasis—pH = ?
- Bacterial vaginosis—pH = ?
- Candidial infection—pH = ?
- In pregnant women amniotic fluid ______ the pH
- What is not helpful?
- WALL
- narrow range
- 3.5– 4.5
- 5.0-6.0
- > 4.5
- 4.0 – 4.5
- raises
- Bacterial cultures
What are some of the microscopy associated with vaginitis Dx?
4
- saline wet mount
- KOH prep
- rapid antigen
- Nucleic acid tests
What will you find on the following:
- saline wet mount 3
- KOH prep 3
What are the following tests used to dx?
3. Rapid antigen and Nucleic acid tests
- Saline wet mount: (evaluate within 20 min.)
- Clue cells—bacterial vaginosis (BV)
- Trichomonads
- Increased PMNs—cervicitis - KOH prep:
- Destroys cells
- Reveals hyphae & budding of yeast
- Amine test—smelling the slide immediately after adding KOH for the “fishy” smell of (BV or trich) - BV and rich
What is the most common cause of discharge of women of childbearing age?
Bacterial Vaginosis
Bacterial Vaginosis
- Abnormality of the normal vaginal flora? 2
- Findings on exam? 3
- Abnormality of the normal vaginal flora:
- Decrease in hydrogen-peroxidase lactobacilli
- Increase in primarily gram negative rods - Findings on exam:
- Fishy odor
- Clue cells
- Thin, white/gray, fishy smelling discharge
BV alone does not cause what? 5
What is usually the complaint?
BV alone does not cause what
- Dysuria
- Dyspareunia
- Pruritis
- Burning
- Vaginal inflammation
- Usual complaint is that of a malodorous or copious discharge
- Up to 75% of infections may be asymptomatic
Amsel criteria for diagnosis of BV
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
BV treatment:
- First line?
- Alternate?
- Preferred: Metronidazole:
- Oral 500mg BID for 7 days (no alcohol)
- Intravaginal (gel) 5g q day for 5 days - Clindamycin:
- Oral 300mg po BID for 7 days
- Intravaginal
2% cream 5g q day for 7 days
Ovules 100mg intravaginal X 3 days
Clindesse 2%, single intravaginal dose of 5g
- _________ as an adjunctive therapy may be helpful
2. Do sexual partners need to be treated?
- Probiotics as an adjunctive therapy may be helpful
2. Sexual partners do not need to be treated
- Describe reoccurence rates?
- Women who have 3 or more documented cases of BV in 12 months be offered what?
- What do we not do for this?
- Recurrence rates are high
- May retreat with same or different regimen - Women who have 3 or more documented cases of BV in 12 months be offered maintenance therapy—metronidazole gel for 7-10 days then twice weekly dosing for 4-6 months
- NOT clindamycin because of toxicity
Vulvovaginal Candidiasis
Second most common cause of vaginitis symptoms and accounts for 1/3 of vaginitis cases—not an STI
1. Primary etiologic agent? 2
2. Pathogenesis? 3
- Candida albicans,
- C. glabrata accounts for the remainder
- Organism migrates from the anus to the vagina and colonizes there
- Less common sexual or relapse from reservoir in vagina
- Infection occurs when there is overgrowth of candida
Risk factors for Candidiasis
4
- DM
- Increased estrogen levels (e.g. OCP, pregnancy)
- Immunosuppression
- Antibiotic use (up to 1/3 of women develop it)
Diagnosis for Candidiasis:
3
- On speculum exam
- KOH wet mount slide (up to 50% negative)
- In rare cases cultures for candida are indicated:
What would you find on the spectulum exam for candiasis? 3
- Thick, white, sometimes “cottage cheese”, discharge
- In severe cases a gray membrane
- pH = 4.0-4.5
Wen would you get a culture for candida?
2
- In multiple recurrent or persistent cases not responsive to treatment (may have resistant pathogen)
- Women with normal pH, no visible pathogen on wet mount
Vulvovaginal Candidiasis
Prevention/Education
5
- Keep the external genital area clean and dry.
- Avoid irritating soaps (including bubble bath), vaginal sprays and douches
- Change tampons and sanitary napkins frequently
- Wear loose cotton (rather than nylon) underwear that doesn’t trap moisture
- Take antibiotics only when prescribed and never take them for longer then necessary
Treatment for candidiasis:
Uncomplicated infection (Mild to moderate signs/symptoms, Probable infection with C. albicans, Healthy, nonpregnant)?
2
- Many OTC intravaginal treatments available and highly effective
Women may prefer oral treatment—
2. Fluconazole (Diflucan) 150 mg x 1 dose prescription and can interact with many drugs stays in vaginal secretions 72 hours
What would make a candida infection complicated?
7
- Severe signs/symptoms
- Infection with other than C. albicans, usually C. glabrata
- Pregnancy,
- DM,
- immunosuppression,
- debilitation
- History of verified (> 4 infections yr.) vaginal candidiasis
Treatment of complicated candida?
4
- Fluconazole 150 mg 2-3 doses 72 hrs apart
- Topical therapy w/ clotrimazole/miconazole/terconazole for 7 – 14 days
- Intravaginal boric acid tablets for 2 weeks (FATAL IF SWALLOWED)
- Flucytosine cream intavaginally qHS for 2 wks
What is the most common STI in the world?
Trichomonas Vaginitis
What is Trichomonas caused by?
Flagellated protozoan—Trichomonas vaginalis—causative organism
Trichomonas Vaginitis
- How can the symptoms from this range in women? 2
- How is the disease transmitted? 3
- Females infections range from
-asymptomatic (50%) to
-acute, severe, inflammatory disease
(Males are generally asymptomatic & the infection resolves spontaneously 90% of the time—the remainder get typical urethritis symptoms) - Women can acquire the infection from men or
- other infected women;
- men do not acquire it from other men
Trichomonas Vaginitis
Presentation?
4
- Malodorous, thin, green/yellow vaginal discharge (70%)
- Burning, dysuria, frequency (urethra commonly involved also)
- Pruritus, dyspareunia, pelvic discomfort
- Post-coital bleeding