Disorders of the Vagina and Vulva Flashcards by Katie Keller

Normal pH of vagina is what?

<4.5 (very acidic)

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A vaginal pH 4.5 or higher is indicative of what?

infection (makes vagina alkaline)

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What is the predominant normal vaginal flora?

Lactobacillus predominates

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What does Lactobacillus produce?

produces hydrogen peroxide

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Which vaginal infection is described below?

Gram negative obligate intracellular bacteria that lack the ability to
make it’s own ATP

Infects columnar epithelium

If untreated, up to 40% may develop pelvic inflammatory disease
(PID)

Chlamydia

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C. trachomatis serotypes L1, L2, L3 cause this

Presents as inguinal or femoral lymphadenopathy in women

A self-limiting vesicle or papule sometimes forms

This is a systemic infection that, if untreated, can cause secondary
infection of the rectal or anal lesions which can lead to abscesses or fistulas

Lymphogranuloma Verereum

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Which vaginal infection is described below?

Frequently asymptomatic

Mucopurulent cervicitis – angry, red congested cervix

Discharge indistinguishable from gonorrhea

Irregular bleeding (post coital)

Dysuria

Chlamydia

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Is a test of cure required for chlamydia?

Unless erythromycin is used, test for cure is not recommended unless symptoms remain or
reinfection is suspected

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Which vaginal infection is described below?

Gram negative intracellular diplococcus

Found in 20% of PID cases

Risk of transmission after one exposure is 70%

Emergence of antimicrobial resistant strains

Gonorrhea

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What are the multiple methods that can be used to diagnose chlamydia?

Culture

Direct fluorescent antibody

Enzyme immunoassay (EIA)

Gen probe – swab

Nucleic acid hybridiziation testing

Nucleic acid amplification testing
(NAAT)

Urine screening

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What is the treatment of choice for chlamydia?

Azithromycin 1 gm PO once

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What is the treatment of choice for chlamydia in pregnant patients?

Azithromycin 1 gm PO once

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There are concerns that gonorrhea may facilitate transmission of what?

HIV

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Risk of transmission of gonorrhea after one exposure is what percentage?

70%

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Which vaginal infection is described below?

Appear within 3-5 days of infection

Copious mucopurulent vaginal discharge in women, may be greenish-yellow

Cervix is inflamed and edematous with discharge from the os

May have purulent anal discharge

Gonorrhea

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What are the multiple methods that can be used to diagnose gonorrhea?

Genital culture

Gen probe

Gram stain

Testing may be added to many liquid based pap smears

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What percentage of gonorrhea cases have a co-infection of chlamydia?

30%

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What is the treatment of choice for gonorrhea?

Aggressive therapy for suspected or confirmed

Ceftriaxone (Rocephin) 250mg IM once

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Which vaginal infection is described below?

Vulvar erythema and edema

Itching

White, curdy discharge (cottage cheese)

Candidiasis

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What organisms are responsible for vaginal candidiasis?

Candida albicans

Candida glabrata

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What are the risk factors for candidiasis?

Antibiotic use

Pregnancy

OCP use

Consider screening for diabetes if recurrent

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What is the gold standard of diagnosing candidiasis?

Vaginal culture

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What is the treatment for vaginal candidiasis?

Fluconazole (Diflucan) 150mg PO x 1 dose, may repeat in 3 days if
symptoms persist

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Which vaginal infection is described below?

Unicellular flagellate protozoan

Colonizes the urethra, vagina, Skene ducts

Non-sexual transmission is infrequent because large numbers of organisms are required to produce infection

Trichomonas

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What is Trichomonas associated with?

Increased incidence of HIV PID Endometritis Preterm birth/low birth weight Premature rupture of the membranes

Which vaginal infection is described in the presentation below? Profuse vaginal discharge - Frothy, green-ish in color, foul smelling at times Swollen and tender labia minora Dysuria Dyspareunia Vaginal itching Vaginal and cervical erythema with multiple small petechiae

Trichomonas

What sign in a Trichomonas infection is found in 10% of cases?

Strawberry cervix

What is the gold standard for diagnosing Trichomonas?

Culture

What is the only FDA approved treatment for Trichomonas?

Metronidazole

Which vaginal infection is described below? Common viral infection capable of causing superficial oral and vulvar ulcerations or necrotic mass of the cervix leading to profuse vaginal discharge

Herpes Simplex Virus

Which type of herpes infection is described below? Causes most genital lesions Genital recurrence likely After primary infection - 1 outbreak – 90% within 1 year, 6 outbreaks – 38%, >10 outbreaks – 20%

HSV-2

Which type of herpes infection is described below? Oral cold sores Responsible for 10-15% of genital (80% of new genital infections) Increasing among adolescents and young adults Genital recurrence not likely

HSV-1

HSV virus may be shed up to how long after lesions appear?

up to 3 weeks

What are not effective at eliminating transmission of HSV?

Condoms

What is a definitive test for HSV?

PCR testing

Pregnant patients with known HSV-2 should be offered suppressive therapy started at how many weeks?

36 weeks

In pregnant patients, what is recommended if herpetic lesions are identified at the time of labor, regardless of whether it is primary or recurrent?

C section

Which vaginal infection is described below? Caused by Treponema pallidum – spirochete Spirochetes pass through intact mucous membranes and abraded skin 10-90 days later, a primary lesion or chancre appears

Syphilis

Transplacental spread of syphilis may occur when during pregnancy?

at any time

indurated, firm, painless ulcer with rolled borders

Chancre- - seen in primary syphilis

How long does it take for chancre to heal in primary syphilis?

Heals spontaneously within 3-6 weeks

Secondary syphilis develops in what time frame following untreated primary syphilis?

4-8 weeks

Secondary syphilis resolves spontaneously in what time frame?

2-6 weeks

Which stage of syphilis is described below? Diffuse systemic spread hematogenously Viral syndrome with diffuse lymphadenopathy - Fever, HA, fatigue, weight loss, muscle aches, patchy hair loss Skin rash - Rough, red or brown lesions on palms and soles Condyloma lata - Moist appearing patches, Highly infective, Broad-based and flat

Secondary syphilis

Which stage of syphilis is described below? Chancre- indurated, firm, painless ulcer with rolled borders, 10-60 days after infection Penis, vulva, vagina, cervix, anus, lips, nose, nipple can be affected Heals spontaneously within 3-6 weeks Painless, rubbery, regional lymphadenopathy

Primary syphilis

Which stage of syphilis is described below? 2-6 weeks following untreated secondary syphilis No signs or symptoms of disease Transmission during this stage unlikely except through blood or placental transfusion

Latent Syphilis

Which stage of syphilis is described below? Develops in 1/3 of untreated cases Cardiac manifestations Ophthalmic and auditory lesions Gummas – lesions of bone and skin Neurologic manifestations

Tertiary Syphilis

Due to high risk of false positives, what is the preferred way to diagnose syphilis?

Must have two positive tests due to possible false-positives with the non-treponemal tests (RPR and VDRL) Common to screen with RPR and confirm with one of the other treponemal-specific tests

What is the follow up schedule for patients treated for syphilis?

Quantitative VDRL titers and exams at 3,6 and 12 months Abstain from sexual intercourse until all lesions are completely healed

What is the DOC for treating syphilis?

Benzathin penicillin G 2.4 million units IM once

Which vaginal infection is described below? This is not an STD – can be due to a change in vaginal pH Caused by polymicrobial change in vaginal flora Anything that changes the pH of the vaginal

Bacterial Vaginosis

What is the most common organism responsible for bacterial vaginosis?

Gardnerella vaginalis

What are the Amsel criteria in gardnerella vaginalis?

Abnormal grey discharge pH greater than 4.5 (normal is 3.2 to 4.5) Positive “whiff” test Presence of clue cells on saline wet mount (epithelial cells stippled with bacteria)

Which vaginal infection is described below? Fishy vaginal odor especially after intercourse Creamy grey-white or yellow vaginal discharge Little or no vaginal irritation Recurrence very common

Bacterial Vaginosis

What factors can help prevent the recurrence of bacterial vaginosis?

Condoms Longer treatment length Prophylactic treatment Acidify the vagina Note: Treating partrer does not decrease recurrence

Condition of the vulva involving thinning, dryness, and irritation of the mucosa Tissue is dry, whitish, non-elastic Found in situations of low estrogen

Vaginal Atrophy

Vaginal epithelium is thin and more susceptible to what in atrophic state?

infection and trauma

What are some signs and symptoms of vaginal atrophy?

Vaginal mucosa is thin with few or absent vaginal folds Vaginal dryness Dyspareunia (Lack of elasticity and dryness)

Vaginal wall defects may result from what?

Childbirth and resulting injury to cardinal ligaments (main support structures of the uterus) Weakening of pelvic structures with aging Increased intra-abdominal pressure (obesity, repeated heavy lifting, chronic cough, etc)

What is the most common cause of vaginal wall defects?

Childbirth

What are the four types of vaginal wall defects?

Uterine Anterior vaginal wall (Cystocele, Cystourethrocele) Posterior vaginal wall (Rectocele, Enterocele (rectum + bowel) Vaginal vault (post-hysterectomy)

Uterus protrudes into the vagina

Uterine Prolapse

Relaxation and descent of bladder into vagina due to weakening or injury (childbirth) to pelvic fascia

Cystocele

What are some signs/symptoms of a cystocele?

“something is bulging or falling out” Incontinence Frequent UTIs due to incomplete bladder emptying May be asymptomatic

Relaxation and descent of rectum posteriorly into vagina resulting from injury and/or weakness of pelvic fascia

Rectocele

What is the most common symptom seen with rectoceles?

constipation

What are some signs/symptoms of a rectocele?

Most common symptom is constipation “something is bulging or falling out” Splinting - Patient will use thumb or toilet paper to apply pressure to posterior vaginal wall to help initiate defecation

Posterior vaginal wall herniation at Pouch of Douglas (posterior culdosack) Likely to contain loops of bowel (Can present as a bowel obstruction) Typically high in vaginal vault - May be able to differentiate this from high rectocele with rectovaginal exam

Enterocele

Uncommon cancer Accounts for only 5% of gynecological cancers Primarily a disease of postmenopausal women

Vulvar Cancer

What is strongly associated in women of younger ages, but not older women with vulvar cancer?

HPV

In cases of vulvar cancer, what is the presenting symptom in >50% of cases?

Pruritis

What are the types of vulvar cancer?

Squamous Cell carcinoma

What is the most common type of vulvar cancer?

Squamous Cell carcinoma Malignant melanoma Basal cell carcinoma Carcinoma of Bartholin’s gland

In vulvar cancer, what percentage of squamous cell cancers arise from labia minora or majora?

65%

In vulvar cancer, what percentage of squamous cell cancers arise from clitoris or perineum?

25%

What is the second most common type of vulvar cancer?

Malignant melanoma

~2-6% of vulvar cancers Most commonly arise on labia minor or clitoris with a tendency to spread toward the urethra and vagina Raised, irritated, pruritic, pigmented lesion

Malignant melanoma

Account for ~1% of vulvar cancers Most are small elevated lesions with an ulcerated center and rolled edges Found almost exclusively on labia majora

Basal cell carcinoma

Account for ~1% of vulvar cancers Because it is difficult to clinically differentiate a tumor of the Bartholin gland from a benign Bartholin cyst, any woman >40 years old should undergo biopsy Recurrence common 5 year survival rate is 65%

Carcinoma of Bartholin’s gland

Disorders of the Vagina and Vulva Flashcards

(79 cards)