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Clin Med - Repro > Lecture 10 - VV Disorders > Flashcards

Lecture 10 - VV Disorders Flashcards

1
Q

What is the most common vaginal complaints?

A

infectious vaginitis

  • BV
  • candidiasis
  • trichomoniasis
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2
Q

What is the normal acidity of the vagina?

A

3.5 - 4.5

mostly aerobic colonization
Lactobacilli

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3
Q

Lactobacilli

A

found in the vagina
produced lactic acid –maintains acidic environment
inhibits growth of bacteria

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4
Q

Physiologic Discharge

A

composed of vaginal squamous cells suspended in fluid

  • clear to slightly cloudy
  • odorless, non-adherent to walls
  • +lactobacilli
  • no itching, burning, or malodor

normal increase in volume during ovulation, after coitus, after menses, and during pregnancy

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5
Q

Wet Mount

A

typically you do two slides

1) KOH
- candida
- “whiff” test for BV
2) saline
- BV, trichomonas

samples obtained from lateral vaginal wall

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6
Q

What is considered a normal wet mount?

A

normal epithelial cells
cell border are well defined, linear, and distinct
lactobacilli

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7
Q

What can you do if a pt comes in on her period with vaginal complaints?

A

nothing
blood with distort the wet mount and pap smear
come back when not on period

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8
Q

BD Affirm VP III

A

FDA approved DNA probe to test for high concentration of gardnarella, trichomonas, and candidia

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9
Q

BV

A

bacterial vaginosis
MC vaginal infection in women 14-49 years old

MC cause of vaginal discharge and odor

pregnant pts at increased risk of preterm delivery

Gardnerella vaginalis

increased pH

50% are asymptomatic

sexually associated

high prevalence in women who have sex with women

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10
Q

What are the risk factors of BV?

A

recent ABX use
douching -alters pH
unprotected sex - alters pH

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11
Q

What are the signs and sxs of BV?

A

increased discharge - white or grey in appearance
“fishy” odor –in 75% of pts
odor may be worse after sex
no dyspareunia

copious thin, white vaginal discharge - not adherent to walls

+KOH “whiff” test
Clue cells on saline wet mount
ph >4.5

stippled cell borders

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12
Q

What findings on wet mount would make you think about BV?

A

+ KOH “whiff” test

Clue cells on saline wet mount

pH >4.5

stippled cell borders

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13
Q

Amsel Criteria

A 
Used to dx BV 
need 3 out of 4: 
-homogenous, thin, grayish-white discharge 
-vaginal pH >4.5 
-positive "whiff" test
- clue cells on wet mount

> 90% sensitive
77% specific

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14
Q

What is the first line treatment for BV?

A

Metrogel Vag (0.75%) - insert one applicator intravaginally QHS (every bedtime) X 5 days

Metronidazole 500mg PO BID x 7 days (NO EtOH)

Clincamycin cream (2%) insert one applicator intravaginally QHS x 7 days

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15
Q

What are the SE of metronidazole?

A

increase risk of yeast infection (true with any ABX)
bloating
metallically taste in mouth

no EtOH

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16
Q

What is the second line treatment for BV?

A

clinamycin 300mg PO x 7 days

Tindazole - 2nd gen nitroimidazole (no EtOH)

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17
Q

How do you treat BV in a pregnant pt?

A

Metronidazole PO 250mg TID x 7 days

Alternative: Clindamycin 300mg PO BID x 7 days

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18
Q

How do you treat BV in a pt with recurrent BV?

A

recurrent means >3/year

consistent condom use
longer treatment periods

explore WHY (what they are doing in their lifestyle) they are continually getting BV

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19
Q

Solosec

A

newly FDA-approved nitroimidazole
secnidazole (solosec) –single dose treatment for BV
longer half life

generated since compliance is a problem with the current 7 day treatments

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20
Q

Yeast infection

A

vulvovaginal candidiasis

2nd MC cause of vaginitis sxs

inflammation + candida
80-90% candida albicans
10-20% candida glabrata

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21
Q

What are the risk factors for yeast infection?

A

ABX use
increased estrogen levels (HRT, OCP, pregnancy)
DM, immunosuppression (steroid use, HIV+)
Douching
Menstrual pad/tampon use
Tight-fitting clothing

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22
Q

What are the signs/sxs of yeast infection?

A

vulvar pruritis - MC symptom

burning and irritation
thick “cottage cheese” like discharge

dysuria
dyspareunia (inflammatory condition)

erythema of vulva and vaginal mucosa
vulvar edema
pH 3.5 - 4.5 (normal)
thick, white discharge adherent to vaginal walls

pseudohyphae on wet mount (tree branch-like)

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23
Q

What is the wet mount of Candida?

A

10% KOH prep

normal pH

pseudohyphae have tree branch like appearance

24
Q

When would you culture for yeast infection?

A

if negative microscopy

persistent sxs

25
Q

What is the treatment for yeast infection?

A

Fluconazole 150mg PO x 1

Topical: 
Miconazole (monistat) - OTC 
Clotrimazone (gynelotrimin) 
Terconazole (Terazol) 
insert applicator at bedtime x 1-3 days
26
Q

How do you treat yeast infection in pts with immunosuppression or recurrent episodes?

A

Fluconazole 150mg PO x 2-3 days 72 hours apart

topical medication - vaginal imidazole 7-14 days

27
Q

How do you treat yeast infection in a pregnant pt?

A

NO oral meds

topical (clotimazole or miconazole) x 7 days

28
Q

What is the yeast infection is caused by C. glabrata instead of C. albicans, how does the treatment change?

A

must be isolated by culture before treatment

Boric Acid 600mg intravaginally x 14 days
made at compounding pharmacy

29
Q

What is the most common no-viral STI worldwide?

A

trichomoniasis

30
Q

Trichomonas vaginalis

A

flagellated protozoan infection

asymptomatic in males
tx both male and female

31
Q

What are the sxs of trichomonas?

A

yellow-greenish vaginal discharge
vulvovaginal irritation
dyspareunia
dysuria

motile flagellated organisms on wet mount
copious frothy (bubbly) cervical -vaginal discharge
“Strawberry cervix”

there can be a LONG dormant period in women

32
Q

Does trichomonas progress to PID?

A

no - non inflammatory

33
Q

How do you dx trichomonas?

A

motile trichomonads on saline wet mount
-pear shaped

usually concomitant BV infection
-Clue cells, +whiff

34
Q

How do you treat trichomonas?

A

partner must be tested

Metronidazole 2g PO x 1
Metronidazole 500mg PO BID x 7 days
no EtOH; Abstain x 1 week

second line
tindazole 2 g PO x1

35
Q

How do you treat trichomonas in pregnancy?

A

metronidazole 2g PO x 1

associated with preterm delivery and low birth wt (if untreated I believe)

36
Q

Bartholin glands are located where?

A

5 and 7 oclock
pea-sized
normally non-palpable

37
Q

What is the function of bartholin glands?

A

maintain moisture of the vagina

38
Q

What is the most common vulvovaginal tumor?

A

bartholin gland cyst

39
Q

What age typically gets bartholin gland cysts?

A

ANY age

if post-menopausal you must r/o malignancy

40
Q

What is the difference between bartholin gland cyst and abscess?

A

abscess is when obstructed duct becomes infected

41
Q

What are the sxs of bartholin cysts?

A

painLESS vulvar mass
most detected on pelvic exam
if very large can have discomfort with sitting, walking, sex
clear, white fluid if drainage occurs

42
Q

What are the sxs of bartholin abscess?

A

tender, erythematous, severe pain with mucopurulent drainage
warm, tender, fluctuant mass
consider culture, gonorrhea/chlamydia

typically end up in the ER d/t pain

43
Q

What is the treatment of bartholin cyst?

A

if asymptomatic, monitor
Sitz bath
consider biopsy to exclude malignancy in high risk populations (post-
menopausal)

44
Q

What is the treatment of bartholin abscess?

A

I and D with placement of Word catheter
+/-ABXs
Bactrim DS (cover MRSA) PO BID x 7 days

45
Q

Word catheter

A

catheter placed after I and D for bartholin abscess

goal: decrease recurrence

left in for 4-6 weeks

46
Q

Marsupialization

A

alternative treatment to word catheter for bartholin abscess

47
Q

Vulvar Cancer

A

4% of gynecologic cancers

typically in postmenopausal women
average age of dx is 68

48
Q

What are the risk factors of vulvar cancer?

A 
HPV types 16, 18, 31 
VIN - vulvar intraepithelial neoplasia 
lichen sclerosus
hx cervical cancer 
HIV infection
49
Q

What is the most common histological type of vulvar cancer?

A

SCC

here paget’s disease has a good prognosis unlike with breast cancer

50
Q

How does vulvar cancer present?

A

vulvar lesion + pruritus

unifocal plaque, ulcer, or mass on labia, clitoris or perineum

+/- vulvar bleeding and pain

51
Q

How do you dx vulvar cancer?

A

biopsy of lesion

52
Q

What is the treatment of vulvar cancer?

A

surgery
wide local resection to preserve vulva and inguinal lymph node dissection (preferred)
radical vulvectomy and regional lymphadenectomy

radiation therapy
often given with chemo

treat based on stage

53
Q

Vaginal Cancer

A

rare
>70y/o
usually secondary to another primary metastatic tumor (cervix is MC)

risk factors:

  • advanced age
  • HPV infection
  • smoking
  • cervical cancer
  • DES exposure

85% SCC

upper third of vagina is MC site

54
Q

What type of cancer is associated with DES?

A

clear cell adenocarcinoma - vaginal cancer

55
Q

How does vaginal cancer present?

A

painless vaginal and/or postcoital bleeding

56
Q

How do you dx vaginal cancer?

A

pelvic exam

vaginal biopsy

57
Q

What is the treatment for vaginal cancer?

A 
surgical excision (hysterectomy and upper vaginectomy) 
radiation therapy

Clin Med - Repro (18 decks)

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