Common Vaginal/Vulvar Conditions

what is vaginitis?

a range of vaginal conditions, typically presenting with discharge or irritation

what does normal vaginal flora of reproductive-age women include?

multiple aerobic, facultative, anaerobic, and obligate anaerobic species

what is the ratio of anaerobes to aerobes in the vagina?

10:1

The bacteria are symbiotic with the

host and are alterable depending on

the vaginal microenvironment.

what is the very dominant aerobe that lives in the vagina?

lactobacillus

what is douching?

can be purchased OTC

solution people use to "rinse" with and they believe it to be cleaning the vagina, but it will actually kill of the things that keep the vagina acidic

what are normal vaginal secretions?

white and flocculent and consist of:

• desquamated vaginal mucosa

• vaginal epithelium transudate

• mucous secretions from the endocervix

• endometrial gland secretions

• lactic acid

• bartholin gland secretions

• sebaceous gland secretions from the vulva

what does lactobacillus do to heel the vagina healthy?

produces lactic acid

this maintains the acidic environment that is inhospitable to many bacteria

what are some normal variants of vaginal flora?

Atopobium vaginae, Megasphaera, and Leptotrichia

what is bacterial vaginosis?

an imbalance of the normal vaginal flora

nothing new is being introduced

what is the process of BV?

Loss of vaginal acidity → loss of Lactobacilli dominance →

alkalization of the vagina → overgrowth of pathogens

what pathogen is most commonly overgrown in BV?

G. vaginalis

what are the risk factors for BV?

• New or multiple sex partners

• Frequent douching

• IUD devices

• Pregnancy

what conditions may be associated with BV?

PROM, PPROM, PTL, PID, endometritis, STIs

what are the s/sxs of BV?

- non-irritating malodorous vaginal discharge (thin grey-white" discharge )

- vaginal muscles and cervical epithelium will appear normal

- no CMT or pelvic pain

this is painless

what is CMT?

cervical motion tenderness

provider inserts fingers into vagina and should be able to lift the cervix, there should be no pain with motion

why may you chose to do a PO regimen over vaginal regimen?

because Metronidazole and Clindamycin are abx that can give you yeast infections if directly interred into the vagina because they will kill the good bacteria that preserves pH

what is Yeast Vulvovaginitis most commonly due to?

secondary to Candida albicans

can be other candida species too

• Candida sp. Is a normal constituent of the vagina

misbalance of flora again

what are risk factors for pathogenic growth in YV?

• Abx use

• Combination oral contraceptives

• Estrogen therapy

• Pregnancy

• DM

• Corticosteroid use

• All forms of immune compromi

what are s/sxs of YV?

• Genital burning

• Pruritus

• Dyspareunia

• Dysuria

• Thick, white, "curd-like" or

"cottage-cheese-like" discharge

• Vaginal mucosa and cervical

epithelium may appear

erythematous and friable

• No CMT

what are the two types of YV?

uncomplicated and complicated

what are the features of uncomplicated YV?

• Sporadic or infrequent

• Mild-to-moderate

• Likely C. albicans

• Non-immunocompromised pt

what is the main features of complicated YV?

- recurrent (4+ ep per year) that are severe

- Non-albicans species

- Women with DM, HIV, debilitation, immunosuppresive therapy or other immunocompromised state

what is the tx of uncomplicated YV?

short course OTC topical antifungal will result in

cure rates of 80-90% OR single dose of Fluconazole 150 mg

what is tx of complicated YV?

7-14 days of topical therapy OR Fluconazole

Q every third day for total of 3 doses (Day 1,4,7)

what is tx of uncomplicated by severe YV?

7-14 days of topical azole or 2 doses of Fluconazole 150

mg 72 hours apart

what is tc for non-albicas species YV?

7-14 days of non-fluconazole azole treatment

(oral or topical) as first line therapy

tichamonis is vaginitis but also STI

what is trichamonas?

a parasitic flagellated protozoan transmitted by

sexual intercourse.**

you can actually also get it from public toilet seats

what does trichamonas cause in men and women?

vaginitis in women and occasionally urethritis in men, but most males are asx

in both it is associated with STIs and can enhance the transmission of HIV

if a pregnant women is infected with rtrich, what can happen?

low birth weight, PROM, and preterm delivery

what is Tx for trich?

Metronidazole

sam as yeast infection!

what is atrophic vaginitis?

An inflammatory process occurring in patients with vaginal atrophy, secondary due to lack of estrogen during menopause

what leads ti changes in vaginal microbiome and cause a shift in normal flora in AV?

decreasing estrogen levels of menopause

Decreased amounts of Lactobacillus sp. And overgrowth of skin

and rectal pathogens.

what will wet mount reveal in AV?

high WBS and decrease lactobacilli

what is tx for AV?

vaginal estrogen creams ~ localized estrogen therapy

what is gonorrhea caused by?

Neisseria gonorrhoeae

gram negative diplococci

what is tx of gonorrhea?

single does of IM ceftriaxone 500mg

need to know dose

usually in glutes

what is tx for ophthalmic gonorrhea in neonates?

Erythromycin ophthalmic ointment

what is used for neonatal ppx of gonorrheal conjunctivitis?

usually erythromycin opthamalic ointment but sometimes tetracycline

pay attentions to the days of life and the different disease they can be based on the day

what is tx for chlamydia?

• Doxycycline 100 mg BID x1 week

• Azithromycin 1g in pregnancy

ceftriaxone shot to tx for gonorrhea as well ?????

what s/sxs for PID?

• Lower abdominal pain

• Pelvic pain

• Vaginal discharge

• Dyspareunia

• Abnormal vaginal bleeding

what are risk factors for PID?

• Intercourse with multiple partners or having a partner who has

multiple partners

• Sexually active under age of 25

• Previous STIs or PID

• Frequent douching

• Unprotected sex

what is presentation/PE of PID?

• Patient's will commonly present with lower abdominal pain and fever.

• (+/-) N/V

• (+) CMT

• (+) friable cervix

• Clinical diagnosis (Confirmatory testing to determine offending pathogen/ cause)

what is tx of PID?

ceftrizone (form gonorrhea) doxy and azithro (chlamydia)

FIX THIS

how do you determine if you to needs to be admitted for PID?

• Suspected tubo ovarian abscess (TOA)

• Pregnancy

• N/V (throwing up meds)

• High fever

• Failure of outpt tx

• Pt compliance is questionable

what is Fitz-Hugh Curtis syndrome?

inflammation of the liver capsule with

adhesion formation resulting in right

upper quadrant pain

• It is an uncommon, chronic

complication of PID affecting women

of childbearing age

what is the most common pathogen involved in FHCS with PID?

Chlamydia trachomatis

what is gold standard for diagnosing FHCS and PID?

laparoscopy

what will laporascopy show in PID?

*edema with exudates

on tubal surfaces, ectopic pregnancy, or tubo-ovarian abscess*

FHCS can be diagnosed directly via visualization of adhesions

between the diaphragm and liver or liver and the anterior abdominal

wall

what is Lymphogranuloma Venereum (LGV)?

Ulcerative STI of the genital area caused by Chlamydia trachomatis

and transferable by vaginal, oral, or anal sex.

what organism causes LGV?

gram negative

chlamydia

what are the stages of LGV?

primary, secondary, late

• Common in the tropical and subtropical areas of the world, rare in

the US.

• Typically affects ages 15-40.

• Increased incidence in HIV (+)

what is primary stage LGV presentation?

development of painless genital ulcer or papules

what is secondary LGV presentation?

development of unilateral or bilateral tender inguinal and/or femoral LAD

what is late LGV presentation?

strictures, fibrosis, fistulae of the anogenital area

what is tx of LGV?

cause by chlmyida so we treat it the same but just much longer (3 weeks)

• Doxycycline 100 mg BID x 21 days

• Erythromycin 500 mg QID x 21 days

• Aspiration of pus-filled buboes

what is chancroid?

exceedingly rare sexually transmitted infection, both in the United States and globally.

what is the causative organism of chancroid?

small gram-negative rod

Haemophilus ducreyi