dr dora milman kaplan medical center rehovot. vulvar secretions from sebaceous, sweat, bartholin,...
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Dr Dora Milman
Kaplan Medical Center
Rehovot
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Vulvar secretions from sebaceous, sweat, Bartholin, Skene glands
Transudate from vaginal wallExfoliated vaginal & cervical cellsCervical mucusEndometrial & oviductal fluidsMicro-organisms and their metabolic
products
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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
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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
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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
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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)
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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)
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Increased risk for:Pelvic inflammatory disease (PID)Postabortal PIDPostoperative cuff infections after
hysterectomyAbnormal cervical cytologyIn pregnancy:PROMPreterm labor and deliveryChorioamnionitisPostcesarean endometritis
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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)
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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)
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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There is NO single diagnostic gold standard
There is NO single diagnostic gold standard
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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
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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?)
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LeukocytosisElevated CRP or ESRPositive test for Gonorrhea or ChlamydiaUltrasound documenting tubo-ovarian
abscessLaparoscopy visually confirming salpingitis
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Empirical, broad-spectrum coverage of likely pathogens, including
N. GonorrhoeaeC. TrachomatisM. Genitalium
Gram-negative facultative bacteriaAnaerobes
Streptococci
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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
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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)
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Infectious:Herpes simplex – HSV – type 1, type 2Syphilis – Treponema pallidumChancroid – Haemophilus ducreyiLymphogranuloma Venerum – Chlamydia
trachomatis serovars L1-3Granuloma Inguinale (Donovanosis) –
Klebsiella granulomatis
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Noninfectious:
Fixed drug reactionsBehchet’s diseaseNeoplasmsTrauma
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HSVType-2, type-1Multiple small grouped vesicles - ulcers;
erythematous baseUsually painfulOccasionally single lesion/fissuresCan be painless or pruriticReactive lymphadenopathy
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Syphilis:Ulcer – usually a single, indurated, with
smooth firm bordersUsually painlessInguinal lymphadenopathy
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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
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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
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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”
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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)
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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
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