week 9- vaginitis Flashcards
vaginal epithelium
non-keratinized, hormone-sensitive, stratified squamous epithelium.
hromones in vaginal
estrogen causing thickening of mucosa
vaginal microbiome - which is most dominant
many species;
(aerobic, facultative anaerobic, and anaerobic species all coexist).
- Anaerobes dominate aerobes 10:1
most important gram positive anaerobes
ananrobic gram + cocci
anaerobic gram + bacilli
how is vagianl pH maintained and what is the pH
estrogen –> glycogen production
glycogen as nutrient for lactobacilli
glycogen metabolism –> lactic acid and hydrogen peroxide –> pH 3.8-4.2
acidic= prevent overgrowth of infections
who has less estrogen and therefore less glycogen and less acidic (what is the ph?) making the vagina more prone to infections
pre puberty and post menopause
pH 6-7.5
ecological changes in what can effect vaginal pH
Changes in hormonal status, menses, and antibiotic use can shift flora composition
Douching and unprotected intercourse (semen) can increase vaginal pH.
things affecting vaginal flora
menses- clear out pathogens
broad spectrum antibiotics –> candida overgrowth
vaginitis sx
vaginal discharge, odor, pruritus, and discomfort
top 3 causes of vulvovaginitis
- **Bacterial Vaginosis: anaerobic bacteria
- **Vuvlovaginal candidiasis: Various Candida species
- **Trichomoniasis: caused by Trichomonas vaginalis (protozoa)
3 causes of 90% of vulvovaginitis infections
candidiasis, trichomoniasis, or bacterial vaginosis.
other 10%: irritants, low estrogen, dermatologic
CHART on slide 17 for different sx of vaignitis depending on cause
i.e. BV is fishy odour
candidiasis is no odour
trichomoniasis fi foul odor, strawberry cervix
etcccccc
bacterial vaginosis and vulvovagianl candidiasis sx
Vulvovaginal Candidiasis (VVC):
* Cheesy, curdy, or flocculent discharge
* Itching
* Vulvar or vaginal inflammation or redness
Bacterial Vaginosis (BV):
* Fishy odor
* Odor makes candidiasis less likely
vulvovaginal candidiasis from which species? most common in?
candida albicans
candida is normal inhabitant of vagina, but overgrow
in childbearing age with lots of estrogen because glycogen is key for candida growth
risk factors for vulvovaginal candidiasis
- Recent antibiotic use
- Heat, moisture and occlusive clothing
- Combined oral contraceptives
- Estrogen therapy
- Pregnancy
- Uncontrolled diabetes
- AIDS
- Corticosteroid use
- Other immunosuppression
wet prep, findings, and pH in vulvovaginal candidiasis
Budding yeasts, pseudohyphae, large numbers of WBCs, lactobacilli, and clumps of epithelial cells will be seen on the wet mount.
- The pH will be less than 4.5, and the amine “whiff” test will be negative.
uncomplicated vs complicated vulvovaginal candidiasis
Uncomplicated Vulvovaginal Candidiasis
* Sporadic or infrequent, and * Mild-to-moderate, and
* Likely C. albicans, and
* Non-immunocompromised patient.
Complicated Vulvovaginal Candidiasis
* Recurrent (four or more episodes in a year), or
* Severe, or
* Non-Albicans species, or
* Women with diabetes mellitus, HIV, debilitation, immunosuppressive therapy (corticosteroids) or other immunocompromised.
bacterial vaginosis cause
imbalance in normal flora
loss of acidity –> loss of Lactobacilli dominance further alkalinizing and leading to an environment that supports the overgrowth of pathogens such as G.
vaginalis, Mobiluncus, Prevotella, Prophyromonas, Peptostrepto coccus, Mycoplasma hominis, and Ureaplasma
main bateria in vaigina
lactobacilli
sx of bacterial vaginosis
- Non-irritating, malodorous vaginal discharge
- vaginal mucosa and cervical epithelium will appear normal
- no cervical motion tenderness or pelvic pain on palpation
risk factors for bacterial vaginosis
- Low estrogen (low glycogen and less Lactobacilli)
- New or multiple sex partners
- Frequent douching
- Intrauterine contraceptive devices
- Pregnancy
- Premature Rupture of Membranes (PROM)
- Preterm Premature Rupture of Membranes (PPROM)
- Preterm Labor (PTL)
- Pelvic Inflammatory Disease (PID)
- Endometritis
- Sexually transmitted infections
- Post-hysterectomy cuff cellulitis
dx of bacterial vaginosis
which main criteria
wet prep, pH, physical
3/4 of Amsel criteria
- Thin, white, homogeneous vaginal discharge
- pH greater than 4.5
- Positive amine whiff test
- Presence of clue cells on microscopic examination
Amsel criteria (3/4) for bacterial vaginosis
- Thin, white, homogeneous vaginal discharge
- pH greater than 4.5
- Positive amine whiff test
- Presence of clue cells on microscopic examination
trichomonas vaginalis from
sexual intercoarse
trichomonads vaginalis vaginitis is associated with
other STIs such as gonorrhea and chlamydia and can enhance transmission of HIV.
–> test!
trichomonas in pregnancy effects
low birth weight, PROM, and preterm delivery.
sx of trichomonas vaginalis
- Malodorous, green-to-yellow, frothy vaginal discharge.
- Vaginal pruritus and irritation.
- Dysuria and dyspareunia.
- Physical exam findings:
- Vaginal mucosa erythema.
- Punctate hemorrhages of the cervix.
tests for trichomonas vaginitis
wet prep (begin with and if inconclusive then DNA probes)
ph > 4.5
positive amine test
culture with diamonds medium (not common)
**PCR
atrophic vaginitis/ Genitourinary Syndrome of Menopause (GSM)
symptoms
- Vaginal dryness.
- Dyspareunia.
- Vaginal inflammation.
- Thinned mucosa.
- Loss of rugae.
- Occasional purulent discharge.
wet mount findings in atrophic vaginitis
- Large numbers of WBCs.
- Occasional parabasal and basal cells.
- Decreased lactobacilli.
- Increased gram-positive cocci and gram-negative rods.
treat atrophic vaginitis
vaginal estrogen therapy
irritant vaginitis risk factors
Soaps, tampons, contraceptive devices (e.g. condoms or diaphragms), sex toys, pessaries, topical products, douching, excessive cleaning, medications, clothing.
allergic vagintiis risk factors
Sperm, douching, latex condoms or diaphragms, tampons, topical products, medications, clothing, atopic history.
when evaluating vaginitis stpes
sexual history, STDS, partners, condoms
prior episodes of vaginitis? treatment?
steroid use? medical conditions? dermatologic? immunosuppressive?
–> HIV, diabetes, dermatologic
hygiene, douching, products, menstrual hisotry
normal vaginal discharge
- Small amounts of vaginal discharge are normal (1-4 mL daily).
- Normal discharge: colorless, white, or pale yellow.
- Emphasize that vaginal discharge increases during ovulation due to cervical mucus changes.
- Clear to white in color
- Not malodorous
- No discomfort or pruritus
- Quantity varies during the menstrual cycle
vaginitis does not cause
acute systematic illness
serious sx that are not in vagintiis
- Serious symptoms (eg, fever, abdominal pain, dizziness, fainting) warrant consideration of upper genital tract disease or toxic shock syndrome (TSS).
- If fever and abdominal pain are present, consider pelvic inflammatory disease (PID).
other potential causes of vaginitis like sx
- Lichen sclerosis * Cervicitis
- Herpes simplex * Pinworms
- Sexual assault
UTI, PID, TSS, malignancy, forge in body, erythema multiform major…
CHARTS on slide 49-50
xx
should you just do history if think have vagintiitis?
Do not rely on history alone, after taking a detailed history, confirm suspected diagnosis with physical exam and microscopy
if abdomen pain or fever along with the vaginal irritation its not vaginitis and probably is
PID, TSS, cervicitis
postmenopausal is
atrophic vagintis
increased discharge yes or no
no: dermatologic conditions, irritants vagintiis
yes: trichomoniasis, bacterial vaginosis, candidiasis
vulvar edema in
andidiasis, trichomoniasis, or dermatologic disorders.
deep dyspareunia in
implying pain with movement of deeper structures such as the uterus, ovaries, fallopian tubes, or bladder.
external dysuria vs internal dysuria
external dysuria (pain experienced in the vulva as urine passes over the skin) from internal dysuria (pain felt deeper in the pelvis in the area of the bladder or urethra). External dysuria most often results from a vulvovaginal problem. Internal dysuria is often accompanied by other lower urinary tract symptoms including urgency and frequency.
upper vs lower tract infections
upper is serious, significant morbidity and urgent systemic antibiotic therapy
physical exam
vulva
speculum: vagina and cervix
get samples for gonococcus and chlamydia
vaginal pH strips
pH >4.5 in
infections due to trichomonads and bacterial vaginosis.
speculum done with
warm water
Lubricants can contain antibacterial agents that will affect the specimens.
polyester tipped swabs ; not cotton
Cotton is toxic to Neisseria gonorrhea, and the wood in the shafts of swabs can be toxic to Chlamydia trachomatis.
cotton is toxic to ____
wood is toxic to ____
in speculum (so use polyester)
Cotton is toxic to Neisseria gonorrhea, and the wood in the shafts of swabs can be toxic to Chlamydia trachomatis.
wet prep findings
type of epithelial cells (mature, parabasal, basal or clue cells) and to examine presence of pseudohyphae/spores (Candida)
clue cells are an abnormal variation of
squamous epithelial cells
clue cells >20% means
gardnerella vaginalis overgrowth
nucleus of white blood cells
Multi-lobed nucleus = polymorphonuclear white blood cells (PMN’s).
white blood cells of 3% in vagina can be
vaginal candidiasis, atrophic vaginitis, or infections (trichomonas, chlamydia, gonorrhea, HSV).
paranasal cells in vagina smear with many WBCs means
desquamative inflammatory vaginitis.
abnormal presence of basal cells indicates
vaginal atrophy or desquamative inflammatory vaginitis with excessive WBCs.
How does trichomonas vaginalis attach to vaginal mucosa
Four anterior flagella, undulating membrane, and axostyle
RBCs can look like
yeast; KOH (in microscopy prep) lyses RBC, yeast remains.
positive whiff test
during KOH prep
Volatilization of the amines leads to a ”fishy” odor
increased numbers of which anerobic bacteria will lead to the production of ____ during a KOH prep
Increased number of anaerobic bacteria (G.
vaginalis, Mobiluncus, Trichomonas as opposed to a predominance of Lactobacillus) will lead to the production of amines.
gold standard for bacterial vaginosis
gram stain
nugent score in gram stain for bacterial vaginosis
Nugent score: is calculated based on the observed quantities of Lactobacillus acidophilus, Gardnerella
vaginalis, Bacteroides species and Mobiluncus species.
gold standard for yeast detection
cell cultures
organisms seen in cell cultures and which is actually helpful
microorganisms, such as yeast, Gardnerella vaginalis, or Trichomonas vaginalis.
–> not helpful for vaginitis
-garnerella is in normal flora
trichomonas needs diamonds medium
-mostly just for yeast
DNA probes for which species in vaginitis
G. vaginalis, Candida species, Trichomonas vaginalis, chlamydia, and gonorrhea
urgent vaginal issues in geriatric populations
vaginal bleeding and pelvic/vulvovaginal pain
side effects of diethylstilbestrol
babies: increased breast cancer risk, vaginal clear cell adenocarcinoma, and cervical neoplasia.
–> these patients are now in their 50s and older
annual pelvic exam for geriatric population
assess vaginal tissue, vulva, and perineum for abnormalities.
rule out fecal impaction
annual genital exam according to American College of Obstetricians and Gynecologists (ACOG)
if >65 you do external genitalia
esp if cognitive impairment
American College of Obstetricians and Gynecologists (ACOG) recommendation for DES daughters
annual internal pelvic exams
even if did hysterectomy
