Disorders of the Vulva and Vagina Flashcards
Causes of vaginitis?
- bacterial vaginosis
- trichomonas
- candidiasis
Normal cell structure of the vulva?
- keratinized squamous epithelium, hair follicles, sebaceous glands, sweat glands, apocrine glands
- occasionally contains breast tissue: may swell and become tender after delivery
Normal cell structure and flora of the vagina?
- nonkeratinized squamous epithelium
- vaginal pH is 4.0-4.5 in premenopausal women
- vaginal flora - lactobacillus and other aerobic and anaerobic bacteria
- normal vaginal secretions: no odor
How common are vaginal sxs?
- extremely common, account for over 10 million office visits/yr
- many women use OTC products (usually anticandidial tx) w/o ever seeing a provider
What are the sxs of vaginitis?
- change in volume, color, or odor of vaginal d/c
- pruritus
- burning
- dyspareunia
- dysuria
- spotting
- erythema
- pelvic discomfort
Can you determine etiology of vaginitis just by H and P?
- no, may mistreat condition
- impt that lab documentation of etiology of vaginitis is determined
- sxs are nonspecific
PE of vagintis?
careful external exam of vulva:
- in bacterial vaginitis the vulva appears normal
- erythema, lesions or fissures may suggest a dermatitis of the vulva
- may be changes suggesting chronic inflammation
- may detect fb
- note characteristics of d/c
- check cervix for erythema and d/c
- check for vaginal trauma
- bimanual exam to check for cervical motion tenderness and uterine tenderness
pH testing for vaginitis?
swab with pH swab or dry swab the wall of the vagina, not pooled secretions
- use narrow range pH paper or swab
- premenopausal women= 3.5-4.5
- trichomoniasis= 5.0-6.0
- bacterial vaginosis= greater than 4.5
- candidiasis= 4.0-4.5
- in pregnant women amniotic fluid raises pH
Are bacterial cultures of the vagina helpful?
- NOPE!
What are saline wet mounts for? What will be seen?
- eval in 20 min
- see clue cells - bacterial vaginosis
- trichomonads
- increased PMNs- cervicitis
What is a KOH used for? What does it reveal? What otehr test is used along with this?
- destroys regular cells and reveals hyphae and budding of yeast
- amine test - smelling the slide immediately after adding KOH for fishy smell (BV or trich)
What other tests are available for trich and BV?
- rapid antigen and nucleic acid tests
What is the MC cause of d/c of women of childbearing age? What is the cause of this? Findings on exam?
- Bacterial vaginosis (40-50%)
- abnormality of normal vaginal flora: decrease in hydrogen-peroxidase lactobacilli and increase in primarily gram negative rods
- findings on exam:
fishy odor, clue cells, and thin, white/gray, fishy smelling d/c
Usual complaint of a pt with BV?
- malodorous or copious d/c
- up to 75% of infections may be asx
What is the amsel criteria for the dx of BV?
at least 3/4 criteria:
- homogenous, thin, grayish white d/c that smoothly coats the vaginal walls
- vaginal pH greater than 4.5
- positive whiff-amine test
- clue cells on saline wet mount, comprising at least 20% of epithelial cells
Tx for BV?
- TOC: metronidazole oral 500 mg BID for 7 days (no alcohol), or intravaginal (gel) 5g qday for 5 days - clindamycin: oral 300 mg po BID for 7 days intravaginal: 2% cream 5g qday for 7 days ovules 100 mg intravaginal x 3 days clindesses 2%, single intravaginal dose of 5 g
- probiotics as adjunctive therapy may be helpful, sexual partners don’t need to be tx
Recurrence rates of BV? How should these be tx?
- recurrence rates are high
- may retx with same or different regimen
- women who have 3 or more documented cases of BV in 12 months be offered maintenace therapy - metronidazole gel for 7-10 days then 2x weekly dosing for 4-6 months
- not clindamycin b/c of toxicity
2nd MC cause of vaginitis sxs? What are the etiologic agents?
- vulvovaginal candidiasis
- accounts for 1/3 of vaginitis cases (not an STI)
- primary etiologic agent: candida albicans, C. glabrata accounts for remainder
Pathogenesis of vulvovaginal candidiasis?
- 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
RFs for candidiasis?
- DM
- increased estrogen levels (OCP, pregnancy)
- immunosuppression
- abx use (up to 1/3 of women develop it)
Dx of candidiasis?
- on speculum exam:
thick, white, sometimes cottage cheese d/c.
in severe cases a gray membrane, pH will be 4.0-4.5 - KPH wet mount slide (up to 50% negative)
- in rare cases cultures for candida are indicated:
in multiple recurrent or persistent cases not responsive to tx (may have resistant pathogen), women with normal pH, no visible pathogen on wet mount
Education for pt to prevent candidiasis?
- keep external genital area clean and dry
- avoid irritating soaps, vaginal sprays, douches
- change tampons and sanitary napkins frequently
- wear loose cotton (rather than nylon) underwear that doesn’t trap moisture
- take abx only when rx and never take them for longer than necessary
Tx of uncomplicated candidiasis infection?
this includes pts with mild to moderate signs/sxs, have probable infection with C. albicans, pt is healthy and not pregnant
tx:
- many OTC intravaginal txs available and highly effective, women may prefer oral tx:
fluconazole (diflucan) 150mgx1 dose - this can interact with many drugs, stays in vaginal secretions for 72 hrs
Tx for complicated candidiasis infection?
this includes pts with severe signs/sxs, infection with other C. albicans (usually C. glabrata), pregnancy, DM, immunocompromised, debilitated, hx of verified (more than 4 infections a yr) of vaginal candidiasis
tx:
- fluconazole 150mg 2-3 doses 72 hrs apart, or topical therapy with clotrimazole/miconazole/terconazole for 7-14 days, or intravaginal boric acid tablets for 2 wks (fatal if swallowed) or flucytosine cream intravaginally qhs for 2 wks
What is the most common STI worldwide? What type of organism is this? Who does this infect? Sxs?
- Trichomonas vaginitis
- flagellated protozoan (causative agent = trichomonas vaginalis)
- females infections range from asx (50%) to acute, severe, inflammatory disease
- males are generally asx and infection resolves spontaneously 90% of the time (the remainder get typical urethritis sxs)
- women can acquire the infection from men or other infected women, but men can’t acquire it from other men
Presentation of trichomonas vaginitis?
- malodorous, thin, green/yellow vaginal d/c (70%)
- burning, dysuria, frequency (urethra commonly involved also- presents like a UTI)
- pruritus, dyspareunia, pelvic discomfort
- post-coital bleeding
Dx of trichomonas?
- on speculum exam you may see green, malodorous, frothy d/c (less than 10%)
- will see strawberry cervix in 2%
- pH 5-6
- mobile T. vaginalis on wet mount (seen 60-70%)
- can do rapid antigen and nucelic amplification tests (usually available where prevalence is high)
- on males can do PCR test on urine or a urethral swab, trying to look for motile trich has very low yield
Tx of trichomonas?
- all women even if asx should be tx if there is an infection
- all partners involved need to be tx and must abstain from sex until finishing abx and are asx
- non-preg females and males:
tinadazole (Tindamax) or metronidazole (flagyl)- 1 time dose of 2 grams (4-500mg pills) - pregnant females: 2 g dose of metronidazole
- nursing females: 2 g dose of flagyl but pump breast milk and discard for 24 hrs after taking
- HIV pts: 7 day course of either med BID
Why do recurrent infections of trichomonas occur? Tx?
- usually due to return to sexual activity too soon and reinfection
- may tx with metronidazole 2g dose again or use 7 day course of 500 mg BID of either drug
- if above fails - can tx with 2 g a day for 5 days
- if still refractory - culture to see if resistant strain
- in general there isn’t a 2nd line abx, desensitization is recommended if pt allergic
Cause of genital herpes? How common in US? What outbreak is the worst?
- caused by HSV 1 and 2
- among the most ubiquitous of human infections
- HSV-2 affecting 26% of adult females and 18% adult males in US (approx 50 mill)
- much higher in certian pops
- Primary outbreak is the worst episode and recurrent outbreaks are generally less severe
Sxs of genital herpes?
- painful genital ulcers and itching
- dysuria
- tender inguinal lymphadenopathy
- may have systemic sxs like HA and fever
Dx of genital herpes?
- PE: multiple vesicle on an erythematous base, vulvar swelling, lymphadenopathy
- dx should be confirmed by viral cell culture (Tzanck smear) or PCR
Management of genital herpes - primary infection?
- needs to be started w/in 72 hrs for 7-10 days:
acyclovir 400mg TID or 200mg 5x a day
famcyclovir 250mg TID
valocyclovir 1000mg BID
Management of genital herpes - recurrent outbreak?
- acylovir: 800 mg BIDx 3 days
- famcyclovir: 1000mg BIDx 1 day
- valocyclovir: 500 mg BIDx 3 days
Suppressive therapy for herpes simplex?
- acyclovir 400 mg BID
- famcyclovir 250 mg BID
- valocyclovir 500 mg 1x a day
What is the most common viral STI in US? Etiologic agent?
- codylomata acuminata (anogenital warts)
- HPV - serotypes 6 and 11
- as many as 50-75% of sexually active people infected with HPV during their lifetime
- women account for 67% of the affected pop.
Clinical manifestations of genital warts?
- pruritus, burning, pain
- bleeding, vaginal d/c
- may have no sxs
- when very large can interfere with defecation and coitus
Tx success for genital warts? Indications for tx?
- must inform pt that prolonged tx with frequent f/u is necessary
- clearance of warts is 35-100% but latent HPV can still exist and 20-30% have recurrence
- spontaneous regression occurs up to 40% of cases
indications:
- alleviation of bothersome sxs
- cosmetic
- b/c of obstruction, dyspareunia, or psychological distress
- to decrease risk of transmission
When should a bx be recommended for genital warts?
if:
- dx is uncertain
- lesion has suspicous features (irregular or unusual pigmentation)
- pt is postmenopausal or immunocompromised
- lesion is refractory to medical therapy
Diff types of tx for genital warts?
chemical destruction:
- podophyllin: must not be used in pregnancy
- trichloracetic acid: highly caustic, can be used in pregnancy
- 5-FU gel is injected into lesions
immunologic:
- imiquimod (aldara): externally applied cream
- interferon alpha - systemic therapy
surgery:
- cryotherapy: liquid nitrogen, or probe cooled with nitrous oxide
- laser therapy: done in operating room with anesthesia
- excisional: knife or scissors, requires anesthesia
Can vertical transmission of genital warts occur?
- yes, HPV can manifest in young children as:
mucosal, conjunctival or laryngeal disease, juvenile-onset respiratory papillomatosis (JRP) is most severe although rare
Presentation of mulloscum contagiosum?
- multiple, 1-2 mm raised, painless lesions
- dome shaped with central dimple
- contains cheesy-white material
- can be sexually transmitted
- tx: cryosurgery, bichloracetic acid, dermal curette but will clear on own eventually
When does atrophic vaginitis occur? What can be done to tx this?
- can occur in women of any age who experience a decrease in estrogenic stimulation of urogenital tissue
- estrogen stimulation:
maintains a well epithelialized vaginal vault, it acts on receptors in the vagina, vulva, urethra, and trigone of bladder - maintains the collagen content of epithelium
- keeps epithelial surfaces moist
- maintains optimal genital blood flow
- maintains acidic vaginal pH (w/o estrogen pH would be over 5)
Main RFs of atrophic vaginitis?
- *- natural menopause
- *- bilateral oophorectomy
- spontaneous premature ovarian failure
- ovarian failure due to radiation, chemo or surgery
- premenopausal meds with anti-estrogenic effect
- post-partum reduction in estrogen prod. during lacatation
- prolactin elevation
- amenorrhea secondary to suppression of hypothalamic pituitary axis b/c of chronic tx with glucocorticoids
Clincal manifestations of atrophic vaginitis?
- vaginal dryness, burning or itching
- decreased lubrication during sex
- dyspareunia
- vulval or vaginal bleeding (post-coital bleeding)
- vaginal d/c
- pelvic pressure or vaginal bulge
- urinary tract sxs - freq., dysuria, and hematuria
PE findings of atrophic vaginitis?
- pale, smooth or shiny vaginal epithelium
- loss of elasticity
- sparsity of pubic hair
- introital narrowing
- fusion or resorption of labia minora
- friable, unrugated epithelium of vagina
- shortened, narrowed and poorly distensible vaginal vault
Common presentation and findings of pt with atrophic vaginitis?
- 2 yrs since natural menopause
- loss of labial and vulvar fullness
- pallor of urethral and vaginal epithelium
- narrow introitus
- minimal vaginal moisture
- loss of urethral meatal turgor
Tx for atrophic vaginitis? Most effective tx?
- indicated if sxs are causing a woman distress
- for vaginal dryness: replens, vagisil, K-Y (use 1-2x a wk)
use lubricants for intercourse: watersoluble (k-y), silicone (Pjur eros)
oil based: elegance women’s lubricant - sexual activity itself may improve vaginal fxn
vaginal estrogen therapy:
most effective, CIs: estrogen dependent tumor
- assoc with urinary tract benefits, usually start with vaginal estrogen therapy: cream, tablet, ring
SE: irritation, bleeding or breast tenderness
- some women need systemic therapy (refer)
- SERM:
ospemifene (osphena)
SE: hot flushes, thromboembolism, endometrial cancer
lichen sclerosis: etiology PP dx sx - hallmark?
- etiology: may be genetics or autoimmune
- pp: intense inflammatory rxn
- 2 peaks: prepubertal girls and postmenopausal women
- dx: bx
- 4% risk of cancer occurring
-sxs:
vulvar pruritus is hallmark and may be so intense as to interfere with sleep, pruritus ani, painful defecation, anal fissures, dyspareunia
Exam findings of lichen sclerosis?
- chronic inflammation
- well-demarcated white, finely wrinkled, atrophic patches
- labia minora often shrink and adhesions of labia majora may cover clitoris
Tx for lichen sclerosis?
- clobetasol propionate 0.05% cream for 6-12 wks (topical steroids)
- then for maintenance therapy apply 1-3x/wk
How common are bartholin gland disorders? Why is a good DDx needed?
- 2-3% of women develop cysts or abscesses of Bartholin glands
- carcinoma and benign tumors are rare
- many vaginal and vulvar lesions mimic bartholin gland disorders need a good ddx
How big are bartholin duct cysts? Sxs? Tx?
- most common large cyst of vulva: 1-3 cm size
- most are asx:
tx not necessray in women less than 40 unless infected or sx - in women older than 40, bx and drainage is performed to exclude carcinoma
- if cyst is large and not resolving then it can be tx with techniques described for tx an abscess
Clinical manifestations of bartholin duct abscess?
- swelling of bartholin gland w/ exquisite pain
- occurs in 2% of women
- on exam: erythematous, warm, tender, and usually fluctuant
- there may be surrounding cellulitis
- infection: usually polymicrobial, STIs less likely but should be tested for in pts who are at higher risk of STIs
Rise in MRSA as etiologic agent
Tx of cyst or abscess?
- I&D: lanced at or behind hymenal ring
- place a word cath into cavity: left in place for at least 4 wks
- marsupialization: done under local anesthesia, longer procedure, reserved for pts who fail 1-2 placements of word catheter, complications: hematoma, scarring, and dyspareunia
What is a cystocele? Causes?
- prolapsed bladder
- bulging of bladder into vagina
- occurs when supportive tissues and muscles b/t bladder and vagina weaken and stretch - bladder bulges into vagina
- causes:
childbirth
repetitive straining for BM
constipation
chronic or violent coughing
heavy lifting
obesity
Tx of cystocele?
- graded - depending on severity
tx: - watchful waiting, avoid heavy lifting or straining
- kegels to strengthen pelvic muscles
- pessary: silicone medical device placed in vagina that supports vaginal wall and hold bladder in place
- anterior vaginal wall repair (colporrhaphy)
What is paget’s disease?
- intraepithelial adenocarcinoma
- extramammary disease may involve genital, perianal, and axillary areas: may be an indication of underlying malignancy
- lesions are brick red, scaly, velvety eczematoid plaque with sharp border
- S/S: itching, burning, bleeding
- cellular origin unclear
Tx of paget’s?
- primary: excision with more than 3 mm border from visible margin
- recurrent disease may be tx with:
radiotherapy
laser
photodynamic therapy
5-FU
imiquimod - local recurrence rate 31-43%
How common is vulvar cancer? RFs?
- 4th MC gyn cancer
- represents 5% of malignancies of female
genital tract - RFs:
HPV infetion (60%)
smoking
lichen sclerosis
vulvar or cervical intraepithelial neoplasia
immunodeficiency syndromes
prior hx of cervical cancer
Northern European ancestry
Clincal manifestations of vulvar cancer?
- unifocal vulvar plaque, ulcer or mass
- in 10% of cases the lesion is too extensive to determine the site of origin
- lesions are multifocal in 5% of cases
- a 2nd malignancy: usually cervical CA is found in up to 22% of pts with vulvar malignancy
- pruritus is common complaint
- many pts are asx: need to inspect
Histological types of vulvar cancer?
- squamous cell: over 90% - keratinizing, differentiated or simplex type - more common
may have warty appearance, predom. assoc with oncogenic strains of HPV (found in younger women) - verrucous carcinoma: variant of squamous cell
- melanoma: 2nd most common vulvar CA
- basal cell carcinoma: 2%
- extramammary paget disease: less than 1%
Mode of spread of Vulvar cancer?
- direct extension to adjacent structures
- lymphatic embolization to regional lymph nodes: can occur early
- hematogenous dissemination: occurs late in the disease
What is VAIN? Cause? Tx?
- vaginal intraepithelial neoplasia - carcinoma: this is a reason why PAPs should be cont. after hysterectomy
- vaginal squamous cell atypia w/o invasion
- consistently assoc with prior or concurrent neoplasia elsewhere in lower genital tract
- 50-90% of pts with VAIN had or currently have either intraepithelial neoplasia or carcinoma of cervix or vulva
- HPV (types 6, 11)assoc with 80% of VAIN cases
-tx:
laser ablation
local excision
5-FU intravaginal
vaginectomy and skin graft
