Non Sexually transmitted infections

Question 1

what is the pathophysiology behind bacterial vaginosis? Including organisms responsible

Answer 1

there is a disturbance to the normal microflora of the vagina. Lactobacilli normally produce acid to create a low pH <4.5 in the vagina to inhibit growth of other organisms.
In bacterial vaginosis there is a reduction in lactobacilli and thus the pH rises and other organisms can grow.

Thus the infection is often polymicrobial but most common organisms found are Gardnerella vaginalis, anaerobes and mycoplasma

Question 2

name two types of no nSTIs

Answer 2

Bacterial vaginosis

Vulvovaginal Candidiasis

Question 3

what are the risk factors for getting bacterial vaginosis?

Answer 3

sexual acitivity can change microflora
receiving oral sex
vaginal soaps and douches 
Abx 
presence of STI 
contraceptive IUD 
smoking 
ethnicity - more common in black

Question 4

what are the clinical features of bacterial vaginosis?

Answer 4

may be asymptomatic
offensive fishy smelling discharge
not usually associated with itching/soreness
thin white/grey homogenous vaginal discharge

Question 5

how does the discharge compare in bacterial vaginosis, candidiasis and trichomonas vaginalis ?

Answer 5

bacterial vaginosis - fishy smelling thin white/grey homogenous discharge

candidiasis - thick white curd like and itchy

Trichomonas vaginalis - thin, frothy, offensive discharge with irritation, dysuria and vaginal inflammation

Question 6

how can bacterial vaginosis be investigated ? what would indicate a positive diagnosis?

Answer 6

high vaginal smear (HVS) and gram staining:

- clue cells
- reduced lactobacilli 
- absence of pus cells 

pH <4.5
KOH whiff test

Question 7

what are clue cells?

Answer 7

cells seen in bacterial vaginosis

vaginal epithelial cells studded with gram variable coccobacilli

Question 8

what is the KOH whiff test?

Answer 8

test for bacterial vaginosis

KOH (alkaline) is applied to discharge which causes the release of a strong fishy odour

Question 9

how is bacterial vaginosis managed?

Answer 9

asymptomatic cases do not require treatment.

otherwise metronidazole - oral or vaginal gel

Clindamycin or Tinidzole may also be used

advice: avoid douching, shower gels and vaginal scents

Question 10

What complications occur during pregnancy in someone with untreated symptomatic bacterial vaginosis?

Answer 10

increased risk of

• premature birth
• miscarriage
• chorioamnionitis

Question 11

how are pregnant women treated for bacterial vaginosis? breastfeeding women?

Answer 11

pregnant: same way as non pregnant - metronidazole
breastfeeding: adviced to use lower doses of metronidazole because it can affect the taste of breast milk.

Question 12

what is vulvovaginal candidiasis?

Answer 12

fungal infection of lower reproductive tract in women

caused by candida albicans in 90% of cases

Question 13

what are the risk factors to candidiasis infection?

Answer 13

pregnancy
diabetes
immunosuppression - HIV, cancer, corticosteroids
broad spec Abx - kills vaginal flora allowing candida to flourish

Question 14

what are the clinical features of candida infection

Answer 14

pruritis of vulvae - which can extend to perianal region in some women
thick white curd like discharge - non offensive
superficial dysuria

signs:

• erythema and swelling of vulvae
• red, pustular lesions with superficial white pseudomembranous plaques
• curd like discharge

Question 15

what are the differentials for vulvovaginal candidiasis?

Answer 15

bacterial vaginosis
UTI
STI
eczema

Question 16

how would you investigate vulvovaginal candidiasis?

Answer 16

in uncomplicated cases the history alone is enough
vaginal pH and examination can be performed

if complicated cases then vaginal smear and microscopy is indicated

Question 17

what is found on vaginal smear and microscopy for candidiasis?

Answer 17

presence of spore and mycelia

Question 18

how is vulvovaginal candidiasis managed?

Answer 18

initial course of intravaginal antifungals such as fenticonazole or clotrimazole - usually inserted into vagina by applicator

oral antifungals - fluconazole or itraconazole - as an alternative treatment.

Topical imidazole can be prescribed as well as oral or intravaginal treatment. This addresses vulval symptoms.

advice - reduce using soaps in the area and wearing tight clothing.

Question 19

what should you do if the symptoms of candidiasis do not resolve within 7 -14days ?

Answer 19

consider alternative diagnosis by measuring vaginal pH and taking swabs for microscopy and culture
consider predisposing risk factors and try to address e.g. diabetes
consider compliance to medication issues.

Question 20

why is candidiasis more common in pregnancy?

Answer 20

O levels stimulate glycogen production which provides a favourable environment for microbes to thrive
also encourages it to stick to walls and grow better

Question 21

how is candidiasis infection in pregnancy managed?

Answer 21

intravaginal anti-fungals
do not use oral anti-fungals
treat vulval symptoms with topical anti-fungals.