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Vagina-Characteristics

  • In adult females, vagina is lined by stratified squamous epithelium. In newborn females, it is lined by transitional epithelium.
  • Squamous epithelium is resistant to gonoccocal infection. Thus, gonoccocal vaginitis cannot occur in young/ adult females.
  • Vagina has local inhabitant bacteria called as Doderlein's bacillus (lactobacilli) which breaks down the glycogen present in vaginal epithelium into lactic acid resulting in acidic pH (A vg, 4.5; Range, 4-5.5) of vagina. The acidic pH of vagina acts as a barrier for external organisms.

The pH of vagina varies with age

 

Age

Viginal pH

In a newborn infanta

Between 4.5 and 7

6-week-old child

7

Puberty

Changes from alkaline to acidic

Reproductive age qroup

4 - 5.5

Preqnancy

3.5 - 4.5

Late postmenopausal

6 - 8

  • pH of vagina also varies along its length, being highest in the upper part because of admixture of alkaline cervical mucus.

Infectious Vulvovaginitis

 
 

Vaginitis

M/C organism

Symptom

Signs

Diagnosis

T/t

Trichomonas vaginitis

M/C vaginitis

Trichomonas vaginalis - Flagellated protozoa

Profuse, frothy yellowish green discharge along with pruritis (itching)

-pH ≥ 5

-Strawberry vagina or angry-looking vagina

Wet mount

microscopy of

vaginal discharge

shows typical

motile f1agellaled

trichomonads

Definitive

Diagnosis

- Culture on

Feinberg-

Whittington

medlav or

Diamonds TYM media 

DOC-

Metronidazole

(500 mg BD or

2 g single dose

recommended)

Both partners

should be treated

simultaneously

In pregnancy DOC

- Metronidazole in

2nd/3rd trimester

 

Candidiasis: M/C vaginitis during pregnancy in

OCP uses/steroid users/ Antibiotic and immuno- compromised

patients

Candida albicans gram positive fungus.

Candida galbrata (<5%)

Candida tropicales

(5%)

Intense pruritis  
Curdy white discharge

Dysuria

Dyspareunia

20% patients are asymptomatic

Severe vulvo- vagintis seen

Cottage-cheese like appearance of discharge

pH of discharge

<4.5

Swollen inflamed genitals

 

On adding 10% KOH to discharge fungal elements seen (Whiff test negative) Definitive

diagnosis: Culture on Sabourauds mediaoor Nickerson media

DOC = Azole

group of antifungals

like f1uconazolel

miconozole which

can be topically

applied or given orally

Both partners

should be treated

simultaneously

In pregnancy

DOC is topical

azole antifungals in

2nd/3rd trimester

Bacterial

vaginosis

No inflammation

lt is termed as vaginosis and not

vaginitis

 

 

o No itcbing

 

Foul smelling dirty

white discharge

 

Note: Bacterial

vaginosis during

pregnancy

leads to preterm

labor, PROM

and postpartum

endometritis

About 50%

patients are

asymptomatic

 

About 50% patient are asymptomatic

 

Thin grey foul

smelling discharge

coating the vagina

pH of discharge

> 4.5

 

Amsel's Criteria

Any 3 ot the

following should

be present:

Thin

homogenous

grayish white

discharge

pH of discharge

> 4.5

Wet film

microscopy

shows masses

of small bacteria

coating epithelial

cells called as

clue cells.

On adding

10% KOH to the

discharge, fishy

odor should be

released (Whiff

test positive)

DOC-

Metronidazole in

pregnant as well

as non-pregnant

females

Dose = 500 mg

twice daily for 7

days

Note: The 2g

one time only

dose used for

trichomoniasis

is not useful

for bacterial

vaginosis.

No need to treat

the male partner

 

 

 

Feature

Candidiasis

Trichomonal vaginitis

Bacterial vaginosis

Etiology

Candida albicans

 Trichomonas vaginalis

Gardnerella vaginalis

 

 

 

Ureaplasma urealyticum

 

 

 

Mycoplasmas

Discharge amount

 Scant

 Profuse

Moderate (malodorous)

Color

 Curdy I cheesy white

 Greenish-yellow frothy

Grayish white homogenous

pH of vagina

 <4.5

 5.5-6.5

>4.7

10% KOH +

 -

 -

Fishy odor (due to release of amines,

secretions

 

 

acridine, and putredine) = Whiff test

Microscopy

 Pseudohyphae

 Flagellate motile

Clue cells (vaginal epithelial cells

 

 

 organism (Hanging

Loaded with coccobacilli)

 

 

 drop preparation)

 

Usual treatment

 Locally: clotrimazole

 Metronidazole

Metronidazole

 

 and miconazole

 

 

 

 Oral: fluconazole

 

 

 

Amsel's Criteria for Diagnosis of Bacterial Vaginosis

 

Grayish white discharge

pH >4.7

Clue cells on microscopy

Whiff test positive

Any three out of four should be present

Pelvic Inflammatory Disease

It is the infection and inflammation of the upper genital tracts, typically involving fallopian tubes, ovaries, and surrounding structures.

 

The primary organisms are sexually transmitted: gonococci, Chlamydia, and mycoplasma. The secondary organisms include Escherichia coli, group B Streptococcus, Klebsiella, ana-anaerobes.

 

Clinical Features of Acute PID

  1. Rise of temperature >38°C
  2. Lower abdominal tenderness
  3. Tenderness on movement of the cervix
  4. Adnexal mass
  5. Blood: leukocytosis >10,000/mm3
  6. ESR raised> 15 mm/h
  7. Laparoscopic evidences of tubal affection
  8. Culdocentesis with purulent fluid having white cell count >30,000/mL

Stages of PID (Gainesville)

 

Stage 1: acute salpingitis without peritonitis

 

Stage 2: acute salpingitis with peritonitis

 

Stage 3: acute salpingitis with tubal occlusion or tube-ovarian complex

 

Stage 4: ruptured tubo-ovarian abscess

 

Stage 5: tubercular salpingitis

 

Differential Diagnosis

  1. Appendicitis
  2. Ruptured ectopic
  3. Torsion/hemorrhage/rupture of ovarian cyst
  4. Endometriosis

Indications of Inpatient Antibiotic Therapy

  1. Suspected pelvic abscess
  2. Severe illness, temperature >38°C
  3. Uncertain diagnosis-where surgical emergencies, for example, ectopic pregnancy cannot be excluded
  4. Unresponsive to outpatient therapy for 48 h
  5. Intolerance to oral antibiotics
  6. Coexisting pregnancy
  7. Patient is known to have HIV infection

CDC Guidelines for Treatments of Pelvic Inflammatory Diseases

 

Outpatient Treatment

 

Regimen A

 

Ofloxacin, 400 mg orally two times daily for 14 days or

 

Levofloxacin, 500 mg orally once daily for 14 days With or without Metronidazole,

 

500 mg orally two times daily for 14 days
 

Regimen B

 

Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or

 

Ceftriaxone, 250 mg intramuscularly, or

 

Equivalent cephalosporin

 

Plus:

 

Doxycycline, 100 mg orally two times daily for 14 days

 

With or without

 

Metronidazole, 500 mg orally twice a day for 14 days

 

Inpatient Treatment

 

Regimen A

 

Cefoxitin, 2 g intravenously every 6 h or

 

Cefotetan, 2 g intravenously every 12 h

 

Plus:

 

Doxycycline, 100 mg orally or intravenously every 12 h
 

Regimen B

 

Clindamycin, 900 mg intravenously every 8 h

 

Plus:

 

Gentamicin, loading dose intravenously or intramuscularly (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 h

Genital Tuberculosis

  • It is almost always a secondary infection, with primary sites being lungs, lymph nodes, abdomen, etc.
  • Hematogenous route is the most common mode of spread from the primary site.
  • Bilateral fallopian tubes are involved in 100% of the cases.
  • Ampulla is the most commonly affected part of the fallopian tube.
  • Initial site of infection is the submucosal layer (interstitial salpingitis).
  • Uterus is involved in 80% of the cases.
  • Cornu of the uterus is commonly affected, as it is in continuity with the fallopian tube.
  • If the patient conceives spontaneously, ectopic pregnancy is the most likely outcome. In active tuberculosis, HSG is contraindicated. HSG findings in a case of tuberculosis are:
    1. Lead pipe tubes
    2. Tobacco pouch appearance
    3. Beaded tubes
    4. Hydrosalpinx
    5. Cornual blocks
    6. Intravasation of the dye
    7. Golf club tube
    8. Sperm head tube
    9. Uterus-honeycomb appearance (Asherman syndrome)

Treatment

  • Genital tuberculosis falls in category 1. The treatment is for 6 months
  • Four-drug AKT (isoniazid, ethambutol, pyrazinamide, and rifampicin)
  • Four drugs are given for 2 months, and two drugs (INH and rifampicin) are given for 4 months
  • Surgery for restoration of fertility (corrective tuboplasty) is contraindicated in genital TB
  • IVF after completion of AKT is the treatment for infertility (provided the uterine cavity is normal)
  • If the endometrium is cicatrized, then IVF and surrogacy should be recommended





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