Prof aboubakr elnashar

1. AEROBIC
VAGINITIS
2018
European
(IUSTI/WHO)
International
Union
against
STI
(IUSTI),
WHO
guideline
Prof.
Aboubakr
Elnashar
Benha
university
hospital,
Egypt
ABOUBAKR
ELNASHAR
▪
Aerobic
vaginitis
(AV)
▪
Also
known
as
desquamative
inflammatory
vaginitis
(DIV)
in
its
severest
manifestation
▪
An
underdiagnosed
vaginal
discharge
syndrome
▪
Form
of
vaginal
dysbiosis*.
▪
In
contrast
to
BV;
the
AV/DIV
spectrum
is
highly
inflammatory
with
very
different
clinical
features.
*Qualitative
and
quantitative
changes,
their
metabolic
activity
and
their
local
distribution
ABOUBAKR
ELNASHAR

2. EPIDEMIOLOGY
▪
PREVALENCE
▪
5–10%
in
non-pregnant
women
▪
3-9%
in
pregnant
women
ABOUBAKR
ELNASHAR
▪
RISK
FACTORS
1.
Multiple
sexual
partners
2.
Inconsistent
use
of
condoms
–
H2O2
–
producing
protection
by
lactobacilli
against
genital
tract
pathogens
is
reportedly
blocked
by
semen.
Consistent
condom
use
could
increase
colonization
of
Lactobacillus
crispatus
in
the
vagina
and
protect
against
AV.
Lactobacilli
also
function
as
immune
modulators
and
reduce
the
levels
of
inflammatory
cytokines
like
interleukin
(IL)-1b
and
IL-6.
3.
Use
of
IUCD–
effect
of
IUD
on
vaginal
flora
is
controversial.
Short-term
IUD
use
has
not
been
shown
to
predispose
women
to
AV.
However,
prior
studies
report
vaginal
colonization
by
Gram-positive
cocci
and
E.
coli
with
IUD
use
which
can
in
turn
increase
predisposition
to
AV.
Further
studies
are
required
to
determine
the
association
and
identify
the
possible
mechanism.
4.
Long-term
usage
of
antibiotics
and
pessaries.
5.
Vaginal
douching
–
cause
a
disequilibrium
in
the
vaginal
microflora
or
induce
inflammation
through
physical
or
chemical
irritation.
ABOUBAKR
ELNASHAR

3. PATHOGENESIS
▪
An
interplay
between
the
infectious
microorganisms
&
host
immune
mechanisms.
1.
Decreased
lactobacillary
protection
2.
Increased
aerobic
microorganisms:
▪
E
coli
▪
Group
B
streptococci
(GBS)
▪
S
aureus
▪
Production
of
sialidase
3.
An
imbalance
in
local
immune
modulation,
increased
inflammatory
cytokine
reaction
and
genetic
susceptibility
ABOUBAKR
ELNASHAR
DIAGNOSIS
▪
Symptoms:
▪
Asymptomatic
(10–20%)
▪
Yellowish
&
foul-smelling
purulent
discharge
(70%)
▪
Rotten
odour
(20%)
–
negative
whiff
test
▪
Severe
burning,
stinging,
linked
to
dyspareunia
(12%)
▪
Intermittent
vulval
&
vaginal
pruritus
(72.54%)
▪
Signs:
▪
Vaginal
erythema
and
oedema
(31.13%)
▪
Vaginal
erosions
and
ulceration
▪
Cervix:
erosion,
hyperaemia,
scattered
bleeding
points
▪
pH>4.5
(94.10%),
can
be
as
high
as
6–8
ABOUBAKR
ELNASHAR

4. Purulent
,
Sticky
yellow
or
green
ABOUBAKR
ELNASHAR
▪
DIV
▪
represents
extreme
form
of
AV
with
increased
severity
of
signs
and
symptoms
▪
Patients
are
typically
symptomatic;
asymptomatic
DIV
occurs
rarely.
▪
Mean
duration
of
symptoms
is
15–31
months
with
fluctuating
severity
▪
50%
of
patients
are
diagnosed
in
peri-
or
postmenopausal
women.
ABOUBAKR
ELNASHAR

5. Microscopy.
▪
The
gold
standard
for
diagnosis
is
wet
mount
microscopy.
▪
AV
score
combines
5
items
▪
creating
a
score
from
0
to
10
ABOUBAKR
ELNASHAR
▪
a
39-year-old
patient
who
presented
with
vaginal
discharge
and
dyspareunia
of
recent
onset.
▪
Flocculent
purulent
discharge,
erythema
and
erosions
visible
on
per
speculum
examination
▪
Phase-contrast
microscopy
image
of
a
wet
mount
1.
Note
the
absence
of
lactobacilli,
presence
of
‘toxic’leucocytes,
full
of
lysozymic
granules,
coccoid
bacterial
flora
and
parabasal
cell
(400).
▪
Gram
stained
vaginal
smear
revealing
leucocytes
(arrows),
near-absent
lactobacilli
and
the
presence
of
Gram-positive
cocci
seen
discretely
as
well
as
in
small
chains
(arrowhead)
and
scattered
Gram-negative
bacilli
(1000)
▪
Multiplex
polymerase
chain
reaction
(PCR)
was
negative
for
Neisseria
gonorrhoeae
as
well
as
Chlamydia
trachomatis.
▪
Nucleic
acid
amplification
test
(NAAT)
for
trichomoniasis
was
negative.
ABOUBAKR
ELNASHAR

6. ABOUBAKR
ELNASHAR
▪
Cultures.
▪
Most
women
with
AV
have
positive
cultures
for
aerobic
bacteria
such
as
Streptococcus
agalactiae,
S.
aureus,
E.
coli
▪
Positive
culture
does
not
indicate
the
woman
has
AV
▪
Not
recommended
for
diagnosis.
▪
Culture
with
antimicrobial
susceptibility
testing
may
aid
in
TT
▪
Molecular
detection.
▪
based
on
molecular
biology
▪
correlate
well
with
moderate-
to-severe
AV
compared
with
microscopy
▪
Need
confirmation
in
larger
trials
assessing
sensitivity
and
specificity.
ABOUBAKR
ELNASHAR

7. ▪
The
Guidelines
Group
recommends
that
the
current
best
test
to
diagnose
AV
in
women
is
microscopy
(Grade
2,
quality
of
evidence:
Grade
B).
ABOUBAKR
ELNASHAR
▪
DD
1.
Trichomoniasis
▪
DIV
occasionally
presents
with
annular
erythematous
papules
with
a
pale
center
involving
cervix
–appearance
of
colpitis
macularis
(27%),
similar
to
trichomoniasis,
or
described
as
papular
colpitis
2.
Erosive
lichen
planus
▪
vaginal
adhesions,
synechiae
and
stenosis
are
extremely
rare
in
DIV,
in
contrast
to
erosive
lichen
planus
▪
examination
of
other
sites,
i.e.
the
cutis,
oral
mucosa,
scalp,
and
nails
often
shows
evidence
of
lichen
planus.
ABOUBAKR
ELNASHAR

8. 3.
Atrophic
vaginitis
▪
Inflammatory
symptoms
and
signs
are
seen
in
both.
▪
Atrophic
vaginitis
is
typically
seen
postmenopausally,
but
has
been
identified
in
lactational
women
as
well.
▪
The
only
clinical
point
that
may
be
useful
in
differentiation
between
the
two
conditions
is
the
predominance
of
atrophic
features
(pale,
dry
vaginal
mucosa
with
loss
of
rugae)
in
patients
with
atrophic
vaginitis.
▪
It
is
noteworthy
that
in
a
woman
with
symptomatic
atrophic
vaginitis
with
vaginal
dysbiosis,
one
must
rule
out
the
use
of
long-acting
progesterone
depot
contraception,
an
iatrogenic
cause
of
vaginal
atrophy.
ABOUBAKR
ELNASHAR
ABOUBAKR
ELNASHAR
TT:
clindamycin
cream
for
7-21
d
Local
estrogen
Local
corticosteroid
for
7-21
d
Metronidazole
Oral:
400–500
mg
twice
daily
for
5–7d
Or
Intravaginal
gel
(0.75%)
daily
for5
days
or
Clindamycin
cream
Intravaginal
(2%)
daily
for
7d

9. Complications
1.
An
increasing
number
of
coinfections
&complications.
2.
An
increased
risk
of
▪
preterm
delivery
and
▪
chorioamnionitis
in
women
with
first
trimester
ABOUBAKR
ELNASHAR
TREATMENT
▪
Recommended
regimens
for
AV:
▪
2%
clindamycin
cream
5
g
intravaginally
for
7–21
days
The
Guidelines
Group
recommends
that
the
current
best
treatment
for
uncomplicated
AV
in
women
is
clindamycin
cream.
(Grade
2,
quality
of
evidence:Grade
C)
Clindamycin
is
active
against
staphylococci
and
streptococci
as
well
as
anaerobes.
▪
In
cases
with
a
significant
atrophy:
Local
oestrogens
▪
Local
corticosteroids:
hydrocortisone
300–500
mg
for
7–21
days
ABOUBAKR
ELNASHAR

10. ▪
Other
TT
▪
Antimicrobials:
kanamycin
ovules
or
moxifloxacin.
▪
Predfoam
enema
applied
intravaginally
(off-label
use)
for
more
severe
cases
▪
Routine
screening
and
treatment
of
male
partner(s)
is
not
indicated
▪
Follow
up:
Women
with
persistent
or
recurrent
symptoms.
ABOUBAKR
ELNASHAR