Disorders of the Vulva and Vagina cervicitis

					Disorders of the Vulva and Vagina
             Vaginitis

    By Lena Kirakosian M.S.N., F.N.P-C
    Clinical Instructor of Family Medicine
       Normal Vaginal Physiology
• Normal vaginal discharge is usually
  white/transparent/thick/odorless
• Vaginal PH 4-4.5
• Microscopic examination:
  – predominantly squamous epithelial cells
  – rarely PMN’s (polymorphonuclear leukocytes)
• Vaginal microbiology
  – Mainly lactobacillus
  – Diphtheroids
  – S.epidermidis
              Epidemiology
• Vulvovaginal symptoms are extremely
  common, accounting for over 10 million
  office visits per year
• The etiology of vaginal complaints includes
  infection of the vagina, cervix, and upper
  genital tract, and a number of non-infectious
  causes such as chemicals or irritants (e.g.,
  spermicides or douching), hormone
  deficiency etc.
            Symptoms of Vaginitis
•   Abnormal vaginal discharge
•   Pruritus
•   Irritation
•   Burning
•   Soreness
•   Odor
•   Dyspareunia
•   Bleeding
•   Dysuria
                      History
• Is there abdominal pain?.
• Has there been exposure to a new sexual partner?
• When did the symptoms start in relation to menses?
• What medications (prescription and nonprescription)
  are being used?.
• What are the patient's hygienic practices (e.g., daily
  use of pantyliners, feminine products)?
            Atrophic Vaginitis
• Pre-pubertal – lactating – postmenopausal
• Reduced endogenous estrogen
• Causing thinning of the vaginal epithelium
• Vaginal epithelium susceptible to trauma and
  infection
• pH high
             Patient Complaints
• Genital
    Dryness/Itching/Burning
    Dyspareunia
    Vulvar pruritus
    Feeling of pressure
    Yellow malodorous discharge /leukorrhea
    Spotting
    Irritation/tear
• Urinary
    Dysuria/ Frequency/Hematuria
    Urinary tract infection
    Stress incontinence
     Clinical Manifestations/PE
• Pale, smooth or shiny vaginal epithelium
• Loss of elasticity or turgor of skin
• Sparsity of pubic hair
• Dryness of labia
• Fusion of labia minora
• Introital stenosis
• Friable, unrugated epithelium
• Pelvic organ prolapse
• Vulvar dermatoses
     Treatment for Atrophic Vaginitis
• Treated with estrogen replacement (vaginal/oral)
• Oral BCP (ethinyl estradiol up to 50ug)
• Conjugated estrogen up to 1.25mg in combo
  w/medroxyprogesterone acetate to prevent
  endometrial hyperplasia
• Vaginal cream 1g daily qhs x1m then ½ dose
  2X/week (1g vaginal cream=.625mg conjugated
  estrogen)
   – should give w/ 2.5mg medrxyprogesterone x14d
• Estrogen vaginal ring (change q3m)      (Estring)
  delivers 6-9ug estrodiol daily
• Vagifem 1tab intravaginally x2w then 3x/w for 3-
  6m
Bacterial Vaginitis (G Vaginalis)
– Most common cause of vaginitis in women of
  childbearing age
– Caused by decrease in hydrogen peroxide-
  producing lactobacilli and increase in
  Gardnerella vaginalis
– May c/o Vaginal discharge usually thin off-
  white/grayish white & nonirritating ,
  malodorous fishy odor (usually worse after
  unprotected intercourse.)
– Risk Factors
– Complications
                    Diagnosis
• Bacterial Vaginosis
  History and PE

  -Clue cells on wet mount
  -Vaginal pH >4.5
  -Positive whiff amine test
  -Grayish-white discharge

  Gram stain
               Treatment
• Bacterial Vaginosis
  – Metronidazole 500mg BID X 7days or
  – Metronidazole 2g single dose
  – Metro gel .75% 1-application intravaginally
    qhs or BID X 5days
  – Clindamycin cream 2% 1-applicator (5g)
    intravaginally qhsX7d
  – Oral clindamycin 300mg BID X 7 Days
 Candidiasis (Candida albicans)
• C/O intense vulvar pruritis & burning, white
  curd-like D/C, irritation, dyspareunia, vulvar
  erythema & edema may occur, as well as
  dysuria
• Accounts for 1/3 of vaginitis cases
• The infection is part of the host
  inflammatory response to the invasion of
  yeast
• Multiple Causes/Risk Factors
                Diagnosis

• Physical Exam
  – pH 4-4.5
  – Wet mount with 10% KOH displays yeast
    buds and hyphae
  – Culture should be performed in persistent
    or recurrent symptoms
        Treatment Options
– Candidiasis
   • Azoles-vaginal
     preps(creams/suppostories/tablets)
     available in different strengths and
     length of use will vary
   • Fluconazole 150mg X1 orally
   • Ketoconzole 200mg orally BID X5days
   • Contraindications
   Trichomonas (Trichomonas
          vaginalis)
Epidemiology
The organism is the flagellated protozoan
 trichomonas vaginalis found in the vagina,
 urethra, and paraurethral organs
Self limiting in men
Spermicidal agents may reduce the rate of
 transmission
Virtually always sexually transmitted
       Clinical Manifestations
May be asymtomatic carrier to severe acute
 inflammatory dz.
Symptoms usually consistent with purulent,
 malodorous, thin discharge.
Usually c/o burning, pruritus, dysuria,
 frequency, and dysparenunia
Generalized inflammation may be present
Vaginal / cervical petechiae may occur
  complications
               Diagnosis
• History and focused physical exam
• Wet mount with NS reveals motile flagellates/
  trichomonads
• Increase Polymorphonuclear leukocytes on
  microscopy (PMN’s)
• pH >4.5
• Culture is the GOLD STANDARD
   – 95% sensitivity and specificity

  Complications
              Treatment
• Metronidazole
  – 2g single dose
  – 500mg BID X7 days

    • Precautions
   Bartholin’s Cyst and Abscess
• An obstruction of the Bartholin’s gland
  resulting in retention of secretions and
  cystic dilatation
• Gland is located deep in the posterior 3rd of
  both labia majora
                Treatment
• Simple incision and drainage may provide
  temporary relief
• Primary treatment is I&D with insertion of a
  word catheter (inflatable bulb tip catheter)
• May also treat with I&D followed by
  marsupialization
• Antibiotics may be necessary
• Recurrent infections may occur requiring a
  permanent opening for drainage
      Vulvar Dystrophies
(nonneoplastic epithelial disorders)

•   Lichen Sclerosus
•   Squamous Cell Hyperplasia
•   Lichen Simplex Chronicus
•   Lichen Planus
•   Psoriasis
                Lichen Sclerosus
• Physical Appearance
   – Thin, white, wrinkled tissue “parchment-like”
   – Agglutination of the labia minor and prepuce
   – Introital stenosis
   – Fissures and telangiectasia
     • Diagnosis
     • Treatment: Topical steroids (low-medium
       potency for mild cases)
        – Clobetasol propionate .05% BIDx1m qdx1-2m
        – Intralesional injections of triamcinolone 0.1% for
          resistant cases
       Squamous Cell Hyperplasia
    (Atopic Eczema/Neurodermatitis)
• Physical Appearance
• Benign epithelial thickening and hyperkeratosis
   – Acute phase with red/moist lesions
   – Causing pruritus leading to rubbing & scratching
   – Circumscribed, single or unifocal
   – Raised white lesions on vulva or labia majora and
     clitoris
      • Treatment: Sitz baths, lubricants, oral
        antihistamines, Medium potency topical steroid
        twice daily
    Lichen Simplex Chronicus
• Physical Appearance
   – Thickened white epithelium on vulva
   – Generally unilateral and localized
      • Treatment: Medium potency steroid
        twice daily prn
                 Lichen Planus
• General Appearance
  – Erosive lesions at vestibule w/without adhesions
    resulting in stenosis
  – May have associated oral mucotaneous lesions
    and desquamative vaginitis
  – Patient c/o irritating vaginal d/c, vulvar soreness,
    intense burning, pruritus, and dyspareunia w/post-
    coital bleeding
  – Types: Papulosquamous LP/Hypertrophophic LP
    /Errosive LP
              Treatment
• Intravaginal hydrocortisone suppositories BID
  x 2m
• Steroid creams (medium-high potency)
• Vaginal estrogen cream if atrophic epithelium
  present
• Vaginal dilators for stenosis
• Surgery for severe vaginal synechiae
• Vulvar hygiene
• Emotional support
                Vulvar Psoriasis

• Physical Appearance
   – Red moist lesions w/without scales

     • Treatment: Topical corticosteroids
            Neisseria Gonorrhoeae
• Involves any portion of the genital tract, the oropharynx or
  may become disseminated
• 50% or more may be asymptomatic or may experience
  copious mucopurulent discharge.
• Diagnosis
   – Gram Stain
   – Culture*/ Endocervical DNA probe
      • Treatment:
            » Ceftriaxone 125mg IM
            » Cefixime 400mg po X1
            » Cipro 500mg po X1
            » Levofloxin 250 po X1
             Chlamydia Trachomatis
• Is the most common sexually transmitted infection
• Many people are asymptomatic / present with
  mucopurulent cervicitis, dysuria, and or post-coital
  bleeding
• Diagnosis
  – Culture *
• Treatment
  –   Azithromycin 1g orally single dose
  –   Doxycycline 100mg BID x 7d
  –   Erythromycin 500mg QID x 7d
  –   Ofloxin 300mg / levofloxin 50mg qd x 7d
• Complications/Risk factors

				
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posted:1/24/2011
language:English
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