Lecture 10: Vulvar/vaginal disorders and STIs WH (RH)

how does increased glycogen lower vaginal pH?

glycogen levels in vaginal tissues --> favors growth of lactobacilli in genital tract --> lactobacilli breaks down glycogen to lactic acid --> lowers pH

T/F Vaginal discharge = Infection

FALSE is normal

When measured on pH paper normal range of vangonal discharge is _______

4.0-4.5

physiological leukorrhea is what?

more noticeable discharge, close to ovulation, during pregnancy or with use of estrogen-containing contraceptives

vaginal microscopy detects what 3 things?

BV, trichomoniasis and yeast

advantages to microscopy

Point of care and provide immediate diagnostic information

disadvantage to vaginal microscopy

- provider training, supplies

- need separate tests for chlamydia and gonorrhea

what does a normal vaginal microscopy predominantly have?

predominance of squamous epithelial cells, Lactobacillus, and rare leukocytes

what is normal vaginal pH???

4-4.4!!!!!!!!

What infections can NAATs detect?

Bacterial vaginosis (BV), candida, trichomonas, gonorrhea, and chlamydia.

is NAAT very sensitive/specific?

yassss (>90%)

What is a disadvantage of NAATs?

Delayed time for diagnosis and need for specialized and/or costly equipment.

What is vulvovaginitis?

The spectrum of conditions that cause vaginal or vulvar symptoms.

What are common symptoms of vulvovaginitis?

Burning, itching, irritation, and abnormal discharge.

What is the most common cause of vulvovaginitis?

Infection

what are the infectious causes of vulvovaginitis?

Bacterial vaginosis (BV)

Vulvovaginal candida

Trichomoniasis

most common bacterial cause of vulvovaginitis is ______________

bacterial vaginosis (BV)

What is Bacterial Vaginosis?

An alteration in the normal vaginal flora.

What bacteria are typically decreased in Bacterial Vaginosis?

Lactobacillus.

What bacteria are commonly overgrown in Bacterial Vaginosis?

Gardnerella vaginalis, Mobiluncus, anaerobic gram-negative rods, and Peptostreptococcus species.

Is Bacterial Vaginosis classified as a sexually transmitted infection (STI)?

No, it is NOT classified as an STI.

What are the risk factors for Bacterial Vaginosis?

Sexual activity with male or female partners.

What is the causative organism of Bacterial Vaginosis?

Polymicrobial (many bugs)

What is a common clinical presentation of Bacterial Vaginosis?

Mild vaginal irritation

What type of discharge is associated with Bacterial Vaginosis?

Thin grey, white or yellow discharge

What characteristic odor is associated with Bacterial Vaginosis/what test?

Amine-like ('fishy') odor = Positive “whiff test”

when discharge is alkalinized with 10% _________, wiff test is positive for Bacterial Vaginosis?

potassium hydroxide

What is the diagnosis method for Bacterial Vaginosis?

Physical exam and vaginal discharge testing (gram stain, naat, amsel's cri)

What is the gold standard for diagnosing Bacterial Vaginosis?

Gram Stain

How is Bacterial Vaginosis more often established clinically?

Through KOH and wet prep.

How many Amsel's Criteria = Bacterial Vaginosis?

3 of the 4 criteria must be met.

What is Amsel's Criteria for Bacterial Vaginosis?

1. Abnormal grey discharge

2. pH > 4.5

3. Positive whiff test

4. Presence of clue cells (>20% epithelial cells)

(for BV) Epithelial cells covered with bacteria to the extent borders are obscured on wet mount

clue cells

“Ground glass” appearance (pepper on your fried eggs)

Bacterial Vaginosis tx non pregnant

-Metronidazole 500mg PO BID x 7 days

-Vaginal Clindamycin cream 2%- 5g once daily x 7 days

-Vaginal Metronidazole gel 0.75%- 5g once daily x 5 days

Bacterial Vaginosis tx pregnant

metronidazole or clindamycin

Bacterial Vaginosis tx for asxs patients

NO eval or treatment!!

Bacterial Vaginosis Complications (3)

-Treatment may decrease risk of PROM and preterm delivery

-Associated with PID and post-op infections

-Increased risk of acquiring HIV and HSV

how to prevent BV?

-Safe sex, no douching

-Treatment of male partners

(will decreases risk of recurrence)

-PO metronidazole plus 2% clindamycin BID x 7 days

What is Vulvovaginal Candidiasis?

Inflammation from a candida species

What is the most common causative organism of Vulvovaginal Candidiasis?

Candida albicans

Is Vulvovaginal Candidiasis considered a sexually transmitted infection (STI)?

No, it is not an STI

What are some risk factors for developing Vulvovaginal Candidiasis?

Pregnancy, obesity, diabetes, immunosuppression, genetics, and recent antibiotic use

*unclear = COCs, contraceptive devices, sexual behavior, diet, tight clothing, or panty liners

CP of Vulvovaginal Candidiasis

-Itching

-Burning, external dysuria and dyspareunia

-Vulva and vaginal tissues often bright red +/- excoriation

-Thick, odorless, adherent “cottage cheese” discharge

What is the most common symptom of Vulvovaginal Candidiasis?

Itching

What type of discharge is associated with Vulvovaginal Candidiasis?

Thick, odorless, adherent 'cottage cheese' discharge

pH of Vulvovaginal Candidiasis

4-4.5

Vulvovaginal Candidiasis dx

-pH of > 4-4.5

-Visualization on microscopy

(Budding yeast, pseudohyphae, hyphae)

-OR Positive NAAT

once diagnosis of vulvovaginal candidiasis is confirmed, categorize as __________ or ___________

complicated, uncomplicated

what is complicated vulvovaginal candidiasis

-sever sxs

-frequent recurrence

-nonalbicans species

-usually d/t DM, infections, immunosuppressed, preg

Vulvovaginal Candidiasis tx uncomplicated

-Oral fluconazole

-Topical azoles

(Miconazole, clotrimazole, etc.)

Vulvovaginal Candidiasis tx pregnant

topical azole vaginally x

Vulvovaginal Candidiasis tx complicated

PO fluconazole (3 doses 3 days part)

Consider __________ or autoimmune disease if recurrent for vulvovaginal candidiasis

Do NOT need to treat ___________ sexual partners

diabetes

asymptomatic

are women prone to vulvovaginal candidiasis after antibiotics?

yes

What medication is recommended to offer at the start and end of antibiotic treatment to prevent vulvovaginal candidiasis?

Fluconazole

Are probiotics recommended for the prevention of vaginal yeast infections?

No, probiotics have not been shown to prevent vaginal yeast infections.

Is there good evidence linking candidiasis to hygienic habits or wearing tight or synthetic clothing?

No, there is no good evidence showing a link.

What type of organism causes Trichomonal Vulvovaginitis?

Trichomonas vaginalis, unicellular flagellate protozoan

What parts of the body can Trichomonas vaginalis infect and who?

Urogenital tract (vagina, urethra, paraurethral glands) in both men and women

What is the most common nonviral STI worldwide?

Trichomonal Vulvovaginitis

What are the risk factors for Trichomonal Vulvovaginitis?

Sexual activity, Female > Male

Trichomonal Vulvovaginitis clinical presentation:

-Frothy, thin, greenish or gray and foul smelling discharge

-Vaginal erythema with small petechiae --> strawberry spots

+/- Vulvar pruritis

-Labia minora may be erythematous and tender

-+/- Dysuria, dyspareunia and post-coital bleeding

+/- Positive whiff test

What is the preferred diagnostic method for Trichomonal Vulvovaginitis?

Positive NAAT

What pH level is associated with Trichomonal Vulvovaginitis?

pH > 4.5

What microscopy finding is indicative of Trichomonal Vulvovaginitis?

flagella in saline

What other STIs should women diagnosed with trichomoniasis be screened for?

Gonorrhea and chlamydia

Trichomonal Vulvovaginitis tx/who gets treatment?

Treat BOTH partners simultaneously

-Female (including pregnant): Metronidazole x 7 days

-Male: Metronidazole PO x 1

(for TV) No sex until both partners have completed treatment AND are _________

asymptomatic

when/who to do repeat testing on for TV?

(Female only) Sometime between 3weeks-3 months after treatment

Trichomonal Vulvovaginitis complications not pregnant

-Increased risk for HIV acquisition/transmission, PID, infertility and cervical cancer

Trichomonal Vulvovaginitis complications yes pregnant

If pregnant --> increased risk of PROM, preterm delivery and low birth weight

how to prevent tv?

use a condom

Atrophy of the vaginal epithelium due to decreased estrogen levels

Atrophic Vaginitis

pH of atrophic vaginitis

pH ≥ 5

clinical presentation of atrophic vaginitis (Vaginal sx)

-vaginal epithelium is thinned

-decreased vaginal discharge, dryness, itching, burning or dyspareunia

clinical presentation of atrophic vaginitis (Urinary sx)

Urgency, frequency, recurrent UTIs and incontinence

Atrophic Vaginitis dx

Clinical (hx + a pelvic exam)

What is the first line treatment for Atrophic Vaginitis?

Nonhormonal vaginal moisturizers and lubricants

Give an example of a hyaluronic acid vaginal moisturizer.

Vagisil or Feminease

When should lubricants be used for Atrophic Vaginitis?

At the time of sexual activity

Give an example of a lubricant for Atrophic Vaginitis.

Astroglide or K-Y jelly

Subsequent Atrophic Vaginitis tx

when is the tx contraindicated?

Low dose intravaginal estrogen (cream, insert or ring)

*May be contraindicated if hx of breast or endometrial cancer

the most common cause of bacterial sexually transmitted infection (STI) in both males and females

Chlamydia Chlamydia trachomatis)

risk factors for Chlamydia

-Under 25 years of age, multiple partners, new partner, partner with concurrent partners, partner with STI

-Increases with higher #of sexual partners, lower SES

Chlamydia mc clinical presentation

asymptomatic! (females infected at the cervix)

If sx, chlamydia can be subtle and nonspecific. give 2 ex.

Cervicitis, Urethritis

cp of cervicitis

Mucopurulent discharge- greenish or yellow

Cervical friability aka vaginal bleeding

cp fo urethritis

Dysuria, frequency

chlamydia dx

NAATs!!!! (Provider OR patient collected)

Rectal and oral C trachomatis infections in persons that engage in receptive anal or oral intercourse can be diagnosed by ___________

swabbing those areas.

*All patients with C. trachomatis infection should be tested for _________ and treated if positive*

Neisseria gonorrhoeae

What is the first-line treatment for Chlamydia?

Doxycycline x 7 days

What is the second-line treatment for Chlamydia in pregnant patients?

Azithromycin x 1, observed if possible

When should repeat testing for Chlamydia be done after treatment?

3 months after treatment

When should repeat testing Chlamydia treatment?

(if pregnant, or if there are persistent symptoms or concern about adherence/reinfection)

4 weeks after treatment

What is the recommendation regarding sexual activity during Chlamydia treatment?

No sex until treatment is complete, asymptomatic, and all partners are treated

What is expedited partner therapy for Chlamydia?

Partner is treated for chlamydia without physical examination or testing

Who should be treated with expedited partner therapy for Chlamydia?

Any sex partner within 60 days of infection, or the most recent sex partner if more than 60 days from infection

Chlamydia Complications

- Salpingitis, PID, ectopic pregnancy and infertility

- Preterm delivery

Transmission to fetus is possible- conjunctivitis or pneumonia

- Lymphogranuloma venereum (LGV)

Conjunctivitis

chlamydia screening for sexually active women ______. how often is screening done?

<25 y/o (or ≥25 years + risk factors)

yearly