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week 9- vaginitis Flashcards

1
Q

vaginal epithelium

A

non-keratinized, hormone-sensitive, stratified squamous epithelium.

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2
Q

hromones in vaginal

A

estrogen causing thickening of mucosa

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3
Q

vaginal microbiome - which is most dominant

A

many species;

(aerobic, facultative anaerobic, and anaerobic species all coexist).

  • Anaerobes dominate aerobes 10:1
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4
Q

most important gram positive anaerobes

A

ananrobic gram + cocci

anaerobic gram + bacilli

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5
Q

how is vagianl pH maintained and what is the pH

A

estrogen –> glycogen production

glycogen as nutrient for lactobacilli

glycogen metabolism –> lactic acid and hydrogen peroxide –> pH 3.8-4.2

acidic= prevent overgrowth of infections

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6
Q

who has less estrogen and therefore less glycogen and less acidic (what is the ph?) making the vagina more prone to infections

A

pre puberty and post menopause

pH 6-7.5

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7
Q

ecological changes in what can effect vaginal pH

A

Changes in hormonal status, menses, and antibiotic use can shift flora composition

Douching and unprotected intercourse (semen) can increase vaginal pH.

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8
Q

things affecting vaginal flora

A

menses- clear out pathogens

broad spectrum antibiotics –> candida overgrowth

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9
Q

vaginitis sx

A

vaginal discharge, odor, pruritus, and discomfort

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10
Q

top 3 causes of vulvovaginitis

A
  • **Bacterial Vaginosis: anaerobic bacteria
  • **Vuvlovaginal candidiasis: Various Candida species
  • **Trichomoniasis: caused by Trichomonas vaginalis (protozoa)
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11
Q

3 causes of 90% of vulvovaginitis infections

A

candidiasis, trichomoniasis, or bacterial vaginosis.

other 10%: irritants, low estrogen, dermatologic

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12
Q

CHART on slide 17 for different sx of vaignitis depending on cause

A

i.e. BV is fishy odour

candidiasis is no odour

trichomoniasis fi foul odor, strawberry cervix

etcccccc

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13
Q

bacterial vaginosis and vulvovagianl candidiasis sx

A

Vulvovaginal Candidiasis (VVC):
* Cheesy, curdy, or flocculent discharge
* Itching
* Vulvar or vaginal inflammation or redness

Bacterial Vaginosis (BV):
* Fishy odor
* Odor makes candidiasis less likely

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14
Q

vulvovaginal candidiasis from which species? most common in?

A

candida albicans

candida is normal inhabitant of vagina, but overgrow

in childbearing age with lots of estrogen because glycogen is key for candida growth

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15
Q

risk factors for vulvovaginal candidiasis

A
  • Recent antibiotic use
  • Heat, moisture and occlusive clothing
  • Combined oral contraceptives
  • Estrogen therapy
  • Pregnancy
  • Uncontrolled diabetes
  • AIDS
  • Corticosteroid use
  • Other immunosuppression
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16
Q

wet prep, findings, and pH in vulvovaginal candidiasis

A

Budding yeasts, pseudohyphae, large numbers of WBCs, lactobacilli, and clumps of epithelial cells will be seen on the wet mount.

  • The pH will be less than 4.5, and the amine “whiff” test will be negative.
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17
Q

uncomplicated vs complicated vulvovaginal candidiasis

A

Uncomplicated Vulvovaginal Candidiasis
* Sporadic or infrequent, and * Mild-to-moderate, and
* Likely C. albicans, and
* Non-immunocompromised patient.

Complicated Vulvovaginal Candidiasis
* Recurrent (four or more episodes in a year), or
* Severe, or
* Non-Albicans species, or
* Women with diabetes mellitus, HIV, debilitation, immunosuppressive therapy (corticosteroids) or other immunocompromised.

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18
Q

bacterial vaginosis cause

A

imbalance in normal flora

loss of acidity –> loss of Lactobacilli dominance further alkalinizing and leading to an environment that supports the overgrowth of pathogens such as G.
vaginalis, Mobiluncus, Prevotella, Prophyromonas, Peptostrepto coccus, Mycoplasma hominis, and Ureaplasma

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19
Q

main bateria in vaigina

A

lactobacilli

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20
Q

sx of bacterial vaginosis

A
  • Non-irritating, malodorous vaginal discharge
  • vaginal mucosa and cervical epithelium will appear normal
  • no cervical motion tenderness or pelvic pain on palpation
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21
Q

risk factors for bacterial vaginosis

A
  • Low estrogen (low glycogen and less Lactobacilli)
  • New or multiple sex partners
  • Frequent douching
  • Intrauterine contraceptive devices
  • Pregnancy
  • Premature Rupture of Membranes (PROM)
  • Preterm Premature Rupture of Membranes (PPROM)
  • Preterm Labor (PTL)
  • Pelvic Inflammatory Disease (PID)
  • Endometritis
  • Sexually transmitted infections
  • Post-hysterectomy cuff cellulitis
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22
Q

dx of bacterial vaginosis

which main criteria

A

wet prep, pH, physical

3/4 of Amsel criteria

  • Thin, white, homogeneous vaginal discharge
  • pH greater than 4.5
  • Positive amine whiff test
  • Presence of clue cells on microscopic examination
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23
Q

Amsel criteria (3/4) for bacterial vaginosis

A
  • Thin, white, homogeneous vaginal discharge
  • pH greater than 4.5
  • Positive amine whiff test
  • Presence of clue cells on microscopic examination
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24
Q

trichomonas vaginalis from

A

sexual intercoarse

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25
trichomonads vaginalis vaginitis is associated with
other STIs such as gonorrhea and chlamydia and can enhance transmission of HIV. --> test!
26
trichomonas in pregnancy effects
low birth weight, PROM, and preterm delivery.
27
sx of trichomonas vaginalis
* Malodorous, green-to-yellow, frothy vaginal discharge. * Vaginal pruritus and irritation. * Dysuria and dyspareunia. * Physical exam findings: * Vaginal mucosa erythema. * Punctate hemorrhages of the cervix.
28
tests for trichomonas vaginitis
wet prep (begin with and if inconclusive then DNA probes) ph > 4.5 positive amine test culture with diamonds medium (not common) ****PCR
29
atrophic vaginitis/ Genitourinary Syndrome of Menopause (GSM) symptoms
* Vaginal dryness. * Dyspareunia. * Vaginal inflammation. * Thinned mucosa. * Loss of rugae. * Occasional purulent discharge.
30
wet mount findings in atrophic vaginitis
* Large numbers of WBCs. * Occasional parabasal and basal cells. * Decreased lactobacilli. * Increased gram-positive cocci and gram-negative rods.
31
treat atrophic vaginitis
vaginal estrogen therapy
32
irritant vaginitis risk factors
Soaps, tampons, contraceptive devices (e.g. condoms or diaphragms), sex toys, pessaries, topical products, douching, excessive cleaning, medications, clothing.
33
allergic vagintiis risk factors
Sperm, douching, latex condoms or diaphragms, tampons, topical products, medications, clothing, atopic history.
34
when evaluating vaginitis stpes
sexual history, STDS, partners, condoms prior episodes of vaginitis? treatment? steroid use? medical conditions? dermatologic? immunosuppressive? --> HIV, diabetes, dermatologic hygiene, douching, products, menstrual hisotry
35
normal vaginal discharge
* Small amounts of vaginal discharge are normal (1-4 mL daily). * Normal discharge: colorless, white, or pale yellow. * Emphasize that vaginal discharge increases during ovulation due to cervical mucus changes. * Clear to white in color * Not malodorous * No discomfort or pruritus * Quantity varies during the menstrual cycle
36
vaginitis does not cause
acute systematic illness
37
serious sx that are not in vagintiis
* Serious symptoms (eg, fever, abdominal pain, dizziness, fainting) warrant consideration of upper genital tract disease or toxic shock syndrome (TSS). * If fever and abdominal pain are present, consider pelvic inflammatory disease (PID).
38
other potential causes of vaginitis like sx
* Lichen sclerosis * Cervicitis * Herpes simplex * Pinworms * Sexual assault UTI, PID, TSS, malignancy, forge in body, erythema multiform major...
39
CHARTS on slide 49-50
xx
40
should you just do history if think have vagintiitis?
Do not rely on history alone, after taking a detailed history, confirm suspected diagnosis with physical exam and microscopy
41
if abdomen pain or fever along with the vaginal irritation its not vaginitis and probably is
PID, TSS, cervicitis
42
postmenopausal is
atrophic vagintis
43
increased discharge yes or no
no: dermatologic conditions, irritants vagintiis yes: trichomoniasis, bacterial vaginosis, candidiasis
44
vulvar edema in
andidiasis, trichomoniasis, or dermatologic disorders.
45
deep dyspareunia in
implying pain with movement of deeper structures such as the uterus, ovaries, fallopian tubes, or bladder.
46
external dysuria vs internal dysuria
external dysuria (pain experienced in the vulva as urine passes over the skin) from internal dysuria (pain felt deeper in the pelvis in the area of the bladder or urethra). External dysuria most often results from a vulvovaginal problem. Internal dysuria is often accompanied by other lower urinary tract symptoms including urgency and frequency.
47
upper vs lower tract infections
upper is serious, significant morbidity and urgent systemic antibiotic therapy
48
physical exam
vulva speculum: vagina and cervix get samples for gonococcus and chlamydia vaginal pH strips
49
pH >4.5 in
infections due to trichomonads and bacterial vaginosis.
50
speculum done with
warm water Lubricants can contain antibacterial agents that will affect the specimens. polyester tipped swabs ; not cotton Cotton is toxic to Neisseria gonorrhea, and the wood in the shafts of swabs can be toxic to Chlamydia trachomatis.
51
cotton is toxic to ____ wood is toxic to ____ in speculum (so use polyester)
Cotton is toxic to Neisseria gonorrhea, and the wood in the shafts of swabs can be toxic to Chlamydia trachomatis.
52
wet prep findings
type of epithelial cells (mature, parabasal, basal or clue cells) and to examine presence of pseudohyphae/spores (Candida)
53
clue cells are an abnormal variation of
squamous epithelial cells
54
clue cells >20% means
gardnerella vaginalis overgrowth
55
nucleus of white blood cells
Multi-lobed nucleus = polymorphonuclear white blood cells (PMN’s).
56
white blood cells of 3% in vagina can be
vaginal candidiasis, atrophic vaginitis, or infections (trichomonas, chlamydia, gonorrhea, HSV).
57
paranasal cells in vagina smear with many WBCs means
desquamative inflammatory vaginitis.
58
abnormal presence of basal cells indicates
vaginal atrophy or desquamative inflammatory vaginitis with excessive WBCs.
59
How does trichomonas vaginalis attach to vaginal mucosa
Four anterior flagella, undulating membrane, and axostyle
60
RBCs can look like
yeast; KOH (in microscopy prep) lyses RBC, yeast remains.
61
positive whiff test
during KOH prep Volatilization of the amines leads to a ”fishy” odor
62
increased numbers of which anerobic bacteria will lead to the production of ____ during a KOH prep
Increased number of anaerobic bacteria (G. vaginalis, Mobiluncus, Trichomonas as opposed to a predominance of Lactobacillus) will lead to the production of amines.
63
gold standard for bacterial vaginosis
gram stain
64
nugent score in gram stain for bacterial vaginosis
Nugent score: is calculated based on the observed quantities of Lactobacillus acidophilus, Gardnerella vaginalis, Bacteroides species and Mobiluncus species.
65
gold standard for yeast detection
cell cultures
66
organisms seen in cell cultures and which is actually helpful
microorganisms, such as yeast, Gardnerella vaginalis, or Trichomonas vaginalis. --> not helpful for vaginitis -garnerella is in normal flora trichomonas needs diamonds medium -mostly just for yeast
67
DNA probes for which species in vaginitis
G. vaginalis, Candida species, Trichomonas vaginalis, chlamydia, and gonorrhea
68
urgent vaginal issues in geriatric populations
vaginal bleeding and pelvic/vulvovaginal pain
69
side effects of diethylstilbestrol
babies: increased breast cancer risk, vaginal clear cell adenocarcinoma, and cervical neoplasia. --> these patients are now in their 50s and older
70
annual pelvic exam for geriatric population
assess vaginal tissue, vulva, and perineum for abnormalities. rule out fecal impaction
71
annual genital exam according to American College of Obstetricians and Gynecologists (ACOG)
if >65 you do external genitalia esp if cognitive impairment
72
American College of Obstetricians and Gynecologists (ACOG) recommendation for DES daughters
annual internal pelvic exams even if did hysterectomy

CMS250 (31 decks)

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