Gyn 2 Pt 2 Flashcards
What is vaginitis and what are the most common causes?
Infectious or non-infectious inflammation of the vaginal mucosa and sometimes the vulva
Many causes: most are infectious or due to normal flora imbalances
Predisposing factors to vaginal bacterial pathogens
- Use of antibiotics (→ ↓ lactobacilli)
- Alkaline vaginal pH due to menstrual blood, semen, or ↓ in lactobacilli
- Poor hygiene
- Frequent douching
- Pregnancy
- DM
- HIV
Most common sx complaints for vaginitis
abnormal vaginal discharge (m/c), irritation, pruritis, erythema
Compare normal vs abnormal discharge
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
Etiology for vaginitis differs depending on what demographic factor?
Patient Age!
Causes of Vaginitis in Kiddos
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
Causes of Vaginitis in Reproductive Age Women:
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
Causes of Vaginitis in Menopausal Women
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)
Additional things that could cause vaginitis at any age:
- 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
Pertinent Hx for Vaginitis
- 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
PE for Vaginitis
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
Labs for Vaginitis
- Wet prep, culture and vaginal pH
- Consider DNA culture for BV, Candida, Trichomonas in chronic conditions
RED FLAGS for Vaginitis
- Trichomonal vaginitis in children (sexual abuse)
- Fecal discharge (suggesting a fistula, even if not seen)
DDX for Vaginitis
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)
Etiology and risk factors of Bacterial vaginosis (BV)
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
What conditions does BV increase the risk of?
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)
BV Sxs
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
Dx of BV
DDX?
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
Etiology and Risk Factors of Candida
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
S/SX of Candida
- 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
Dx of Candida
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
DDX for Candida
- contact irritant or allergic vulvitis
- chemical irritation
- vulvodynia
- Paget’s disease
- Cytolytic vaginosis
Definition and Risk Factors of Atrophic/Inflammatory Vaginitis
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
Sxs of Atrophic/Inflammatory Vaginitis
- DC: Clear or purulent
- Dyspareunia, dysuria, vaginal irritation
- Vaginal pruritus, erythema, burning, pain or minor bleeding
- Thin and dry vaginal mucosa
Dx of Atrophic/Inflammatory Vaginitis
DDX?
Dx:
- pH >6
- Wet prep: Inc WBC’s, dec lactobacillus, parabasal cells
- Mb inc. cocci (streptococci overgrowth)
DDX: erosive lichen planus
Definition/Etiology of Trichomonas
- caused by trichomod protozoa
- a STI
Signs/Sxs of Trichomonas:
- 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
Dx of Trichomonas
- pH > 5.5
- Wet Prep: Elevated WBC’s, flagellated trichomod
- Can be dx. Incidentally on PAP smear
Etioliogy of Cytolytic Vaginosis
S/Sxs
Overgrowth of lactobacillus strain Sxs/Signs - Burning, pruritus - rawness - vulvovaginitis - dyspareunia - erythematous & excoriated tissue
Dx of Cytolitic Vaginosis
- pH: normal or ≤ 3.5
- wet prep: small amount WBC’s, increased rods, false/atypical clue cells
Definition and Etiology of Pelvic Inflammatory Disease (PID)
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
Risk Factors of PID
- 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
SSxs of PID
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
PE of PID
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)
Dx/Labs for PID:
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
Complications for PID:
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
Treatment for PID
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.
DDX for PID
Endometriosis Appendicitis Ectopic pregnancy Bowel disorders Septic abortion UTI Complicated ovarian cyst
Etiology and Sxs of Gonorrhea
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
Labs for Gonorrhea
Most serious complication?
↑ 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
Etiology and Sxs of Chlamydia
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
Labs for Chlamydia
Sequelae?
↑ 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
Etiology and Sxs of Cervicitis:
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
What is ENDOMETRIOSIS?
What surfaces is it most commonly found on?
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.
Pathogenesis of Endometriosis
Bleeding from implants initiates inflammation → fibrin deposition → adhesion formation → scarring which distorts peritoneal surfaces of organs and pelvic anatomy
What are some of the hypotheses of etiology for Endometriosis?
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
Factors that lower risk
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)
Sxs & Signs OF ENDOMETRIOSIS
W
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
PE Endometriosis
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.
Dx of Endometriosis
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
Treatment/management of Endometriosis
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
