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
2
Q
Clinical signs of of Trichomonas vaginalis
A
discharge - may be frothy and green / yellow in 10-30%. Strawberry cervix (punctate haemorrhages)
3
Q
Diagnosis of Trichomonas vaginalis
A
Microscopy of vaginal discharge
TV NAATs
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
5
Q
Which STI is a flagellate Protozoan
A
Trichomonas vaginalis
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
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
8
Q
what type of organism is Trichomonas vaginalis
A
flagellated protozoon
9
Q
what anatomical structures can Trichomonas vaginalis infect?
A
In women - vagina, urethra, paraurethral glands
In men - urethra, subpreputial sac
10
Q
Transmission of Trichomonas vaginalis
A
almost exclusively through sexual intercourse
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
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
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
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
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
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
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
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
19
Q
Sample sites for diagnosis of Trichomonas vaginalis in men
A
Urine NAAT
Urethral culture
culture of first-void urine
20
Q
What is the timeframe for reading a wet-prep microscopy slide and why
A
within 10min
trichomonads will quickly loose motility
21
Q
sensitivity of microscopy to diagnose trichomonas in women with discharge
A
as low as 45–60% in women
lower in men
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
23
Q
what is the sensitivity of NAATs testing for trichomonas vaginalis
A
88%–97%
24
Q
What is the spontaneous cure rate of Trichomonas vaginalis
A
20–25%.
25
Treatment of Trichomonas vaginalis
Metronidazole 2 g PO STAT
OR
Metronidazole 400–500 mg BD 5–7 / 7
26
Alternative regimen to metronidazole for treatment of Trichomonas vaginalis
Tinidazole 2g PO STAT
similar activity to metronidazole
more expensive
27
Treatment of Trichomonas vaginalis in pregnancy
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
28
Treatment of Trichomonas vaginalis in breastfeeding
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
29
Treatment of Trichomonas vaginalis in HIV positive patients
Metronidazole 400–500 mg BD 5–7 / 7
A 2-g STAT oral dose may not be as effective among HIV-infected patients
30
Advice re reactions to treatment with metronidazole
Avoid alcohol for the duration of treatment and 48 h afterwards
possibility of a disulfiram-like reaction
31
what history should be checked with treatment failure for Trichomonas vaginalis
check:
- Compliance
- exclude vomiting of metronidazole
- Sexual history for possibility of re-infection
- if partner(s) have been treated
32
Treatment protocol for non-response to standard Trichomonas vaginalis therapy
exclude re-infection and non-adherence
Repeat course 7-day Metronidazole 400–500 mg BD
40% respond to a repeat course
33
Treatment protocol for non-response to a second course of standard Trichomonas vaginalis therapy
Higher-dose course of Metronidazole 800 mg TDS 7/7
OR
tinidazole 2 g OD for 5–7 days
34
Treatment protocol for non-response to a second course of standard Trichomonas vaginalis therapy
Higher-dose course of Metronidazole 800 mg TDS 7/7
OR
tinidazole 2 g OD for 5–7 days
35
Treatment protocol for non-response to a thrid course of Trichomonas vaginalis therapy
```
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
```
36
Treatment options for TV if both high dose metronidazole or tinidazole have failed
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
37
When is a TOC recommended for TV
only if the patient remains symptomatic following treatment
| or if symptoms recur
38
Contact tracing and treatment for TV
Screen and empirically treat
- Current partners
- Partners within 4 weeks prior to presentation
39
What is the commonest cause of abnormal discharge in women of reproductive age?
```
Bacterial vaginosis (BV)
Reported prevalence 5 - 50%
```
40
What are the dominant bacteria in the healthy vagina?
Lactobacilli
41
What is the normal PH of a healthy vagina?
pH maintained < 4.5
42
What is the PH of the vagina with bacterial vaginosis
In BV the pH of vaginal fluid is > 4.5 - up to 6.0
43
Risk factors for BV
```
vaginal douching
receptive cunnilingus
Black race
recent change of sexual partner
smoking
presence of an STI
```
44
Common species involved in bacterial vaginosis
```
dominated by anaerobic + facultative anaerobic bacteria
Gardnerella vaginalis
Mycoplasma hominis
Bacteroides
Mobilincus
```
45
Symptoms of bacterial vaginosis
Malodorous discharge (fishy)
Cream / grey discharge - commonly adheres to wall of vagina
Asymptomatic carriers
More prominent during menstruation
46
What do clue cells suggest
Bacterial vaginosis
| Clue cell = epithelial cell covered in bacteria
47
Management of bacterial vaginosis
```
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
Is BV associated with signs of inflammation or itching?
Usually no
49
Complications of BV
- 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
Diagnosis of BV using Amsels criteria
```
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
Diagnosis of BV using Hay/Ison criteria
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
Diagnosis of BV using Nugget score
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
What approach to diagnosis of BV is recommended in GUM clinics?
Hay/Ison criteria
54
Why can isolation of Gardnerella vaginalis not be used to diagnose BV?
it can be cultured from the vagina of >50% normal women
55
what other causes of abnormal discharge can BV co-exist with?
candidiasis
trichomoniasis
cervicitis
56
General advice for women diagnosed with BV
avoid vaginal douching
Avoid use of shower gel
avoid use of antiseptic agents
avoid using shampoo etc in the bath
57
When is treatment indicated for BV
* Symptomatic women
* Women undergoing some surgical procedures
* Women not volunteering symptoms who opt for treatment if offered
58
Alternative treatment regimens for BV
Tinidazole 2G STAT
Or
Clindamycin 300mg PO BD 7 days
59
What is the advice regarding use of metronidazole gel and drinking alcohol
No data
| it is not recommended at present
60
What should patients be advised when using clindamycin cream PV?
Clindamycin cream can weaken condoms
61
Treatment of BV during pregnancy
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
Treatment of BV whilst breastfeeding
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
BV and TOP advice
Studies support screening and treating BV prior to TOP
Reduce incidence of subsequent endometritis and PID
Either metronidazole or clindamycin cream
64
Management of Recurrent bacterial vaginosis
- 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
Define acute vulvovaginal candidiasis
First or single isolated presentation of vulvovaginal candidiasis
66
Symptoms of candidal vulvovaginitis
White / thick PV discharge - non-offensive
Itching
Soreness
erythematous skin - possible peeling, pustules or papules
67
When to refer candidal vulvovaginitis for specialist input
Unclear diagnosis
No improvement despite tx
Immunocompromised patient
Systemic treatment needed
68
Treatment of candidal vulvovaginitis
first line = Fluconazole capsule 150mg, STAT PO
If oral treatment unsuitable / CI
Clotrimazole pessary 500mg STAT PV
69
lifestyle advice for women with vulvovaginal candidiasis
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
Types of candida species
```
Candida albicans
Candida tropicalis
Candida glabrata
Candida krusei
Candida parasilosis
```
71
Define recurrent vulvovaginal candidiasis
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
what are the 2 categories of recurrent vulvovaginal candidiasis
1) Good / complete response to therapy - asymptomatic between episodes
2) poor / partial response to therapy - persistence of symptoms between treatments
73
What is the aetiology of vulvovaginal candidiasis
```
Fungal infection
Caused by yeasts
Belong to the genus Candida
> 20 Candida species cause human infiction
Candida albicans is most common
```
74
What type of micro-organism are yeasts and what is special about them?
eukaryotic
unicellular
fungi
Can develop multicellular characteristics by forming pseudohyphae and biofilms
75
What proportion of Vulvovaginal candidiasis is caused by Candida albicans
80-89%
76
What proportion of women will have at least one episode of Vulvovaginal candidiasis in their lifetime
75%
40–45% will have two or more episodes
77
What proportion of women will develop recurrent Vulvovaginal candidiasis
6% of women of reproductive age
78
What is the probability of developing recurrent Vulvovaginal candidiasis after an initial infection
10% at the age of 25 years
| 25% at the age of 50 years
79
Risk factors for developing recurrent Vulvovaginal candidiasis
```
• 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
Clinical signs of vulvovaginal candidiasis
* vaginal discharge - non-offensive and curdy (may be thin or absent)
* erythema
* fissuring
* swelling/oedema
* satellite lesions
* excoriation marks
81
Do asymptomatic women colonised with candida require treatment?
No
Up to 20% of women of reproductive age may be colonized with Candida spp. and have no clinical
signs or symptoms
82
Diagnosis of vulvovaginal candidiasis
clinical diagnosis
+/- microscopy
( +/- culture - not recommended for acute VVC)
83
Microscopy findings of vulvovaginal candidiasis
Presence of:
- blastospores
- pseudohyphae
- neutrophils
84
Why is fungal culture not recommended in acute Vulvovaginal candidiasis?
Not a cost-effective addition to microscopy
Not a reliable test on its own
Unable to differentiate colonisation from infection
85
What is the name of the solid fungal culture medium
solid fungal growth medium = Sabouraud plate
86
Treatment of candidal vulvovaginitis in pregnancy
AVOID fluconazole
longer treatment course
Clotrimazole pessary 500mg PV at night for 7 consecutive nights
87
Recommended treatment of severe Vulvovaginal Candidiasis
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
Recommended Regimen for Recurrent Vulvovaginal Candidiasis
Induction = fluconazole 150mg PO every 72 hours x 3 doses
Maintenance = fluconazole 150mg PO once a week for 6 months
89
Alternative Regimen for Recurrent Vulvovaginal Candidiasis
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
Recommended Regimen for Non-albicans Candida species and azole resistance
- 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
Recommended treatment regimen for recurrent Vulvovaginal Candidiasis in pregnancy
Induction = topical imidazole therapy for 10-14 days
Maintenance = Clotrimazole pessary 500mg PV weekly
92
Advice re fluconazole use and breastfeeding
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
Define balanitis
inflammation of the glans penis
94
Define posthitis
posthitis = inflammation of the prepuce
95
Infective causes of balanitis
```
Candida albicans
Trichomonas vaginalis
Streptococci (Group A and B)
Anaerobes
Gardnerella vaginalis
Staphylococcus aureus
Mycobacteria
Syphilis
Herpes simplex virus
Human papillomavirus
Entamoeba histolytica
```
96
Dematological causes of balanitis
```
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
Non dermatological, non infective causes of balanitis
| miscellaneous
Trauma
Irritant
Poor hygiene
98
Presenting symptoms of Balanitis
```
· Local rash - may be scaly or ulcerated
· Dyspareunia / soreness
· Itch
· Odour
· Inability to retract foreskin
· Discharge from glans / behind foreskin
```
99
Signs of Balanitis
Erythema / Purpura
Leukoplakia
Scaling
Sclerosis
```
Ulceration / Fissuring
Crusting
Exudate
Oedema
Odour
Phimosis
```
Lymphadenopathy
Nongenital rash
Oral signs in
Arthritis
100
Complications of Balanitis
· Phimosis
· Meatal stenosis
· Malignant transformation
101
Diagnosis of cause of balanitis
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
Aims of treatment of balanitis
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
Non specific management advice for balanitis
· 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
Management of candidal balanitis
- 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
Management of Anaerobic balanoposthitis
Metronidazole 400mg BD 7/7
Alternative regimen
Coamoxiclav 375mg TDS 7/7
or Clindamycin cream BD until resolved
106
What is balanitis xerotica obliterans
Lichen sclerosus of the penis
107
Symptoms of Lichen sclerosus of the penis
```
Itching
soreness
skin splitting
haemorrhagic blisters
dyspareunia
problems with urination
May be asymptomatic
```
108
Signs of lichen sclerosis of the penis
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
Complications of lichen sclerosis of the penis
· Phimosis
· Urethral stenosis
· Malignant transformation
