1、Vaginitis,pathophysiology etiology diagnosis treatmentPauls boat,The dynamic vagina,vaginal secretions, exfoliated cells, cervical mucosa lactobacillus acidophilus estrogen glycogen vaginal pH metabolic byproducts of flora and pathogens,Causes of vaginitis,antibiotics contraceptives sexual intercour
2、se douching stress hormones allergies and chemical irritation,Bacterial vaginosis,proliferation of Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus species most common cause 1/3 to 2/3 asymptomatic 15 to 19% of all women 10 to 30% pregnant women,BV misc.,role of sexu
3、al transmission unclear risk for preterm labor and PROM increased frequency of abnl PAPs, PID, endometritis Sxs: profuse malodorous discharge Exam: thin grayish discharge, seldom vaginal or vulvar irritation,Risks associated with BV,Early sexual debut new or multiple sex partners IUD (50% contract i
4、t over 2y) OCP Lesbians/receptive oral sex no RCTs but association with douche, c-section and around time of menses,Amsels criteria,thin, homogenous discharge positive “whiff” test “clue cells” present on microscopy vaginal pH 4.5,BV treatment,metronidazole 500 mg BID x 7 days clindamycin 2% cream q
5、hs x 7 days metrogel 0.75% BID x 5 day (vs. QD),metronidazole 250 mg TID x 7 days metronidazole 2 g po single dose metrogel (no previous PTL),Vulvovaginal Candidiasis,second most common in U.S. Candida albicans predominates increasing frequency of non-albicans species (C. glabrata) Risks: OCPs, diap
6、hragm, IUD, early intercourse, 4X/month, receptive oral sex, diabetes, recent antibiotics. endogenous vaginal flora in 50% women,Vaginal candidiasis,not sexually transmitted nor related to number of sexual partners treatment of male partner of no benefit c/o pruritis, vaginal irritation, dysuria vul
7、vovaginal itching not normal in healthy women (lichen sclerosis, vulvar cancer) exam: thick white discharge, no odor, normal pH vulvar and vaginal erythema,diagnostics,pH normal ( 4.5) pseudohyphae, budding yeast cells negative “whiff” test GS and culture in select cases,non c. albicans,multiple bud
8、ding yeast absence of pseudohyphae,vulvovaginal candidiasis Rx,topical antifungals (clotrimazole, miconazole, terconazole) fluconazole (Diflucan) 150 mg single dose Boric acid 600 mg in size 0 gelatin capsules, IV, daily x 7 to 14 d,14 day oral azole, plus 6 months maintenance with: nizoral 100 mg d
9、aily, sporanox 100 mg daily, fluconazole 150 BIW or clotrimazole vag supp 500 mg weekly boric acid,Trichomoniasis,third most common (10-25%) protozoan Trichomonas vaginalis sexually transmitted (treat partner) Risks: IUD, smoking, multiple partners 20 to 50% asymptomatic a/w PROM and PTL,Evaluation,
10、c/o copious, malodorous, discharge, pruritis, vaginal irritation exam: edema/erythema, “strawberry” cervix, frothy, purulent discharge pH 4.5 motile pear-shaped with flagella, many polys may be whiff positive,Trich treatment,metronidazole 2 g single dose (not recommended in 1st trimester) metronidaz
11、ole 500 mg bid x 7 days treat the partner do not treat asymptomatic pregnant patients if it recurs, 2-4 g metronidazole QD x 10-14 days, send a culture/sensitivity.,Atrophic Vaginitis,Due to decreased estrogen, decreased glycogen, less lactic acid production and then a rise in pH Symptoms: soreness,
12、 postcoital burning, dyspareunia, occasional spotting Exam: thin, erythematous mucosa, few folds, may have petechiae pH 5-7, smear with polys, G- rods,Atrophic vaginitis,Treatment: topical estrogen QHS x 1-2 weeks,Other considerations,Dermatitis of the vulva: consider dermatoses such as contact dermatitis, eczema, psoriasis as well as lichen planus and lichen sclerosis. Biopsy if unsure stop the itch/scratch cycle with topical steroids,Others.,Address clothing, allergens, etc. symptoms improved with BID warm soaks add an anti-histamine,
