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Dip GUM > Vulvovaginitis / Balanitis > Flashcards

Vulvovaginitis / Balanitis Flashcards

1
Q

Symptoms of Trichomonas vaginalis

A

Asymptomatic in 10 - 50% of F
Vulval itching +/- soreness
PV discharge
offensive discharge - may be frothy / green

Occasional - Dysuria / Abdo discomfort

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2
Q

Clinical signs of of Trichomonas vaginalis

A 
discharge - may be frothy and green / yellow in 10-30%.
Strawberry cervix (punctate haemorrhages)
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3
Q

Diagnosis of Trichomonas vaginalis

A

Microscopy of vaginal discharge

TV NAATs

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4
Q

Treatment of Trichomonas vaginalis

A 
Metronidazole 400mg BD for 5-7 days 
Or
Metronidazole 2 g STAT PO
OR
PV metronidazole gel (0.75%) OD 5 days 
OR
PV clindamycin cream (2%) OD  7 days 
Tx both partners
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5
Q

Which STI is a flagellate Protozoan

A

Trichomonas vaginalis

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6
Q

Non infective causes of abnormal vaginal discharge?

A 
Retained foreign body, 
Iflammation due to allergy or irritation, 
Tumours, 
Atrophic vaginitis,
Cervical ectopy,
Cervical polyps
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7
Q

Balanitis can be caused by:

A

Poor hygiene, leading to a build-up of smegma.
Irritation under the foreskin caused by urine / soaps / shower gels / other skin irritants
Thrush
Bacterial infection.
Sexually transmitted infections
Skin conditions - such as eczema / psoriasis / lichen sclerosus

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8
Q

what type of organism is Trichomonas vaginalis

A

flagellated protozoon

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9
Q

what anatomical structures can Trichomonas vaginalis infect?

A

In women - vagina, urethra, paraurethral glands

In men - urethra, subpreputial sac

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10
Q

Transmission of Trichomonas vaginalis

A

almost exclusively through sexual intercourse

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11
Q

Symptoms of Trichomonas vaginalis in women

A 
10–50% asymptomatic.
vaginal discharge
vulval itching
dysuria
 offensive odour,
Occasionally - low abdominal discomfort or vulval ulceration
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12
Q

Symptoms of Trichomonas vaginalis in men

A

15 - 50% asymptomatic
usually present as sexual partners of infected women. .

urethral discharge
dysuria.
urethral irritation
urinary frequency
Rarely - copious purulent urethral discharge
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13
Q

Signs of Trichomonas vaginalis in women

A

Vaginal discharge – varying in consistency from thin / scanty to profuse and thick
- classical frothy yellow discharge occurs in 10–30%
Vulvitis / vaginitis
strawberry cervix - 2%
5–15% no abnormalities on examination

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14
Q

Signs of Trichomonas vaginalis in men

A

Urethral discharge (20–60% men)
No signs, even in the presence of symptoms suggesting urethritis:
Rarely balanoposthitis

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15
Q

Complications of Trichomonas vaginalis

A

associated with preterm delivery and low birth weight
Unclear if causal association
TV at delivery may predispose to maternal postpartum sepsis
epidemiological association between HIV and TV
TV infection may enhance HIV transmission

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16
Q

Who should be tested for trichomonas vaginalis

A

women complaining of vaginal discharge or vulvitis
Women found to have evidence of vulvitis or vaginitis

Men who are contacts of TV contacts
considered for men with persistent urethritis

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17
Q

Sample sites for diagnosis of Trichomonas vaginalis in women

A

Swab from the posterior fornix at the time of speculum examination

Alternative option = Self-administered vaginal

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18
Q

What type of test is used to diangose trichomonas vaginalis

A

NAATS - gold standard
Culture
Microscopy - wet preparation - Detection of motile trichomonads by light- field microscopy

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19
Q

Sample sites for diagnosis of Trichomonas vaginalis in men

A

Urine NAAT
Urethral culture
culture of first-void urine

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20
Q

What is the timeframe for reading a wet-prep microscopy slide and why

A

within 10min

trichomonads will quickly loose motility

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21
Q

sensitivity of microscopy to diagnose trichomonas in women with discharge

A

as low as 45–60% in women

lower in men

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22
Q

What stain can be used to increase the likelihood of detecting trichomonas vaginalis on microscopy

A

acridine orange
stains dead organisms
can give a higher sensitivity than wet microscopy
not widely used

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23
Q

what is the sensitivity of NAATs testing for trichomonas vaginalis

A

88%–97%

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24
Q

What is the spontaneous cure rate of Trichomonas vaginalis

A

20–25%.

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25
Q

Treatment of Trichomonas vaginalis

A

Metronidazole 2 g PO STAT
OR
Metronidazole 400–500 mg BD 5–7 / 7

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26
Q

Alternative regimen to metronidazole for treatment of Trichomonas vaginalis

A

Tinidazole 2g PO STAT
similar activity to metronidazole
more expensive

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27
Q

Treatment of Trichomonas vaginalis in pregnancy

A

Metronidazole - not known if it has any effect on pregnancy outcomes
No evidence of teratogenicity
Can be used in all stages of pregnancy and breast feeding

Avoid high- dose regimen in pregnancy.

Tinidazole - Avoid in pregnancy / breastfeeding - safety not established

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28
Q

Treatment of Trichomonas vaginalis in breastfeeding

A

Metronidazole
Can be while breast feeding
Metronidazole enters breast milk and may affect its taste
Avoiding high doses if breast feeding
If using a single dose of metronidazole discontinue breast feeding for 12–24h to reduce infant exposure

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29
Q

Treatment of Trichomonas vaginalis in HIV positive patients

A

Metronidazole 400–500 mg BD 5–7 / 7

A 2-g STAT oral dose may not be as effective among HIV-infected patients

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30
Q

Advice re reactions to treatment with metronidazole

A

Avoid alcohol for the duration of treatment and 48 h afterwards
possibility of a disulfiram-like reaction

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31
Q

what history should be checked with treatment failure for Trichomonas vaginalis

A

check:

  • Compliance
  • exclude vomiting of metronidazole
  • Sexual history for possibility of re-infection
  • if partner(s) have been treated
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32
Q

Treatment protocol for non-response to standard Trichomonas vaginalis therapy

A

exclude re-infection and non-adherence

Repeat course 7-day Metronidazole 400–500 mg BD

40% respond to a repeat course

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33
Q

Treatment protocol for non-response to a second course of standard Trichomonas vaginalis therapy

A

Higher-dose course of Metronidazole 800 mg TDS 7/7
OR
tinidazole 2 g OD for 5–7 days

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34
Q

Treatment protocol for non-response to a second course of standard Trichomonas vaginalis therapy

A

Higher-dose course of Metronidazole 800 mg TDS 7/7
OR
tinidazole 2 g OD for 5–7 days

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35
Q

Treatment protocol for non-response to a thrid course of Trichomonas vaginalis therapy

A 
Resistance testing - if available 
OR high-dose tinidazole regimens
Tinidazole 1 g BD or TDS, 14 days 
OR 2 g BD  14 days 􏰂 
OR PV tinidazole 500 mg BD 14 days
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36
Q

Treatment options for TV if both high dose metronidazole or tinidazole have failed

A

Limited evidence

  • Paromomycin PV 250mg OD or BD 14 days
  • Furazolidone PV 100 mg BD 12–14 days
  • Acetarsol pessaries 500 mg ON 14 days
  • 6% Nonoxynol–9 pessaries ON 14 days
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37
Q

When is a TOC recommended for TV

A

only if the patient remains symptomatic following treatment

or if symptoms recur

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38
Q

Contact tracing and treatment for TV

A

Screen and empirically treat

  • Current partners
  • Partners within 4 weeks prior to presentation
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39
Q

What is the commonest cause of abnormal discharge in women of reproductive age?

A 
Bacterial vaginosis (BV) 
Reported prevalence 5 - 50%
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40
Q

What are the dominant bacteria in the healthy vagina?

A

Lactobacilli

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41
Q

What is the normal PH of a healthy vagina?

A

pH maintained < 4.5

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42
Q

What is the PH of the vagina with bacterial vaginosis

A

In BV the pH of vaginal fluid is > 4.5 - up to 6.0

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43
Q

Risk factors for BV

A 
vaginal douching
receptive cunnilingus
Black race
recent change of sexual partner
smoking
presence of an STI
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44
Q

Common species involved in bacterial vaginosis

A 
dominated by anaerobic + facultative anaerobic bacteria
Gardnerella vaginalis
Mycoplasma hominis
Bacteroides 
Mobilincus
45
Q

Symptoms of bacterial vaginosis

A

Malodorous discharge (fishy)
Cream / grey discharge - commonly adheres to wall of vagina
Asymptomatic carriers
More prominent during menstruation

46
Q

What do clue cells suggest

A

Bacterial vaginosis

Clue cell = epithelial cell covered in bacteria

47
Q

Management of bacterial vaginosis

A 
Metronidazole 400mg BD for 5-7 days 
Or
Metronidazole 2 g STAT PO
OR
PV metronidazole gel (0.75%) OD 5 days 
OR
PV clindamycin cream (2%) OD  7 days
48
Q

Is BV associated with signs of inflammation or itching?

A

Usually no

49
Q

Complications of BV

A
  • increased risk of HIV acquisition I
  • prevalence of BV is high in women with PID
  • associated with post-TOP endometritis and PID
  • In pregnancy - associated with late miscarriage / preterm birth / preterm premature rupture of membranes / postpartum endometritis
  • BV ? associated with NGU in male partners
50
Q

Diagnosis of BV using Amsels criteria

A 
Amsel’s criteria
At least 3 of 4 criteria are present 
(1) Thin, white, homogeneous discharge
(2) Clue cells on wet mount microscopy
(3) pH of vaginal fluid >4.5
(4) Release of a fishy odour on adding alkali (10% KOH).
51
Q

Diagnosis of BV using Hay/Ison criteria

A

A Gram stained vaginal smear
The Hay/Ison criteria:
- grade 1 (Normal): Lactobacillus morphotypes predominate
- grade 2 (Intermediate): Mixed flora, some Lactobacilli, Gardnerella or Mobiluncus also present
- grade 3 (BV): Predominantly Gardnerella and/or Mobiluncus. Few / absent Lactobacilli.

  • grade 0 No bacteria present
  • grade 4 Gram-positive cocci predominate
52
Q

Diagnosis of BV using Nugget score

A

A Gram stained vaginal smear
Nugent score derived from estimating proportions of bacterial morphotypes

Score between 0 - 10
Normal = < 4
intermediate = 4-6
BV = >6

53
Q

What approach to diagnosis of BV is recommended in GUM clinics?

A

Hay/Ison criteria

54
Q

Why can isolation of Gardnerella vaginalis not be used to diagnose BV?

A

it can be cultured from the vagina of >50% normal women

55
Q

what other causes of abnormal discharge can BV co-exist with?

A

candidiasis
trichomoniasis
cervicitis

56
Q

General advice for women diagnosed with BV

A

avoid vaginal douching
Avoid use of shower gel
avoid use of antiseptic agents
avoid using shampoo etc in the bath

57
Q

When is treatment indicated for BV

A
  • Symptomatic women
  • Women undergoing some surgical procedures
  • Women not volunteering symptoms who opt for treatment if offered
58
Q

Alternative treatment regimens for BV

A

Tinidazole 2G STAT
Or
Clindamycin 300mg PO BD 7 days

59
Q

What is the advice regarding use of metronidazole gel and drinking alcohol

A

No data

it is not recommended at present

60
Q

What should patients be advised when using clindamycin cream PV?

A

Clindamycin cream can weaken condoms

61
Q

Treatment of BV during pregnancy

A

no evidence of teratogenicity from using metronidazole during the first trimester

some evidence - treatment before 20 weeks gestation reduces the risk of pre-term birth

Symptomatic pregnant women should be treated in the usual way

62
Q

Treatment of BV whilst breastfeeding

A

Metronidazole enters breast milk -
May affect its taste
Manufacturers advise avoid high doses

Small amounts of clindamycin enter breast milk

Recommend intravaginal treatment for lactating women

63
Q

BV and TOP advice

A

Studies support screening and treating BV prior to TOP
Reduce incidence of subsequent endometritis and PID
Either metronidazole or clindamycin cream

64
Q

Management of Recurrent bacterial vaginosis

A
  • Suppressive 0.75% metronidazole vaginal gel - twice a week for 16 weeks
  • Probiotic lactobacilli therapy - applied daily for 3 weeks
  • Antibiotics then probiotic therapy
  • Lactic acid gel - not adequately evaluated
65
Q

Define acute vulvovaginal candidiasis

A

First or single isolated presentation of vulvovaginal candidiasis

66
Q

Symptoms of candidal vulvovaginitis

A

White / thick PV discharge - non-offensive
Itching
Soreness
erythematous skin - possible peeling, pustules or papules

67
Q

When to refer candidal vulvovaginitis for specialist input

A

Unclear diagnosis
No improvement despite tx
Immunocompromised patient
Systemic treatment needed

68
Q

Treatment of candidal vulvovaginitis

A

first line = Fluconazole capsule 150mg, STAT PO

If oral treatment unsuitable / CI
Clotrimazole pessary 500mg STAT PV

69
Q

lifestyle advice for women with vulvovaginal candidiasis

A

good skin care advice
• avoid local irritants - perfumed soaps / wipes
• use an emollient - soap substitute / moisturiser / barrier cream
• Avoid bubble baths or shampooing hair in bath water
• Wear breathable clothing
• Avoid panty liners
• Avoid vaginal douching
No need to avoid sex

70
Q

Types of candida species

A 
Candida albicans
Candida tropicalis
Candida glabrata
Candida krusei
Candida parasilosis
71
Q

Define recurrent vulvovaginal candidiasis

A

At least 4 episodes per 12 months
with at least one confirmed by culture
and at least one other confirmed by microscopy or culture

72
Q

what are the 2 categories of recurrent vulvovaginal candidiasis

A

1) Good / complete response to therapy - asymptomatic between episodes
2) poor / partial response to therapy - persistence of symptoms between treatments

73
Q

What is the aetiology of vulvovaginal candidiasis

A 
Fungal infection 
Caused by yeasts 
Belong to the genus Candida
> 20 Candida species cause human infiction 
Candida albicans is most common
74
Q

What type of micro-organism are yeasts and what is special about them?

A

eukaryotic
unicellular
fungi
Can develop multicellular characteristics by forming pseudohyphae and biofilms

75
Q

What proportion of Vulvovaginal candidiasis is caused by Candida albicans

A

80-89%

76
Q

What proportion of women will have at least one episode of Vulvovaginal candidiasis in their lifetime

A

75%

40–45% will have two or more episodes

77
Q

What proportion of women will develop recurrent Vulvovaginal candidiasis

A

6% of women of reproductive age

78
Q

What is the probability of developing recurrent Vulvovaginal candidiasis after an initial infection

A

10% at the age of 25 years

25% at the age of 50 years

79
Q

Risk factors for developing recurrent Vulvovaginal candidiasis

A 
• poorly controlled diabetes mellitus
• immunosuppression
• endogenous and exogenous oestrogen (including pregnancy, HRT and possibly the combined oral
contraceptive pill)
• antibiotic use in preceding 3m 
• ? steroid use
• ? concomitant atopic 
•  chronic stress - weakly associated 
•  ? Iron deficiency anaemia 
•  Mannose binding lectin codon 54 gene polymorphism is associated with recurrent and acute VVC
80
Q

Clinical signs of vulvovaginal candidiasis

A
  • vaginal discharge - non-offensive and curdy (may be thin or absent)
  • erythema
  • fissuring
  • swelling/oedema
  • satellite lesions
  • excoriation marks
81
Q

Do asymptomatic women colonised with candida require treatment?

A

No

Up to 20% of women of reproductive age may be colonized with Candida spp. and have no clinical
signs or symptoms

82
Q

Diagnosis of vulvovaginal candidiasis

A

clinical diagnosis
+/- microscopy
( +/- culture - not recommended for acute VVC)

83
Q

Microscopy findings of vulvovaginal candidiasis

A

Presence of:

  • blastospores
  • pseudohyphae
  • neutrophils
84
Q

Why is fungal culture not recommended in acute Vulvovaginal candidiasis?

A

Not a cost-effective addition to microscopy
Not a reliable test on its own
Unable to differentiate colonisation from infection

85
Q

What is the name of the solid fungal culture medium

A

solid fungal growth medium = Sabouraud plate

86
Q

Treatment of candidal vulvovaginitis in pregnancy

A

AVOID fluconazole
longer treatment course

Clotrimazole pessary 500mg PV at night for 7 consecutive nights

87
Q

Recommended treatment of severe Vulvovaginal Candidiasis

A

Fluconazole 150mg PO on day 1 and 4

Alternative regimens:

  • Clotrimazole 500mg PV on day 1 and 4
  • Miconazole PV 1200mg on day 1 and 4
88
Q

Recommended Regimen for Recurrent Vulvovaginal Candidiasis

A

Induction = fluconazole 150mg PO every 72 hours x 3 doses

Maintenance = fluconazole 150mg PO once a week for 6 months

89
Q

Alternative Regimen for Recurrent Vulvovaginal Candidiasis

A

Induction = topical imidazole therapy for 7-14 days a

Maintenance = 6 months - Clotrimazole pessary 500mg PV once a week
OR Itraconazole 50-100 mg PO daily

90
Q

Recommended Regimen for Non-albicans Candida species and azole resistance

A
  • Nystatin pessaries 100,000units PV at night for 12-14 consecutive nights

Alternative Regimens:

  • Boric acid PV suppositories 600mg daily for 14 days
  • Amphotericin B vaginal suppositories 50mg OD for 14 days
  • Flucytosine 5g cream or 1g pessary PV with amphotericin or nystatin daily for 14 days
91
Q

Recommended treatment regimen for recurrent Vulvovaginal Candidiasis in pregnancy

A

Induction = topical imidazole therapy for 10-14 days

Maintenance = Clotrimazole pessary 500mg PV weekly

92
Q

Advice re fluconazole use and breastfeeding

A

Fluconazole concentrations in breast milk - very low
unlikely to be harmful

maintain breastfeeding after a single 150mg dose of Fluconazole
Avoid breastfeeding after repeated or high doses of fluconazole

93
Q

Define balanitis

A

inflammation of the glans penis

94
Q

Define posthitis

A

posthitis = inflammation of the prepuce

95
Q

Infective causes of balanitis

A 
Candida albicans
Trichomonas vaginalis
Streptococci (Group A and B)
Anaerobes
Gardnerella vaginalis
Staphylococcus aureus
Mycobacteria
Syphilis
Herpes simplex virus
Human papillomavirus
Entamoeba histolytica
96
Q

Dematological causes of balanitis

A 
Lichen sclerosus (balanitis xerotica obliterans)
Zoon's balanitis 
Psoriasis
Circinate balanitis
Pre­malignant conditions:
     · Bowen’s disease
     · Bowenoid papulosis
    · Erythroplasia of Queyrat
Lichen planus
Immuno­-bullous disorders
Contact allergy
Fixed drug eruption
Stevens­ Johnson syndrome
97
Q

Non dermatological, non infective causes of balanitis

miscellaneous

A

Trauma
Irritant
Poor hygiene

98
Q

Presenting symptoms of Balanitis

A 
· Local rash ­- may be scaly or ulcerated
· Dyspareunia / soreness
· Itch
· Odour
· Inability to retract foreskin
· Discharge from glans / behind foreskin
99
Q

Signs of Balanitis

A

Erythema / Purpura
Leukoplakia
Scaling
Sclerosis

Ulceration  / Fissuring 
Crusting
Exudate
Oedema 
Odour
Phimosis

Lymphadenopathy
Non­genital rash
Oral signs in
Arthritis

100
Q

Complications of Balanitis

A

· Phimosis
· Meatal stenosis
· Malignant transformation

101
Q

Diagnosis of cause of balanitis

A

biopsy - to exclude pre­malignant disease
typical clinical appearances of certain balanitides
Sub­preputial swab - Candida spp + bacterial culture ­
Urinalysis for glucose ­
Herpes NAATs - if ulceration
Dark ground micro and syphilis serology - if ulceration
Culture /wet prep - TV
Other STI screening
Dermatology opinion

102
Q

Aims of treatment of balanitis

A

to diagnose and treat STI causes
to minimise sexual dysfunction
to minimise urinary dysfunction
to exclude penile cancer and to treat pre­ malignant disease

103
Q

Non specific management advice for balanitis

A

· Avoid soaps while inflammation is present
· Advise about effect on condoms if creams are being applied
· Detailed explanation of their specific condition + any long­term implications for them + their partner

104
Q

Management of candidal balanitis

A
  • Clotrimazole cream 1% OR Miconazole cream 2%
    Apply BD until symptoms settled
    Alternative regimens
  • Fluconazole 150mg PO STAT - if symptoms severe
  • Topical imidazole with 1% Hydrocortisone ­ if marked
    inflammation is present
105
Q

Management of Anaerobic balanoposthitis

A

Metronidazole 400mg BD 7/7

Alternative regimen
Co­amoxiclav 375mg TDS 7/7
or Clindamycin cream BD until resolved

106
Q

What is balanitis xerotica obliterans

A

Lichen sclerosus of the penis

107
Q

Symptoms of Lichen sclerosus of the penis

A 
Itching
soreness 
skin splitting
haemorrhagic blisters
dyspareunia
problems with urination
May be asymptomatic
108
Q

Signs of lichen sclerosis of the penis

A

Typical appearance - white patches on
may be haemorrhagic vesicles / purpura
rarely blisters / ulceration

Architectural changes - blunting coronal sulcus / phimosis / wasting of the prepuce / meatal thickening and narrowing

109
Q

Complications of lichen sclerosis of the penis

A

· Phimosis
· Urethral stenosis
· Malignant transformation

Dip GUM (27 decks)

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