Vulvovaginal Health & Infections

Question 1

Why might menopause place one at a higher risk for UTIs?

Answer 1

Menopause is marked by a time of lower-potency estrogen (estrone - E1). Low estrogen levels lead to a thinner, less active vaginal epithelium with scant lactobacilli, increasing the pH (6-8). Increasing pH and relative lack of lactobacilli increase risk for infection

Question 2

Priority goal of vulvovaginal care

Answer 2

keep the vulva dry and free from irritants

Question 3

Patient education regarding routine vulvovaginal care

Answer 3

wash with warm water; avoid douches, wipes, sprays, and powders; wear cotton underwear and avoid thongs; use unscented cotton menstrual hygiene products; avoid scented detergent, bubble baths, and scented oils; avoid shaving and waxing; wipe front to back after voiding and defecation

Question 4

Normal appearance of the vaginal on physical exam

Answer 4

pink, rugaeted, moist vaginal muscosa (“well-estrogenized”)

Question 5

Normal vaginal pH

Answer 5

3.5-4.5

Question 6

Normal vaginal discharge

Answer 6

clear to cloudy, white, flocculent (loosely clumped). Minimal to small in amount

Question 7

Normal wet mount findings

Answer 7

numerous lactobacilli, normal squamous epithelial cells

Question 8

Menstrual Cycle: vaginal discharge is egg white - clear, viscous

Answer 8

mid-cycle

Question 9

Menstrual Cycle: vaginal discharge is thick, pasty, sometimes yellow-ish

Answer 9

luteal phase

Question 10

Estrogen promotes the growth of this bacteria as part of the healthy vaginal flora

Answer 10

lactobacilli

Question 11

Alkaline pH of the vagina

Answer 11

> 4.5

Question 12

KOH stands for….

Answer 12

potassium hydroxide

Question 13

What is the purpose of having a separate KOH wet mount? (2)

Answer 13

1. whiff/amine test for bacterial vaginosis

2. lyses the WBCs and trich making the candida easier to see

Question 14

INTERPRET: Perineal laceration affecting the skin and subcutaneous tissue, with perineal muscles intact

Answer 14

1st degree

Question 15

INTERPRET: Perineal laceration extending into the fascia and muscles of the perineal body, with the anal sphincter intact

Answer 15

2nd degree

Question 16

INTERPRET: Perineal laceration extending through the fascia/musculature and some or all of the external anal or internal anal sphincters

Answer 16

3rd degree

Question 17

INTERPRET: Perineal laceration involving the perineal muscles, external and internal anal sphincters, and the rectal mucosa

Answer 17

4th degree

Question 18

1st degree perineal lacerations after vaginal childbirth can be expected to heal….

Answer 18

within a few weeks

Question 19

INTERPRET: FGM/C involving partial or total removal of the clitoris

Answer 19

Type 1 (clitordectomy)

Question 20

INTERPRET: FGM/C involving partial or total removal of the clitoris and labia minora, with or without the labia majora

Answer 20

Type 2 (excision)

Question 21

INTERPRET: FGM/C involving narrowing of the vagina with the creation of a covering seal by repositioning either labia, with or without excision of the clitoris

Answer 21

Type 3 (Infibulation)

Question 22

Vaginitis vs. Vaginosis

Answer 22

ITIS = inflammation
OSIS = abnormal increase or production of

Question 23

Generally, name for increased inflammation of the vagina with increased discharge and WBCs

Answer 23

vaginitis

Question 24

Generally, name for increased discharge from the vagina, without inflammation or WBCs

Answer 24

vaginosis

Question 25

(3) most common causes of vulvovaginitis

Answer 25

bacterial vaginosis, candidal infections, trichomoniasis

Question 26

Causes of Bacterial Vaginosis (1)

Answer 26

An alkaline environment leading to the overgrowth of anaerobes

Question 27

DIAGNOSE: Pt presents with CC of vaginal itching and irritation. Endorses postcoital spotting, dyspareunia, and urinary discomfort. On speculum exam, you note a fishy odor and increased thin, gray-white milky discharge that is homogenous and adherent to the vaginal walls.

Answer 27

Bacterial vaginosis

Question 28

Amsel Criteria for Bacterial Vaginosis

Answer 28

3 out of the 4 must be present: - thin, white adherent vaginal discharge - pH >4.5 - positive whiff or amine test - >20% of epithelial cells must be clue cells

Question 29

INTREPRET: You prepare a wet mount slide and conduct pH testing for cc of vaginal discharge. You note a positive whiff test on your KOH slide. pH is 4.5. On saline mount, >20% of epithelial cells are clue cells.

Answer 29

Bacterial vaginosis

Question 30

Priority patient education when prescribing metronidazole

Answer 30

NO alcohol during therapy and for 24 hours after completion of therapy

Question 31

Drugs of choice for treatment of symptomatic BV (2)

Answer 31

metronidazole or clindamycin vaginal or oral

Question 32

Alternative therapies for BV

Answer 32

probiotics, boric acid, vinegar douches, tea tree oil, garlic suppositories

Question 33

Cause of Vulvovaginal Candidiasis (VVC)

Answer 33

Complex relationship between host immune function, estrogen, virulence of the candida strain, and increased vaginal pH

Question 34

DIAGNOSE: Pt presents with CC of vaginal and vulvar itching. Endorses dysuria. On speculum exam, found to have thick clumpy white discharge, a swollen red vagina, and white patches of discharge on the vaginal walls.

Answer 34

Vulvovaginal candidiasis (VVC)

Question 35

In patients with recurrent vulvovaginal candidiasis infections, consider underlying _____ (4) and get a yeast culture

Answer 35

HIV, DM, pregnancy, non-albicans strain of candida

Question 36

INTREPRET: You prepare a wet mount slide and conduct pH testing for cc of vaginal discharge. You note pseudohyphae on the wet mount. The vaginal pH is normal

Answer 36

Vulvovaginal candidiasis

Question 37

Pharmacologic treatment for VVC

Answer 37

OTC antifungal ('-azole') creams, suppositories, and oral agents

Question 38

Alternative therapies for VVC

Answer 38

gentian violet, white vinegar, probiotics, yogurt

Question 39

Only recommended treatment for VVC in pregnant clients

Answer 39

topical antifungal -azoles (EXCEPT FLUCONAZOLE, which may be teratogenic)

Question 40

New name for atrophic vaginitis

Answer 40

Genitourinary syndrome of menopause (GSM)

Question 41

Cause of Genitourinary Syndrome of Menopause (GSM)

Answer 41

Decreased estrogen production in perimenopause and menopause, or any medications that reduce estrogen production

Question 42

DIAGNOSE: Pt presents with CC of vaginal itching, burning, urinary frequency, pain, vaginal dryness, and dyspareunia. On physical exam, you note pale vaginal walls with decreased ruggae, and petechiae lining the walls, scant vaginal secretions. She reports her LMP was 8 months ago

Answer 42

Genitourinary syndrome of menopause (GSM)

Question 43

INTREPRET (2): You prepare a wet mount slide and conduct pH testing for cc of vaginal discharge. You note parabasal cells on wet mount, increased WBCs, reduced lactobacilli. The pH is increased (>5)

Answer 43

Genitourinary syndrome of menopause (GSM), Desquamative inflammatory vaginitis (DIV)

Question 44

Pharmacologic treatment for GSM

Answer 44

Start with OTC lubricants and moisturizers. May consider vaginal preparations of low dose estrogen. An FDA-approved option for treating vaginal dryness is ospemifene (SERM)

Question 45

Cause of Desquamative Inflammatory Vaginitis (DIV)

Answer 45

Non-infectious inflammation in perimenopausal and menopausal women leads to bacterial disruption whereby the lactobacilli are replaced with gram-positive coccobacilli (such as group b strep)

Question 46

DIAGNOSE: Pt presents with CC of vaginal irritation, burning, and dyspareunia. On speculum exam, you note profuse, purulent yellow/green vaginal discharge and vaginal/vestibular erythema. There is no loss of vulvovaginal architecture.

Answer 46

Desquamative inflammatory vaginitis (DIV)

Question 47

Pharmacologic management of DIV

Answer 47

Clindamycin cream 2-4 weeks. Reevaluate in 4 weeks. Consider adding a low dose estrogen if GSM is present, too.

Question 48

DIAGNOSE: Pt presents with CC of headache, vomiting, and new rash. On physical exam, found to have a high fever, rash appears generalized, erythematous, macular. You note non-pitting edema and erythema of the palms and soles, with desquamation of some fingers. On speculum exam, you note hyperemic vaginal mucosa, with vulvovaginal tenderness.

Answer 48

Toxic shock syndrome (TSS)

Question 49

Priority predisposing factors for TSS

Answer 49

within 5 days of onset of menses and recent tampon use

Question 50

(2) causative agents for TSS

Answer 50

staph aureus, strep pyogenes

Question 51

Priority patient education with h/o TSS

Answer 51

avoid barrier contraceptive methods and tampons

Question 52

Treatment for TSS

Answer 52

life threatening emergency, refer to the hospital

Question 53

Cause of Bartholin Gland Cysts

Answer 53

fluid and mucus build-up after obstruction of a duct

Question 54

Etiology of bartholin gland cysts vs. abscess

Answer 54

``` cysts = non-infectious abscess = infectious ```

Question 55

DIAGNOSE: Pt presents for routine well-woman exam, no CC. On pelvic exam, you note a visible round-oval mass at the vestibular entrance

Answer 55

Bartholin gland cyst

Question 56

Management of Bartholin Gland Cyst in pre-menopausal pt

Answer 56

If small and asymptomatic, does not require treatment. If large and symptomatic, managed similarly to abscess

Question 57

Management of Bartholin Gland Cyst in post-menopausal women

Answer 57

refer for cancer evaluation

Question 58

Causes of Bartholin Gland Abscess

Answer 58

infection of the bartholin fluid, most commonly by e coli found in the skin and vaginal flora. Rarely, can be caused by gonorrhea or chlamydia

Question 59

DIAGNOSE: Pt presents with CC of sudden onset vulvar pain, tenderness. Endorses difficulty sitting and walking, dyspareunia. On physical exam, you note a tender, flucuant mass at the vestible with erythema of the overlying skin, and labial edema

Answer 59

Bartholin gland abscess

Question 60

Management of Bartholin Gland Abscess (3)

Answer 60

I&D with packing; word catheter; or referral to specialist for marsupialization (CULTURE NOT INDICATED)

Question 61

Cause of Hidradenitis Suppirativa

Answer 61

Genetic and hormone defects in the base of the folliculophilosebaceous unit. The plugged hair follicles fill with keratin and sebum, causing rupture, inflammation, scarring, and draining sinus tracts

Question 62

DIAGNOSE: Pt presents with chief complaint of vulvar pain and inflamed hair follicles. She has been squeezing the hair follicle to pop it but it is making it worse. On physical exam, you note exquisitely painful nodules that were draining, and a few that had scarred. You examine the breasts and axilla, and there are no additional nodules

Answer 62

Hidradenitis suppurativa

Question 63

How do you make a diagnosis of Hidradenitis suppurativa

Answer 63

purely history and physical. You are looking for typical lesions in the typical locations with a relapsing, chronic pattern. No lab tests are needed to diagnose.

Question 64

This condition is often misdiagnosed as simple folliculitis in its early stages

Answer 64

Hidradenitis suppurativa

Question 65

Patient education for lifestyle management of Hidradenitis Suppurativa

Answer 65

avoid trauma (tight clothing, continuous moisture, squeezing), tobacco cessation, weight management, choose tampons over pads, (dairy?)

Question 66

Medical treatment options for hidradenitis suppurativa

Answer 66

topical and oral antibiotics, anti-androgens, immunosuppressants, humira, baratric surgery, wide excision for extensive disease

Question 67

cause of contact dermatitis

Answer 67

allergen or irritant

Question 68

DIAGNOSE: Pt presents with CC of vaginal itching. Speculum exam is generally normal, with mild vulvar erythema and evidence of excoriations from itching.

Answer 68

contact dermatitis

Question 69

Treatment recommendations for contact dermatitis

Answer 69

avoid irritant, topical corticosteroid ointment

Question 70

Cause of Lichen Sclerosus

Answer 70

chronic mucocutaneous disorder, that is likely autoimmune

Question 71

DIAGNOSE: Pt presents with CC of severe vulvar burning and itching. Endoses dyspareunia. States it initially started as dull, non-specific vulvar irritation. On physical exam, you note areas of hypopigmentation in a figure 8 pattern, thin pappery skin, and a loss of vaginal architecture

Answer 71

Lichen Sclerosus

Question 72

Treatment for Lichen Sclerosus

Answer 72

Defer a biopsy until 12 week treatment trial with high potency topical steroids with a 3 month taper.

Question 73

If you suspect Lichen Sclerosus, make sure to r/o....

Answer 73

thyroid disease

Question 74

Most debilitating of the Lichen conditions

Answer 74

Lichen planus

Question 75

DIAGNOSE: Pt presents with CC of severe vulvar burning and itching. Endoses dyspareunia. On physical exam, you note well-demarcated papular lesions/erosions on the vulva with white straie and a loss of genital architecture. You inspect the oropharynx, and note oral lesions as well

Answer 75

Lichen Planus

Question 76

Treatment for lichen planus

Answer 76

Super potent topical steroid x3 months and/or intralesions injection. Refer erosive disease to dermatology.

Question 77

Variant of atopic dermatitis - a vulvar disorder that causes pruritis

Answer 77

Lichen simplex chronicus

Question 78

DIAGNOSE: Pt presents CC of vaginal itching. States "I always get yeast infections and my provider calls in abx, but this one won't go away". States that the scratching and rubbing offer intense but temporary relief. The itching is worse at night

Answer 78

Lichen simplex chronicus

Question 79

Medication treatment for lichen simplex chronicus

Answer 79

Topical -caine to numb the area, oral antihistamine to reduce itching, potent topical steroid ointment tapered x3-4 months.