Description #
This is an Obstetrics and Gynecology unit.
Learning Objectives #
The Students should be able to:
– Normal vaginal appearance and secretions
– Diagnosis of different causes of Vulvovaginitis and explain the infectious and non-infectious causes
– Explain treatment options
Definition of Vulvovaginitis #
Vulvovaginitis is defined as inflammation of vagina and vulva. It is characterized by abnormal vaginal discharge with or without pruritis. It may be caused by infectious or non-infectious causes.
Vaginal Discharge:
Normal Vaginal discharge is white or transparent sometimes mocusy in nature it’s produced by ovi ducts, endometrium, cervical mucos, as well as many glands in the vagina like bartholin gland and skene gland.
Normal vaginal Ph is acidic in the reproductive age group due to production of lactic acid and hydrogen peroxide by the bacteria called lacto bacili . Lacto bacili feed on glycogen. Acidic PH prevents overgrowth of candida and other microorganisms.
It’s important to know that variations in vaginal discharge may occur. So when a woman complains of heavy but asymptomatic vaginal discharge it will be worth considering “natural explanations” of her symptom. These natural explanations are physiological increase in the vaginal secretions that is known as “Physiologic Leucorrhoea”.
When would you see physiologic leucorrhoea? In pregnancy, combined oral contraceptives, ovulation and during sexual activity we will see heavy but asymptomatic vaginal discharge.
Factors altering protective normal microflora:Sexual intercourse, Douching, foreign body like forgotten tampon
Infectious causes #
The common infectious causes which account for 90% cases of vaginitis are:
- Bacterial vaginosis (40 to 50 percent of cases)
- Vulvovaginal candidiasis (20 to 25 percent of cases)
- Trichomoniasis (15 to 20 percent of cases)
Non-Infectious Causes:
-Chemical or other irritant causing allergies, hypersensitivity, and contact dermatitis:Seminal plasma allergy, latex condoms, spermicides, soaps, topical antifungals, feminine hygiene products like scented panty liners, perfumes
-Lichen simplex: itch-scratch-itch cycle leads to leathery brownish skin
-Traumatic vaginitis
-Atrophic vaginitis: seen typically in postmenopausal women – low estrogen – thin vaginal epithelium – vaginal dryness – prone to infection
-Postpuerperal atrophic vaginitis
-Desquamative inflammatory vaginitis (steroid-responsive)
-Erosive lichen planus: is a chronic mucocutaneous disease that affects the skin, tongue, and oral mucosa.The typical rash of lichen planus is well-described by the “5 Ps”: well-defined pruritic, planar, purple, polygonal papules. The cause of lichen planus is not known. It is not contagious and does not involve any known pathogen. Currently there is no cure for lichen planus but there are certain types of medicines used to reduce the effects of the inflammation. Lichen planus may go into a dormant state after treatment. There are also reports that lichen planus can flare up years after it is considered cured. Scarring which may cause shortening, narrowing, or closure of the vagina .Medicines used to treat lichen planus include: Oral Steroids, oral retinoid and immunosuppressant medications.
-Collagen vascular disease, Behcet’s syndrome ( a rare systemic form of Vasculitis that often presents with mucous membrane ulceration, and ocular involvements ), pemphigus syndromes ( blistering autoimmune disease that affect the skin and mucous membranes)
-Idiopathic vaginitis
Diagnostic investigations #
Diagnostic Tests:
- pH of the vaginal discharge (nitrazine paper):Collect the vaginal discharge from the lateral vaginal wall during speculum exam
- Whiff test:Sample of vaginal secretions are placed in a test tube with 10% KOH
- KOH test: Place sample on glass slide and visualize at low power (10x) for pseudohyphae and spores
- Gram stain of vaginal discharge
- Wet mount of vaginal discharge: Vaginal secretion sample from the posterior fornix and lateral wall are placed in test tube with small amount of normal saline and place sample on glass slide with cover slip.
- Culture of vaginal discharge
- Cervical cultures (to rule out chlamydia and gonorrhea)
Bacterial Vaginosis #
BV is not caused due to a single organism, it is characterized by decrease in the concentration of normally dominant lactobacilli and an increase in concentration of other organisms especially anaerobes like Gardnerella vaginalis, Prevotella, mobiluncus, hemophilus, e. coli, mycoplasma hominis, ureaplasma urealyticum, bacteroides etc.
BV usually happens after disruption of healthy vaginal micro flora (typically lactobacilli) and woman commonly complain about:
-Heavy white milky discharge “coats walls of vagina”
-Funny fishy smell (worse around menses/ after sex)
-Absence of vulvovaginal irritation
-Often no predisposing factors, sometimes associated with a new partner or IUD use
BV is not considered a “true infection” – So it is NOT an STI .
Diagnosis of BV:
Amsel’s Criteria : 3 out of 4
1. Characteristic of the discharge: Thin, white, yellow, homogeneous vaginal discharge
2. PH of the vaginal discharge: Vaginal pH > 4.5
3. Whiff test (amine test) : Positive “whiff” or amine test (by adding 10% KOH)
4. Wet mount (saline microscopy): Clue cells present (epithelial cells with adherent coccobacilli
Treatment:
We only treat BV if the patient is symptomatic or high risk pregnancy for preterm labour and prior to any instrumentation and gynecology surgery.
Treat with:
Metronidazole 500 mg po bid x 7 days, OR
Metronidazole gel 0.75%, one appl. (5 g) intravaginally, od x 5 d OR
Clindamycin cream 2%, one applicator (5 g) intravaginally qhs x 7 days
For asymptomatic patients treatment is unnecessary except in:
• high risk pregnancy ( Hx of preterm delivery)
• Prior to IUD insertion
• Prior to gyne surgery or instrumentation
After treatment follow-up is not necessary unless symptoms recur. Re-testing after 4 weeks in pregnancy is suggested.
We do not need to treat the partner as it’s not considered as STI.
Trichomoniasis #
Trichomoniasis is a sexually transmitted infection caused by parasitic flagellated protozoa: Trichomonas vaginalis.
It has a transmission rate of 70% from penis to vagina or vulva to vulva (lesbian)
The diagnosis of Trichomoniasis should be followed by screening for other STIs and empiric treatment of partners
Women complain from purulent, malodorous thin vaginal discharge, burning, pruritis, dysuria, frequency, dyspareunia, post-coital bleeding
Signs:
-This is an infection = inflammation of the vulva/vagina and cervix.
-Characteristic : strawberry cervix
–pH>4.5
Treatment is like BV except:
– treat partner regardless of symptoms
– screen for other STDs
– report to CDC
-Avoid intercourse till TX completed
Metronidazole 500 mg po bid x 7 days OR
Metronidazole 2g po x 1
Candidiasis #
Approximately 90% of Vulvovaginal candidiasis infections are caused by
Candida Albicans. The remaining cases are caused by Candida glabrata, Candida tropicalis or Torulopsis glabrata.
Candida infections generally do not coexist with other infections and are not considered to be sexually transmit-ted, although 10% of male partners have concomitant penile infections.
Risk Factors for Candidiasis:
– Pregnancy
– Diabetes
– Obesity
– Immunosuppression from any cause (HIV, steroid use)
– On oral contraceptives
– Recent broad-spectrum antibiotic therapy
– Practices that keep the vaginal area warm and moist, such as wearing tight clothing or the habitual use of panty liners
The most common presenting complaint for women with candidiasis is itching, although up to 20% of women may be asymptomatic. Burning, external dysuria, and dyspareunia are also common. The vulva and vaginal tissues are often bright red in color, and excoriation is not un-common in severe cases. A thick, adherent “cottage cheese” discharge with a pH of 4 to 5 is generally found. This discharge is odorless.
Multiple studies conclude that a reliable diagnosis can-not be made on the basis of history and physical examination alone.
Diagnosis:
Diagnosis requires either visualization of spores or pseudohyphae on Wet mount preparation or Gram Stain, or10% KOH microscopy, or a positive culture in a symptomatic woman.
Latex agglutination tests may be of particular use for non-Candida albicans strains, because they do not demonstrate the pseudohyphae on wet prep.
Treatment of candidaiasis:
Clotrimazole (brand name Canestan) 1% cream 5g intravaginally x 7-14d OR
Clotrimazole 500 mg vaginal tablet, one tablet in a single application OR
Miconazole (brand name Monistat) 100 mg vaginal suppository od x 7d OR
Fluconazole 150 mg oral tablet, one tablet x1
Treatment #
- enhanced hygiene and local measures (handwashing, white cotton underwear, no nylon tights, no tight fitting clothes, no sleeper pajamas; sitz baths, avoid bubble baths; use mild detergent, eliminate fabric softener; avoid prolonged exposure to wet bathing suits; urination with legs spread apart)
- A&D® dermatological ointment to protect vulvar skin
- infectious: treat with antibiotics for organism identified