Dr Dora Milman

Kaplan Medical Center

Rehovot

Vulvar secretions from sebaceous, sweat, Bartholin, Skene glands

Transudate from vaginal wallExfoliated vaginal & cervical cellsCervical mucusEndometrial & oviductal fluidsMicro-organisms and their metabolic

products

The type, amount of cells, mucus and fluids are determined by biochemical processes that are influenced by hormone levels

Vaginal secretions may increase in the middle cycle due to increase in the amount of cervical mucus

These cycle variations do not occur when oral contraceptives are used

The vaginal desquamative epithelial cells are responsive to amounts of estrogen and progesterone:

Superficial cells – the main type in the reproductive age, predominate when estrogen stimulation is present

Intermediate cells – during the luteal phase – stimulation by progesterone

Parabasal cells – absence of either hormone, in postmenopausal without HRT

The normal vaginal flora – mostly aerobicAn average of six types of bacteriaThe most common – Hydrogen peroxide-

producing lactobacilliNormal vaginal pH is lower than 4.5 (due to

production of Lactic acid by lactobacilli and vaginal epithelial cells)

Normal vaginal secretions are floccular, white, usually located in the posterior fornix

Microscopy of normal vaginal secretions:Many superficial epithelial cellsFew white blood cellsFew, if any, Clue cells (superficial vaginal

epithelial cells with adherent bacteria, usually Gardnerella vaginalis, wich obliterates the crisp cell border)

An alternation of normal vaginal flora: loss of lactobacilli, overgrowth of predominantly anaerobic bacteria

The most common form of vaginitisAnaerobes, G. vaginalis, Mycoplasma hominis

– 100-1,000 times higher than in normal women

The possible triggers: repeated alkalinization of the vagina (frequent sexual intercourse or use of douches)

Increased risk for:Pelvic inflammatory disease (PID)Postabortal PIDPostoperative cuff infections after

hysterectomyAbnormal cervical cytologyIn pregnancy:PROMPreterm labor and deliveryChorioamnionitisPostcesarean endometritis

A fishy vaginal odor, particularly following coitus

Vaginal secretions – gray, thinly coat the vaginal wall

The pH higher than 4.5Microscopy: increased number of clue cells

and leukocytesThe addition of KOH to the vaginal secretions

releases a fishy, aminelike odor (the “whiff” test)

Inhibition of anaerobes but not vaginal lactobacilli.

Metronidazole – orally 500 mgX2 for 7 days or vaginal gel 0.75% for 5 days

Clindamycin – 100 mg ovules intravaginally for 3 nights or 2% vaginal cream for 7 nights or 300 mg X2 for 7 days

No need of treatment of male sexual partner (no improvement of therapeutic results)

Sexually transmitted flagellated parasite Trichomonas vaginalis

High transmission rateAn anaerobe, with ability to generate

Hydrogene to combine with Oxygen to create an anaerobic environment

Often accompanies BV (as many as 60% of cases of trichomoniasis)

Local immune factors and inoculum size influence the appearance of symptoms

Profuse, purulent, malodorous vaginal discharge, vulvar pruritus

A patchy vaginal erythema and colpitis macularis (“strawberry” cervix)

The pH of vaginal secretions higher than 5.0

Microscopy: motile trichomonads, increased number of WBC

Clue cells may be presentThe whiff test may be positive

Morbidity (in association with BV) – postoperative cuff cellulitis after hysterectomy, P-PROM, preterm delivery

Tests for other STD: Neisseria gonorrhoeae, Chlamydia trachomatis

Serologic testing for Syphilis and HIV should be considered

Metronidazole – the drug of choice: a single-dose (2 g orally) or 500 mg twice daily for 7 days - a cure rate 95%

The sexual partner should be treated!Vaginal treatment is not effective

An estimated 75% of women experience at least one episode of VVC during lifetimes

Candida albicans – 85-90% of vaginal yeast infections

C. glabrata, c. tropicalis – rare, tend to be resistant to therapy

Predisposing factors: antibiotic use, pregnancy, diabetes

Decrease in cell-mediated immunity (pregnancy, diabetes) leads to higher incidence of candidiasis

Vulvar pruritus, vaginal discharge – “cottage cheese” or watery, or homogeneously thick

External dysuria, vulvar burning, dyspareuniaErythema and edema of the vulva, vagina. The

cervix appears normalThe pH of the vagina is usually normal

(<4.5)Fungal elements appear in as many as 80% of

casesThe whiff test is negativeA fungal culture

Topically applied azole – 80-90% relief of symptoms

Oral fluconazole in a single 150-mg doseComplicated VVC – an additional 150-mg

dose of fluconazole 72 hours after the first dose or 10-14 days of topical treatment

Ajunctive treatment – a weak topical steroid – 1% hydrocortisone cream – for relieve of external irritation

4 or more episodes in a year – a small number of women

Persistent irritative symptoms of the vestibule and vulva

Diff. diagnosis with chronic atopic dermatitis or atrophic vulvovaginitis

Fluconazole 150 mg every 3 days for 3 doses and supression with 150 mg weekly for 6 months

One half – recurrence of the symptoms

In Menopause – naturally or secondary to oophorectomy

Inflammatory vaginitisIncreased purulent vaginal dischargeDyspareuniaPostcoital bleedingA result of atrophy of the vaginal and vulvar

epitheliumTopical Estrogen – cream or tablets, or

systemic HRT

Two types of cervical epithelium: squamous – ectocervical – an extension of vaginal epithelium, and glandular - in endocervix

the ectocervical infections – as in the vagina – Trichomonas, Candida, HSV

The endocervical infections –N. gonorrhoeae, C. trachomatis

A purulent endocervical discharge, yellow or green – “mucopus”

Gram stain- Increased number of neutrophils- Intracellular G- diplococci (gonorrhea)- If negative for gonococci, the presumptive

diagnosis is chlamydial cervicitisNucleic acid amplification tests for gonorrhea

and chlamydia The etiology of 50% of endocervicitis is

unknown

Treatment of Gonorrhea and ChlamydiaTreatment of sexual partners!Treatment of BV, commonly associated with

cervicitisFluoroquinolone resistance is common in N.

gonorrhoeae N. gonorhoeae – Ceftriaxone, 250 mg IM –

single doseC. trachomatis – Doxycycline, 100 mg X2 for

7 daysAzithromycin, 1 g orally as single dose

Acute infection of the upper female genital tract – uterus, oviducts, ovaries, often involvement of neighboring pelvic organs

Endometritis,salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, perihepatitis

N. gonorhoeae, C. trachomatis are often implicated

Vaginal flora (BV micro-organisms)Haemophilus influenzae, group A

streptococci, pneumococci

Chronic pelvic pain – as many as one-third of women with PID.

Infertility - injury to fallopian tube – loss of ciliary action, fibrosis, occlusion - hydrosalpinx (in IVF – negative consequences on the rates of pregnancy, implantation, early pregnancy loss, preterm birth, and live delivery)

Ectopic pregnancy - 7.8% after laparoscopically-confirmed PID versus 1.3% without PID at laparoscopy.

Lower abdominal pain– may be subtle, worsens during coitus, may onset during or shortly after menses, usually bilateral

Abnormal uterine bleeding – in one-third of patients with PID

New vaginal dischargeFever, chillsNon of these signs is neither sensitive nor

specific

There is NO single diagnostic gold standard

There is NO single diagnostic gold standard

Previous episode of PIDSex during mensesVaginal douchingBacterial vaginosisIntrauterine device Age less than 25 years Young age at first sex Nonbarrier contraception Oral contraception New, multiple, or symptomatic sexual

partners

Fever – only about one-halfDiffuse tenderness greatest in the lower

quadrantsReboundRight upper quadrant tenderness – Fitz-Hugh-

Curtis syndrome – perihepatitis – 10% of patients with PID

Purulent endocervical dischargeCervical motion and adnexal tendernessLow-grade fever, weight loss, abdominal pain –

susp. Actinomycosis (IUD?)

LeukocytosisElevated CRP or ESRPositive test for Gonorrhea or ChlamydiaUltrasound documenting tubo-ovarian

abscessLaparoscopy visually confirming salpingitis

Empirical, broad-spectrum coverage of likely pathogens, including

N. GonorrhoeaeC. TrachomatisM. Genitalium

Gram-negative facultative bacteriaAnaerobes

Streptococci

Mild – outpatient regimenHospitalization – when: - the diagnosis is uncertain - pelvic abscess is suspected - clinical disease is severe - poor compliance Evaluate sexual partners for gonococcal and

chlamydial urethritis

An end-stage process of acute PIDA palpable pelvic mass - agglutination of

pelvic organsHospitalization!About 75% respond to antimicrobial therapy

aloneFailure to respond to antimicrobial therapy

after 72 hours – the need for drainage – percutaneous, transvaginal or surgical exploration (laparoscopy)

Infectious:Herpes simplex – HSV – type 1, type 2Syphilis – Treponema pallidumChancroid – Haemophilus ducreyiLymphogranuloma Venerum – Chlamydia

trachomatis serovars L1-3Granuloma Inguinale (Donovanosis) –

Klebsiella granulomatis

Noninfectious:

Fixed drug reactionsBehchet’s diseaseNeoplasmsTrauma

HSVType-2, type-1Multiple small grouped vesicles - ulcers;

erythematous baseUsually painfulOccasionally single lesion/fissuresCan be painless or pruriticReactive lymphadenopathy

Syphilis:Ulcer – usually a single, indurated, with

smooth firm bordersUsually painlessInguinal lymphadenopathy

Chancroid:Begin as papules that go on to ulcerateSharply circumscribed or irregular, ragged

undermined edgesMultiple ulcersNot induratedBase with gray or yellow exudateVery painful50% with inguinal adenopathy

Granuloma inguinale:One or more nodular lesions that ulcerateUsually painlessSlowly enlarge friable ulcers, with raised,

rolled marginsGranulation-like lesions“kissing” lesionsLymphadenopathy – less common, though

nodular lesions may appear as pseudobuboes

LGV – Lymphogranuloma venerum:Often begins as a single papule or a small and

shallow ulcerUsually painlessRapid spontaneous healingTender lymphadenopathySuppuration of the lymph nodes A painful “buboe”

Infectious or noninfectiousSexual and medical historyUlcer - single or multiple? Recurrent? Painful?

Indurated or no? Suppurative? Lymphadenopathy?

Underlying HIV infection? (oropharyngeal thrush, significant concomitant inguinal, cervical, axillary lymphadenopathy)

Supportive laboratory testing (the appearance of genital ulcers may vary and overlap)

Tests for STD’s – C. trachomatis, N. gonorhoeae, HIV, Hepatitis B, Hepatitis C

Atypical presentation in the immunocompromised host

Follow-upTo exclude non-infectious causes