Vulvar/Vaginal Disease [DOC]


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Vulvar/Vaginal Disease [DOC]

  1. 1. UNIT THREE: GYNECOLOGY SECTION A: GENERAL GYNECOLOGY OBJECTIVE 35: VULVAR AND VAGINAL DISEASE Rationale: Vaginal and vulvar symptoms are frequent patient concerns. In order to provide appropriate care, the physician must understand the common etiologies of these problems, as well as appropriate diagnostic and management options. The student will be able to describe: A. Normal vaginal appearance and secretions B. Evaluation and management of common vulvar and vaginal problems including: 1. Vaginitis due to bacteria, fungi, trichomonads, viruses, foreign bodies and atrophy 2. Dermatological conditions of the vulva 3. Bartholin’s gland disease 4. Vulvodynia 5. Trauma
  2. 2. I. Normal Findings A. White, high viscosity B. Clear C. pH ≤ 4.5 D. No significant odor E. Lactobacilli present F. Absent mycelia, Trichomonas, etc. II. Evaluating complaints A. History • 1. Discomforts: pain, burning, itching • Discharge Color (gray, white, clear, yellow) Amount Character – Watery – Thick Odor – foul-smelling, “fishy” • Medical illnesses • Medications • Use of soaps, hygiene products • Presence of mass, lesion(s) B. Physical examination • Vulva Inflammation Mass Pigmented or infected lesions Fissure, ulceration Atrophy • Other sites Oral mucosa Eyes Joints Skin C. Examination of vaginal discharge • Gross inspection of vulva, vagina, cervix reveals mucopurulence • Obtain discharge sample from vaginal vault • Obtain GC/Chlamydia cultures from endocervix as indicated • Test pH < 4.5 – Normal – Candida > 4.5 – Bacterial vaginosis – Trichomoniasis
  3. 3. • Wet prep Mix 1 drop discharge with 1 or 2 drops normal saline on clean slide, add cover slip Look for hyphae under lower power Look for leukocytes, clue cells, Trichomonas under high power • KOH prep Add a drop of 10% KOH to a drop of discharge on clean slide, add coverslip Indicated if suspect candida and wet prep unrevealing • Amine (“whiff”) test Add drop KOH to slide or test tube with discharge in small amount saline Strong amine (fishy) odor compatible with bacterial vaginosis • Cultures of vaginal discharge rarely indicated III. Specific Infections A. Candida vulvovaginitis • Clinical findings Pruritus Asymptomatic (15-25%) Discharge (thick, white, cottage cheese-like) pH < 4.5 • Risk factors Antimicrobial administration Diabetes Pregnancy Decreased cell mediated immunity ± Oral contraception • Microbiology Candida albicans (80-90%) Candida glabrata Candida tropicalis • Wet preparation (KOH) Branching filaments and blastospores C. albicans – hyphae C. glabrata – spores only pH 4.0-4.4 • Diagnosis Wet prep (sensitivity 22-80%) Pap smear (50% sensitive) Gram stain (100% sensitive) Culture on Sabouraud’s medium 2
  4. 4. • Treatment MEDICATION DOSAGE/DELIVERY LENGTH OF TREATMENT Butoconazole 2% cream 5 g intravaginally 3 days Clotrimazole 1% cream 5 g intravaginally 7 to 14 days Clotrimazole 100 mg tablet 1 tablet intravaginally 7 days Clotrimazole 500 mg tablet 1 tablet intravaginally 1 application Miconazole 2% cream 5 g intravaginally 7 days Miconazole 200mg suppository 1suppository intravaginally 3 days Miconazole 100mg suppository 1suppository intravaginally 7 days Tioconazole 6.5% ointment 5 g intravaginally 1 application Terconazole 0.4% cream 5 g intravaginally 7 days Terconazole 0.8% cream 5 g intravaginally 3 days Terconazole 80 mg suppository 1suppository intravaginally 3 days Fluconazole 150 mg oral tablet 150 mg. p.o. One dose • Chronic/recurrent candidiasis Risk factors – Exogenous estrogens – Chronic antibiotics – Chronic diseases, diabetes – Immune compromise Therapy – Protracted therapy with oral antifungals (watch for liver toxicity) – Antifungal prophylaxis during antibiotic therapy – Boric acid gelatin capsules vaginally. – D/C antibiotics – Better control of diabetes/immune status B. Trichomoniasis • Clinical presentation Malodorous discharge, frothy, yellow-gray or green Dysuria Vulvovaginal irritation Asymptomatic in 20%-50% of women with the organism • Risk factors Casual sex partners Multiple sex partners • Microbiology 3
  5. 5. Protozoan Unicellular, flagellated, motile 15 µm in size (slightly larger than a leukocyte) • Wet prep Motile Trichomonads pH > 4.5 Large number of leukocytes • Diagnosis Wet prep Culture on Diamonds medium Pap smear (low sensitivity and specificity) • Treatment Creams not as effective due to fact that Trichomonas can live in urethra, bladder, Skene’s glands Metronidazole (Flagyl) – Only known effective medication – Single dose of 2 gm orally – 500 mg bid orally x 7 days – Warn against ETOH consumption while taking – Treatment of male partner – Cure rate – 95% C. Bacterial Vaginosis • Association with other disorders Pelvic inflammatory disease Posthysterectomy vaginal cuff cellulitis Postabortal infection Preterm delivery Premature rupture of membranes Amnionitis Postpartum endometritis • Risk factors Lower socioeconomic status Multiple or uncircumcised partners Smoking Increasing parity Presence of other STDs Douching • Bacteriology Anaerobes – Bacteroides sp. – Peptostreptococcus sp. – Eubacterium sp. – Mobiluncus sp. Facultative anaerobes 4
  6. 6. – Gardnerella vaginalis – Mycoplasma hominis • Discharge Homogenous, white, gray Malodorous (fishy, musty), increases after intercourse pH > 4.5 Clue cells present Lactobacilli absent or present in very low numbers Other bacteria – Anaerobes (Bacteroides, Mobiluncus) predominate – Gardnerella vaginalis (at increased concentrations) – Mycoplasma hominis • Wet prep Clue cells on microscopic examination – Vaginal epithelial cells – Indefinite outlines obscured by “clumps of sand” – Granular appearance – Bacilli attached to cell surfaces Minimal inflammatory response (few leukocytes) • Diagnosis Clinical diagnosis (3 of 4 criteria) – Clue cells on microscopic exam – pH > 4.5 – Positive KOH “whiff” test – secondary to release of amines – Homogeneous discharge Culture diagnosis – Unreliable, has no role – G. vaginalis found in up to 60% of normal vaginal cultures • Treatment Metronidazole 500 mg po bid x 7 days Metronidazole gel 0.75% /1 appl (5grams) per vagina qd X 5 days Clindamycin cream 2% /1 appl (5 grams) per vagina qhs x 7 nights Chronic infection – Protracted therapy – Different antibiotics – Consider treatment of male partner (controversial) • Pregnancy All symptomatic pregnant women should be tested and treated BV associated with adverse pregnancy outcome – PROM – Preterm labor 5
  7. 7. – Chorioamnionitis – PP endometritis – Post C-section wound infection Multiple studies and meta-analyses have not demonstrated a consistent association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns IV. Dermatological conditions of the vulva A. Inflammatory lesions • Contact dermatitis Avoid irritant Local treatment with hydrocortisone (0.025%-0.1%) • Seborrheic dermatitis • Psoriasis Multifocal Erythematous vulvar patches Generally without scales • Fungal Candidiasis Tinea cruris • Vulvar vestibulitis (vulvodynia) Grossly normal Erythema of vestibule Pain on contact with vestibule Dyspareunia, coitus impossible in some cases Treatment – all modalities controversial, questionable benefit – Interferon or steroid injections – Biofeedback, psychological support – Tricyclic antidepressants (pain management doses) – Antifungals (empirically) – Surgical: vestibulectomy B. Ulcerative lesions • Behçet’s disease Vulvar ulcers, oral/buccal ulcers, iritis Treat with prednisone • Crohn’s disease Vulvovaginitis Fistulas Pyoderma gangrenosum Erythema nodosum Abscess Treatment – metronidazole • STDs – see Objective 39 C. Vulvar dystrophies (Nonneoplastic epithelial cell disorders of the vulva)) • Lichen sclerosis 6
  8. 8. Clinical findings – Usually postmenopausal; 10-15% occurs in children – Non-specific, patchy, white labial skin – Thin, parchment-like skin – Does not involve vagina or labia majora – Atrophic destruction of labia minora may cause introital stenosis Diagnosis – biopsy shows – Hyperkeratosis – Loss of rete pegs – Thin epithelium – Underlying collagenization – Neutrophils present Treatment – Clobetasol propionate 0.05% BID x 1 mo., then tapered – Testosterone in petrolatum (less effective) • Squamous cell hyperplasia Clinical findings – Gray, pink or white firm patches – Thickened, hyperkeratotic areas – Pruritus common Biopsy – Increased cellular elements – Parakeratosis, hyperkeratosis – Chronic infiltrates – Acanthosis – Mixed dystrophies – lichen sclerosis Treatment – hydrocortisone (fluorinated), topical or subcutaneous injection • Vulvar intraepithelial neoplasia White, red or pigmented lesions May be pruritic Associated with HPV, other lower genital tract neoplasia Premalignant potential • Other lesions Cysts, i.e. sebaceous, inclusion Papillary, i.e. condylomata Nevi, i.e. need to exclude melanoma Squamous cell carcinoma Melanoma V. Bartholin glands A. Bartholin gland abscess • Symptoms Pain 7
  9. 9. Tenderness • Signs Unilateral swelling of posterior labium majus Redness in overlying skin Labial edema • Treatment Warm soaks Antibiotics Incision and drainage with Word catheter placement Marsupialization (sewn open) B. Bartholin cyst • Symptoms Asymptomatic Discomfort with sexual intercourse, if large • Signs Unilateral Non-tender Tense cystic mass located in posterior labium majus • Treatment None Word catheter placement Marsupialization of cyst Bartholinectomy rarely done today C. Recurrent Bartholin gland abscess • Suspicions for adenocarcinoma if postmenopausal References American College of Obstetricians and Gynecologists Technical Bulletin H-226. Vaginitis. ACOG Washington DC: 1996. Mishell, DR ed., Comprehensive Gynecology, 3rd ed., Mosby, St. Louis, MO, 1997. Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997 8
  10. 10. DIAGNOSIS AND MANAGEMENT OF VAGINITIS/CERVICITIS AGENT MAJOR SYMPTOM FINDINGS DIAGNOSIS TREATMENT 1 Candida albicans Itching Cheesy white exudate; pH 4.0-4.4 Wet prep or KOH prep Clotrimazole, Miconazole, Nystatin, Fluconazole (Long term fluconazole for refractory or immunocompromised cases) 2 Chlamydia Discharge Mucopurulent discharge, erosion Culture Micro Trak Azithromycin, Doxycycline 3 Trichomonas vaginalis Odor Frothy greenish exudate Wet prep (Acridine Orange) Metronidazole both (all) partners 4 Gonorrhea Discharge Cervical discharge Cervical culture (Gram stain) APPG & Probenecid, Ampicillin & Probenecid 5 Genital herpes Pain Ulcerative, vulvar vesicles & ulcers Tzanck prep, Virus culture Acyclovir, Famciclovir, valacyclovir 6 Bacterial vaginosis Discharge Thin gray discharge; pH 5.0- 5.5 Wet prep, sniff test (gas) Metronidazole p.o. or vaginally Vaginal clindamycin 7 Chemical Discharge Erythema; may be ulcerative History & exclusion of other causes Stop contact; topical cortisone short term 8 Foreign body Discharge Ulceration, purulent discharge (look for rash) Gram stain; routine culture Removal; antibiotic if staphylococcal or toxic 9 Physiologic Discharge No odor or erythema Wet prep; history; exclusion of other causes; cervical culture Reassurance 10 Atrophic Itching, dry sensation, dyspareunia Pale, atrophic mucosa and loss of rugation Evidence estrogen deficiency, lactation, menopause Topical/oral estrogen 9