Disorders of the Vulva and Vagina Flashcards Preview

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Flashcards in Disorders of the Vulva and Vagina Deck (74)
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1

What components make up the vulva? 5


Occasionally contains what?

1. Keratinized squamous epithelium,
2. hair follicles,
3. sebaceous glands,
4. sweat glands,
5. apocrine glands

1. Occasionally contains breast tissue – may swell and become tender after delivery

2

1. What kind of tissue makes up the vagina?

2. Vaginal pH os what?

3. Vaginal flora is made up of what? 3

1. Nonkeratinized squamous epithelium

2. Vaginal pH is 4.0- 4.5 in premenopausal women

3. Vaginal flora –
-lactobacillus and other
-aerobic and
-anaerobic bacteria

3

Symptoms of vaginitis?
8

1. A change in the volume, color, or odor of vaginal discharge
2. Pruritus
3. Burning
4. Dyspareunia
5. Dysuria
6. Spotting
7. Erythema
8. Pelvic discomfort

4

Vaginitis
1. What is it important to document about veginitis?

2. One CANNOT determine etiology from _________ alone and may mistreat the condition

1. etiology of the vaginitis

2. history and PE

5

Careful external examination of the vulva:
1. In bacterial vaginitis the vulva appears how?

2. What may suggest a dermatitis of the vulva? 3

1. In bacterial vaginitis the vulva appears normal

2.
-Erythema,
-lesions or
-fissures may suggest a dermatitis of the vulva

6

What things should we do in the exam for vaginitis?
5

1. May detect a foreign body
2. Note characteristics of vaginal discharge even though classic examples are not always the case
3. Check the cervix for erythema and discharge
4. Check for vaginal trauma
5. Bimanual exam to check for cervical motion tenderness and uterine tenderness

7

1. swab with a pH swab or dry swab the ______ of the vagina, not pooled secretions

2. Use __________ pH paper or swab
3. Premenopausal women—pH = ?
4. Trichomoniasis—pH = ?
5. Bacterial vaginosis—pH = ?
6. Candidial infection—pH = ?
7. In pregnant women amniotic fluid ______ the pH
8. What is not helpful?

1. WALL

2. narrow range

3. 3.5– 4.5
4. 5.0-6.0
5. >4.5
6. 4.0 – 4.5
7. raises
8. Bacterial cultures

8

What are some of the microscopy associated with vaginitis Dx?
4

1. saline wet mount
2. KOH prep
3. rapid antigen
4. Nucleic acid tests

9

What will you find on the following:
1. saline wet mount 3
2. KOH prep 3

What are the following tests used to dx?
3. Rapid antigen and Nucleic acid tests

1. Saline wet mount: (evaluate within 20 min.)
-Clue cells—bacterial vaginosis (BV)
-Trichomonads
-Increased PMNs—cervicitis

2. KOH prep:
-Destroys cells
-Reveals hyphae & budding of yeast
-Amine test—smelling the slide immediately after adding KOH for the “fishy” smell of (BV or trich)

3. BV and rich

10

What is the most common cause of discharge of women of childbearing age?

Bacterial Vaginosis

11

Bacterial Vaginosis
1. Abnormality of the normal vaginal flora? 2
2. Findings on exam? 3

1. Abnormality of the normal vaginal flora:
-Decrease in hydrogen-peroxidase lactobacilli
-Increase in primarily gram negative rods

2. Findings on exam:
-Fishy odor
-Clue cells
-Thin, white/gray, fishy smelling discharge

12

BV alone does not cause what? 5

What is usually the complaint?

BV alone does not cause what
1. Dysuria
2. Dyspareunia
3. Pruritis
4. Burning
5. Vaginal inflammation

1. Usual complaint is that of a malodorous or copious discharge
-Up to 75% of infections may be asymptomatic

13

Amsel criteria for diagnosis of BV
4

At least 3 of the 4 criteria:
1. Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
2. Vaginal pH > 4.5
3. Positive whiff-amine test
4. Clue cells on saline wet mount, comprising at least 20% of epithelial cells

14

BV treatment:
1. First line?
2. Alternate?

1. Preferred: Metronidazole:
-Oral 500mg BID for 7 days (no alcohol)
-Intravaginal (gel) 5g q day for 5 days

2. Clindamycin:
-Oral 300mg po BID for 7 days
-Intravaginal

2% cream 5g q day for 7 days
Ovules 100mg intravaginal X 3 days
Clindesse 2%, single intravaginal dose of 5g

15

1. _________ as an adjunctive therapy may be helpful
2. Do sexual partners need to be treated?

1. Probiotics as an adjunctive therapy may be helpful
2. Sexual partners do not need to be treated

16

1. Describe reoccurence rates?

2. Women who have 3 or more documented cases of BV in 12 months be offered what?

3. What do we not do for this?

1. Recurrence rates are high
-May retreat with same or different regimen

2. Women who have 3 or more documented cases of BV in 12 months be offered maintenance therapy—metronidazole gel for 7-10 days then twice weekly dosing for 4-6 months

3. NOT clindamycin because of toxicity

17

Vulvovaginal Candidiasis
Second most common cause of vaginitis symptoms and accounts for 1/3 of vaginitis cases—not an STI
1. Primary etiologic agent? 2
2. Pathogenesis? 3

1.
-Candida albicans,
-C. glabrata accounts for the remainder

2.
-Organism migrates from the anus to the vagina and colonizes there
-Less common sexual or relapse from reservoir in vagina
-Infection occurs when there is overgrowth of candida

18

Risk factors for Candidiasis
4

1. DM
2. Increased estrogen levels (e.g. OCP, pregnancy)
3. Immunosuppression
4. Antibiotic use (up to 1/3 of women develop it)

19

Diagnosis for Candidiasis:
3

1. On speculum exam
2. KOH wet mount slide (up to 50% negative)
3. In rare cases cultures for candida are indicated:

20

What would you find on the spectulum exam for candiasis? 3

1. Thick, white, sometimes “cottage cheese”, discharge
2. In severe cases a gray membrane
3. pH = 4.0-4.5

21

Wen would you get a culture for candida?
2

1. In multiple recurrent or persistent cases not responsive to treatment (may have resistant pathogen)

2. Women with normal pH, no visible pathogen on wet mount

22

Vulvovaginal Candidiasis
Prevention/Education
5

1. Keep the external genital area clean and dry.

2. Avoid irritating soaps (including bubble bath), vaginal sprays and douches

3. Change tampons and sanitary napkins frequently

4. Wear loose cotton (rather than nylon) underwear that doesn't trap moisture

5. Take antibiotics only when prescribed and never take them for longer then necessary

23

Treatment for candidiasis:
Uncomplicated infection (Mild to moderate signs/symptoms, Probable infection with C. albicans, Healthy, nonpregnant)?
2

1. Many OTC intravaginal treatments available and highly effective

Women may prefer oral treatment—
2. Fluconazole (Diflucan) 150 mg x 1 dose prescription and can interact with many drugs stays in vaginal secretions 72 hours

24

What would make a candida infection complicated?
7

1. Severe signs/symptoms
2. Infection with other than C. albicans, usually C. glabrata
3. Pregnancy,
4. DM,
5. immunosuppression,
6. debilitation
7. History of verified (> 4 infections yr.) vaginal candidiasis

25

Treatment of complicated candida?
4

1. Fluconazole 150 mg 2-3 doses 72 hrs apart
2. Topical therapy w/ clotrimazole/miconazole/terconazole for 7 – 14 days
3. Intravaginal boric acid tablets for 2 weeks (FATAL IF SWALLOWED)
4. Flucytosine cream intavaginally qHS for 2 wks

26

What is the most common STI in the world?

Trichomonas Vaginitis

27

What is Trichomonas caused by?

Flagellated protozoan—Trichomonas vaginalis—causative organism

28

Trichomonas Vaginitis
1. How can the symptoms from this range in women? 2
2. How is the disease transmitted? 3

1. Females infections range from
-asymptomatic (50%) to
-acute, severe, inflammatory disease
(Males are generally asymptomatic & the infection resolves spontaneously 90% of the time—the remainder get typical urethritis symptoms)

2.
-Women can acquire the infection from men or
-other infected women;
-men do not acquire it from other men

29

Trichomonas Vaginitis
Presentation?
4

1. Malodorous, thin, green/yellow vaginal discharge (70%)
2. Burning, dysuria, frequency (urethra commonly involved also)
3. Pruritus, dyspareunia, pelvic discomfort
4. Post-coital bleeding

30

Trichomonas Dx?
5

1. On speculum exam MAY see green, malodorous, frothy discharge (