vaginitis.pptx

slides about vaginitis- OG

1. VAGINITIS Adithya S MBBS Govt Thiruvarur Medical College

2. VAGINITIS Inflammation of the Vaginal wall is called Vaginitis. There is evidence of increase in WBCs in the vaginal fluid. Commonly seen in infections caused by Trichomoniasis, candidiasis and herpes, STDs including HIV infections.

3. Normal Vaginal Secretions Characteristics - White, odorless Components: Secretions from Glands of vulva Transudate from vaginal wall Secretions from Cervical glands Tubal and endometrial glands

4. Normal Flora Aerobic bacteria – Lactobacilli, Streptococcus, staphylococcus Anaerobic bacteria – Peptococcus, peptostreptococcus, Bacteroides Normal pH: 3.8-4.5 Microscopy – Desquamated epithelial cells, few white blood cells, Lactobacilli

5. 03 01 02 Pathological Variations- Vaginitis Bacterial Vaginosis -50% Trichomoniasis – 15-20% Monilial (Candidal) – 20-25% Most Common:

6. 04 01 02 Pathological Variations- Vaginitis Vulvovaginitis in childhood Vaginitis due to Chlamydial trachomatis Atrophic vaginitis(Senile Vaginitis) Less Common: 03 05 Secondary Vaginitis Toxic Shock Syndrome

7. General Features of Vaginitis

8. Symptoms – Pruritis, Burning in vagina, Malodourous discharge Dyspareunia

9. Physical Findings Congestion of vaginal walls, Microhemorrhages, abnormal discharge- copious, foul smelling Increase in vaginal pH Tenderness/discomfort during pelvic examination

10. Hanging Drop examination- Trichomonas organisms KOH treated preparation – pseudo mycelia and spores in Candida infections Whiff Test- Fishy odor on adding 10% KOH to vaginal secretion Gram’s stain – Bacterial vaginosis Investigations:

11. Culture: Chocolate Agar: Sabornaud’s medium or Nickerson’s medium – Candida Special enriched medium – Trichomonas infections

12. TRICHOMONAS VAGINITIS

13. Vaginal Trichomoniasis - Sexually Transmitted Causative Organism - Trichomonas vaginalis, a pear-shaped unicellular flagellate motile protozoa Symptoms: Vaginal Discharge – Yellowish Green, Frothy, foul smelling Vaginal pH > 4.5 Pruritis Dysuria Dyspareunia

14. Signs Inflamed, Edematous Vulva Copious fowl smelling, thick, yellowish green discharge Punctuate hemorrhagic spots on vagina giving Strawberry appearance

15. Diagnosis Firstly, based on above clinical suspicion and findings Confirmatory tests: Hanging drop Preparation: Indicates presence of actively motile flagellate Trichomonas vaginalis. If found negative, repeat examination. Culture: Diamond’s TYM or Feinberg Whittington Medium Not routinely used Pap Smear : Size of organism same as nucleus of epithelial cells NAAT – Nucleic Acid Amplification test Trichomonas Rapid test

16. Treatment Metronidazole 200 mg thrice daily Orally for 1 week or 2g is an alternative. Tinidazole/Secnidazole single 2 gm dose PO is equally effective. The husband should be given the same treatment schedule for 1 week. The husband should use condom during coitus irrespective of contraceptive practice until the wife is cured. Complications in pregnancy: PPROM Preterm labor

17. Candidal Vaginitis (Monilial)

18. Causative organism – Candida albicans (90%) Fungal infections Other Candida species (10%) Fungi can easily grow and multiply when lactobacilli concentration decreases Risk factors: Pregnancy Oral contraceptive use Menstruation Antibiotic use Obesity Diabetes Immunosuppression – Corticosteroids, Immunosuppressive drugs, HIV infection

19. Clinical findings Pruritis Discharge – Scanty, Curdy white or cottage cheese like discharge Vaginal pH < 4.5 Dysuria (Splash Dysuria) Vulvar erythema, oedema, scratch marks may be seen

20. Diagnosis Wet Smear of vaginal discharge is prepared. KOH solution (10%) is added to lyse the other cells. Filamentous form of mycella, pseudo hyphae can be seen under the microscope. Culture in Nickerson’s or Sabouraud’s media— become positive in 24–72 hours. PAP smear: Hyphae identified, spores – smaller than the nucleus of epithelial cell SHISH KEBAB appearance

21. Treatment Corrections of the predisposing factors Local fungicidal preparations (polyene or azole) group Nystatin, clotrimazole, miconazole, econazole used as either vaginal cream or pessary. Oral Fluconazole 150 mg oral stat. For Recurrent Candidiasis > 4 episodes in a year, vaginal boric acid capsule (600 mg gelatin capsules) is effective. Boric acid inhibits fungal cell wall growth.

22. Bacterial Vaginosis

23. Vaginosis (earlier as nonspecific vaginitis/Gardnella vaginalis/ Corynebacterium vaginitis and anaerobic vaginitis) Bacterial vaginosis is termed vaginosis rather than vaginitis, because it is associated with alteration in the normal vaginal flora. Decrease in the number of lactobacilli in the vaginal discharge with 100-fold increase in growth of other anaerobic bacteria. Lactobacilli reduce pH and release hydrogen peroxide toxic to other bacteria, so reduction in their number allows other bacteria, i.e. aerobic and anaerobic bacteria, to grow.  Hemophilus influenzae, G.vaginalis, Mobilincus hominis – Gram positive Rod-shaped bacteria Corkscrew spinning anaerobic. Bacterial Vaginosis- Polymicrobial condition Risk Factors – Multiple sex partners, This is not STD but sexually associated

24. Clinical findings Vaginal discharge – foul smelling discharge, white, milky Vaginal pH > 4.5 No Pruritis, dysuria, dyspareunia

25. Diagnosis Whiff Test: Fishy amine like odor on addition of KOH to the discharge. Characteristic test for Bacterial Vaginosis Wet mount saline microscopy: Clue cells(Vaginal epithelial cell-(fuzzy border) to which bacterial cells adhered) Pap smear – Clue cells Gram staining- 90% sensitive and 83% specific DNA probe and Gas liquid chromatography also useful

26. Treatment Metronidazole 400mg B.D 7days avoided in first trimester Ampicillin 500 mg/ cephalosporin 500 mg b.i.d for 7 days Tetracycline 500 mg 4 times a day, Doxycycline 100 mg twice a day, sulphafurazole for 10-14 days in non pregnant women –alternative Clindamycin 2% cream / oral clindamycin 300 mg daily 7 days Ornidazole 500 mg vaginal tablet 7days Lacteal Gel neutralizes vaginal pH protein free acidifying gel Complications: PID, Chorioamnionitis, PROM, Preterm labor

27. Amsel’s Criteria – Diagnosis of Bacterial vaginosis White, milky, non viscous discharge adherent to vaginal wall pH of discharge > 4.5 (pH 5-7) Fishy odor on adding 10% KOH Positive Whiff test Presence of Clue cells Increased number of G.vaginalis and reduced number of leucocytes and lactobacilli

28. Vulvovaginitis

29. Vulvovaginitis More common in childhood Causative organism- Pyogenic coccus or E.coli, Trichomonas vaginalis and Monilia Transmitted from adults or another child by hands, toilet, clothes or utensils. Threadworm infections are common. Occasionally, due to sexual abuse Before making diagnosis foreign body must be excluded, proper smear, examination under anesthesia and inspecting the upper vagina

30. Symptoms and signs Reddened edematous vulva Labial adhesions may form sometime Profuse purulent discharge with soreness and irritation

31. Treatment Local and systemic antibiotics Ethinylestradiol 0.01 mg – increase vaginal epithelial resistance and improves acidity

32. Secondary Vaginitis Vaginitis secondary to chronic infection of cervix - endocervicitis The effective eradication of cervix is essential to clear vaginal infection Childhood injuries of genital tract – Cervical tear other causes Vesicovaginal, ureterovaginal urinary fistulae and rectovaginal fistulae Growth on cervix: Ca cervix or Cervical polyp causes secondary vaginitis Vaginitis Medicamentosa : Chemicals, douches, Arsenic pessaries All forms of vaginitis in which primary cause is not vaginal are included here: Foreign body- Presence of vaginal pessary (to manage prolapse or retroversion) Vaginitis Infective Conditions of Cervix-

33. ATROPHIC VAGINITIS (SENILE VAGINITIS)

34. Atrophic vaginitis (senile vaginitis) Vaginitis in postmenopausal women is called atrophic vaginitis. Atrophy of the vulvovaginal structures due to estrogen deficiency. The vaginal defense is lost. Vaginal mucosa is thin and is more susceptible to infection and trauma. Desquamation of the vaginal epithelium which may lead to formation of adhesions and bands between the walls.

35. Clinical Features Yellowish or blood stained vaginal discharge. Dyspareunia Discomfort, dryness, soreness in the vulva.

36. Diagnosis Senile vaginitis may produces blood stained discharge so exclude cancer of endometrium or endocervix Senile vaginitis and senile endometriosis may coexist- These are excluded prior to therapy On Examination Tender Vagina red and inflamed, mucosa is excoriated, Patchy granular vaginitis

37. Treatment Oestrogen therapy- to improve resistance of vaginal epithelium, raise glycogen content, lower vaginal pH Ethinylestradiol 0.01 mg daily for 3 weeks Pessary/ointment/ cream containing estrogen

38. TOXIC SHOCK SYNDROME (TSS)

39. Toxic shock syndrome (TSS) TSS is commonly seen in menstruating women between 15 and 30 years of age following the use of tampons (polyacrylate). Other condition associated with TSS is use of female barrier contraceptives (diaphragm). It is characterized by the following features of abrupt onset Fever >38.9°C. Diffuse macular rash, myalgia. Gastrointestinal : Vomiting, diarrhea. Cardiopulmonary : Hypotension, adult respiratory distress syndrome. Platelets: < 100,000/mm3 . Renal : ↑ BUN (> twice normal). Hepatic : Bilirubin, SGOT, SGPT rise twice the normal level. Caused due to endotoxin released from Staphylococcal aureus and Streptococci

40. Treatment Correction of hypovolemia with i.v fluids cephalosporin, gentamycin, penicillin Prevention Vaginal tampons or contraceptive sponge should never be left in vagina for more than 24hr

41. Characteristics Trichomoniasis Candidiasis Bacterial vaginosis Chlamydia Normal vaginal discharge color Greenish yellow Curdy white Gray white to green yellow white mucopurulent white consistency Thin, frothy thick thin thick thin Whiff test(see p.148) negative negative Positive(fishy amine) negative negative pH >5 <4.5 >5 <4.5 <4.5 pruritus +++ ++ Non irritating _ _ Diagnosis (Wet mount microscopy) motile Trichomonas Hyphae or spores Clue cells (>20%) Chlamydia NAAT _ Treatment Metronidazole 2 gm single dose or 200 mg. TID × 7 days Imidazole Fluconazole 150 mg P.O. weekly for 6 weeks Metronidazole 200 mg. TID × 7 days Azithromycin 1 gm orally single dose _ Differential diagnosis of vaginal discharge

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