DISORDERS OF THE VULVA & VAGINA Flashcards
TYPES OF VAGINITIS
- bacterial vaginosis
- trichomoniasis
- candidiasis
VULVA is made up of ______________ squamous cell epithelium
keratinized
hair follicles
sebaceous glands
sweat glands
apocrine glands
– Occasionally contains breast tissue….may swell and become tender after delivery
VAGINA is made up of ______________ squamous cell epithelium
nonkeratinized
vaginal pH
3.5 - 4.5
vaginal flora is made up of
lactobacillus & other aerobic and anaerobic bacteria
normal vaginal secretions have NO ODOR
SYMPTOMS OF VAGINITIS
A change in the volume, color, or odor of vaginal discharge Pruritus Burning Dyspareunia Dysuria Spotting Erythema Pelvic discomfort
WHY IS IT IMPORTANT TO FIND THE ETIOLOGY OF VAGINITIS
It is important that laboratory documentation of the etiology of vaginitis be determined
Symptoms are very nonspecific
One CANNOT determine etiology from history and PE alone and may mistreat the condition
be careful with physical exam of vaginitis, because with bacterial vaginitis, the vulva ______________
APPEARS NORMAL
if erythema, lesions or fissures are present = may suggest vulvar
dermatitis
PHYSICAL EXAM FOR VAGINITIS
Begin with careful external examination of the vulva:
- In bacterial vaginitis the vulva appears normal
- Erythema, lesions or fissures may suggest a dermatitis of the vulva
- Changes suggesting chronic inflammation?
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
pH testing for vaginitis - technique
swab with a pH swab or dry swab the WALL of the vagina, not pooled secretions
Use narrow range pH paper or swab (jen says to use pH paper of 4.0 - 5.0)
pH of premenopausal women
3.5 - 4.5 (jen says 3.8 - 4.5)
pH of bacterial vaginosis
> 4.5
pH of trichomoniasis
5.0 - 6.0
pH of candidiasis
4.0 - 4.5
in pregnancy, what does the amniotic fluid do to the pH of the vagina
amniotic fluid raises the pH
bacterial cultures of the vagina
ARE NOT HELPFUL
Saline wet mount for vaginitis
- evaluate within 20 minutes
Clue cells—bacterial vaginosis (BV)
Trichomonads
Increased PMNs—cervicitis
clue cells on saline wet mount indicate
BV - bacterial vaginosis
increased PMNs on saline wet mount indicate
cervicitis
KOH prep for vaginitis
to determine if fungal
see hyphae & budding yeast
what is the amine test
smelling the slide immediately after adding KOH for the “fishy” smell of BV or trichomonas
a positive amine test is indicative of
bacterial vaginitis
“fishy” odor after adding KOH to secretions = could be either BV or trichomonas
Most common cause of discharge of women of childbearing age (40-50%)
BV - BACTERIAL VAGINOSIS
Will be less lactobacilli present in conditions such as
yeast & bacterial vaginosis
Thin, white/gray discharge
bacterial vaginosis
what is bacterial vaginosis
Abnormality of the normal vaginal flora:
- Decrease in hydrogen-peroxidase lactobacilli
- Increase in primarily gram negative rods
bacterial vaginosis has a decrease in _________________ and an increase in __________
decrease in lactobacilli
increase in primarily gram negative rods
FINDINGS ON EXAM FOR BV
- fishy odor (both during exam & with KOH amine test)
- positive Clue cells on wet mount
- thin white/gray discharge
what is the usual complaint of BV
malodorous or copious discharge
BV itself does NOT cause symptoms of
Dysuria Dyspareunia Pruritis Burning Vaginal inflammation
- Up to 75% of BV infections may be
ASYMPTOMATIC
what criteria is used to diagnose BV
Amsel criteria
Amsel criteria for diagnosing BV
- need 3/4 of the following criteria to diagnose BV
1) Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
2) Vaginal pH > 4.5
3) Positive whiff-amine test
4) Clue cells on saline wet mount, comprising at least 20% of epithelial cells
treatment of choice for BV
METRONIDAZOLE (FLAGYL)
- oral = 500mg BID x 7 days (no alcohol)
- intravaginal gel 5g qd x 5 days
don’t have ________ while on metronidazole (flagyl)
alcohol
another treatment option for BV (after metronidazole)
CLINDAMYCIN
- oral or intravaginal
2 treatment options for BV
1) metronidazole (flagyl)
2) clindamycin
________ may be useful as adjunctive therapy for BV along with antibiotics
probiotics
do sexual partners also need to be treated when woman has BV
no
recurrence of BV
recurrence rates are high
May retreat with same or different regimen
Women who have 3 or more documented cases of BV in 12 months can be offered maintenance therapy:
metronidazole gel for 7-10 days then twice weekly dosing for 4-6 months
NOT clindamycin because of toxicity
women who have 3+ documented cases of BV in 1 year
treat with maintenance therapy of metronidazole
metronidazole gel x 7-10 days, then twice weekly x 4-6 months
do NOT give __________ for BV recurrences due to _____________
do not give CLINDAMYCIN for BV recurrences, due to toxicity
MOST COMMON STI WORLDWIDE
Trichomonas vaginitis
flagellated protozoan
trichomonas vaginalis
infects both men & women
trichomonas vaginalis
Female 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
malodorous, thin, green/yellow vaginal discharge
trichomonas
SYMPTOMS OF TRICHOMONAS VAGINALIS
Malodorous, thin, green/yellow vaginal discharge (70%)
Burning, dysuria, frequency (urethra commonly involved also)
Pruritus, dyspareunia, pelvic discomfort
Post-coital bleeding
DIAGNOSIS OF TRICHOMONAS
On speculum exam MAY see green, malodorous, frothy discharge (<10%)
pH 5-6
Mobile T. vaginalis on wet mount (seen 60-70%)
Can do rapid antigen and nucleic 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
“STRAWBERRY CERVIX”
trichomonas
do partners of those infected with trichomonas need to be treated
yes
trichomonas treatment for men & non-pregnant women
Tinadozole (Tindamax)
2g x 2 days
or
Metronidazole (Flagyl) -
500mg bid x 7 day or 2g single dose
trichomonas treatment for pregnant women
metronidazole 2g single dose
trichomonas treatment for nursing women
2 g dose of Flagyl
BUT need to pump & dump x 24 hours after taking it
recurrent trichomonas infections are usually due to
Usually due to return to sexual activity too soon and reinfection
how to treat recurrent trichomonas infections
⦁ may treat recurrent infections with Metronidazole 2g dose again or use 7 day course of 500mg BID of either Metronidazole or Tinadazole
⦁ If the above fails, can treat with 2g qd x 5 days
⦁ if still refractory - culture to see if strain is resistant
- in general, there is not a second line antibiotic
- desensitization is recommended if the patient is allergic
trichomonas treatment for HIV+ patients
⦁ 7 day course of either Tinadazole or Metronidazole
prolapsed bladder
cystocele
bladder bulges into the vagina
cystocele
why does a cystocele occur
This occurs when the supportive tissues & muscles between the bladder and the vagina weaken and stretch => bladder bulges into the vagina
Causes of Cystocele
⦁ childbirth ⦁ repetitive straining for bowel movements ⦁ constipation ⦁ chronic or violent coughing ⦁ heavy lifting ⦁ obesity
cystocele treatment
- watchful waiting!
- avoid heavy lifting or straining
- Pelvic floor (Kegel) exercises can be done to strengthen the pelvic muscles
- Pessary = a silicone medical device placed in the vagina that supports the vaginal wall and holds the bladder in place
- Anterior vaginal wall repair (Colporrhaphy)
Pessary
a silicone medical device placed in the vagina that supports the vaginal wall and holds the bladder in place
lichen sclerosis etiology may be linked to _________ or _________
genetics or autoimmune
pathophysiology of lichen sclerosis
intense inflammatory reaction
peaks of lichen sclerosis
⦁ pre-pubertal girls
⦁ post-menopausal women
diagnosis of lichen sclerosis
BIOPSY
SYMPTOMS OF LICHEN SCLEROSIS
⦁ Hallmark** = Vulvar Pruritus - may be so intense as to interfere with sleep ⦁ Pruritus ani ⦁ Painful defecation ⦁ anal fissures ⦁ dyspareunia
hallmark symptom of lichen sclerosis
vulvar pruritus - may be so intense as to interfere with sleep
lichen sclerosis exam
- chronic inflammation
- well-demarcated white, finely wrinkled, atrophic patches
- the labia minora often shrinks & adhesions of the labia majora may cover the clitoris
- well-demarcated white, finely wrinkled, atrophic patches
lichen sclerosis
- the labia minora often shrinks & adhesions of the labia majora may cover the clitoris
lichen sclerosis
treatment for lichen sclerosis
⦁ Clobetasol proprionate 0.05% cream x 6-12 weeks (topical steroid)
⦁ then use for maintenance therapy (1-3x/week)
2nd most common cause of vaginitis symptoms
vulvovaginal candidiasis
is vulvovaginal candidiasis an STI?
NO
primary etiologic agent of vulvovaginal candidiasis
Candida Albicans
Candida glabrata = accounts for the rest
PATHOGENESIS OF CANDIDIASIS
- the organism can migrate from the anus to the vagina & colonize there
- less common cause = sexual or relapse from reservoir in the vagina
- Infection occurs when there is an overgrowth of candida
RISK FACTORS FOR CANDIDIASIS
⦁ DM
⦁ Increased Estrogen levels (OCP, Pregnancy)
⦁ Immunosuppression
⦁ ***Antibiotic use
up to 1/3 of women develop yeast infxns from abx use
DIAGNOSIS OF CANDIDIASIS
o Speculum exam
⦁ thick, white, sometimes “cottage cheese” discharge
⦁ in severe cases = gray membrane
⦁ pH = 4.0 - 4.5
o KOH wet mount slide (up to 50% are negative) - but would see hyphae & budding yeast
o In rare cases, cultures for candida are indicated
⦁ multiple, recurrent, or persistent cases that are not responding to treatment (may have a resistant pathogen)
⦁ women with a normal pH, and no visible pathogen on wet mount
SPECULUM EXAM OF CANDIDIASIS
⦁ thick, white, sometimes “cottage cheese” discharge
⦁ in severe cases = gray membrane
⦁ pH = 4.0 - 4.5
“cottage cheese” discharge
vulvovaginal candidiasis
in what rare cases are cultures indicated for candidiasis
⦁ multiple, recurrent, or persistent cases that are not responding to treatment (may have a resistant pathogen)
⦁ women with a normal pH, and no visible pathogen on wet mount
PREVENTION/EDUCATION FOR CANDIDIASIS
- Keep the external genital area clean & dry
- avoid irritating soaps (including bubble bath), vaginal sprays & douches
- change tampons / 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 than necessary
what classifies uncomplicated candidiasis
mild to mod signs/symptoms
probable Candida albicans infection
healthy & not pregnant
treatment of uncomplicated candidiasis
⦁ many OTC intravaginal treatments are available & highly effective
⦁ RX = Fluconazole (Diflucan) 150mg x 1 dose
- stays in vaginal secretions x 72 hrs - can interact with many drugs**
treatment of complicated candidiasis
⦁ Fluconazole 150mg: 2-3 doses 72 hours apart
⦁ topical therapy with Clotrimazole/ miconazole/ terconazole x 7-14 days
⦁ Intravaginal boric acid tablets x 2 weeks (fatal if swallowed***)
⦁ Flucytosine cream intravaginally qhs x 2 weeks
intravaginal boric acid tablets x 2 weeks; risk =
fatal if swallowed!!!
what constitutes complicated candidiasis
severe signs/symptoms
Infection not due to C. albicans (usually C. glabrata)pregnant
DM
immunosuppression
debilitation
hx of recurrent verified (> 4 infxns/yr) candidal infections
herpes outbreak: primary vs recurrent
The primary outbreak = the worst episode; recurrent outbreaks are generally less severe
GENITAL HSV SYMPTOMS
⦁ painful genital ulcers ⦁ itching ⦁ dysuria ⦁ tender inguinal lymphadenopathy ⦁ may have systemic symptoms: Headache, Malaise, Fever
DIAGNOSIS OF HSV
o EXAM
- “multiple vesicles on an erythematous base”
- vulvar swelling
- lymphadenopathy
- confirmation of diagnosis = by viral cell culture or PCR
“multiple vesicles on an erythematous base”
GENITAL HSV
DIAGNOSIS OF HSV SHOULD BE CONFIRMED BY
by viral cell culture or PCR
treatment for HSV
- the treatment for a PRIMARY infection needs to be started within 72 hrs
- treatment = 7-10 days
⦁ acyclovir (zovirax) - 400mg TID x 7-10 days
⦁ famcyclovir (famvir) - 250mg TID x 7-10 days
⦁ valacyclovir (valtrex) - 1000mg BID x 7-10 days - for RECURRENT infections
⦁ acyclovir 800mg BID x 3 days
⦁ famcyclovir 1000mg BID x 1 day
⦁ valacyclovir 500mg BID x 3 days - SUPPRESSIVE therapy
⦁ acyclovir 400mg BID
⦁ famcyclovir 250mg BID
⦁ valacyclovir 500mg QD
MOST COMMON VIRAL STD IN THE US
condylomata acuminate (genital warts)
etiologic agent of condylomata acuminate (anogenital warts)
HPV
SIGNS/SYMPTOMS OF GENITAL WARTS
⦁ pruritus, burning, pain
⦁ bleeding, vaginal discharge
⦁ may have no symptoms!
INDICATIONS FOR GENITAL WARTS TX
- alleviation of bothersome symptoms
- cosmetic
- obstruction, dyspareunia, psychological distress
- decrease risk of transmission
recommend biopsy for genital warts if:
⦁ diagnosis is uncertain
⦁ lesion has suspicious features (irregular or unusual pigmentation)
⦁ patient is postmenopausal or immunocompromised
⦁ lesion is refractory to medical therapy
TREATMENT FOR GENITAL WARTS
o Chemical Destruction
⦁ Podophyllin (DO NOT USE if pregnant)
⦁ Trichloroacetic acid (highly caustic - can be used during pregnancy)
⦁ 5-FU gel - injected into lesions
o Immunologic
⦁ Imiquimod (Aldara) cream
⦁ Interpheron alpha - systemic therapy
o Surgery
⦁ cryotherapy - LN2 or probe cooled with nitrous oxide
⦁ Laser therapy - in operating room with anesthesia
⦁ Excisional - knife or scissors, requires anesthesia
TREATMENT FOR GENITAL WARTS:
- chemical destruction
__________ can’t be used if pregnant
_________ can be used if pregnant
podophyllin - DON’T use if pregnant
trichloroacetic acid = can be used if pregnant
GENITAL WARTS & PREGNANCY - can transmission occur?
YES
- vertical transmission CAN occur
⦁ either through bloodstream prior to birth
⦁ or at the time of birth - as infant passes through infected birth canal
HPV can manifest in young children as:
⦁ mucosal, conjunctival, or laryngeal disease
⦁ juvenile onset respiratory papillomatosis (JRP) - severe, but rare
Dome shaped with central dimple (umbilicated)
molluscum contagiosum
MOLLUSCUM CONTAGIOSUM
- multiple 1-2mm raised, painless lesions
- **Dome shaped with central dimple (umbilicated)
- contain cheesy-white material
- can be sexually transmitted
treatment for molluscum
- cryosurgery
- bichloracetic acid
- dermal curette
atrophic vaginitis can occur in
women of any age who experience a decrease in estrogenic stimulation of urogenital tissue
the effect of estrogen stimulation on urogenital system
- maintains a well-epithelialized vaginal vault
- estrogen acts on receptors in the vagina, vulva, urethra & trigone of the bladder
- estrogen maintains the collagen content of epithelium
- keeps epithelial surfaces moist
- maintains optimal genital blood flow
- maintains acidic vaginal pH (without estrogen, pH > 5)
RISK FACTORS FOR ATROPHIC VAGINITIS
⦁ natural menopause
⦁ bilateral oophorectomy
⦁ spontaneous premature ovarian failure
⦁ ovarian failure due to radiation, chemo or surgery
⦁ premenopausal meds with anti-estrogenic effects
⦁ post-partum reduction in estrogen production during lactation
⦁ prolactin elevation
⦁ amenorrhea secondary to suppression of the hypothalamic-pituitary axis due to chronic treatment with glucocorticoids
SYMPTOMS OF ATROPHIC VAGINITIS
⦁ vaginal dryness, burning or itching
⦁ decreased lubrication during sex
⦁ dyspareunia
⦁ vulvar or vaginal bleeding (postcoital bleeding)
⦁ vaginal discharge
⦁ pelvic pressure or vaginal bulge
⦁ Urinary tract symptoms (frequency, dysuria, hematuria)
PHYSICAL EXAM FINDINGS OF ATROPHIC VAGINITS
⦁ pale, smooth or shiny vaginal epithelium
⦁ loss of elasticity
⦁ sparsity of pubic hair
⦁ introital narrowing
⦁ lack of moisture
⦁ fusion or resorption of the labia minora
⦁ friable, unrugated epithelium of the vagina
⦁ shortened, narrowed, and poorly distensible vaginal vaults
TREATMENT OF ATROPHIC VAGINITIS
o for Vaginal dryness
- Vaginal moisturizers (Replens, Vagisil, K-Y) - use 1+ times/week
- Use vaginal lubricants at the time of coitus
⦁ water soluble products = astroglide, K-Y jelly
⦁ silicone based products = pjur eros, ID millennium
⦁ oil based = Elegance women’s lubricant
- sexual activity itself may improve vaginal function
o Vaginal estrogen therapy = MOST EFFECTIVE TREATMENT
- contraindications = a woman with estrogen-dependent tumor
- associated with urinary tract benefits
- usually start with vaginal estrogen therapy (cream, tablet or ring)
⦁ SE = vaginal irritation, bleeding or breast tenderness
- some women need systemic therapy
⦁ SERM - selective estrogen receptor modulator = Ospemifene oral tabs (Osphena)
⦁ SE = hot flashes, thromboembolism, endometrial cancer
most effective therapy for atrophic vaginitis
estrogen therapy
usually start with vaginal estrogen therapy (cream, tablet or ring)
some women need systemic therapy
SERM (selective estrogen receptor modulator) for atrophic vaginitis treatment in women who need systemic estrogen therapy (vaginal estrogen therapy not enough)
Ospemifene oral tablets (Osphena)
contraindications to estrogen therapy for atrophic vaginitis
woman with an estrogen-dependent tumors
SE to vaginal estrogen therapy (cream, ring, tablet)
vaginal irritation, bleeding, breast tenderness
SE to SERM (Osphena/Ospemifene) systemic treatment of estrogen therapy for atrophic vaginitis
hot flashes
thromboembolism
endometrial cancer
Many vaginal & vulvar lesions mimic
Bartholin gland disorders
Most common large cyst of the vulva
Bartholin duct cyst
treatment of Bartholin’s duct cysts
- treatment not necessary in women < 40 unless they become infected or symptomatic
- if the cyst is large & not resolving = can then treat with the same technqiues you would use for an abscess
most Bartholin’s duct cysts are
asymptomatic
symptoms of Bartholin duct abscess
- swelling of the Bartholin gland with exquisite pain
- on exam = erythematous, warm, tender and usually fluctuant (can push around)
- there may be surrounding cellulitis
INFECTION of Bartholin duct abscess
usually polymicrobial
STIs are LESS likely - but still test pt if they are at high risk for STIs
There has been a rise in MRSA as etiologic agent
treatment of Bartholin’s duct cyst or abscess
I&D - lance at or behind the hymenal ring
- place a wick to continue drainage;
- place a word catheter into the cavity and leave it in for at least 4 weeks
Marsupialization of Bartholin duct cyst/abscess
- longer procedure done under local anesthesia
- reserved for patients who fail 1-2 placements of a word catheter
- procedure = cut slit into cyst/abscess and suture down edges - makes recurrence less likely
- Complications = hematoma, scarring, dyspareunia
Marsupialization of Bartholin’s duct is reserved for patients who
failed 1-2 placements of a word catheter
complications of marsupialization procedure
scarring
hematoma
dyspareunia (painful sex)
SIGNS/SYMPTOMS OF PAGET’S DISEASE
- itching
- burning
- bleeding
PAGET’S DISEASE LESIONS
Lesions are brick red, scaly, velvety, eczematoid plaques with sharp borders
Paget’s disease May be an indication of an _____________
underlying malignancy
primary treatment for Paget’s disease
excision: excision with > 3 mm border from visible margin
Paget’s disease treatment
- primary treatment = excision with > 3 mm border from visible margin
- recurrent disease may be treated with: Radiotherapy, Laser, Photodynamic therapy, 5-FU, Imiquimoid
Local recurrence rate = 31-43%
recurrent Paget’s disease treatment
Radiotherapy, Laser, Photodynamic therapy, 5-FU, Imiquimoid
brick red, scaly, velvety, eczematoid plaques with sharp borders
Paget’s disease
kind of looks like lichen sclerosis
RISK FACTORS FOR VULVAR CANCER
⦁ HPV infection (60%)*** ⦁ smoking ⦁ lichen sclerosis ⦁ vulvar or cervical intraepithelial neoplasia ⦁ immunodeficiency syndromes ⦁ prior hx of cervical cancer ⦁ Northern european ancestry
largest risk factor for vulvar cancer
HPV infection
- ***a second malignancy - usually _____________ = is found in up to 22% of patients with a vulvar malignancy
cervical cancer
vulvar malignancy = may also have _______
cervical cancer
unifocal vulvar plaque, ulcer or mass
vulvar cancer
lesions are multifocal in 5% of cases
___________is a common complaint with vulvar cancer
Pruritus
most common histological type for VULVAR CANCER
SQUAMOUS CELL
HPV infection = largest risk factor for
vulvar cancer
squamous cell
vulvar cancer
modes of transmission for vulvar cancer (3)
- direct extension to adjacent structures
- lymphatic embolization to regional lymph nodes - can occur early
- hematogenous dissemination - occurs late in the disease
may involve genital, perianal and axillary areas
paget’s disease
the reason to continue PAP smears after a hysterectomy
VAIN = VAGINAL INTRAEPITHELIAL NEOPLASIA
most common cause of VAIN
HPV (types 6&11) - account for 80% of VAIN
TREATMENT for VAIN
- laser ablation
- local excision
- 5-FU
- vaginectomy & skin graft
what is VAIN
Vaginal squamous cell atypia without invasion
scariest thing about VAIN
consistently associated with prior or concurrent neoplasia elsewhere in the lower genital tract
⦁ 50-90% of patients with VAIN had or currently have either intraepithelial neoplasia or carcinoma of the cervix or vulva
consistently associated with prior or concurrent neoplasia elsewhere in the lower genital tract
VAIN
HPV accounts for majority of cases of
VAIN
and is also a risk factor for Vulvar cancer
