Vulvovaginal Health & Infections Flashcards
Why might menopause place one at a higher risk for UTIs?
Menopause is marked by a time of lower-potency estrogen (estrone - E1). Low estrogen levels lead to a thinner, less active vaginal epithelium with scant lactobacilli, increasing the pH (6-8). Increasing pH and relative lack of lactobacilli increase risk for infection
Priority goal of vulvovaginal care
keep the vulva dry and free from irritants
Patient education regarding routine vulvovaginal care
wash with warm water; avoid douches, wipes, sprays, and powders; wear cotton underwear and avoid thongs; use unscented cotton menstrual hygiene products; avoid scented detergent, bubble baths, and scented oils; avoid shaving and waxing; wipe front to back after voiding and defecation
Normal appearance of the vaginal on physical exam
pink, rugaeted, moist vaginal muscosa (“well-estrogenized”)
Normal vaginal pH
3.5-4.5
Normal vaginal discharge
clear to cloudy, white, flocculent (loosely clumped). Minimal to small in amount
Normal wet mount findings
numerous lactobacilli, normal squamous epithelial cells
Menstrual Cycle: vaginal discharge is egg white - clear, viscous
mid-cycle
Menstrual Cycle: vaginal discharge is thick, pasty, sometimes yellow-ish
luteal phase
Estrogen promotes the growth of this bacteria as part of the healthy vaginal flora
lactobacilli
Alkaline pH of the vagina
> 4.5
KOH stands for….
potassium hydroxide
What is the purpose of having a separate KOH wet mount? (2)
- whiff/amine test for bacterial vaginosis
2. lyses the WBCs and trich making the candida easier to see
INTERPRET: Perineal laceration affecting the skin and subcutaneous tissue, with perineal muscles intact
1st degree
INTERPRET: Perineal laceration extending into the fascia and muscles of the perineal body, with the anal sphincter intact
2nd degree
INTERPRET: Perineal laceration extending through the fascia/musculature and some or all of the external anal or internal anal sphincters
3rd degree
INTERPRET: Perineal laceration involving the perineal muscles, external and internal anal sphincters, and the rectal mucosa
4th degree
1st degree perineal lacerations after vaginal childbirth can be expected to heal….
within a few weeks
INTERPRET: FGM/C involving partial or total removal of the clitoris
Type 1 (clitordectomy)
INTERPRET: FGM/C involving partial or total removal of the clitoris and labia minora, with or without the labia majora
Type 2 (excision)
INTERPRET: FGM/C involving narrowing of the vagina with the creation of a covering seal by repositioning either labia, with or without excision of the clitoris
Type 3 (Infibulation)
Vaginitis vs. Vaginosis
ITIS = inflammation OSIS = abnormal increase or production of
Generally, name for increased inflammation of the vagina with increased discharge and WBCs
vaginitis
Generally, name for increased discharge from the vagina, without inflammation or WBCs
vaginosis
(3) most common causes of vulvovaginitis
bacterial vaginosis, candidal infections, trichomoniasis
Causes of Bacterial Vaginosis (1)
An alkaline environment leading to the overgrowth of anaerobes
DIAGNOSE: Pt presents with CC of vaginal itching and irritation. Endorses postcoital spotting, dyspareunia, and urinary discomfort. On speculum exam, you note a fishy odor and increased thin, gray-white milky discharge that is homogenous and adherent to the vaginal walls.
Bacterial vaginosis
Amsel Criteria for Bacterial Vaginosis
3 out of the 4 must be present:
- thin, white adherent vaginal discharge
- pH >4.5
- positive whiff or amine test
- > 20% of epithelial cells must be clue cells
INTREPRET: You prepare a wet mount slide and conduct pH testing for cc of vaginal discharge. You note a positive whiff test on your KOH slide. pH is 4.5. On saline mount, >20% of epithelial cells are clue cells.
Bacterial vaginosis
Priority patient education when prescribing metronidazole
NO alcohol during therapy and for 24 hours after completion of therapy
Drugs of choice for treatment of symptomatic BV (2)
metronidazole or clindamycin vaginal or oral
Alternative therapies for BV
probiotics, boric acid, vinegar douches, tea tree oil, garlic suppositories
Cause of Vulvovaginal Candidiasis (VVC)
Complex relationship between host immune function, estrogen, virulence of the candida strain, and increased vaginal pH
DIAGNOSE: Pt presents with CC of vaginal and vulvar itching. Endorses dysuria. On speculum exam, found to have thick clumpy white discharge, a swollen red vagina, and white patches of discharge on the vaginal walls.
Vulvovaginal candidiasis (VVC)
In patients with recurrent vulvovaginal candidiasis infections, consider underlying _____ (4) and get a yeast culture
HIV, DM, pregnancy, non-albicans strain of candida
INTREPRET: You prepare a wet mount slide and conduct pH testing for cc of vaginal discharge. You note pseudohyphae on the wet mount. The vaginal pH is normal
Vulvovaginal candidiasis
Pharmacologic treatment for VVC
OTC antifungal (‘-azole’) creams, suppositories, and oral agents
Alternative therapies for VVC
gentian violet, white vinegar, probiotics, yogurt
Only recommended treatment for VVC in pregnant clients
topical antifungal -azoles (EXCEPT FLUCONAZOLE, which may be teratogenic)
New name for atrophic vaginitis
Genitourinary syndrome of menopause (GSM)
Cause of Genitourinary Syndrome of Menopause (GSM)
Decreased estrogen production in perimenopause and menopause, or any medications that reduce estrogen production
DIAGNOSE: Pt presents with CC of vaginal itching, burning, urinary frequency, pain, vaginal dryness, and dyspareunia. On physical exam, you note pale vaginal walls with decreased ruggae, and petechiae lining the walls, scant vaginal secretions. She reports her LMP was 8 months ago
Genitourinary syndrome of menopause (GSM)
INTREPRET (2): You prepare a wet mount slide and conduct pH testing for cc of vaginal discharge. You note parabasal cells on wet mount, increased WBCs, reduced lactobacilli. The pH is increased (>5)
Genitourinary syndrome of menopause (GSM), Desquamative inflammatory vaginitis (DIV)
Pharmacologic treatment for GSM
Start with OTC lubricants and moisturizers. May consider vaginal preparations of low dose estrogen. An FDA-approved option for treating vaginal dryness is ospemifene (SERM)
Cause of Desquamative Inflammatory Vaginitis (DIV)
Non-infectious inflammation in perimenopausal and menopausal women leads to bacterial disruption whereby the lactobacilli are replaced with gram-positive coccobacilli (such as group b strep)
DIAGNOSE: Pt presents with CC of vaginal irritation, burning, and dyspareunia. On speculum exam, you note profuse, purulent yellow/green vaginal discharge and vaginal/vestibular erythema. There is no loss of vulvovaginal architecture.
Desquamative inflammatory vaginitis (DIV)
Pharmacologic management of DIV
Clindamycin cream 2-4 weeks. Reevaluate in 4 weeks. Consider adding a low dose estrogen if GSM is present, too.
DIAGNOSE: Pt presents with CC of headache, vomiting, and new rash. On physical exam, found to have a high fever, rash appears generalized, erythematous, macular. You note non-pitting edema and erythema of the palms and soles, with desquamation of some fingers. On speculum exam, you note hyperemic vaginal mucosa, with vulvovaginal tenderness.
Toxic shock syndrome (TSS)
Priority predisposing factors for TSS
within 5 days of onset of menses and recent tampon use
(2) causative agents for TSS
staph aureus, strep pyogenes
Priority patient education with h/o TSS
avoid barrier contraceptive methods and tampons
Treatment for TSS
life threatening emergency, refer to the hospital
Cause of Bartholin Gland Cysts
fluid and mucus build-up after obstruction of a duct
Etiology of bartholin gland cysts vs. abscess
cysts = non-infectious abscess = infectious
DIAGNOSE: Pt presents for routine well-woman exam, no CC. On pelvic exam, you note a visible round-oval mass at the vestibular entrance
Bartholin gland cyst
Management of Bartholin Gland Cyst in pre-menopausal pt
If small and asymptomatic, does not require treatment. If large and symptomatic, managed similarly to abscess
Management of Bartholin Gland Cyst in post-menopausal women
refer for cancer evaluation
Causes of Bartholin Gland Abscess
infection of the bartholin fluid, most commonly by e coli found in the skin and vaginal flora. Rarely, can be caused by gonorrhea or chlamydia
DIAGNOSE: Pt presents with CC of sudden onset vulvar pain, tenderness. Endorses difficulty sitting and walking, dyspareunia. On physical exam, you note a tender, flucuant mass at the vestible with erythema of the overlying skin, and labial edema
Bartholin gland abscess
Management of Bartholin Gland Abscess (3)
I&D with packing; word catheter; or referral to specialist for marsupialization (CULTURE NOT INDICATED)
Cause of Hidradenitis Suppirativa
Genetic and hormone defects in the base of the folliculophilosebaceous unit. The plugged hair follicles fill with keratin and sebum, causing rupture, inflammation, scarring, and draining sinus tracts
DIAGNOSE: Pt presents with chief complaint of vulvar pain and inflamed hair follicles. She has been squeezing the hair follicle to pop it but it is making it worse. On physical exam, you note exquisitely painful nodules that were draining, and a few that had scarred. You examine the breasts and axilla, and there are no additional nodules
Hidradenitis suppurativa
How do you make a diagnosis of Hidradenitis suppurativa
purely history and physical. You are looking for typical lesions in the typical locations with a relapsing, chronic pattern. No lab tests are needed to diagnose.
This condition is often misdiagnosed as simple folliculitis in its early stages
Hidradenitis suppurativa
Patient education for lifestyle management of Hidradenitis Suppurativa
avoid trauma (tight clothing, continuous moisture, squeezing), tobacco cessation, weight management, choose tampons over pads, (dairy?)
Medical treatment options for hidradenitis suppurativa
topical and oral antibiotics, anti-androgens, immunosuppressants, humira, baratric surgery, wide excision for extensive disease
cause of contact dermatitis
allergen or irritant
DIAGNOSE: Pt presents with CC of vaginal itching. Speculum exam is generally normal, with mild vulvar erythema and evidence of excoriations from itching.
contact dermatitis
Treatment recommendations for contact dermatitis
avoid irritant, topical corticosteroid ointment
Cause of Lichen Sclerosus
chronic mucocutaneous disorder, that is likely autoimmune
DIAGNOSE: Pt presents with CC of severe vulvar burning and itching. Endoses dyspareunia. States it initially started as dull, non-specific vulvar irritation. On physical exam, you note areas of hypopigmentation in a figure 8 pattern, thin pappery skin, and a loss of vaginal architecture
Lichen Sclerosus
Treatment for Lichen Sclerosus
Defer a biopsy until 12 week treatment trial with high potency topical steroids with a 3 month taper.
If you suspect Lichen Sclerosus, make sure to r/o….
thyroid disease
Most debilitating of the Lichen conditions
Lichen planus
DIAGNOSE: Pt presents with CC of severe vulvar burning and itching. Endoses dyspareunia. On physical exam, you note well-demarcated papular lesions/erosions on the vulva with white straie and a loss of genital architecture. You inspect the oropharynx, and note oral lesions as well
Lichen Planus
Treatment for lichen planus
Super potent topical steroid x3 months and/or intralesions injection. Refer erosive disease to dermatology.
Variant of atopic dermatitis - a vulvar disorder that causes pruritis
Lichen simplex chronicus
DIAGNOSE: Pt presents CC of vaginal itching. States “I always get yeast infections and my provider calls in abx, but this one won’t go away”. States that the scratching and rubbing offer intense but temporary relief. The itching is worse at night
Lichen simplex chronicus
Medication treatment for lichen simplex chronicus
Topical -caine to numb the area, oral antihistamine to reduce itching, potent topical steroid ointment tapered x3-4 months.
