Infections of the Genital Tract - Part II
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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
- 6. INFECTIONS OF THE VAGINA PART II @helenvmadamba CDUCM 2016
- 7. Diseases Characterized by Vaginal Discharge • Bacterial vaginosis • Trichomoniasis • Vulvovaginal Candidiasis @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
- 11. Symptoms of vaginal infection • Vaginal discharge • Superficial dyspareunia • Dysuria • Odor • Vulvar burning • Pruritus @helenvmadamba CDUCM 2016
- 12. DISEASES CAUSING VAGINITIS • Fungus (Candidiasis) 25% • Protozoan (Trichomoniasis) 25% • Bacterial infection (Bacterial vaginosis) 50% @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
- 23. CDC 2015 STD Guidelines @helenvmadamba CDUCM 2016
- 24. CDC 2015 STD Guidelines @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 @helenvmadamba CDUCM 2016
- 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 @helenvmadamba CDUCM 2016
- 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
- 36. CDC 2015 STD Guidelines @helenvmadamba CDUCM 2016
- 37. CDC 2015 STD Guidelines @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