Vaginal/Vulvar Disorders

Question 1

Bacterial Vaginosis

Answer 1

• Definition: Alteration in vaginal flora→Overgrowth of facultative anaerobes
  
  • Gardnerella Vaginalis → increased incidence with increased number of partners
  • NOT a reportable infection
• S/sxs:
  
  • homogenous, thin, grayish-white discharge that smoothly coats the vaginal wall
  • Pruritus, irritation, erythema & edema
• Dx:
  
  • AMSEL Criteria (need ¾)
    
    1. gray/white discharge
    2. vaginal pH >4.5
    3. Positive whiff-amine test fishy odor when a drop of 10% KOH is added to vaginal discharge sample
    4. Clue cells on wet mount (>20% = highly diagnostic)
• Tx:
  
  • Metronidazole 500mg BID x 7 days
  • Clindamycin 2% cream 5g intravaginally at bedtime for 7 days

Question 2

Trichomoniasis

Answer 2

• Definition:
  
  • vaginal infection caused by protozoan parasite trichomonas vaginalis
  • Trichomoniasis in pregnancy = premature rupture of membranes & preterm labor
• S/sxs:
  
  • “Frothy” gray or yellow green discharge
  • Complaints of discharge and pruritus
  • Can be asymptomatic
• PE:
  
  • “strawberry cervix” = punctate hemorrhages on the cervix
• Dx:
  
  • NAAT
  • POCT
  • PAP test result may state “trichomonas noted”
  • Wet mount microscopy
• Tx:
  
  • Oral metronidazole 500mg BID x 7 days for women
  • Oral metronidazole 2 g orally in single dose for men
  • Both partners should be treated
    
    • → wait to resume sexual contact until both have been treated (expedited partner therapy)
  • Retest at 3 months
    
    • Council on condoms, avoid douching, male circumcision can reduce risk

Question 3

Vuvlovaginal Candidiasis

Answer 3

• Definition:
  
  • Overgrowth of Candida species in the Vagina → Candida albicans
  • EXTREMELY COMMON
  • NOT Sexually transmitted
  • Risks:
    
    • immunocompromised, douching
• S/sxs:
  
  • Pruritus, vaginal soreness, dyspareunia, external vulvar burning, external dysuria
  • Abnormal vaginal discharge, odorless, thick, white and clumpy (but can be thin or watery)
  • Vulvar & labial erythema, fissures and satellites popular lesions
• Dx:
  
  • Vaginal pH < 4.5
    
    • (normal KOH and saline wet mount)
  • Clinical Dx
  • Vaginal cx
    
    • rare and used for more complicated or recurrent infx to confirm dx
• Tx:
  
  • uncomplicated:
    
    • OTC intravaginal Agents
    • Prescription Intravaginal Agents
    • Oral Agents:
      
      • Fluconazole 150 mg orally in a single dose
  • complicated:
    
    • 7-10 days of topical azole therapy
      
      • PLUS: 2 doses of fluconazole 150 mg 72 hours apart

Question 4

Vaginal Atrophy

Answer 4

• Definition: thinning of the vaginal walls that occurs with decline in circulating estrogen. Progressive & unlikely to resolve on its own
  
  • estrogen maintains healthy pH, natural lubrication, vaginal elasticity, & vulvar skin
• S/sxs:
  
  • vaginal dryness
  • dyspareunia, bleeding after intercourse
  • reduced lbidio (d/t decreased testosterone, usually resolves after age 65)
  • vaginal infx, vulvar pain
  • dysuria, increased frequency & urgency
  • recurrent UTIs
• PE:
  
  • labia minora resorption, pallor, redness
  • loss of vaginal rugae
  • tissue fragility & fissures
  • urethral eversion or prolapse
  • loss of hymenal remnants
• Dx:
  
  • clinical
• Tx:
  
  • vaginal moisturizers: replenish & maintain water content
  • Vaginal lubricants: coats vagina, eases penetration
  • topical vaginal estrogens: estrace, premarin (from a pregnant horse’s urine)
  • Ospemifene: for painful intercourse (PO), tissue selective estrogen agonist/antagonist
  • Frequent sexual activity may lessen symptoms

Question 5

Vaginal Prolapse

Answer 5

• Definition: protrusion of the vagina through the vaginal wall or vaginal orifice
• Risks:
  
  • hysterectomy
• S/sxs:
  
  • vaginal or pelvic pressure; heaviness; bulging; bowel or bladder symptoms
• Dx:
  
  • Grading:
    
    • 1: descent above the hymen
    • 2: descent to the hymen
    • 3: descent beyond the hymen
    • 4: total prolapse
• Tx:
  
  • pessary
  • surgery: attach the the vagina to the pelvic ligaments or lower part of the spine

Question 6

Rectocele

Answer 6

• Definition: prolapse of the rectal wall into the vagina
• Risks: childbirth, heavy lifting, menopause
• s/sxs:
  
  • pelvic pressure
  • bulge into vainga
  • defecatory dysfunction: constipation, straining, incomplete emptying
  • low back pain
• Dx:
  
  • colonoscopy
• Tx:
  
  • Conservative: kegel exercises & pelvic floor training
  • pessary
  • surgery