AUFSOM Physiology-I

CASE PRESENTATION YCRA

CASE
McQueen 23 year old female Residing at Angeles City Sexually active

CASE
Has been experiencing FISHY white discharge after intercourse in the past 3 months Thought discharge was normal Consulted an OB when vaginal itchness developed.

HISTORY
McQueen was the only child in the family She and her boyfriend had their first sexual intercourse 3 months ago. She was a chain smoker,started at the age of 15

HISTORY
She currently works on a call center company in Clark, Balibago She usually go to work at 11:00pm and go home around 7:00am

SALIENT FEATURES
Chief complaint of Vaginal itchness Pelvic exam was done and noted white discharge FISHY odor was prominent Vaginas pH is 5.5 Gram Staining resulted to GPCB (Gram Positive Coccobacilli

DIFFERENTIAL DIAGNOSIS

Vulvovaginal Candidiasis

DIFFERENTIAL DIAGNOSIS

Vulvovaginal Candidiasis
Caused

by Candida albicans (diploid FUNGUS) usually when there is altered immune status (opportunistic pathogen) Typical symptoms are vulvar itching and/or irritation Vaginal disharge is usually scanty, white and adherent plaques
Source: Essentials of Pathophysiology 7th edition Lippincott

DIFFERENTIAL DIAGNOSIS

Vulvovaginal Candidiasis

DIFFERENTIAL DIAGNOSIS

Trichomonal Vaginitis

DIFFERENTIAL DIAGNOSIS

Trichomonal Vaginitis
Caused

by Trichomonas vaginalis (anaerobic flagellated protozoan) Considered as sexually transmitted disease(STD) Typical sympotms are profuse purulent(maybe white) discharge and vulvar itching STRAWBERRY-cervix (colposcopy)
Source: Essentials of Pathophysiology 7th edition Lippincott

DIFFERENTIAL DIAGNOSIS

Trichomonal Vaginitis

DIFFERENTIAL DIAGNOSIS

Bacterial Vaginosis
Caused

by Gardenerella vaginalis, various anaerobic bacteria and mycoplasmas Typical symptom is a malodorous, moderate, white or gray discharge that coats the vaginal walls

Source: Essentials of Pathophysiology 7th edition Lippincott

Bacterial Vaginosis

BACTERIAL VAGINOSIS
It was discovered by Gardner and Dukes in 1980 through culture It was believed that Gardnerella Vaginalis (causative agent),a Gram Positive Bacteria, was 40% - 70% part of the normal flora of the vagina Anaerobes was also part of the normal flora that produces amines (trimethylamine) that favors the growth of G. Vaginalis raising the pH

BACTERIAL VAGINOSIS

It is then characterized by absence of the normal lactobacillus species in the vagina and an overgrowth of other organisms, including G. vaginalis, Mobiluncus species, and numerous anaerobes

BACTERIAL VAGINOSIS
The root cause is the imbalance of pH (acidity levels) inside the vagina, which leads to an overgrowth of harmful bacteria resulting in an unhealthy vaginal flora. The human vagina sees a balance of good and bad bacteria, and bacterial vaginosis happens when the bad bacteria (anaerobes) outgrow the good bacteria leading to problems.

BACTERIAL VAGINOSIS

BACTERIAL VAGINOSIS

Risk Factors
Child

Bearing Age* Multiple sexual partners Recent intercourse with a new partner Intrauterince devices for contraception Vaginal douching Cigarette smoking

BACTERIAL VAGINOSIS
Increases the Risk for(complications): Pelvic Inflammatory Disease Preterm Labor Premature ROM Post Partum Endometritis Spontaneous abortion

Source: Harrisons Principles of Internal Medicine, 16th edition

BACTERIAL VAGINOSIS
It is characterized by symptoms of vaginal malodor and a slightly to moderately increased white discharge, which appears homogeneous, is low in viscosity, and smoothly coats the vaginal mucosa The odor is characterize as fishy- or ammonia-smelling discharge that fails to produce an inflammatory response that is characteristic of most infections

BACTERIAL VAGINOSIS

Pathophysiology

BOOK BASED / CLIENT/BOOK BASED

Predisposing factor: Child Bearing Age

Precipitating factors: Multiple sexual partners Recent Intercourse with a new partner Intrauterine devices Vaginal Douching Cigarette Smoking D

PATHOPHYSIOLOGY
D

Decreases vaginal colonization of hydrogen peroxideproducing Lactobacilli (good bacteria)

Clue cells Increases the growth of Gardenella Vaginalis (bad bacterica)

White or Gray homogenous Discharge

PATHOPHYSIOLOGY
Increases the growth of Mobilincus spp.

Produces volatile amines (trimethylamines)

Further increases the growth of G. Vaginalis Increases the pH Malodorous or Fishy Odor

Decreses Inflammatory Response

PATHOPHYSIOLOGY
Increases the Risk for: Pelvic Inflammatory Disease Preterm Labor Premature ROM Post Partum Endometritis Spontaneous abortion

Source: Essentials of Pathophysiology 7th edition Lippincott

DIAGNOSTIC PROCEDURES
Amsel Criteria Must include any three of the following four clinical abnormalities:

objective

signs of increased white homogeneous vaginal discharge a vaginal discharge pH of <4.5 liberation of a distinct fishy odor immediately aftermixed with a 10% solution of KOH

DIAGNOSTIC PROCEDURES

Amsel Criteria
microscopic

demonstration of Clue cells (vaginal epithelial cells coated with coccobacillary organisms giving them a granular appearance and indistinct borders)

Source: Harrisons Principles of Internal Medicine, 16th edition

CLUE CELLS
Vaginal epithelial clue cells. Note granular appearance due to adherent Gardnerella vaginalis and indistinct cell margins

Normal vaginal epithelial cells. The cell margins are distinct and lack granularity.

DIAGNOSTIC PROCEDURES

Gram Staining
Method

of differentiating bacterial species into two large groups (Gram-positive and Gramnegative). Most sensitive for BV (90%)

Source: Pocket Guide to Diagnostics 4th Ed. ,Diana Nicoll MD,PhD, MPA

DIAGNOSTIC PROCEDURES

Vaginal fluid pH
Obtain

by using Nitrazine Paper Color of the Paper doesnt change if pH is normal Turns Blue if alkalinic and Red if acidic 74.3% sensitive to BV 81.3% together with the symptoms

Source: Pocket Guide to Diagnostics 4th Ed. ,Diana Nicoll MD,PhD, MPA

MEDICAL MANAGEMENT

It is important to treat bacterial vaginosis and eliminate it at the earliest to prevent further complications.

MEDICAL MANAGEMENT
The standard dosage of metronidazole for the treatment of bacterial vaginosis is 500 mg orally bid for 7 days Oral clindamycin (300 mg bid for 7 days) and clindamycin ovules (100 g intravaginally once at bedtime for 3 days) have also been approved.

MEDICAL MANAGEMENT

Intravaginal treatment with 2% clindamycin cream [one full applicator (5 g containing 100 mg of clindamycin phosphate) each night for 7 nights] or with 0.75% metronidazole gel [one full applicator (5 g containing 37.5 mg of metronidazole) twice daily for 5 days] is also approved for use in the United States and does not elicit systemic adverse reactions
Source: Harrisons Principles of Internal Medicine, 16th edition

MEDICAL MANAGEMENT
Unfortunately, longterm recurrence (i.e., several months later) is distressingly common after either oral or intravaginal treatment. So it is adivsed to finish the time frame of your prescribed medicines and take note of the risk factors of BV.

Source: Harrisons Principles of Internal Medicine, 16th edition

REFERENCES
Harrisons Principles of Internal Medicine, 16th Edition Source: Essentials of Pathophysiology 7th Edition Lippincott Pocket Guide to Diagnostics 4th Ed. ,Diana Nicoll MD,PhD, MPA