19.Infection Of Vaginal


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  • 19.Infection Of Vaginal

    1. 1. Infections of Vulva , Vagina and Cervix <ul><li>Dr. Bibo Yuan M.D, Ph.D. </li></ul><ul><li>[email_address] </li></ul><ul><li>OB/GYN Department, General Hospital, </li></ul><ul><li>Tianjin Medical University </li></ul>
    2. 2. <ul><li>The narrow neck of the uterus is called the cervix. Situated at the bottom of your uterus, the cervix normally acts as a barrier, preventing bacteria and viruses from traveling from your vagina into your uterus. </li></ul>Female reproductive system
    3. 3. Ecosystem in vagina <ul><li>Estrogen </li></ul><ul><li>pH in vagina: 3.5-4.0 </li></ul><ul><li>Vaginal flora: lactobacilli ;acidogenic corynebacteria </li></ul>
    4. 4. Bartholin’s duct cyst and abscess <ul><li>Causes: obstruction of main duct of Bartholin’s gland result in retention of secretion and cystic dilatation. </li></ul><ul><li>Cause of obstruction: </li></ul><ul><li>Infection </li></ul><ul><li>Inspissated mucus </li></ul><ul><li>Congenital narrowing of the duct </li></ul>
    5. 5. Bartholin’s duct cyst and abscess <ul><li>Sign and symptoms: </li></ul><ul><li>Some of them have no symptoms, once the abscess formed, patient will feel pain, tenderness, and dyspareunia. </li></ul><ul><li>Surrounding tissues become edematous and inflamed, fluctuant, tender mass is usually palpable. </li></ul>
    6. 6. Bartholin’s duct cyst and abscess <ul><li>Treatment: </li></ul><ul><li>Drainage of infected cyst or abscess; </li></ul><ul><li>Antibiotics; </li></ul><ul><li>Excision of the cyst may be required in recurrent cases. </li></ul>
    7. 7. Diseases Characterized by Vaginal Discharge <ul><li>Vaginitis is usually characterized by a vaginal discharge and/or vulvar itching and irritation, and a vaginal odor might be present. The three diseases most frequently associated with vaginal discharge are : </li></ul><ul><li>Bacterial Vaginosis </li></ul><ul><li>Trichomoniasis </li></ul><ul><li>Candidiasis </li></ul><ul><li>Various diagnostic methods are available to identify the etiology of an abnormal vaginal discharge. The cause of vaginal symptoms usually can be determined by pH and microscopic examination of fresh samples of the discharge. Laboratory testing fails to identify the cause of vaginitis in a minority of women. </li></ul>
    8. 8. Bacterial Vaginosis <ul><li>Bacterial Vaginosis (BV) is the name of a condition in women where the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria. It is sometimes accompanied by discharge, odor, pain, itching, or burning. </li></ul>
    9. 9. Bacterial Vaginosis <ul><li>BV is a polymicrobial clinical syndrome resulting from replacement of the normal H2O2–producing Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus sp.), G. vaginalis , and Mycoplasma hominis . </li></ul><ul><li>Bacterial Vaginosis Picture </li></ul>Bacterial Vaginosis homogeneous, thin, white discharge
    10. 10. Bacterial Vaginosis <ul><li>Diagnostic Considerations </li></ul><ul><li>BV can be diagnosed by the use of clinical criteria or Gram </li></ul><ul><li>stain. Clinical criteria require three of the following symptoms or signs: </li></ul><ul><li>homogeneous, thin, white discharge that smoothly coats </li></ul><ul><li>the vaginal walls; </li></ul><ul><li>presence of clue cells (epithelial cells with borders obscured by small bacteria) on microscopic examination; </li></ul><ul><li>pH of vaginal fluid >4.5; and </li></ul><ul><li>a fishy odor of vaginal discharge before or after addition </li></ul><ul><li>of 10% KOH (i.e., the whiff test). </li></ul>
    11. 11. Bacterial Vaginosis <ul><li>Diagnostic Considerations </li></ul><ul><li>When a Gram stain is used, determining the relative concentration of lactobacilli (long Gram-positive rods), Gram negative and Gram-variable rods and cocci (i.e., G. vaginalis , Prevotella , Porphyromonas , and peptostreptococci), and curved Gram-negative rods ( Mobiluncus ) </li></ul><ul><li>Culture of G. vaginalis is not recommended as a diagnostic tool because it is not specific. </li></ul>
    12. 12. Bacterial Vaginosis Obtaining a sample of the discharge The whiff test
    13. 13. Bacterial Vaginosis <ul><li>Treatment </li></ul><ul><li>All women who have symptomatic disease require treatment. </li></ul>Recommended Regimens for nonpregnant woman Metronidazole 500 mg orally twice a day for 7 days OR Metronidazole gel , 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream , 2%, one full applicator (5 g) Intravaginally at bedtime for 7 days
    14. 14. Bacterial Vaginosis <ul><li>Follow-Up </li></ul><ul><li>Follow-up visits are unnecessary if symptoms resolve. Because recurrence of BV is not unusual, women should be advised to return for additional therapy if symptoms recur. </li></ul><ul><li>Management of Sex Partners </li></ul><ul><li>The results of clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner(s). Therefore, routine treatment of sex partners is not recommended. </li></ul>
    15. 15. Bacterial Vaginosis <ul><li>Treatment </li></ul><ul><li>All pregnant women who have symptomatic disease require treatment. </li></ul><ul><li>Recommended Regimens for pregnant woman </li></ul><ul><li>Metronidazole 250 mg orally three times a day for 7 days </li></ul><ul><li>OR </li></ul><ul><li>Clindamycin 300mg orally twice a day for 7 days </li></ul>
    16. 16. Bacterial Vaginosis <ul><li>Follow-Up of Pregnant Women </li></ul><ul><li>Treatment of BV in asymptomatic pregnant women who are at high risk for preterm delivery might prevent adverse pregnancy outcomes. Therefore, a follow-up evaluation 1 month after completion of treatment should be considered to evaluate whether therapy was effective. </li></ul>
    17. 17. Trichomonas Vaginitis <ul><li>Trichomoniasis is caused by the protozoan T. vaginalis . </li></ul><ul><li>Many infected women have symptoms characterized by a diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation. However, some women have minimal or no symptoms. </li></ul>Note the &quot;Frothy&quot; Discharge seen around the cervix.
    18. 18. Trichomonas Vaginitis <ul><li>SIGNS AND SYMPTOMS </li></ul><ul><li>About 50% of women infected with trichomoniasis do not have symptoms. The severity of discomfort varies greatly from woman to woman and from time to time in the same woman. Symptoms can be worse during pregnancy or right before or after a menstrual period. </li></ul><ul><li>Principle symptom-persistent vaginal discharge (profuse, extremely frothy, greenish, foul smelling) </li></ul><ul><li>Vaginal itching, irritation, and pain. </li></ul><ul><li>Patchy redness of the genitals, including labia and vagina. </li></ul><ul><li>Frequent, painful dysuria, if urine touches inflamed tissue. </li></ul><ul><li>Generalized vaginal erythema with multiple small petechiae </li></ul>
    19. 19. Trichomonas Vaginitis <ul><li>Diagnostic Considerations </li></ul><ul><li>Diagnosis of vaginal trichomoniasis is usually performed </li></ul><ul><li>by microscopy of vaginal secretions , but this method has a sensitivity of only approximately 60%–70% and requires immediate evaluation of wet preparation slide for optimal results. </li></ul><ul><li>Culture is the most sensitive and specific commercially available method of diagnosis. In women in whom trichomoniasis is suspected but not confirmed by microscopy, vaginal secretions should be cultured for T. vaginalis . </li></ul><ul><li>DNA probe test, which detects genetic material (DNA) of the Trichomonas organism. This test is rarely needed to identify trich and is usually available only in research studies. </li></ul>
    20. 20. Trichomonas Vaginitis <ul><li>Recommended Regimens </li></ul><ul><li>Metronidazole 2 g orally in a single dose </li></ul><ul><li>OR </li></ul><ul><li>Tinidazole 2 g orally in a single dose </li></ul><ul><li>The cure rate in treating trich using oral metronidazole is 90% to 95%. </li></ul><ul><li>In resistant cases oral metronidazole may be repeated after 4 to 6 weeks </li></ul><ul><li>Alternative Regimen </li></ul><ul><li>Metronidazole 500 mg orally twice a day for 7 days </li></ul>
    21. 21. Trichomonas Vaginitis <ul><li>Follow-Up </li></ul><ul><li>Follow-up is unnecessary for men and women who become </li></ul><ul><li>asymptomatic after treatment or who are initially asymptomatic. </li></ul><ul><li>Management of Sex Partners </li></ul><ul><li>Sex partners of patients with T. vaginalis should be treated. Patients should be instructed to avoid sex until they and their sex partners are cured. </li></ul>
    22. 22. Trichomonas Vaginitis <ul><li>Special Considerations </li></ul><ul><li>Pregnancy </li></ul><ul><li>Vaginal trichomoniasis has been associated with adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and low birthweight. However, data do not suggest that metronidazole treatment results in a reduction in perinatal morbidity. </li></ul><ul><li>Women may be treated with 2 g of metronidazole in a single dose. Metronidazole is pregnancy category B (animal studies have revealed no evidence of harm to the fetus, but no adequate, well-controlled studies among pregnant women have been conducted). </li></ul>
    23. 23. Vulvovaginal Candidiasis <ul><li>VVC usually is caused by C. albicans but occasionally is caused by other Candida sp. or yeasts. </li></ul><ul><li>An estimated 75% of women will have at least one episode of VVC, and 40%–45% will have two or more episodes. </li></ul><ul><li>On the basis of clinical presentation, microbiology, host factors, and response to therapy, VVC can be classified as either uncomplicated or complicated. Approximately 10%–20% of women will have complicated VVC, suggesting diagnostic and therapeutic considerations. </li></ul>
    24. 24. Vulvovaginal Candidiasis <ul><li>Typical symptoms of VVC include : </li></ul><ul><li>pruritus, </li></ul><ul><li>vaginal soreness, </li></ul><ul><li>dyspareunia, </li></ul><ul><li>external dysuria. </li></ul><ul><li>None of these symptoms is specific for VVC. </li></ul><ul><li>Abnormal vaginal discharge: </li></ul><ul><li>White, &quot;curd-like“, cheesy vaginal </li></ul><ul><li>discharge. </li></ul>
    25. 25. Vulvovaginal Candidiasis <ul><li>Uncomplicated VVC </li></ul><ul><li>Sporadic or infrequent VVC </li></ul><ul><li>Mild-to-moderate VVC </li></ul><ul><li>Likely to be Candida albicans </li></ul><ul><li>Nonimmunocompromised women </li></ul><ul><li>Complicated VVC </li></ul><ul><li>Recurrent VVC </li></ul><ul><li>Severe VVC </li></ul><ul><li>Nonalbicans candidiasis </li></ul><ul><li>Women with uncontrolled diabetes, debilitation, or are immunosuppression, or those who are pregnant. </li></ul>
    26. 26. Vulvovaginal Candidiasis <ul><li>Uncomplicated VVC </li></ul><ul><li>Diagnostic Considerations in Uncomplicated VVC </li></ul><ul><li>Based on </li></ul><ul><li>1 Clinical features </li></ul><ul><li>external dysuria and vulvar pruritus, pain,swelling, and redness. Signs include vulvar edema, fissures,excoriations, or thick curdy vaginal discharge. </li></ul><ul><li>2 Demonstration of candidal mycelia </li></ul><ul><li>either 1) a wet preparation (saline, 10% KOH) or Gram stain of vaginal discharge demonstrates yeasts or pseudohyphae or 2) a culture or other test yields a positive result for a yeast species. </li></ul><ul><li>3 Normal vaginal pH<4.5 </li></ul>
    27. 27. Vulvovaginal Candidiasis <ul><li>Treatment for Uncomplicated VVC </li></ul><ul><li>Short-course topical formulations (i.e., single dose and regimensof 1–3 days) effectively treat uncomplicated VVC. </li></ul><ul><li>The topically applied azole drugs are more effective than nystatin. Treatment with azoles results in relief of symptoms and negative cultures in 80%–90% of patients who complete therapy. </li></ul>
    28. 28. Vulvovaginal Candidiasis <ul><li>Recommended Regimens for Uncomplicated VVC </li></ul><ul><li>Intravaginal Agents: </li></ul><ul><li>Butoconazole 2% cream 5 g intravaginally for 3 days* </li></ul><ul><li>OR </li></ul><ul><li>Clotrimazole 1% cream 5 g intravaginally for 7–14 days* </li></ul><ul><li>OR </li></ul><ul><li>Clotrimazole 100 mg vaginal tablet for 7 days </li></ul><ul><li>OR </li></ul><ul><li>Miconazole 2% cream 5 g intravaginally for 7 days* </li></ul><ul><li>Oral Agent: </li></ul><ul><li>Fluconazole 150 mg oral tablet, one tablet in single dose </li></ul>
    29. 29. Vulvovaginal Candidiasis <ul><li>Complicated VVC </li></ul><ul><li>Recurrent Vulvovaginal Candidiasis (RVVC) </li></ul><ul><li>RVVC, usually defined as four or more episodes of symptomatic VVC in 1 year, affects a small percentage of women(<5%). The pathogenesis of RVVC is poorly understood, and the majority of women with RVVC have no apparent predisposing or underlying conditions. Vaginal cultures should be obtained from patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including nonalbicans species, particularly Candida glabrata. </li></ul><ul><li>Recommend : </li></ul><ul><li>a longer duration of initial therapy </li></ul><ul><li>e.g.,7–14 days of topical therapy or a 100 mg, 150 mg, or 200 mg oral dose of fluconazole every third day for a total of 3 doses (day 1, 4, and 7); </li></ul><ul><li>Maintenance Regimens </li></ul><ul><li>Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months is the first line of treatment. </li></ul>
    30. 30. Vulvovaginal Candidiasis <ul><li>Complicated VVC </li></ul><ul><li>Severe VVC </li></ul><ul><li>Severe vulvovaginitis (i.e., extensive vulvar erythema, dema excoriation, and fissure formation) is associated with lower clinical response rates in patients treated with short courses of topical or oral therapy. Either 7–14 days of topical azole or 150 mg of fluconazole in two sequential doses (second dose 72 hours after initial dose) is recommended. </li></ul><ul><li>Compromised Host </li></ul><ul><li>Women with underlying debilitating medical conditions (e.g., those with uncontrolled diabetes or those receiving corticosteroid treatment) do not respond as well to short-term therapies. Efforts to correct modifiable conditions should be made, and more prolonged (i.e., 7–14 days) conventional antimycotic treatment is necessary . </li></ul><ul><li>Pregnancy </li></ul><ul><li>VVC frequently occurs during pregnancy. Only topical azole therapies, applied for 7 days, are recommended for use among pregnant women. </li></ul>
    31. 31. Cervicitis <ul><li>Two types of cells line your cervix: flat, skin-like cells (squamous cells) and glandular cells that secrete mucus. The same organisms responsible for vaginitis, can cause cervicitis. Cervicitis is an inflammation of the cervix, Most cases of cervicitis are caused by infection with sexually transmitted diseases, including gonorrhea and chlamydia. </li></ul><ul><li>Successful treatment of cervicitis involves addressing the cause of the inflammation. In most cases of cervicitis, antibiotics are used to clear an underlying infection. Sexual partner may also be treated to prevent the patient becoming reinfected. </li></ul>
    32. 32. Cervicitis <ul><li>Acute cervicitis </li></ul><ul><li>Chronic cervicitis </li></ul>
    33. 33. Cervicitis <ul><li>Acute cervicitis- Signs and symptoms </li></ul>Two major diagnostic signs characterize acute cervicitis: 1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen and 2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os . Either or both signs might be present. Some patients is asymptomatic, but some women complain of an abnormal vaginal discharge and intermenstrual vaginal bleeding Lab findings: Mucopurulent cervicitis is defined as gross evidence of purulent material at an inflamed cervix along with a microscopic presence of ten or more polymorphonuclear leukocytes per microscopic field on Grams stain of material obtained from the endocervical canal.
    34. 34. Cervicitis <ul><li>Acute cervicitis </li></ul><ul><li>Treatment: </li></ul><ul><li>Select proper treatment should based on: </li></ul><ul><li>Patient age and desire for pregnancy </li></ul><ul><li>Whether she is presently pregnant or is breast feeding </li></ul><ul><li>The severity of the cervical infection </li></ul><ul><li>The presence of complicating factors </li></ul><ul><li>Previous treatment </li></ul><ul><li>Note: Instrumetation and topical therapy should be avoided during the acute phase of cervicitis and before the menses </li></ul><ul><li>Treatment should target pathogen : </li></ul><ul><li>For example, acute cervicitis is associated with vaginitis due to a specific organism, treatment must be directed accordingly </li></ul>
    35. 35. Cervicitis <ul><li>Chronic cervicitis </li></ul><ul><li>Signs and symptoms: </li></ul><ul><li>leukorrhea may be the chief symptom, could be frankly purulent and variable in color, or it may present as thick, tenacious, turbid mucus. </li></ul><ul><li>Other signs include the following: Bleeding; Itching; Irritation of the external genitals; Pain during intercourse; </li></ul><ul><li>Bleeding or spotting after sexual intercourse or between periods; A burning sensation during urination </li></ul>
    36. 36. Chronic cervicitis <ul><li>Pathology of Chronic cervicitis </li></ul><ul><li>Cervical erosion occurs when the surface of the cervix is replaced with inflamed tissue from the cervical canal. The condition may be caused by trauma, infection or chemicals. </li></ul><ul><li>Cervical erosion </li></ul>
    37. 37. Chronic cervicitis <ul><li>Pathology of Chronic cervicitis </li></ul><ul><li>cervical polyps </li></ul>Cervical polyps are small, smooth, red, fingerlike growths in the passage extending from the uterus to the vagina (cervical canal).
    38. 38. Chronic cervicitis <ul><li>Pathology of Chronic cervicitis </li></ul><ul><li>Nabothian cysts </li></ul><ul><li>The cervix is lined with glands that normally secrete mucus. These endocervical glands can become filled with secretions that accumulate as a pimple-like elevation called Nabothian cysts. These cysts are not a threat to health and no treatment is necessary. </li></ul>
    39. 39. Chronic cervicitis <ul><li>Treatment for chronic Cervicitis: </li></ul><ul><li>Select proper treatment should based on: </li></ul><ul><li>Patient age and desire for pregnancy </li></ul><ul><li>Whether she is presently pregnant or is breast feeding </li></ul><ul><li>The severity of the cervical infection </li></ul><ul><li>The presence of complicating factors </li></ul><ul><li>Previous treatment </li></ul><ul><li>Surgical procedures may be useful for treatment of symptomatic chronic cervicitis. PAP smear is need to exclude malignant lesion. </li></ul><ul><li>Cryosurgery, electrocauterization, laser theray </li></ul>
    40. 40. Reference <ul><li>Sexually Transmitted Diseases Treatment Guidelines, 2006 </li></ul><ul><li>Department of health and human services Centers for Disease Control and Prevention, USA </li></ul>
    41. 41. Objectives <ul><li>Know about the causes, clinical manifestations, prevention of infections of the vulva; </li></ul><ul><li>Master the epidemiology, cause, clinical manifestation, diagnosis, prevention and treatment of trichomonal vaginitis, vulvovaginal candidiasis, and bacterial vaginosis; </li></ul><ul><li>Know about the causes clinical manifestations, diagnosis and treatment of infantile vaginitis and senile vaginitis; </li></ul><ul><li>Master the pathological changes, clinical manifestations, diagnosis, and treatment of cervicitis. </li></ul>