Vaginal Infections

anatomy

  • Birth Canal → lies between the bladder and the rectum → lower end has the Bartholin’s glands → lined with stratified squamous epithelium that contains glycogen.

  • glycogen conversion into lactic acid (4-4.5) catalyzed by lactobacillus → helps to regulate pH of vagina → to prevent the risk of prevent vaginal infections (increase in pH level)

  • pap smear test (not tested) → for cervical cancer → if detected early, good prognosis is very high → check for cancerous cells by going in all the way.

  • main focus on the organism that colonize the vagina is LACTOBACILLUS 80-90% ; but there are others like Corynebacteria, streptococcus, staphylococcus epidermidis, Gardnerella vaginalis, Peptostreptococcus, Bacteroidesm, E.coli and candida albicans → try not to upset the flora to prevent the overgrowth of these bacteria that cause infection.\

factors that affect the vagina ecosystem

  • hormonal changes → affects amount of glycogen and the amount of discharge in the area.

  • aging → menopause etc.

  • certain diseases (diabetes mellitus: immunocompromised)

  • use of medication that upset/change the flora (antibiotics/contraceptives)

  • hygiene

  • douching/rinsing or washing the inside of your vagina with soap

  • sexual intercourse (seminal pH is 4-4.5, but it becomes more alkaline during sexual activity)

  • the number of sexual partners that you have → different organisms

physiology

  • normal discharge can be around 1.5g of vaginal fluid → odorless, clear or white, thin, viscous or sticky

  • increase in discharge is common in pregnancy, ovulation, menses or with sexual excitement or emotional flares (moody)

  • alternation in vaginal secretions can also indicate whether there is higher or lower amount of irritation to the area.

common vaginal infections and differences

  • Bacterial Vaginosis

  • Trichomoniasis

  • VVC (Vulvovaginal Candidiasis) → only one that can be treated w/o prescription antibiotics

  • all these complications of BV and Trichomoniasis can lead to pelvic inflammatory disease, urinary tract infection, endometriosis and infertility (most important).

BV

Trichomoniasis

VVC

prescription?

yes

yes

yes/no

most common (1st)

2nd most common

Name of Causative Bacteria

G.vaginalis

Anaerobes.

Trichomonoiasis vaginalis

Candida Albicans/Candida Fungi (80-92%) — about 50% of women will have one or more infections caused by this by age 25.

OR

  • C.glabrata

  • C.tropicalis

Risk Factors

  • Low socioeconomic status

  • douching

  • smoking

  • multiple sex partners

  • unprotected sexual intercourse

  • Low socioeconomic status

  • douching

  • smoking

  • multiple sex partners

  • unprotected sexual intercourse

  • pregnancy

  • high-dose estrogen

  • estrogen replacement therapy (don’t like period) → increase glycogen (but if too acidic, imbalance also occurs → feeds candida albicans and others)

  • Menstruation (pH goes up)

  • Diabetes → immunocompromised → in hyperglycemia, the C.albicans have special surface proteins that allow it to remain undetected by the neutrophil attacks.

  • treatment of broad spectrum antibiotics

  • corticosteroids, immunosuppressants → microbiota with opportunistic or true pathogens can cause infection.

  • oral sex (mouth organisms are different from vaginal bacteria → hence you’re introducing new bacteria.

  • use of intrauterine devices ( IUD)

Signs and Symptoms

  • irritation

  • itching

  • dysuria

  • increase vaginal discharge

presence of erythema and itching

  • thick and white discharge → cottage cheese like

  • no odour

  • irritation, itching, burning, soreness, erythema and dysuria→ pain in urination

  • dyspareunia → painful sex may also occur due to irritation and discomfort caused by the infection.

  • normal pH levels.

Difference in Odour

Fishy Odour

Foul smell

No smell

Discharge

Thin and sometimes foamy

Frothy

Thick white, cottage cheese like.

Color of Discharge

Off-white. discoloured (green/grey)

Yellow-green/grey

White

Complications

PID/UTI/Pre-term labor/Low birth weight/infertility or transmission of HIV

PID/UTI/Pre-term labor/Low birth weight/infertility or transmission of HIV

  • if you don’t treat this immediately, there are not many complications or any at all.

Exclusion for self-treatment → if you are pregnant, or below 12 years old, concurrent symptoms like fever or pain on back, shoulder or abdomen, on medication that can predispose to VVC (corticosteroids), medical disorders that can predispose to VVC or recurrent VVC (>3 infections per year or in the past 2 months)

  • antifungal products used → imidazole antifungals (miconazole, clotrimazole) → for uncomplicated VVC → exist as vaginal creams, suppositories and tablets.

  • advantage → superior efficacy → improved patient compliance due to ease of use → less frequent local reactions and short treatment duration

Medications that need to memorise

Miconazole Nitrate 2%

clotrimazole 1%

Isoconazole

Fluconazole

Cream → apply daily BD (outer)

Cream → apply BD daily (outer)

pessaries → vaginal tablets (inserted)

pessaries → 100 mg (1 tab 6 days)

pessaries → 200 mg (1 tab 3 days)

pessaries → 500 mg (1 table single app)

ovule 600 mg→ 1 tablet single app

150 mg tablet → single oral dose

Triazole

Itraconazole and Fluconazole (no need insert and no need prescription → but try not to give because its a very strong antifungal and wouldn’t want any antifungal resistance.

Mechanism of action

alters the membrane permeability of fungal cells

inhibits the CYP450 enzyme → lanosterol-14-alpha-demethylase → reduce ergosterol

reduced ergosterol content causes increase in lanosterols like methylated sterols → structural damage to fungal membranes → loss of function for the bacterial cell due to leakage of cellular components

alters the membrane permeability of fungal cells

inhibits the CYP450 enzyme → lanosterol-14-alpha-demethylase

reduced ergosterol content causes increase in lanosterols like methylated sterols → structural damage to fungal membranes → loss of function for the bacterial cell.

alters the membrane permeability of fungal cells

inhibits the CYP450 enzyme → lanosterol-14-alpha-demethylase

reduced ergosterol content causes increase in lanosterols like methylated sterols → structural damage to fungal membranes → loss of function for the bacterial cell.

  • They are very safe and appreciably absorbed → only potential vulvovaginal burning/itching/irritation → no drug interactions except for warfarin → only harmful if you are allergic to azoles

alternative therapies

  • use lactobacillus acidophillus preparation

  • sodium bicarbonate sitz path (1 tsp in 1 pint (450 ml) of water) → 15 mins

  • gentian violet/potassium permanganate → dilute in 1 pint and use for cleansing of vagina (antiseptics)

  • itchiness → use hydrocortisone 1% or benzocaine.

patient-counselling

  • symptoms should improve after 2-3 days and disappear/resolve within a week

  • avoid tight clothing like jeans or underwear → gives high moisture and humidity while allows microbes to grow.

  • seek medical evaluation if symptoms persist after a week or if recur after 2 months or occur 3 times within 12 month interval

  • don’t use perfumed soaps while washing

  • avoid/don’t douch