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CPD > Gyn 2 Pt 2 > Flashcards

Gyn 2 Pt 2 Flashcards

1
Q

What is vaginitis and what are the most common causes?

A

Infectious or non-infectious inflammation of the vaginal mucosa and sometimes the vulva
Many causes: most are infectious or due to normal flora imbalances

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2
Q

Predisposing factors to vaginal bacterial pathogens

A
  • Use of antibiotics (→ ↓ lactobacilli)
  • Alkaline vaginal pH due to menstrual blood, semen, or ↓ in lactobacilli
  • Poor hygiene
  • Frequent douching
  • Pregnancy
  • DM
  • HIV
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3
Q

Most common sx complaints for vaginitis

A

abnormal vaginal discharge (m/c), irritation, pruritis, erythema

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4
Q

Compare normal vs abnormal discharge

A

abnormal when: odor is offensive, pruritis or irritation, burning, pain, blood in discharge, amount of discharge is distressing to the woman

Normal discharge: Milky white/mucoid, odorless, non-irritating

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5
Q

Etiology for vaginitis differs depending on what demographic factor?

A

Patient Age!

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6
Q

Causes of Vaginitis in Kiddos

A

infxn usu involves GI tract flora –> common contributing factors are: poor perineal hygiene, not wiping hands after BM, fingering the area in response to pruritis

Others:

  • Chemicals in bubble baths/soaps can cause inflammation
  • Foreign bodies
  • S/t specific pathogens: strep, staph, candida, occ’l. pinworms and E.Coli
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7
Q

Causes of Vaginitis in Reproductive Age Women:

A

Usu infectious. M/C types: trichomonas vaginitis (STI), Bacterial Vaginosis (BV), Candida

Other contributing factors:

  • things that ↑ pH such as: menstrual blood, semen, tight non-porous underclothing, poor hygiene, frequent douching and diaphragm/spermicide use
  • Foreign bodies (forgotten tampons)
  • Inflammatory vaginitis (non-infectious) is UNcommon in this age group
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8
Q

Causes of Vaginitis in Menopausal Women

A

Usu atrophic or inflammatory vaginitis, mb overlapping BV or candida
• Decrease in estrogen causes vaginal thinning, ↓ lactobacillus, ↑ vaginal pH increasing vulnerability to infection and inflammation
• Poor hygiene (patients who are incontinent or bed-ridden)

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9
Q

Additional things that could cause vaginitis at any age:

A
  • Fistulas between the intestine and genital tract
  • Pelvic radiation or tumors
  • CHEMICALS: Hygiene sprays, perfumes, laundry soaps, bleaches, menstrual pads, fabric softeners, fabric dyes, synthetic fibers, bathwater additives, toilet tissue, spermicides, vaginal lubricants/creams, latex condoms, vaginal contraceptive rings or diaphragms
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10
Q

Pertinent Hx for Vaginitis

A
  • Qual/quant. of discharge and relation to menstrual cycle
  • Pruritus, burning, or pain
  • Duration and intensity
  • changes in urination
  • Self-treatment/chemicals incl: douching, vaginal creams, lubricants, BC use (OC’s, condoms, vaginal ring, etc)
  • OB/gyn history, menstrual history
  • Pregnancies
  • Sexual habits/practices and orientation
  • Personal hygiene: including changes in laundry products, sprays or perfumes
  • Does male sexual partner have urethral discharge, pruritis, penile lesions or post-coital irritation? Female partner as well – ask about sexual practices
  • Recurrent symptoms
  • Treatments tried and response to treatment

PMHx

  • Recurrent antibiotic use, hypothyroid, DM, HIV, other immunosuppressive d/os (risk factors for candida)
  • Crohn’s dz, GU/GI cancer, pelvic/rectal surgery, lacerations during delivery (fistulas)
  • Unprotected intercourse or multiple sexual partners (STIs)

ROS: Fever, chills, abdominal or suprapubic pain, polyuria, polydipsia

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11
Q

PE for Vaginitis

A

EXTERNAL/SPECULUM: Lymph Nodes; Examine external genitalia, vaginal mucosa, glands, urethra and cervix for erythema, edema, excoriation & lesions, amount of d/c, color & odor; Assess vaginal pH
BIMANUAL: assess for CMT, adnexal or uterine tenderness

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12
Q

Labs for Vaginitis

A
  • Wet prep, culture and vaginal pH

- Consider DNA culture for BV, Candida, Trichomonas in chronic conditions

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13
Q

RED FLAGS for Vaginitis

A
  • Trichomonal vaginitis in children (sexual abuse)

- Fecal discharge (suggesting a fistula, even if not seen)

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14
Q

DDX for Vaginitis

A

DDX:

  • Infection: BV, Candida, Trichomonas, Cytolytic, Beta-hemolytic strep
  • Atrophic vaginitis (loss of lubrication)
  • UTI
  • Allergy and irritation
  • Malignancy higher in the tract
  • Psychological factors: abuse, rape, loss of libido, trauma
  • Derm dzs – lichen sclerosus, lichen simplex chronicus
  • Systemic diseases
  • Paget’s disease (looks like Candida)
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15
Q

Etiology and risk factors of Bacterial vaginosis (BV)

A

Most common infectious vaginitis
- DT Unbalanced ecology! ↓ lactobacillus leads to ↑ anaerobic bacteria

Risk Factors: IUD’s, Low vitamin D, Poor nutritional status, Douching, No condom use, Anal sex before vaginal intercourse/sex/penetration, Partner change: increased #, uncircumsized, new male, Sex with uncircumcised male partners, Spermicides, Smoking, Non-white ethnicity

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16
Q

What conditions does BV increase the risk of?

A

Main highlights: PID, HPV, Pre-term labor & pre-term birth
Others: Post-abortion and post-partum endometritis, Post-hysterectomy vaginal cuff infections, Chorioamnionitis, Pre-mature rupture of membranes (PROM)

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17
Q

BV Sxs

A

Mild and often ASx!

  • Vaginal D/C usu malodorous (fishy odor), gray, thin and profuse; usu stronger after menses and intercourse (pH more alkaline)
  • Common: Pruritus and irritation
  • UNcommon: Erythema and edema
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18
Q

Dx of BV

DDX?

A 
AMSEL's CRITERIA (3-4 req'd):
o	gray discharge
o	vaginal pH >4.5
o	fishy odor
o	clue cells present on wet prep (KOH test) – pleomorphic rods

Also: usually < 50 WBC’s (if higher likely concomitant infection-trich., GC, CT-need additional testing)

DDX: Trichomonas vaginitis

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19
Q

Etiology and Risk Factors of Candida

A 
most FUNGAL vaginitis is caused by Candida species, usu albicans
Risk Factors:
- use of antibiotics or corticosteroids
- pregnancy
- constrictive undergarments
- immunocompromised
- use of IUD
- OC’s or vaginal ring
- Diabetes, HIV
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20
Q

S/SX of Candida

A
  • Thick white cottage cheese D/C that adheres to vaginal wall
  • Vaginal or vulvar pruritus, burning or irritation
  • Erythema, edema and excoriation are common, s/t fissures at introitus
  • Dyspareunia is common
  • Sx. Increase the week BEFORE menses
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21
Q

Dx of Candida

A

Wet prep: budding yeast, pseudohyphae and sometimes mycelia (If no buds or pseudohyphae are visualized, mb Glabrata strain of Candida)

  • *Only 30% of the time are yeast seen on wet-prep
  • pH will be normal (<50
22
Q

DDX for Candida

A
  • contact irritant or allergic vulvitis
  • chemical irritation
  • vulvodynia
  • Paget’s disease
  • Cytolytic vaginosis
23
Q

Definition and Risk Factors of Atrophic/Inflammatory Vaginitis

A

Definition: vaginal inflammation with the absence of usu causes of infectious vaginitis
Risk Factors
- E loss d/t menopause, POF/POI
- Genital atrophy predisposes to inflammatory vaginitis and increases risk of recurrence
- Possible autoimmune

24
Q

Sxs of Atrophic/Inflammatory Vaginitis

A
  • DC: Clear or purulent
  • Dyspareunia, dysuria, vaginal irritation
  • Vaginal pruritus, erythema, burning, pain or minor bleeding
  • Thin and dry vaginal mucosa
25
Q

Dx of Atrophic/Inflammatory Vaginitis

DDX?

A

Dx:

  • pH >6
  • Wet prep: Inc WBC’s, dec lactobacillus, parabasal cells
  • Mb inc. cocci (streptococci overgrowth)

DDX: erosive lichen planus

26
Q

Definition/Etiology of Trichomonas

A
  • caused by trichomod protozoa

- a STI

27
Q

Signs/Sxs of Trichomonas:

A
  • D/C: copious yellow/green frothy
  • soreness of vulva and perineum
  • dyspareunia, dysuria
  • mb edema of the labia
  • punctate red (strawberry) spots vaginal walls and surface of the cervix
  • mb urethritis or cystitis
28
Q

Dx of Trichomonas

A
  • pH > 5.5
  • Wet Prep: Elevated WBC’s, flagellated trichomod
  • Can be dx. Incidentally on PAP smear
29
Q

Etioliogy of Cytolytic Vaginosis

S/Sxs

A 
Overgrowth of lactobacillus strain
Sxs/Signs
-	Burning, pruritus
-	rawness
-	vulvovaginitis
-	dyspareunia
-	erythematous & excoriated tissue
30
Q

Dx of Cytolitic Vaginosis

A
  • pH: normal or ≤ 3.5

- wet prep: small amount WBC’s, increased rods, false/atypical clue cells

31
Q

Definition and Etiology of Pelvic Inflammatory Disease (PID)

A

PID is an infection of the upper female genital tract-the cervix, uterus, fallopian tubes, and ovaries

Etiology

  • SPREAD: microorgs ascend from the vagina/cervix into endometrium, fallopian tubes commonly; If severe, into the ovaries and then peritoneum
  • A polymicroorganism etiology: Neisseria Gonorrhea (GC), Chlamydia trachomatis (CT), and STIs are common causes
  • Other causes: anaerobic and aerobic bacteria, including pathogens that cause bacterial vaginosis
  • In women 35 y/o usu caused by an overgrowth of anaerobic/aerobic bacteria in vagina that ascend
32
Q

Risk Factors of PID

A
  • Hx of STI’s or PID
  • IUD in women >35
  • Young, Single, Drinker with no kids (Nulliparous), but has lots of sex
  • Low socioeconomic status
  • Non-white ethnicity

Adolescents: Occurs when they have older sex partners, hx. of child protective services involvement and hx of attempted suicide

33
Q

SSxs of PID

A

Sxs can be asx –> mild –> severe

  • Lower abdominal pain: radiation to the back/sacrum
  • Fever
  • Cervical discharge
  • Abnormal uterine bleeding
  • Onset is particularly common during or after menses
  • Dysuria
  • N/V
  • PID dt GC is usu more acute with more severe sxs than when dt CT

Acute salpingitis: Lower abdominal pain (s/t upper abd) present BL (mb unilateral); early: signs mb mild or absent; Later – CMT, guarding and rebound tenderness

34
Q

PE of PID

A

VITALS: Fever of 101ᴼ F or greater, Increased pulse rate
EXTERNAL: Inguinal lymphadenopathy with tenderness, Guarding and rebound tenderness
SPECULUM: Cervix red, erythematous and easily friable, Yellow green mucopurulent discharge from os
BIMANUAL: Uterine, adenexal, and/or CMT, enlarged skene’s glands enlarged, tender (with GC or CT)

35
Q

Dx/Labs for PID:

A

High index of suspicion on PE (all types of tenderness)
Wet prep: > 10 WBC’s/hpf
CBC: elevated WBC count
ESR increased >15 mm/hr
* If all of the above are negative it probably excludes endometritis/PID
TVUS: If the pt cannot be assessed d/t pain
Pregnancy test: to R/O ectopic pregnancy
PCR, culture or DNA probe for GC and Chlamydia, or Aptima test on urine

36
Q

Complications for PID:

A 
Fitz-Hugh-Curtis syndrome
Tubo-ovarian abscesses --> rupture --> severe sx. & possible septic shock; likely if treatment is late or incomplete
Pain, fever and peritoneal signs
Hydrosalpinx
Peritonitis (surgical emergency)
Adhesions & tubal scarring
Infertility
Adnexal torsion
Tubal scarring and adhesions → Chronic pelvic pain, menstrual irregularities, infertility, and increased risk of ectopic pregnancy
37
Q

Treatment for PID

A

Any women with risk of PID and either CMT, uterine or adnexal pain MUST be treated with 2 or 3 antibiotics

(SAVE THE TUBES!!!)

36 hours of onset of initial sxs increases the likelihood of infertility
If patients do not respond to antibiotics within 42-72 hours, TVUS is done ASAP & if dx is still uncertain laparoscopy should be done.

38
Q

DDX for PID

A 
Endometriosis
Appendicitis
Ectopic pregnancy
Bowel disorders
Septic abortion
UTI
Complicated ovarian cyst
39
Q

Etiology and Sxs of Gonorrhea

A

Dt Neisseria gonorrhea (Gram neg intracellular diplococcus) infecting the vagina, urethra, rectum & pharynx. Both male and female carriers. 7-10 day incubation period. * Reportable disease

S/SX: Sxs 7-21 days after exposure
Green/yellow mucopurulent cervical discharge (acutely)
Mb urinary sxs
Bartholin and Skene’s glands may also be infected
Reddened cervix, local glands inflamed
Pelvic pain and fever

40
Q

Labs for Gonorrhea

Most serious complication?

A 
↑ pH
↑ WBC’s (> 100/hpf) on wet prep
↑ ESR and WBC
DX: Culture or gene probe MUST be done to confirm
Aptima (urine)
liquid pap

*Most serious complication is PID in women

41
Q

Etiology and Sxs of Chlamydia

A

Infection of urethra and cervix with Chlamydia trachomatis
*Reportable disease

S/Sxs: 
most women asx (up to 70%)
NO external DC in most cases 
May mimic GC infection, outcome may be the same as GC
Urethritis symptoms
42
Q

Labs for Chlamydia

Sequelae?

A

↑ pH
Wet prep: ↑ WBC’s > 100/hpf
Fluorescent Ab test should be performed
Gene probe, Aptima (urine), liquid pap can test for CT with GC

Sequelae: bartholinitis, bartholin gland cysts, damage to fallopian tubes, PID

43
Q

Etiology and Sxs of Cervicitis:

A

Inflammation of the cervix; endocervical junction especially vulnerable to infxn

  • Causes: STDs (m/c), then Staph, strep and E coli
  • may be a major problem during L&D

S/Sxs: red congested friable cervix, mb ulceration, pus

44
Q

What is ENDOMETRIOSIS?

What surfaces is it most commonly found on?

A

Noncancerous d/o: implants similar to endometrial tissue are found outside the uterine cavity.

Most commonly found on peritoneal & serosal surfaces: broad ligaments, posterior cul-de-sac, uterosacral ligaments, and ovaries.
Less commonly found on surfaces of small & lg intestines, ureters, bladder, vagina, cx, surgical scars, pleura, & pericardium.

45
Q

Pathogenesis of Endometriosis

A

Bleeding from implants initiates inflammation → fibrin deposition → adhesion formation → scarring which distorts peritoneal surfaces of organs and pelvic anatomy

46
Q

What are some of the hypotheses of etiology for Endometriosis?

A 
Retrograde flow of menses (recently disproven)
Coelomic metaplasia
Embryonic rests theory
Estrogen dominance
Defective formation & metabolism of estrogen
Environmental Exposure
PCB’s from meat, fish, eggs and milk
Candida overgrowth in GI tract - exacerbating factor
Genetics
Lymphatic/vascular problems
Immune system 
Menstruation Preconditioning Hypothesis
Metaplasia
47
Q

Factors that lower risk

A

o Exercise – esp if begun before 15 yo, > 7h/wk or both
o Cigarette Smoking → ↑ SHBG
o Pregnancy – multiple
o Low dose OC (continuous or cyclic)

48
Q

Sxs & Signs OF ENDOMETRIOSIS

W

A

Extent of endometrial implants/endometriosis DOES NOT reflect SX presentation
*PAIN & INFERTILITY (M/C sxs)
Pelvic pain – dysmenorrhea, deep dyspareunia
Pelvic mass – endometriomas
Dyschezia – esp during menses
Dysuria, suprapubic pain
Infertility: About 25-50% of infertile women

49
Q

PE Endometriosis

A

EXTERNAL: vulvar lesions (rarely)
SPECULUM EXAM: mb vaginal lesions in post fornix or cx
BIMANUAL EXAM: mb normal, or mb retroverted or fixed uterus, enlarged, tender ovaries, fixed ovarian masses, induration in the cul-de-sac, nodularity of uterosacral ligaments
RECTOVAG: thickened septum, re-check cul-de-sac & ligaments.

50
Q

Dx of Endometriosis

A

Dx only by Bx during laparoscopy or laparotomy

TVUS, CT, MRI, IV urography, barium enema – can s/t identify extent of dz process & monitor progress – but not specific or adequate for dx.
Serum Ca 125 (>35 units/mL) & antiendometrial Ab – may help monitor dz, but still investigational

51
Q

Treatment/management of Endometriosis

A

ND Tx: Symptomatic treatment for pain (ex. Mirena), more definitive treatment is based on pts age, sxs, desire to preserve fertility & extent of d/o
Allopathic options are: Rx to suppress ovarian fxn & implants, surgical resection, & surgery + Rx

CPD (4 decks)

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