62. Diseases of vulva and vagina

Question 1

what is the normal physiology of and microbiology of the vagina?

Answer 1

THE NEWBORN`S VAGINAL EPITHELIUM IS STRONGLY ESTROGENIZED AND RICH IN GLYCOGEN, OF LACTIC ACID-PRODUCING LACTOBACILLI. THIS RESULTS IN A LOW PH (≤ 4.7), WHICH PROMOTES FURTHER GROWTH OF ACIDOPHILIC- PROTECTIVE MICROFLORA.

WITHIN DAYS OF BIRTH, ESTROGEN DECREASES, AND THE VAGINAL EPITHELIUM BECOMES THIN, ATROPHIC, AND LARGELY DEVOID OF GLYCOGEN. IN THIS ENVIRONMENT, THE PH RISES. AS A CONSEQUENCE, THE PREDOMINANT VAGINAL MICROFLORA BECOMES DIVERSE GRAM-POSITIVE COCCI AND BACILLI

THE ONSET OF PUBERTY AND OVARIAN STEROIDOGENESIS, THE VAGINA AGAIN BECOMES ESTROGENIZED, AND THE GLYCOGEN CONTENT INCREASES. LACTIC ACID-AND HYDROGEN PEROXIDE (H2O2) – PRODUCING LACTOBACILLI AGAIN PREDOMINATE, RESULTING IN SELF-SUSTAINING VAGINAL PH OF BETWEEN 3.8 AND 4.5.

Question 2

what can alter the protective vaginal flora

Answer 2

ANTIBIOTICS

spraying WITH WATER OR NONBUFFERED SOLUTIONS MAY TRANSIENTLY ALTER THE PH

SEXUAL INTERCOURSE WITH INTRODUCTION OF SEMEN RAISES THE PH TO 7.2 FOR 6 TO 8 HOURS, MAKING THE VAGINA RECEPTIVE TO STI PATHOGENS

THE PRESENCE OF A FOREIGN BODY (FORGOTTEN DIAPHRAGM OR TAMPON IN ADULTS OR VARIOUS SMALL OBJECTS IN CHILDREN) DRAMATICALLY DISRUPTS NORMAL VAGINAL CLEANSING MECHANISMS AND MAY LEAD TO SECONDARY INFECTION

Question 3

PHYSIOLOGIC INCREASES IN VAGINAL AND ENDOCERVICAL FLUID OCCUR?

Answer 3

DURING PREGNANCY, AT MID MENSTRUAL CYCLE, AND DURING INTERCOURSE

Question 4

what are the vaginal diseases ?

Answer 4

bacterial vaginosis

vulvovaginal candiasis

trichomoniasis

others :
STI

mucopurulent cervicitis caused by chlamydia , neisseria and gonorrhoea lead to vaginal irritation

less common - atrophic vaginitis

foriegn body vaginitis

Question 5

what can mimic infectious vaginitis ?

Answer 5

irritation from sexual activity and allergen containing substance

Question 6

pathoetiology of bacterial vaginosis

Answer 6

due to disruption of the vaginal flora - lactobacillus jeneseni and lactobacillus crispatus

causes Bv complex micro-organism to invade

Question 7

what are the bv complex micro-organisms ?

Answer 7

gardnerella vaginalis

genital mycoplasma

vaginal anaerobic bacteria

prevotella

bactericides

mobiluncus

Question 8

what increases the risk of BV ?

Answer 8

new sexual partner , smoking , intrauterine device and frequent douching , antibiotic use

Question 9

what are the signs and symptoms of BV ?

Answer 9

may be asymptomatic

a profuse , milky , discharge - fishy smelling

no dyspareunia

burn with urination

Question 10

what are the complications of having BV

Answer 10

doubles the risk of having other sexually transmitted diseases such as HIV

also causes PROM if regnant

Question 11

how do we diagnose bacterial vaginosis ?

Answer 11

a profuse , milky , discharge
amine or fishy odour after alkalisation with a drop of KOH (positive whiff test)

ph of the vagina goes more alkaline going over 4.5

vaginal wall normal

wet mound microscopy
clue cells - epithelia cells with bacteria attached to them - they are found from the vaginal discharge and sodium chloride is added and put under microscope

Question 12

what is the organism which causes vulvovaginal candiasis ?

Answer 12

candida albicans

Cabinda glabrata less often

Question 13

candida infection is more common in whom?

Answer 13

VVC is more common in women after menarche and less common after menopause

Question 14

why is Vvc more common in women who have menarche ?

Answer 14

because candida growth is favourable in estrogenated tissues

Question 15

what increases the risk of VVC ?

Answer 15

oral contraceptives

diaphragm use with spermicide

immunosuppression - HIV / antibiotics / steroid

diabetes mellitus

Question 16

what are the symptoms of VVC ?

Answer 16

vaginal and vulvar itching - pruritus

burning with urination

dyspareunia

odourless cottage cheese like vaginal discharge

Question 17

what is the diagnosis of VVC ?

Answer 17

vaginal wall erythema and edema

ph less than 4.5

whiff test is negative

vaginal wet mound microscopy - Budding yeast, pseudohypha

microbial culturing

Question 18

what is trichomoniasis caused by ?

Answer 18

protozoan T vaginalis (it is an STI)

Question 19

what are the symptoms in trichomoniasis?

Answer 19

half of the time asymptomatic

genital itching

bad smelling yellow green purulent discharge

dysuria

dyspareunia

strawberry cervix

burning sensation

Question 20

what are the complication of trichomoniasis ?

Answer 20

increases risk of getting HIV and aids

also PROM

Question 21

how to diagnose vaginal trichomoniasis ?

Answer 21

vaginal wall is erythema

vaginal ph more than 5

wife test -positive

vaginal wet mound microscopy - flagellated protozoa

or microbial culturing

nucleic acid amplification tests (NAATs)

Question 22

what is the treatment for trichomoniais?

Answer 22

pregnant and non pregnant women - metronidazole

Question 23

what causes atrophic vaginitis

Answer 23

tissue thinning bacuse of not enough estrogen causing a secondary infection -premenarchal and after menopause

decreased ovarian function - radiation and chemotherapy or oophorectomy

medication with antiestrogen properties - tamoxifen

smoking

breast feeding

Question 24

what is the signs and symptoms of atrophic vaginitis ?

Answer 24

vaginal dryness
- dyspareunia

dysuria

vulvuar pruruitis

discharge which may be clear or purulent, yellow, and occasionally with blood
malodorous

vulvar erythem

Question 25

what is the diagnosis of atrophic vaginitis ?

Answer 25

indication lower estrogen levels: little pubic hair, loss of the labial fat pad, thinning and resorption of the labia minora, narrowing of the vaginal opening. Pale, smooth or shiny vaginal epithelium; loss of elasticity or turgor of skin; internal exam will reveal the presence of low vaginal muscle tone, the lining of the vagina appears smooth, shiny, pale with loss of folds. the ph is higher than 4.5 serum oestrogen levels cytological examinations of vaginal smear / papanicolaou of vagina immature basal cells and increased proportion of parabasal cells replacicing superficial epithelial cells which are diminishing

Question 26

what is the treatment for atrophic vaginitis ?

Answer 26

topical estrogen | vaginal moisturisers

Question 27

what is the cause of foreign body vaginitis ?

Answer 27

sexual abuse forgotten or lost tampons condoms

Question 28

how is genital herpes transmitted ?

Answer 28

genital herpes - HSV 2 sexually

Question 29

what is the complication of genital herpes in pregnancy ? and no in pregnancy ?

Answer 29

high risk at first trim increase fetal mortality- miscarriage PROM cause microcephaly , microopthalmia , if occurs in second trim - not bad ? go into labour less than 6 weeks after a first episode of genital herpes, your immune system won’t have had time to produce antibodies to protect your baby. There is thus a high chance of passing the virus to your baby if you have a vaginal CNS disease Meningoencephalitis (manifesting with fever, lethargy, irritability) Skin, eye, and mouth disease Vesicular skin lesions trouble breathing -grunting, blue appearance (cyanosis), rapid breathing short periods of no breathing dessimentaed - sepsis jaundice ========= there is reoccurrence as it resides in the nerve ganglion until it is triggered again

Question 30

what is the signs and symptoms of genital herpes simplex?

Answer 30

can appear on the vulva, perineum, buttocks, anal area, cervix, and inside of the vagin Most patients are asymptomatic multiple , bilateral , painful red bumps or white vesicles the vesicles can burst to ulcerate unusual vaginal discharge pruritus Painful lymphadenopathy in the groin area fever myalgia Recurrence is common.

Question 31

diagnosis of genital herpes simplex ?

Answer 31

Light microscopy findings on a Tzanck smear does not differentiate from hsv1 and 2 and vriella zzoter virus PCR viral culture specific serum antibodies

Question 32

what is the treatment for genital herpes ?

Answer 32

there is no cure but symptomatic treatment and prevention of reoccurrence with acyclovir

Question 33

what are the symptoms of HPV16 and 18 (31/33)?

Answer 33

90 parent of cases no symtoms and resolves spontaneously but in some HPV persists and presents as warts (mostly vulva , cervix and anus) precancerous lesions but transmission to fetus is rare

Question 34

nearly all cervical cancer is caused by ?

Answer 34

HPV16 and 18

Question 35

what is the prevention of HPV 16 and 18 ?

Answer 35

gardasil - HPV like particle vaccine

Question 36

what is the treatment of HPV ?

Answer 36

should not be used in pregnancy : doctor applied medication - podophylin resin patient applied medication -podofilox cryotherapy , surgical , laser ablation excision

Question 37

what is is vulvitis ?

Answer 37

inflammation of the vulva including - labio maoris and minors ,introits

Question 38

different vulval diseases ?

Answer 38

``` PYOGENIC all caused by staph areas pyogenic - vulval cellulitis folliculitis ``` ====== viral genital herpes Condylomata accuminata ===== bartholinitis - Escherichia coli, Staphylococcus, Streptococcus bartholin cyst

Question 39

describe the clinical manifestation of the pyogenic vulva infection

Answer 39

vulval cellulitis - limited, in majority, upto the labiocrural fold. The vulva is swollen, red, and tender. purulent discharge dysuria pruitis

Question 40

treatmnet of pyogenic vulval infections ?

Answer 40

vulval cellulitis- systemic antibiotics local hot compress analgesics folliculitis / furunculosis -furunculosis -bath containing potassium permanganate loca and systemic antibiotics

Question 41

clinical feature of bartholinitits

Answer 41

local pain and discomfort even to the extent of difficulty in walking or sitting. tenderness and induration of the posterior half of the labia when palpated between thumb outside and the index finger inside the vagina purulent secretion from duct pain during intercourse The infection may resolute completely or an abscess is formed. In others, the infection subsides only to recur in future. In such cases, the gland becomes fibrotic. Too often, the duct lumen heals by fibrosis with closure of the orifice → pent up secretion of the gland → formation of bartholin cyst

Question 42

treatment for bartholinitis ?

Answer 42

Hot compress area and analgesics to relieve pain are instituted. Systemic antibiotic like ampicillin if abcess -Abscess should be drained at the earliest opportunity

Question 43

treatment for bartholin cyst ?

Answer 43

Marsupialization is the An incision is made on the inner aspect of the labium minus just outside the hymenal ring includes the vaginal wall and the cyst wall. The cut margins of the either side are to be trimmed off to make the opening an elliptical shape The edges of the vaginal and cyst wall are sutured by interrupted catgut - free drainage

Question 44

what causes genital warts or condyloma acuminate ?

Answer 44

Human Papilloma Virus (HPV) usually type 6 and 11 sexually transmitted

Question 45

clinical signs and symptoms of condyloma accuminata

Answer 45

multiple papillary lesion grow in clusters along a narrow stalk giving it a cauliflower appearance anogenital HPV infection is: Cervix 70%, Vulva 25%, Vagina 10%

Question 46

treatment of condyloma accuminata

Answer 46

local cytostatic treatment (e.g., 5-FU, trichloroacetic acid, podophyllin, or immune response modifiers (e.g., imiquimod, interferon alpha) Cryotherapy: freezing external warts with CO2, N2O, or N2 In case of numerous warts: curettage, laser surgery, or electrocoagulation ``` preventive HPV vaccine (Types 6 and 11) can prevent ```

Question 47

treatment of bacterial vaginosis ?

Answer 47

internal gel that regulates the vaginal ph back to normal | metronidazole gel / clindamycin cream

Question 48

vulvovaginal candiasis ?

Answer 48

fluconazole tablet | butoconozole cream