Lecture 10 - VV Disorders Flashcards
What is the most common vaginal complaints?
infectious vaginitis
- BV
- candidiasis
- trichomoniasis
What is the normal acidity of the vagina?
3.5 - 4.5
mostly aerobic colonization
Lactobacilli
Lactobacilli
found in the vagina
produced lactic acid –maintains acidic environment
inhibits growth of bacteria
Physiologic Discharge
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
Wet Mount
typically you do two slides
1) KOH
- candida
- “whiff” test for BV
2) saline
- BV, trichomonas
samples obtained from lateral vaginal wall
What is considered a normal wet mount?
normal epithelial cells
cell border are well defined, linear, and distinct
lactobacilli
What can you do if a pt comes in on her period with vaginal complaints?
nothing
blood with distort the wet mount and pap smear
come back when not on period
BD Affirm VP III
FDA approved DNA probe to test for high concentration of gardnarella, trichomonas, and candidia
BV
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
What are the risk factors of BV?
recent ABX use
douching -alters pH
unprotected sex - alters pH
What are the signs and sxs of BV?
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
What findings on wet mount would make you think about BV?
+ KOH “whiff” test
Clue cells on saline wet mount
pH >4.5
stippled cell borders
Amsel Criteria
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
What is the first line treatment for BV?
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
What are the SE of metronidazole?
increase risk of yeast infection (true with any ABX)
bloating
metallically taste in mouth
no EtOH
What is the second line treatment for BV?
clinamycin 300mg PO x 7 days
Tindazole - 2nd gen nitroimidazole (no EtOH)
How do you treat BV in a pregnant pt?
Metronidazole PO 250mg TID x 7 days
Alternative: Clindamycin 300mg PO BID x 7 days
How do you treat BV in a pt with recurrent BV?
recurrent means >3/year
consistent condom use
longer treatment periods
explore WHY (what they are doing in their lifestyle) they are continually getting BV
Solosec
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
Yeast infection
vulvovaginal candidiasis
2nd MC cause of vaginitis sxs
inflammation + candida
80-90% candida albicans
10-20% candida glabrata
What are the risk factors for yeast infection?
ABX use
increased estrogen levels (HRT, OCP, pregnancy)
DM, immunosuppression (steroid use, HIV+)
Douching
Menstrual pad/tampon use
Tight-fitting clothing
What are the signs/sxs of yeast infection?
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)
What is the wet mount of Candida?
10% KOH prep
normal pH
pseudohyphae have tree branch like appearance
When would you culture for yeast infection?
if negative microscopy
persistent sxs
What is the treatment for yeast infection?
Fluconazole 150mg PO x 1
Topical: Miconazole (monistat) - OTC Clotrimazone (gynelotrimin) Terconazole (Terazol) insert applicator at bedtime x 1-3 days
How do you treat yeast infection in pts with immunosuppression or recurrent episodes?
Fluconazole 150mg PO x 2-3 days 72 hours apart
topical medication - vaginal imidazole 7-14 days
How do you treat yeast infection in a pregnant pt?
NO oral meds
topical (clotimazole or miconazole) x 7 days
What is the yeast infection is caused by C. glabrata instead of C. albicans, how does the treatment change?
must be isolated by culture before treatment
Boric Acid 600mg intravaginally x 14 days
made at compounding pharmacy
What is the most common no-viral STI worldwide?
trichomoniasis
Trichomonas vaginalis
flagellated protozoan infection
asymptomatic in males
tx both male and female
What are the sxs of trichomonas?
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
Does trichomonas progress to PID?
no - non inflammatory
How do you dx trichomonas?
motile trichomonads on saline wet mount
-pear shaped
usually concomitant BV infection
-Clue cells, +whiff
How do you treat trichomonas?
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
How do you treat trichomonas in pregnancy?
metronidazole 2g PO x 1
associated with preterm delivery and low birth wt (if untreated I believe)
Bartholin glands are located where?
5 and 7 oclock
pea-sized
normally non-palpable
What is the function of bartholin glands?
maintain moisture of the vagina
What is the most common vulvovaginal tumor?
bartholin gland cyst
What age typically gets bartholin gland cysts?
ANY age
if post-menopausal you must r/o malignancy
What is the difference between bartholin gland cyst and abscess?
abscess is when obstructed duct becomes infected
What are the sxs of bartholin cysts?
painLESS vulvar mass
most detected on pelvic exam
if very large can have discomfort with sitting, walking, sex
clear, white fluid if drainage occurs
What are the sxs of bartholin abscess?
tender, erythematous, severe pain with mucopurulent drainage
warm, tender, fluctuant mass
consider culture, gonorrhea/chlamydia
typically end up in the ER d/t pain
What is the treatment of bartholin cyst?
if asymptomatic, monitor
Sitz bath
consider biopsy to exclude malignancy in high risk populations (post-
menopausal)
What is the treatment of bartholin abscess?
I and D with placement of Word catheter
+/-ABXs
Bactrim DS (cover MRSA) PO BID x 7 days
Word catheter
catheter placed after I and D for bartholin abscess
goal: decrease recurrence
left in for 4-6 weeks
Marsupialization
alternative treatment to word catheter for bartholin abscess
Vulvar Cancer
4% of gynecologic cancers
typically in postmenopausal women
average age of dx is 68
What are the risk factors of vulvar cancer?
HPV types 16, 18, 31 VIN - vulvar intraepithelial neoplasia lichen sclerosus hx cervical cancer HIV infection
What is the most common histological type of vulvar cancer?
SCC
here paget’s disease has a good prognosis unlike with breast cancer
How does vulvar cancer present?
vulvar lesion + pruritus
unifocal plaque, ulcer, or mass on labia, clitoris or perineum
+/- vulvar bleeding and pain
How do you dx vulvar cancer?
biopsy of lesion
What is the treatment of vulvar cancer?
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
Vaginal Cancer
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
What type of cancer is associated with DES?
clear cell adenocarcinoma - vaginal cancer
How does vaginal cancer present?
painless vaginal and/or postcoital bleeding
How do you dx vaginal cancer?
pelvic exam
vaginal biopsy
What is the treatment for vaginal cancer?
surgical excision (hysterectomy and upper vaginectomy) radiation therapy
