TL: Vaginitis/Pelvic Inflammatory Disease Flashcards
Bacterial (Gardnerella) Vaginosis
- Bacterial vaginosis is the most prevalent cause of vaginal discharge or malodor, occurring in up to 30 percent of women.
- It occurs when the normal Lactobacillus species in the vagina are replaced with anaerobic gram-variable rod Gardnerella Vaginallis, resulting in reduced levels of hydrogen peroxide and organic acids usually present in the vagina.
- The underlying cause of bacterial vaginosis is not fully understood.
- More than 50 percent of women with bacterial vaginosis are asymptomatic.
- The fishy odor caused by production of amines from anaerobic bacteria found in many of these patients is predictive of bacterial vaginosis.
- When vaginal alkalinity increases after sexual intercourse (with the presence of semen) and during menses (with the presence of blood), the odor becomes more prevalent.
- Bacterial vaginosis is associated with sexual activity but not sexually transmitted.
- Vaginal discharge is a more common but less specific symptom.
- Bacterial vaginosis is not associated with vaginal mucosal inflammation and rarely causes vulvar itch.
Bacterial (Gardnerella) Vaginosis Sequelae
- Bacterial vaginosis, even when asymptomatic, is associated with a high incidence of endometritis and pelvic inflammatory disease following abortion and gynecologic procedures in the general population.
- Among women with bacterial vaginosis, no overall increased risk of developing pelvic inflammatory disease has been found. Bacterial vaginosis is associated with late miscarriages, premature rupture of membranes, and preterm birth.
- Both symptomatic and asymptomatic bacterial vaginosis have been strongly linked with an increased risk of human immunodeficiency virus (HIV)-1 transmission.
Bacterial (Gardnerella) Vaginosis Diagnosis
- In clinical practice, bacterial vaginosis is diagnosed by the presence of three out of four Amsel Criteria:
- Thin, homogenous vaginal discharge
- Vaginal pH greater than 4.5
- Positive whiff test (fishy amine odor when 10 percent potassium hydroxide solution is added)
- At least 20 percent CLUE cells (vaginal epithelial cells with borders obscured by adherent Gardnerella on wet-mount preparation or Gram stain; have a stippled appearance along the outer margin.
- In a prospective observational study of 269 women, a vaginal pH of more than 4.5 was found to be the most sensitive (89 percent) and a positive whiff test was the most specific (93 percent) method of detecting bacterial vaginosis. The positive presence of these two tests is as sensitive as three or more Amsel criteria. Culture of Gardnerella vaginalis is not recommended because of low specificity. Cervical cytology has no clinical value for diagnosing bacterial vaginosis, especially in asymptomatic women, because it has low sensitivity
Bacterial (Gardnerella) Vaginosis Treatment
- Current treatment recommendations from the Centers for Disease Control and Prevention (CDC) are metronidazole or clindamycin.
- Nonpregnant women with symptomatic disease require antibacterial therapy to relieve vaginal symptoms.
- Other benefits of treatment include decreasing the risk of HIV and other sexually transmitted infections and reducing infectious complications following abortion or hysterectomy.
- Metronidazole, 500 mg twice daily for one week, is effective for treating bacterial vaginosis.
- Treatment of sex partners and follow-up visits if symptoms are resolved are not recommended.
Alcohol and Metronidazole
- Patients taking metronidazole should abstain from alcohol because it can cause a disulfiramlike reaction. Patients will get a headache with nausea, vomiting and flushing with concomitant alcohol consumption.
- Too much acetyladehyde!
Trichonoiasis
- Symptoms and signs of trichomoniasis are not specific, and diagnosis by microscopy is more reliable.
- Features suggestive of trichomoniasis are flagellated protozoan trichomonads seen with saline, leukocytes more numerous than epithelial cells, positive whiff test, and vaginal pH greater than 4.5.
-The wet-mount preparation is an inexpensive and quick point of care test with variable sensitivity of 58 to 82 percent, and is influenced by the experience of the examiner and the number of parasites in the vaginal fluid sample.
•The diagnosis can also be made by nucleic acid amplification testing (NAAT) in urine.
Trichonoiasis Treatment
- Metronidazole in a dosage of 500 mg twice daily for seven days will treat trichomoniasis. Patients taking metronidazole should abstain from alcohol because it can cause a disulfiram-like reaction. Patients will get a headache with nausea, vomiting and flushing with concomitant alcohol consumption.
- Sex partners should be treated simultaneously.
- To reduce recurrence, partners should avoid resuming sexual intercourse until both have completed treatment and are asymptomatic.
- Retesting should be performed 3 months after treatment.
Vulvovaginal Candidiasis
- An estimated 75 percent of women will have at least one episode of vulvovaginal candidiasis, and 40 to 45 percent will have two or more.
- Gram-positive lactobacilli comprise a major part of the normal vaginal flora and exist in balance with other colonizers at a normal vaginal pH of 4.0-4.5.
- Changes in the host vaginal environment precipitate and induce pathologic effects of the organism and lead to overgrowth of yeast, most commonly Candida.
- Systemic antibiotic use, diet high in refined sugars, systemic corticosteroid therapy, uncontrolled diabetes mellitus, causes for immunosuppression (HIV) are risk factors for vulvovaginal candidiasis.
- Antibiotic use is the most common cause of Candida vaginitis due to reduction of the lactobacilli population, which facilitates Candida overgrowth.
Vulvovaginal Candidiasis Diagnosis
- Although symptoms of vulvovaginal candidiasis such as pruritus, vaginal soreness, dyspareunia, and thick white “cottage cheese” vaginal discharge are common, none of them are specific.
- Most patients can be diagnosed by microscopic examination of vaginal secretions with a 10% potassium hydroxide solution (sensitivity, 65 to 85 percent). Budding yeast or psuedohyphae will be seen on wet mount.
- Vaginal pH is usually normal (4.0 to 4.5).
Vulvovaginal Candidiasis Treatment
•Treatment of uncomplicated vulvovaginal candidiasis involves a short course of antifungals; oral fluconazole or intravaginal antifungal preparations are similarly effective.
Pelvic Inflammatory Disease Pathogenesis
•PID is most commonly caused by ascending infection due to C. trachomatis, N. gonorrhea, anaerobes (bacteroides and anaerobic cocci) but it also be caused by U. urealyticum, Streptococci agalactiae, G. vaginalis, M. hominis, M. genitalium, Hemophilus influenza, enteric Gram-negative rods, cytomegalovirus (CMV), and Candida.
Pelvic Inflammatory Disease Clinical Manifestations
•Signs and symptoms include lower abdominal pain, abnormal bleeding, dyspareunia, fever, vaginal discharge, and nausea/vomiting. Symptoms are more abrupt and severe with N. gonorrhea than C. trachomatis. Complications include infertility, chronic pelvic pain, and ectopic pregnancy. In addition, Fitz-Hugh-Curtis Syndrome can occur with N. gonorrhea or C. trachomatous infection in which there is direct extension through the fallopian tube leading to perihepatitis.
Pelvic Inflammatory Disease Diagnosis
- Cervical motion tenderness is a sensitive but not specific sign that w women has PID. Laboratory testing includes an endocervical swab a C. trachomatis and N. gonorrhea nucleic amplification test (NAAT).
- Other diagnostic modalities that may be needed are transvaginal sonography or magnetic resonance imaging, Doppler studies, and as last resorts, endometrial biopsy or laparoscopy.
Pelvic Inflammatory Disease Treatment
- For outpatients, treatment with ceftriaxone and doxycycline +/- metronidazole (for anaerobic bacteria).
- For women with more severe disease requiring hospitalization, treatment is with an intravenous cephalosporin (cefoxitin or cefotetin) and doxycycline is indicated.
