Vulvovaginitis

Question 1

Trichomoniasis Infection Signs

Answer 1

• Copious, malodorous, yellow-gray, frothy, purulent discharge
• ~70% asymptomatic
• Whiff test pos.
• Fishy odor
• Vaginal irritation
• Usually pruritus
• “Strawberry cervix”; erythematous macules covering the vaginal wall and ectocervix
• Vagina pH >4.5

Question 2

Trichomoniasis Treatment

Answer 2

Recommended Regimen

• Metronidazole 2g PO 1 dose

*can be used pregnancy

• Tinidazole 2g PO 1 dose

Alternate Regimen

• Metronidazole 500mg PO 2x daily for 7 days

Must obstain from sex during treatment

Question 3

Trichomoniasis Diagnosis

Answer 3

• Elevated vaginal pH (>4.5)
• Motile trichomonads
• Many polymorphs
• Whiff test may be pos.
• Rapid antigen test (10min) and dipstick test (Affirm), a nucleic acid probe (45min) or culture can be used to diagnose if wet mount is noncontributory

Question 4

Candidiasis Symptoms

Answer 4

• Thick, white “cottage cheese” like discharge, vulvar/vaginal pruritus and dysuria
• Inflammation and erythema
• Vaginal pH <4.5
• No odor
• Whiff test neg.
• May have burning, irritation, dyspareunia
• Candida can be part of vaginal flora

Question 5

Candidiasis Treatment

Answer 5

• Fluconazole
• In fluconazole resistant species use Boric Acid suppository (has to be inserted in vagina)

Question 6

Candidiasis Diagnosis

Answer 6

• Normal vaginal pH
• Microscopy shows pseudohyphae, mycelia tangles, or budding yeast cells
• Neg. whiff test

Question 7

Candida balantis

Answer 7

• HIV and Candidiasis

Question 8

Candida balantis Treatment

Answer 8

• Topical such as clotrimazole or miconazole cream or oral fluconazole 150-200mg OD up to seven days

Question 9

Congenital cutaneous candidiasis

Answer 9

• Infant born from mother w/ yeast infection during 3rd trimester
• Disseminated rash, oral thrush and diffuse lymphadenopathy
• Full recovery is expected in FT infants

Question 10

Congenital cutaneous candidiasis Treatment

Answer 10

• Topical ketoconazole

Question 11

Bacterial Vaginosis Predisposing Factors

Answer 11

Anything that disturbs the normal flora of the vagina

• Presence of concomitant STIs-especially trichomoniasis
• Multiple sex partners
• Earlier coital experience
• IUD
• New sexual partner
• Antibiotic therapy
• Absence of H2O2-producing Lactobacili

Question 12

Bacterial Vaginosis Symptoms

Answer 12

• Foul-smelling “fishy” vaginal odor that increases after sex
• Thin, dull-gray, nonpruritic, homogenous discharge that adheres to vaginal wall
• Vaginal pH >4.5
• Pruritus
• Burning during urination
• Up to 50% have no complaints
• Whiff test pos.

Question 13

Lactobacillus

Answer 13

• Protective role in the vagina
• Acidophilic lactobacilli predominant organisms in normal vaginal flora
• Lactobacilli found in 96% of women w/ normal vaginal flora vs. only 52% of women w/ BV
• Produce lactic acid and H2O2
• Protects against BV, overgrowth of Candida, adherence of C. albicans to epithelial cells
• Inhibit E. coli and prevent UTI

Question 14

Elevated vaginal pH causes

Answer 14

• Normal vagina pH: 3.8-4.2; controls composition of normal vaginal flora
• Elevated pH assoc. w/:

*loss of H2O2-producing Lactobacilli

*bacterial vaginosis, trichomoniasis

*possibly enhanced HIV transmission

Question 15

Bacteria causing “fishy odor”

Answer 15

• BV
• Trichomoniasis

Question 16

KOH “Whiff” Test

Answer 16

• Sample of vaginal secretions place in a test tube w/ 10% KOH
• KOH alkalizes amines produced by anaerobic bacteria; results in a sharp “fishy odor”

Question 17

BV Complications/Assoc. Conditions

Answer 17

• Obstetric conditions

*preterm birth, premature rupture of membranes, amniotic fluid infection, low birthweight, chorioamnionitis, postpartum endometritis

• PID

Question 18

BV Treatment

Answer 18

• Similar to Trichomoniasis
• Metronidazole
• Tinidazole
• Clindamycin cream

*NOT for pregnant women

Question 19

BV Diagnosis

Answer 19

• Elevated pH (>4.5)
• Clue cells (epithelial cells coated w/ coccobacilli)
• Pos. whiff test (fishy odor noted after adding potassium hydroxide to the discharge)

Question 20

PID Diagnosis CDC Criteria

Answer 20

CDC minimal criteria

• Uterine tenderness
• Adnexal tenderness +/- cervical motion tenderness
• Other symptoms include: endocervical discharge, fever, lower abdominal pain

Question 21

PID Complications

Answer 21

• Infertility: 15-24% w/ 1 episode PID secondary to gonrrhea or chlamydia
• 7x risk of ectopic pregnancy w/ 1 episode PID
• Chronic pelvic pain in 18%
• Pelvic pain due to adhesions
• Infection-induced selective loss of ciliated epithelial cells along the fallopian tubes resulting in impaired ovum transport

Question 22

Definitive Criteria for PID

Answer 22

• Histologic evidence of endometritis on endometrial biopsy
• Transvaginal sonography or MRI showing thickened, fluid filled tubes or Doppler studies suggesting pelvic infection (tubal hyperemia)
• Laparoscopic abnormalities showing tubal purulent exudate, erythema and edema
• “Chandelier sign”- painful pelvic exam

Question 23

PID Diagnosis Algorithm

Answer 23

Question 24

Fitz-Hugh Curtis Syndrome

Answer 24

• RUQ pain due to perihepatic adhesions “violin strings” (b/w liver capsule and peritoneum)
• Due to PID

Question 25

2 Hypotheses to how chlamydia ascends to upper genital tract

Answer 25

• Hypothesis 1: Cellular paradigm assumes that actively infected epithelial cells have a key role by secreting chemokines that damage the tissues directly. Identifying and treating infections before they ascend should be the main focus of control programs
• Hypothesis 2: Immunological paradigm assumes that tissue damage occurs b/c of T-cell responses involved in clearing infection (repeat or persistent). Prevention of repeat infections should be prioritized.

Question 26

PID Treatment

Answer 26

• Cefotetan
• Doxycycline

Alternate Perenteral Regimen

• Ampicillin/Sulbactam
• Doxycycline