Vaginitis Flashcards
What is the most common microbe found in the vagina?
Lactobacillus acidophilus
What are the typical characteristics of vaginal discharge and what is a normal pH?
Normal vaginal discharge is clear or milky without malodor
Normal pH is 3.5 to 4.7 in reproductive age women
When do vaginal and Endocervical fluid increase normally?
In pregnancy, during mid menstrual cycle, during intercourse or arousal
What occurs to vaginal fluid after menopause and why?
Decreased production because estrogen levels are decreased
Makes you more at risk for infection
What are the components of vaginal fluid?
Cervical mucus
Endometrial or oviductal fluid
Exudate from Bartholin’s or Skene’s glands
Transudates from vaginal squamous epithelium
Exfoliated squamous cells and metabolic products of microflora
What alters the protective vaginal microflora
Douching
Sexual intercourse with presence of semen
Foreign body
Antibiotics
What does douching do?
Alters pH and suppresses protective bacteria, allowing overgrowth
What is the presence of semen in the vagina do?
Raises pH to up to 7.2 for 6 to 8 hours
pathogens can proliferate
What do foreign bodies in the vagina do?
Disrupts vaginal cleansing mechanism and May lead to infection
What do antibiotics do to the vagina?
Suppress is growth of normal flora
Some women are more sensitive than others
What is vaginitis?
Inflammation of the vagina characterized by discharge, odor, irritation, and/ or itching
Very uncomfortable
what are the most common vaginal infections?
Bacterial Vaginosis (22%-50%)
Candidiasis (17-39%)
Trichomoniasis (4%-35%)
Attributes of vaginal discharge
Quantity
Duration
Color
Consistency
Odor
Evaluation of vaginal discharge
Physical and pelvic examination
Determination of pH of fluid
10% KOH on discharge for “amine odor” (fishy) seen in trichomonas or BV
Wet mount preparation
- Collect samples of discharge from posterior fornix mixed into 2 mL of saline
- Drop on slide with coverslip.
- Examine under microscope.
What is the most prevalent vaginal infection?
Bacterial Vaginosis (BV)
BV results from disruption of normal vaginal flora when lactobacilli are lost and anaerobic and aerobic bacteria increase
What are the most common bacteria is to cause BV?
Gardnerella vaginalis
Mycoplasma hominis
Ureaplasma urealyticum
Risk factors and complications of BV
Risk factors:
Change in sexual partner(s) smoking IUD and douching May increase patient’s risk
In pregnant women leads to increased risk of premature rupture of membranes, preterm, labor, and preterm delivery. If it’s untreated past the 20 week mark.
In nonpregnant woman increases risk of PID and HIV transmission
Clinical manifestations of BV
Primary symptom is profuse, milky, FROTHY, WHITE to gray vaginal discharge with a amine or FISHY odor
No underlying erythema
50% of women may be asymptomatic
How do you make a diagnosis of BV
Made if 3/4 criteria are present:
Homogenous white to gray adherent discharge
Vaginal pH greater than 4.5
Release of fishy odor (positive Whiff test) with KOH
Clue cells (epithelial cells with clumped bacteria on the cell wall) on a wet mount
What is not used in diagnosis of BV
Culture because it is not specific
What is the treatment for bacterial vaginosis?
Drug of choice:
Metronidazole (Flagyl)
500 mg PO BID x 7 d
OR
Clindamycin (Cleocin)
2% cream- one applicator (5g) intravaginally at bedtime x 7d
OR
Metronidazole Gel 75%
One applicator (5g) intravaginally daily x 5d
What is the treatment for BV in pregnant patients?
Metronidazole
250 mg PO TID x 7d
Is partner treatment recommended in BV?
No- it’s not sexually transmitted
What should patients avoid with metronidazole?
Alcohol
Patient should not consume alcohol for two days after treatment causes severe G.I. upset
What is vulvovaginal candidiasis? What causes it?
Yeast infection
Candida albicans causes 90% of cases
Used his present in vagina, but symptoms appear with overgrowth
75% of women experience this in their lifetime
What increases risk for infection for vulvovaginal candidiasis?
Pregnancy, uncontrolled diabetes mellitus, oral contraceptives, IUDs, diaphragm use with spermicide, young age at first intercourse, HIV infection, antibiotic use, douching , perfumed feminine hygiene sprays, tight clothing and underwear, wet bathing suit
Is vulvovaginal candidiasis sexually transmitted
It’s not know, but sometimes male partners can have irritation
Clinical manifestations of vulvovaginal candidiasis
Classic presentation includes vaginal itching, burning, irritation, and +/- dysuria
Physician exam findings include vulvovaginal erythema, swelling, satellite lesions (around rectum)
Excoriation may be present from scratching
What is the discharge of candida vaginitis like?
Discharge is usually odorless, white, thick, curdy and has a cottage cheese appearance
What does a wet mount show in vulvovaginal candidiasis
Microscopic examination shows budding yeast, pseudohyphae, and mycelial tangles
Diagnosis of vulvovaginal candidiasis
Fungal culture may be needed, but you don’t have to
Negative whiff test
pH less than 4.5
Cottage cheese appearance d/c
Treatment of vulvovaginal candidiasis
Topical antifungal medications:
Butoconazole 2% cream (Femstat3) (OTC)
5g intravaginally for 3 days
Clotrimazole 1% cream
5gm inserted intravaginally q day x 7-14 days
Oral Antifungal Medications
Fluconazole (Diflucan)
150 mg po x1 dose
***Give both clotrimazole and fluconazole
Is treatment of partner recommended with vulvovaginal candidiasis
No, it’s not sexually transmitted
What is trichomoniasis? Caused by?
Caused by protozoan trichomonas vaginalis
Trichomonas infects vaginal epithelium, endocervix urethra, Bartholins/Skenes glands
Risk factors for trichomoniasis
SPREAD SEXUALLY
Unprotected intercourse with multiple sexual partners
IUD use
Condoms and spermicides reduce transmission rates
Classic manifestations of trichomoniasis
Green to yellow frothy vaginal discharge with musty odor, dyspareunia, vulvovaginal irritation, dysuria
Strawberry cervix (punctate hemorrhages)
50% of women are asymptomatic
Diagnosis of trichomoniasis
Motile protozoa, mature epithelial cells, and white blood cells seen on saline wet prep
Elevated vaginal pH of 5 to 6.5
PCR and antigen testing are available
Culture is very sensitive, will come up in urine
Complications of trichomoniasis
is associated with adverse pregnancy outcomes
Prematurity
Low birth weight
Increased risk of HIV transmission ( because inflammation of vaginal mucosa)
Treatment of trichomoniasis
Because trichomoniasis is very sensitive to metronidazole, the recommended treatment is:
Metronidazole (Flagyl) 2 gm PO x 1 dose results in 90% cure rate (camuses some nausea)
OR
Metronidazole 500 mg PO BID x 7d gives comparable results
Should the partner receive treatment of trichomoniasis
Yes, it’s sexually transmitted
Treatment of trichomoniasis in pregnancy
Associated with adverse pregnancy outcomes
Unclear if treatment in pregnancy reduces perinatal morbidity
Metronidazole 2gm PO x 1 dose
What is atrophic vaginitis caused by and who is it seen in most common?
Information of vagina and vulva due to decreased levels of estrogen
Most commonly in postmenopausal woman or women who’s ovaries no longer produce estrogen
What does atrophy of vaginal epithelium result in
Atrophic vaginitis
Clinical manifestations of atrophic vaginitis
Vaginal discharge, dysuria, frequency, vulvar itching, burning, bleeding, or spotting, or dyspareunia
PE findings:
Watery discharge, generalized vulvar erythema, excoriation
Vaginal walls become thin/paperlike
On speculum examination the epithelium is pale with erythematous patches, superficial blood vessels which made bleed
What does a Pap smear show with atrophic vaginitis?
Immature basal cells replacing superficial vaginal epithelial cells
Treatment of atrophic vaginitis
Topical estrogen available in cream, vaginal suppositories, rings
Estradiol vaginal ring or estradiol hemihydrate (vagifem) intravaginal tablets
Be careful of giving estrogen hormone, especially to those with history of cancer, so try water-based lubricant first
Can recommend herbal supplements
