Vulvovaginal disorders Flashcards
The Normal Healthy Vaginal Environment is due to
· Symbiotic relationship of multiple aerobic, facultative anaerobic and obligate
anaerobic species
Vaginal Mucosa is made up of
stratified squamous non-keratinized epithelium
- relatively anerobic habitat
pH of the Normal Healthy Vaginal Environment
pH between 4.0 - 4.5
* Alkaline environment thanks primarily to Lactobacillus species (gram-
positive species that produces H 2O 2 , bacteriocins compounds, organic
acids including lactic and fatty acids)
Glycogen function in the vaginal environment
Glycogen present in vaginal mucosal cells – provides nutrients to the
ecosystem, metabolized to lactic acid (low in childhood and diminishes after
menopause = lower prevalence of lactobacillus species à rise in pH à altered
environment à risk of infections)
What things can cause vaginal dysbiosis?
· Hormone levels (age, pregnancy, menstrual cycle)
· Sexual activity
· Chronic stress
· Medications, soaps, detergents
· Regional disparities (local biome) & hygiene/
cultural practices
· Genetic factors such as immune system
What is Vulvovaginitis?
inflammation of the vulva and vagina
Vulvovaginitis etiology & risk factors
Etiology: pathogens (infection) or non-pathogenic sources causing
skin reaction (soaps, detergents, intercourse)
* candida albicans
* Trichomonas vaginalis
* Bacterial vaginosis
* Condylomata acuminata
Risk Factors: recent sexual activity, hormone changes, use of
contraceptives, tampons or douches
Vulvovaginitis presentation & eval?
HPI – onset, location, duration of sx,
character of sx, ?triggers (ask about risk factors), palliating and alleviating
factors, LMP date, recent medications
PE – external exam of vulva, speculum exam of vagina & cervix
Diagnostic evaluation of vulvovaginitis
Labs – obtain cultures for yeast, BV, trichomonas
UA for GC/Chlamydia
pH
Wet mount prep
+/- STI testing
Treatment of vulvovaginitis
infections (covered later), pt education of risk factors: avoid/stop offending agent, sitz bath, ?short course of topical steroids
What is Vulvar Dermatoses?
benign and neoplastic disorders of the lower vaginal tract
Lichen Sclerosus
a chronic skin condition that results in thin white patches on the skin, usually associated with vulva & perineum
Vulvar Dermatoses: Lichen Sclerosus etiology & risk factors
Etiology: unknown (Theories: Autoimmune, vitamin A deficiency, pathogen)
* Not a/w LS of pregnancy, hysterectomy or hormone replacement
Risk Factors: age; a/w a higher risk of vulvar malignancy
(squamous cell ~5%)
Clinical features and eval of Vulvar Dermatoses: Lichen Sclerosus
HPI - Pruritis, dysuria, dyspareunia, sx often
worse at night
PE – ivory-white, circumscribed atrophic patches, skin appears thin and
crinkled texture is generally pathognomonic; may involve perineum.
Treatment of Vulvar Dermatoses: Lichen Sclerosus
- symptom control – topical corticosteroids, gentle cleansers, avoidance of harsh chemicals, abrasion like sex or panty liners;
- Estrogen cream – used only to help with epithelial integrity
- prevention of anatomical changes – surgeryC
Complications & referral considerations of vulvar Dermatoses: Lichen Sclerosus
Complications: skin thins over time risking infection, labia minora
regression, clitoral concealment, urethral obstruction
Referral: derm or gyn for biopsy, in long-standing cases to rule out
malignancy
Dermatoses: Lichen Simplex Chronicus etiology
vulvar skin changes resulting from chronic-
trauma from scratching/irritation; skin responds by thickening –> lichenification
* Irritation from any number of precipitating causes:
* Yeast infections, STIs, etc.
* Dermatitis (moisturizers, tight clothing, over-
washing, sweat, etc.)
Risk factors of Dermatoses: Lichen Simplex Chronicus
poor adherence to treatments for
precipitating causes; worse with stress
Clinical features of Dermatoses: Lichen Simplex Chronicus
thickened vulvar skin with increased
skin markings, no loss of anatomical structure
Diagnosis of Dermatoses: Lichen Simplex Chronicus
Evaluation: Rule out candidiasis/other possible precipitating causes
Biopsy to rule out psoriasis which can contribute to malignancies
Treatment & Management of Dermatoses: Lichen Simplex Chronicus
STOP THE SCRATCH CYCLE!
* oral antihistamines, topical steroids, treatment of underlying condition
Dermatoses: Contact Dermatitis
inflammatory response to a primary irritant or allergen
Etiology & Risk Factors of Contact Dermatitis
based on allergy profile; about 54% of
unexplained cases of vulvar puritus and inflammation
Clinical Presentation of Contact Dermatitis
immediate itching/burning
sensation (irritant); delayed onset of itching, localized erythema, edema, and possibly vesicle/bullae formation if due to allergen
Evaluation: consider patch testing, look for associated conditions: candidiasis, psoriasis, SCC
Dermatoses: Contact Dermatitis diagnosis
primarily based on H&P and evaluation for other conditions
Treatment of Dermatoses: Contact Dermatitis
- remove offending agent,
- restore skin barrier function (sitz bath plain water, plain petrolatum),
- treat any underlying infection,
- Consider topical steroids
- Cool packs (NOT COLD)
- Antihistamine (hydroxyzine)
Bartholin’s Gland Abscess etiology
Bartholin gland is obstructed
secondary to either trauma or
inflammation
Clinical Presentation of Bartholin’s Gland Abscess
pain, swelling, erythema, dyspareunia, difficulty
walking
Management &Treatment of a Bartholin’s Gland Abscess
depends on size and if it is self-draining
* Small: sitz baths, warm compresses
* Moderate-Large: I&D, culture, Word catheter placement, +/- antibiotic if systemic sx
Complications of a Bartholin’s Gland Abscess
large abscesses or cyst formations may require marsupialization vs. complete excision
Cystocele
weak vaginal wall à protrusion of bladder into vaginal vault
Risk Factors for a cystocele
multiparous, age, hysterectomy, obesity/increased abdominal pressure,
genetics
Clinical Presentation of Cystocele
dyspareunia, incomplete bladder emptying à recurrent UTIs and/or incontinence, discomfort with coughing/lifting/standing
Evaluation & Diagnosis of a cystocele
PE – clinical, bladder studies
Treatment & Management of a cystocele
Mild – pelvic floor PT/kegels, vaginal estrogen
Mod/Severe – pessary, surgery (refer to urology, GYN)
Rectocele etiology & risk factors
Etiology: Increased pelvic floor pressure
Risk Factors: multiparous, age, repeated heavy
lifting, chronic constipation, straining, cough
Clinical presentation & evaluation of a rectocele
Clinical Presentation: sensation of hernia,
constipation or fecal incontinence, dyspareunia
Evaluation & Diagnosis: PE (clinical)
Management & Treatment of a rectocele
Expectant: pelvic floor
training, avoidance of risk factors
Referral: for pessary or surgery if severe, worsening
Vaginal/Uterine Prolapse etiology and risk factors
Etiology: Stretched/weakened pelvic floor muscles and ligaments
Risk Factors: Multiparous, age, genetics, obesity
Clinical Presentation & evaluation of Vaginal/Uterine Prolapse
dyspareunia, incomplete bladder emptying à recurrent UTIs
and/or incontinence, discomfort with coughing/lifting/standing
Evaluation & Diagnosis: PE – clinical, bladder studies
Treatment & Management of Vaginal/Uterine Prolapse
Mild – pelvic floor PT/kegels, vaginal estrogen
Mod/Severe – pessary, surgery (refer to urology, GYN
Supportive measures for Pelvic Organ Prolapse
- High-fiber diet and laxatives to improve constipation
- Weight reduction in persons with obesity
- Limitation of straining and lifting are helpful
The only cure for symptomatic cystocele, rectocele, or enterocele is _____
corrective surgery
Vaginal Candidiasis etiology
C. albicans normal resident of the human body
* imbalance between this yeast and its host à candidiasis.
* Other species: C tropicalis and C glabrata,
* Sexual transmission is uncommon, and treatment of sexual partners is
unnecessary
Risk factors for Vaginal Candidiasis
mmunosuppression, diabetes mellitus (some meds), pregnancy, and recent broad-spectrum antibiotic use
Clinical presentation & eval of Vaginal Candidiasis
Clinical Presentation: vulvar pruritus, burning, erythema, and edema,
Evaluation & Diagnosis: On PE you may see excoriations (common),
* Ivory-white vaginal discharge “cottage cheese–like”
* Microscopic examination with saline and 10% KOH prep –> yeast
Treatment & Management of Vaginal Candidiasis
Consider probiotic products (lactobacillus)
Uncomplicated = sporadic, immunocompetent pts, and likely C albicans
* Azoles very effective
* Fluconazole 150 mg PO x 1
Complicated = frequent recurrence, severe symptoms, immunosuppressed pts and/or non-albicans species
* Fluconazole 100-mg, 150mg or 200 mg PO q72h (once every 3 days) x 3 doses
* Consider suppression therapy with fluconazole
MOST COMMON CAUSE of vaginal discharge among reproductive age women
Bacterial Vaginosis
Bacterial Vaginosis etiology
overgrowth of anaerobic species, usually Gardnerella, but also
Prevotella, Mobiluncus, and Bacteroides species; Atopobium vaginae.
There is also a significant reduction in Lactobacillus.
Risk Factors for Bacterial Vaginosis
not considered an STI
* multiple or new sexual partners, female partners, oral sex, douching, Black race,
smoking, and intrauterine device (IUD) use
* condom use lowers the risk
Clinical presentation of Bacterial Vaginosis
- nonirritating, malodorous vaginal discharge but not always present.
- examination reveals no abnormalities: vagina is not erythematous, cervix is
normal in appearance
Evaluation & Diagnosis of Bacterial Vaginosis
PE
Wet Prep: swab-collected sample of
discharge mixed with drops of saline on a
microscope slide
_____ are the most reliable
indicators of BV
Clue cells
Bacterial Vaginosis complications
observed in women with BV include:
* vaginitis, endometritis, post-abortal endometritis,
* pelvic inflammatory disease (PID) unassociated with Neisseria gonorrhoeae or Chlamydia trachomatis,
* susceptibility to human immunodeficiency virus (HIV) acquisition, and
* acute pelvic infections following pelvic surgery, especially hysterectomy
Vaginal Chlamydia etiology & risk factors
Etiology: sexually transmitted C trachomatis infection
Risk factors: unprotected sex (of any kind), multiple partners
Vaginal Chlamydia clinical features and eval
Clinical Features: pelvic pain, vaginal discharge (white),
dysuria
Evaluation & Diagnosis: Nucleic Acid Amplification Test
(NAAT) of urine sample, vaginal or cervical swab, reportable
disease
Complications of vaginal chlamydia
Pelvic Inflammatory Disease
abstinence until woman/partners treated and asymptomatic
Vaginal Gonorrhea etiology & risk factors
Etiology: sexually transmitted N. gonorrheae infection
Risk Factors: unprotected sex (all kinds), multiple sexual partners and MSM
Most frequently reported ID in the US
Vaginal Chlamydia
Women are often asymptomatic who have _____
Vaginal Gonorrhea
Clinical Presentation & eval of Vaginal Gonorrhea
Clinical Presentation: often asymptomatic, yellowish discharge, pelvic pain, dysuria
Evaluation & Diagnosis: NAAT endocervical swab
Complications of vaginal gonorrhea
Pelvic Inflammatory Disease
abstinence until woman/partners treated and asymptomatic
