Heavily lifted from the CDC STD Treatment Guidelines 2015, this is a discussion on infections affecting the vagina. This was a lecture delivered to an audience of second year medical students at the Cebu Doctors University College of Medicine.
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Infections of the Genital Tract - Part II
1. Infections ofInfections of
the Genitalthe Genital
TractTract
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Doctors University College of Medicine
February 2016
@helenvmadamba CDUCM 2016
3. LECTURE OUTLINE
• Infections of the Vulva
• Bartholin’s gland abscess
• Ectoparasites
• Diseases characterized by Ulcers
• HPV and Anogenital Warts
• Infections of the Vagina
• Diseases Characterized by Vaginal Discharge
• Infections of the Cervix
• Diseases Characterized by Cervicitis
@helenvmadamba CDUCM 2016
4. LECTURE OUTLINE
• Infections of the Upper Genital Tract
• Pelvic Inflammatory Disease
• Sexual Assault & STDs
@helenvmadamba CDUCM 2016
5. The Five P’s
1. Partners
2. Practices
3. Prevention of
Pregnancy
4. Protection from
STDs
5. Past history of
STDs
@helenvmadamba CDUCM 2016
8. VAGINA
• Normal vaginal pH approx 4.0 in pre-
menopausal women
• Estrogen stimulates glycogen content of
vaginal epithelial cells.
• Lactobacillus
• aerobic gram positive rod
• found in 62% to 88% of asymptomatic women
• regulator of normal vaginal flora
• 60% vaginal lactobacilli strains make hydrogen
peroxide which inhibits the growth of bacteria
• destroys HIV in vitro
@helenvmadamba CDUCM 2016
9. VAGINA
• Lactic acid, pH 3.8 – 4.5
• maintains normal vaginal
• inhibit adherence of bacteria to vaginal
epithelial cells
• Normal physiologic vaginal discharge
• Epithelial cells
• Normal bacterial flora
• Water
• Electrolytes
• Other chemicals
@helenvmadamba CDUCM 2016
13. • Vaginal discharge is the most common
symptom in gynecology
• The clinical diagnosis of the etiology of
vaginitis depends on:
• Measurement of the vaginal pH
• KOH test
• Examination of the vaginal secretion under
the microscope
@helenvmadamba CDUCM 2016
14. Common Vaginal Infections
Symptoms signsSymptoms signs ExaminationExamination
FindingsFindings
pHpH Wet mountWet mount
NormalNormal White floccular orWhite floccular or
curdy, odorlesscurdy, odorless
disharge present indisharge present in
dependent portionsdependent portions
of vaginaof vagina
3.8 – 4.53.8 – 4.5
BacterialBacterial
vaginosisvaginosis
Increased white thinIncreased white thin
discharge, increaseddischarge, increased
odorodor
Thin whitish grayThin whitish gray
homogenoushomogenous
discharge sometimesdischarge sometimes
frothyfrothy
>4.5>4.5
basicbasic
Clue cells >20%Clue cells >20%
shift in flora,shift in flora,
amine odor afteramine odor after
KOH smearKOH smear
CandidiasisCandidiasis Increased white thickIncreased white thick
discharge, pruritus,discharge, pruritus,
dysuria, burningdysuria, burning
Thick curdyThick curdy
discharge, vaginaldischarge, vaginal
erythemaerythema
<4.5<4.5
AcidicAcidic
Hyphae orHyphae or
sporesspores
TrichomonasTrichomonas Increased yellowIncreased yellow
frothy discharge,frothy discharge,
increased odor,increased odor,
pruritus, dysuriapruritus, dysuria
Yellow frothyYellow frothy
discharge with ordischarge with or
without vaginal orwithout vaginal or
cervical erythemacervical erythema
>4.5>4.5
BasicBasic
MotileMotile
trichomonadstrichomonads
Increased whiteIncreased white
cellscells
@helenvmadamba CDUCM 2016
15. BACTERIAL
VAGINOSIS (BV)
• polymicrobial clinical syndrome
resulting from replacement of the
normal H202-producing Lactobacillus sp
in the vagina with high concentrations
of anaerobic bacteria (e.g., Prevotella
sp. and Mobiluncus sp.), G. vaginalis,
and Mycoplasma hominis.
• most prevalent cause of vaginal
discharge or malodor.
@helenvmadamba CDUCM 2016
16. BACTERIAL
VAGINOSIS (BV)
• Associated with:
• multiple male or female partners
• A new sex partner
• Douching
• Lack of condom use
• Lack of vaginal lactobacilli
• Women who have never been sexually active can
also be affected
• Women with BV are at increased risk for the
acquisition of some STDs (HIV, N gonorrhoeae,
C trachomatis and HSV-2)
@helenvmadamba CDUCM 2016
18. Amsel’s Criteria:
3 of the following symptoms or signs
• Homogeneous, thin, white discharge that
smoothly coats the vaginal walls;
• Presence of clue cells on microscopic
examination;
• pH of vaginal fluid >4.5; and
• A fishy odor of vaginal discharge before or
after addition of 10% KOH (i.e., whiff test).
@helenvmadamba CDUCM 2016
19. Nugent criteria
• Gram stain morphology score (1-10) based on
lactobacilli and other morphotypes
• A score of 1-2 indicates normal flora
• A score of 7-10 bacterial vaginosis
• High interobserver reproducibility
@helenvmadamba CDUCM 2016
20. Acceptable diagnostic tests for
BV
• DNA probe-based test for high concentrations of G.
vaginalis (Affirm VP III, Becton Dickinson, Sparks,
Maryland)
• A prolineaminopeptidase test card (Pip Activity
TestCard, Quidel, San Diego, California)
• OSOM BVBluetest
• PCR (for research purposes)
@helenvmadamba CDUCM 2016
25. TRICHOMONIASIS
• caused by Trichomonas vaginalis
• a unicellular protozoon that inhabits the
vagina and lower urinary tract, specially
the Skene’s gland in females.
• a highly contagious sexually transmitted
disease.
• Incubation period: 4-28 days
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26. TRICHOMONIASIS
• It is a hardy organism and will survive for
up to 24 hours on a wet towel and up to
6 hours on moist surface.
• Primary symptom:
• profuse frothy vaginal discharge with an
unpleasant odor
• diffuse, malodorous, yellow-green vaginal
discharge with vulvar irritation
@helenvmadamba CDUCM 2016
28. High Risk for infection
• Women who have new or multiple
partners
• Have a history of STDs
• Exchange sex for payment
• Use injection drugs
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29. Diagnosis
• Microscopy of vaginal secretions,
with sensitivity of 60% to 70%
requires immediate evaluation of
wet preparation slide for optimal
results
• OSOM Trichomonas Rapid Test (Genzyme Diagnostics,
Cambridge, Massachusetts)
• Affirm VP III (Becton Dickenson, San Jose, California)
• APTIMA T. vaginalis Analyte Specific Reagents (ASR, Gen-
Probe, Inc)
• Culture of vaginal secretions
• Liquid-based Pap test
@helenvmadamba CDUCM 2016
30. CDC 2015 STD Guidelines
Sex partners of patients with T. vaginalis should be
treated.
@helenvmadamba CDUCM 2016
31. VULVOVAGINAL
CANDIDIASIS
• caused by Candida albicans and
occasionally by other Candida species or
yeasts
• associated with normal vaginal ph (<4.5)
• At least 75% of women will have at least
one episode of VVC and 40-45% will have
two or more episodes within their
lifetime.
@helenvmadamba CDUCM 2016
32. VULVOVAGINAL
CANDIDIASIS
• Symptoms : pruritus, vaginal soreness,
dyspareunia, external dysuria and
abnormal vaginal discharges
• Signs : vulvar edema, fissures,
excoriations or thick curdy vaginal
discharges
• On the basis of clinical presentation,
microbiology, host factors, response to
therapy: uncomplicated or complicated.
@helenvmadamba CDUCM 2016
35. Miconazole 1,2000 mg vaginal
suppository, one suppository for
1 day
Fluconazole 150 mg oral tablet,
one tablet in single dose
@helenvmadamba CDUCM 2016
38. These slides will be uploaded onto
http://www.slideshare.net/HelenMadamba
@helenvmadamba CDUCM 2016
39. Infections ofInfections of
the Genitalthe Genital
TractTract
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Doctors University College of Medicine
February 2016
@helenvmadamba CDUCM 2016