CHAPTER 27 - vulvitis and VAGINITIS Patients with vulvitis or vaginitis may pres ent with acute symptoms, subacute

or indolent, which vary from minimal symptoms to really disabling. The history of the patient and their symptoms, although the y are generally nonspecific, can indicate chemical causes, allergic or other cau ses different from any infectious cause. The vulvar tissue irritation, which are well supplied, usually leads to intense itching. The most common vaginal infect ions are most often with a characteristic pattern (Table 27.1). The vaginal secr etions are always present to some extent and are considered normal. When abnorma l, the number and characteristics of the secretions also depend on the influence of chemical conditions, mechanical or pathological. Understanding the physiolog ical and pathophysiological processes responsible for both abnormal and normal d eclines makes the diagnosis of vulvitis and vaginitis is accurate. The clinical history taking is especially important in patients with vulvar symptoms, and sho uld include the history of hygiene and sexual practices, use of deodorant and fe minine products, change in detergent, and other aspects of contact such as new c lothes or unusual clothes. A thorough physical examination by inspection and pal pation is also important, as well as microscopic visualization of vaginal secret ions and discharges with the help of saline and potassium hydroxide (KOH). (Figu re 27.1). Table 27.1 Clinical aspects of vaginal discharge and vaginal infections common p hysiological characteristic findings Candidiasis Trichomoniasis Vaginosis bacter ial physiological s (BV) vaginal pH 3.8 to 4.2> 4.5 â ¤ 4.5> 4.5 (usually) white d ischarge, of course, flocculant Fine, homogeneous, gray white, sticky, often â Pre sent (fish) Bad odor, discharge, worse after RS, Blanco possible itching, ripeni ng, "cheese cut" times Absent â Green-yellow frothy, adherent Possible â to this (fi sh) Bad smell frothy discharge, dysuria, vulvar itching KOH Test Whiff Absent The patient's main complaints of None Itching, burning, discharge Misdiagnosis or overtreatment of a physiological condition is doomed to failure and may even make the patient worse. The vulva and vagina are covered by stratif ied squamous epithelium. The vulva containing follicles and sebaceous follicles, as well as apocrine sweat glands, whereas the vaginal epithelium is not keratin ized and lacking such specialized items. The skin of the vulva is also vulnerabl e to irritation secondary vaginal secretions, and both the vulva and vagina are vulnerable to contact with external irritants (such as waste of soap, perfumes, fabric softeners, or oxiurus infestation). The vulva and vagina are also sites o f symptoms and injuries of many sexually transmitted diseases such as herpes gen italis, human papilloma virus, syphilis, chancroid, granuloma inguinale, lymphog ranuloma venereum, and molluscum contagiosum (see chapter 28). Vulvitis Vulvar irritation and itching are the reasons for approximately 10% of visits to the gynecologist. The indications of a possible infection include erythema, ede ma, and ulcerations in the skin. Ulcerative lesions should suggest the possibili ty of a sexually transmitted disease such as herpes or syphilis. Other systemic diseases such as Crohn's disease may also occur in the same way. Papillary lesio ns suggest the possibility of a condyloma condyloma acuminatum or a can. The exp

loration of these and other sexually transmitted diseases should be made careful ly. The vulvar skin is also prone to many common skin lesions, including intertr igo, seborrhea, seborrheic dermatitis and psoriasis, as well as allergic reactio ns and parasitic infection such as Pthirus pubis (pubic lice or crabs) and Sarco ptes scabiei (mite .) The excoriation caused by scratching of the patient and th e cracks in the skin of the vulva are commonly found in cases of vulvar irritati on secondary to a vaginal discharge. The itching leads to chronic itching and ex coriation, and when it becomes chronic is sometimes called neurodermatitis. Besi des treating the underlying cause of itching, these patients may benefit from th e use of a corticosteroid cream (hydrocortisone 1% 2-3 times a day) to relieve i nflammation and itching cycles, when it comes to a neurodermatitis. The diffuse redness of the skin accompanied by vulvar itching and / or burning, but without any obvious cause,€suggest the possibility of a secondary allergic vulvitis. Th e list of potential local irritants can be very broad, and includes the feminine hygiene sprays, deodorant tampons or pads (especially with deodorants or perfum es), tight synthetic underwear, colored or scented towels or soap residue or sof tener (used for washing clothes). Even the local use of contraceptives and sex o bjects can be the source of irritation. A careful history, combined with the rem oval of the suspected cause, usually confirms the diagnosis and therapy is neces sary. In rare cases, the use of hydrocortisone cream (1% cream applied two times a day in the affected areas) may be necessary to decrease the local inflammator y response. The causes allergic vulvitis are frequently found in pediatric patie nts who present with vulvovaginal itching. But apart from these causes should be noted that pediatric patients may have other sources of irritation such as a fo reign (especially if accompanied by vaginitis or discharge), as well as residues of sexual abuse or infection oxiurus. Local Candida infection is another cause of vulvar pruritus. This etiology should be considered in patients with diabetes and other persons subject to this infection, as well as in situations where the re is an adequate response to treatment. The diagnosis and treatment are describ ed later in this chapter. In older patients, the intense itching of the vulva ma y occur due to atrophic changes as a result of declining estrogen levels. This i s typically associate with a thin, pale vaginal mucosa, atrophic vaginitis, and a yellowish discharge with a pH greater than 5.5. The skin of the vulva and peri neum have a red appearance, smooth and shiny look something symmetrically. The b iopsy will reflect the hypoplastic nature of this condition and help differentia te it from lichen sclerosus, which has a similar appearance. When atrophic chang es are the cause, estrogen replacement, either local or systemic, is the treatme nt of choice. (See Chapter 38). In the case of lichen sclerosus, the local application of a pr opironato of clobetasol cream 0.05% 2 times a day is usually effective. The alte rnatives that have been used, although less effectively, including the propirona to 2% testosterone and progesterone cream to 3%. Vulvar itching can be caused by P pubis infestation or S. scabiei. (Figure 27.2), especially if the itch is pre sent mons. The itching is caused by allergic sensitization of the bites of paras ites. The crabs or pubic lice is a different kind of head lice and was acquired by close contact sheets or towels. The crabs are found only in hairy areas, whil e the mites, but transmitted in the same way, can be found anywhere on the skin surface. The diagnosis is usually made by viewing their excreta on the skin, lic e or eggs on and along the hair, or switching to the adult form. Local treatment with two applications of lotion hexaclorhidato of benzene (Kwell) is usually su ccessful for the infection of any of these two parasites. The clothes, sheets an d everything that has been in close contact should be disinfected or treated for breaking the cycle of infection. Other specific therapies for both pubic and S. Pthirus scabies include lindane and permethrin. The vulva is prone to them than any other skin diseases of the skin surface. Con tact dermatitis is relatively common, with skin surfaces swollen and red, someti mes with vesicles and secondary infection. The treatment consists of removing th e substance or material cause, and use wet compresses of Burrow's solution, dilu

ted 1 in 20, and applied several times a day followed by the respective drying. Hydrocortisone (0.5% to 1%) or the corticosteroid fluoronizado (Valisone, 0.1%) can be applied several times a day to control symptoms. Psoriasis affects 1% to 3% of women and seems to have a familiar pattern. This disease of the skin and generalized prur itus of unknown cause is presented with redness of the skin and silvery scales a nd is generally refractory to corticosteroid fluoronizado. The hidroadenitis sup purativa is a chronic and relentless skin, causing deep, painful sores, as well as a fetid discharge.€Its differential diagnosis includes Crohn's disease of th e vulva. The local antibiotics and steroids are sometimes successful, but wide e xcision of involved skin areas is generally required. Because of the nonspecific nature of symptoms and physical findings, patients presenting with vulvitis and do not respond to initial therapy should be eligible for a vulvar biopsy to his tologically the underlying etiology. Particularly in older patients, an initial biopsy is often of value, especially if initial therapy failed, a biopsy should usually be applied, since the presentation of one or more medical treatment fail ed without a specific diagnosis by biopsy is often noted in an unrecognized vulv ar malignancy. VAGINITIS The most common symptom associated with infections of t he vagina is the discharge. The discharge from the vagina is physiologically nor mal, therefore, not all vaginal discharge indicate infection. This distinction i s important for the diagnosis but occasionally it is difficult for the patient t o understand or accept. Vaginal secretions arise from several sources. Most of t he liquid portion consists of the cervical mucus. A small amount of moisture fro m the discharge is contributed by the endometrial fluid, exudate accessory gland s as Skene and Bartholin glands, and vaginal transudate. Exfoliated squamous cel ls of the vaginal wall secretion give an opaque white to color and provide some increase in consistency. The action of the vaginal flora itself may also contrib ute to secretion. The sum of all these components are the normal secretions of t he vagina that provides physiological lubrication prevents dryness and irritatio n. The number and characteristics of this mixture vary under the influence of ma ny factors, including hormonal and fluid status, pregnancy, immunosuppression an d inflammation. Asymptomatic women occurs in a range, about 1.5 g of vaginal flu id per day. The normal vaginal secretions are odorless. After puberty, increased levels of glycogen in the vaginal tissue promotes growth of lactobacilli (Doder lein bacilli) in the genital tract. These bacteria convert the glycogen to lacti c acid, reducing pH from a range of 6-8, which is common before puberty (and aft er menopause), the range of normal vaginal pH of 3.5 to 4.5 on a women of reprod uctive age. Lactobacillus addition, a wide range of other aerobic and anaerobic bacteria can usually be found in the vagina at concentrations of 108-109 colonie s per mL of vaginal fluid. Because the vagina is a virtual space, not an open tu be, a relationship of anaerobic bacteria / aerobic 5:1 is normal. Increased vagi nal discharge is associated with an identifiable microbial cause in 80-90% of ca ses. Hormonal or chemical causes account for most of the remaining cases. The Most vaginal infections are caused by synergistic bacteria (bacterial vaginosis, nonspecific vaginitis), fungi (Candida) and protozoa such as Trichomonas vagina lis (trichomoniasis). Bacterial infections represent approximately 50% of infect ions, while fungi and Trichomonas represent approximately 25% each. Through care ful consideration and a simple microscopic research, the etiology of the symptom s of the patient usually can be established. The value is given to the microscop ic examination of vaginal spotting can not be overstated. For this reason, it is suggested that any patient who complains of a vaginal discharge or irritation s hould be assessed directly before therapy. An increase in vaginal discharge is c onsidered physiological during pregnancy and in the middle of the cycle in a non pregnant woman. Although the increase in the amount of discharge is normal at th is time, patients complain of symptoms should be evaluated to rule out pathologi cal causes. Bacterial Vaginosis (BV) was previously thought that the infection w as caused by Gardnerella vaginalis (formerly called Haemophilus vaginalis or Cor ynebacterium), the BV is now understood as a symbiotic infection of anaerobic ba

cteria (Bacteroides, Peptococcus, and Mobiluncus species) and Gardnerella , and both contribute to the clinical findings (Table 27.2). A woman with BV often com plain about a musty odor or fishy odor with increased discharge thin white to ye llow gray. The download may cause some moderate vulvar irritation, usually in ab out one fifth of cases.€Vaginal discharge is slightly adherent to the vaginal w all and has a pH greater than 4.5. Mixing some of these secretions with KOH (10% ) free amine can be detected by its smell of fish (whiff test (the smell test) p ositive). A microscopic examination done under a small amount of saline solution shows a slight increase in white blood cells, accumulation of bacteria, and "cl ue cells" features, which are epithelial cells with numerous coccoid bacteria tr apped on its surface, making them appear to have edge unclear and a cytoplasmic "ground glass" (Figure 27.3). The diagnosis of BV is defined by three of the fol lowing four criteria: (1) homogeneous discharge, (2) pH greater than 4.5, (3) "W hiff test" positive, and (4) presence of clue cells. The BV can be treated with oral metronidazole (Flagyl, 500 mg twice daily for 7 days) or intravaginal cream s, using metronidazole (Metrogel) 0.75% vaginal gel twice daily for 5 days or cl indamycin (Cleocin) vaginal cream 2% once daily for 7 days or 100 mg suppository at bedtime for three consecutive nights. Alternative options include oral metro nidazole 2 g in a single dose, clindamycin 300 mg orally twice daily for 7 days. Still remains a subject of debate, the fact that BV is sexually transmitted or not. Although treatment of the (as) partner (s) sexual (es) of the patient with frequent recurrences is not recommended by the Center for Disease Control, this is a common practice among doctors to treat couples. Table 27.2 Vaginitis - Ecology altered bacterial vaginosis organisms Normal Find ings 108 1011 Anaerobic / aerobic 5:1 1000:1 High Low H2O2 Production of Lactoba cillus Gardnerella 96% 35% 5-60% 95% Mobiluncos 0-5% 50-70% Mycoplasma hominis 1 5-30% 60-70% The trichomonas vaginitis Trichomonas vaginalis is a flagellate pro tozoan that lives only in the vagina, Skene's ducts and male and female urethra, and may be freely transmitted by sex. Over 60% of couples of women with trichom onas infection, may also be infected. Despite the large number of symptomatic ca ses of vaginitis caused by this organism, more than half of women with trichomon as in the vaginal canal are asymptomatic. Symptoms of trichomonas infection vary from mild to severe, and can include vulvar itching or burning, abundant, ranci d-smelling discharge, dysuria and dyspareunia. Although not present in all women , the discharge associated with trichomonas infection is usually "frothy" thin a nd with a greenish-yellow to gray, with a pH greater than 4.5. The examination m ay reveal edema or erythema of the vulva. Petechiae "characteristic" strawberry patches are described as being in the top of the vagina or cervix, but are now f ound in only about 10% of patients affected. The diagnosis is confirmed by micro scopic examination in normal saline suspension. The wet stain may show large num bers of mature epithelial cells, white cells, and trichomonas. The spindle is a protozoan trichomonas slightly larger than white blood cell. It has 3-5 flagella that extend from the narrow end (tail). This scourge produce active motion whic h facilitates identification of the organism. (Figure 27.3) The treatment for trichomonas infection is oral metronidazole. Because trichomon as is sensitive to metronidazole therapy 1 day, with 2 grams orally, usually giv es a 90% cure rate. Treatment with 500 mg two times daily for 7 days or 250 mg t hree times daily for 7 days gives similar results. Many doctors prefer the 1-day therapy because of their low cost and greater compliance with treatment. Metron idazole vaginal gel two times daily for 5 days is also now recommended. Treating sexual partners of women with trichomonas infection is recommended, and often i ncludes a single dose therapy. Abstinence from alcohol when taking metronidazole is necessary to avoid a possible disulfiram-like reaction. The use of metronida zole during pregnancy is not recommended due to reports of teratogenicity. Many doctors, however, use this drug in the last half of pregnancy for highly symptom atic patients. Even when the pH is generally associated with trichomonas infecti on is different to that found in bacterial vaginosis, estimates show a prevalenc e of more than 25% prevalence of bacterial vaginosis in those patients with tric

homonas. Because metronidazole is helpful for these two conditions, this debate is not significant for most patients. This may, however,€be worth considering i n patients who received alternative therapies or in those with frequent recurren ce of vaginal infections. Although follow-up examinations of patients with trich omonas to measure the cure is often recommended, these are not cost-beneficial, except in rare patients with a history of frequent recurrences. In these patient s, reinfection or low compliance of treatment should be considered and the possi bility of infection with more than one agent or other underlying disease. VAGINI TIS Moniliales O Moniliales Candida infections of the vagina are caused by commo n fungi (locate) transmitted through the air. Approximately 90% of infections "m ushrooms" are caused by Candida albicans with <10% caused by Candida glabrata, Candida tro picalis, or Torulopsis glabrata. Candida infections usually do not coexist with other infections and are not considered sexually transmitted, even when 10% of m ale partners have co-infections of the penis. Candidiasis is most likely to occu r in women who are pregnant, diabetic, obese, immunosuppressed with oral contrac eptives or corticosteroids, or have had broad-spectrum antibiotic therapy. The p ractices that keep the vaginal area hot and humid, such as wearing tight clothin g or use protective usual daily, may also increase the risk of yeast infections. The most common complaint in women with candidiasis is itching, although more t han 20% of women may be asymptomatic. The burning, external dysuria and dyspareu nia are also common. Vulvar and vaginal tissues are often bright red and abrasio ns are not uncommon in severe cases. A thick, sticky vaginal discharge "cottage cheese type" ï with a pH of 4-5 is usually found. This download is odorless. The d iagnosis of candidiasis is based on history and physical findings and confirmed by the identification of hyphae and buds on microscope slides (with a drop of wa ter) of vaginal discharge made with 10% KOH solution, which most cells smooth ep ithelial cells and white (Figure 27.3). There is no direct correlation between t he degree of symptoms and the number of organisms present. Because of the false negative tests with microscopic plates are not uncommon, with culture confirmati on can be obtained using the medium or Sabouraud Nickerson. The latex agglutinat ion test may be of particular use for strains other than Candida albicans becaus e these do not show the film pseudohyphae on microscopy. The treatment for yeast infection is mainly topical application of one of the synthetic imidazoles (Tab le 27.3). These agents give good cure rates after 3-7 days of treatment. Althoug h there are more than 90% relief of symptoms with this therapy, 20-30% of patien ts experience recurrence after 1 month. Nystatin-based treatments or povidone ha ve proven less effective than the imidazoles. Resistant strains of Candida tropi calis and Torulopsis glabrata may respond to therapy with gentian violet or Terc onazole. Because the non-compliance of treatment is the most common cause of rec urrence and because some women find the topical agent inconvenient or difficult to implement, treatment with oral agent fluconazole (Diflucan), 150 mg single do se was become widely used. Patients with frequent recurrences should be carefull y evaluated for possible risk factors such as diabetes or immune defects. For re currence or resistance, ketoconazole 100 mg two times daily for 10 days can be e ffective. Local prophylactic therapy with an antifungal agent should be consider ed when systemic antibiotics are prescribed. Table 27.3 Topical treatments for Agent Formula Imidazole Miconazole (Monistat) 2% Cream 200 mg vaginal suppository butoconazole (Femstat) 2% Cream Clotrimazole (Lotrimin gynecology) Cream 1% 100 mg suppository (Micelex-G) Vaginal Tioconazo le ( Vagistat-500 mg Suppository 1) Vaginal Cream 6.5% Polyaenus Trazol 200.000 Nystatin Vaginal Tablet U Terconazole (Terazol) Cream 0.4% 0.8% Cream 80 mg vagi nal suppository Candida vaginitis Dosage 5 grams 2 times a day x 14 days of 1 g daily x 3 days 5 grams each day x 3 days 5 1 1 5 grams per day x 7 days gram daily dose x 7 gram s in one dose

1 per day x 14 days 5 grams each day x 7 days 5 grams each day x 3 days every da y x 3 days VAGINITIS CHRONICLE A problem for both patients and physicians, is vaginitis "ch ronic" or "recurring." The patients complain, often bitterly, persistent vaginal discharge, odor, or both,€without a readily identifiable cause or satisfactory response to treatment. These patients often have "tried everything" and visited many doctors without success. You must obtain a thorough history covering medic al conditions and sexual habits and hygiene. A physical examination and microsco pic evaluation methodology are also required. In addition to the three most comm on causes previously noted, one must evaluate alternative explanations for the c omplaints of these patients. Infection Chlamydia can be presented as a vulvovaginitis. Because Chlamydia trachomatis is the organism most common sexually transmitted in the United States, its role in chronic or recurrent cases should be evaluated (see Chapter 28). Cytolytic Vagi nitis is a common but little known cause of cyclic vulvovaginitis. Although the exact pathophysiology is unknown, is thought to be caused by an overgrowth of la ctobacillus in the vagina, resulting in increased vaginal acidity, with subseque nt cytolysis, vaginal discharge and vulvovaginal irritation. This diagnosis shou ld be considered when common etiologies have been ruled out. A high index of sus picion should be present if the vaginal pH is between 3.5 and 4.5 and symptoms w orsen during the luteal phase. The therapy involves the use of towels instead of tampons, discontinue the medication prior antifungals, and the use of sitz bath s with baking soda (4 tablespoons in 1-2 ounces of hot water) two times a day, a nd showers ( 30-60 grams of baking soda in a quart of warm water) every 2-3 week s. Desquamative inflammatory vaginitis is characterized by purulent vaginal disc harge, exfoliation of epithelial cells with vulvovaginal burning and erythema, r elatively few lactobacilli and overgrowth of Gram-positive cocci, usually strept ococci. The vaginal pH is greater than 4.5. Initial therapy is Clindamycin cream 2% applied daily for one week. The victims of rape (recent or past) can be desc ribed this way. A frank explanation of the possibility of reinfection should be carried out in individuals with true recurrences. The existence of additional se xual contacts for the patient or their partner should be evaluated in a non-judg mental. Alternative sources of excessive vaginal moisture, such as chronic cervi cal infections should be evaluated. When the patient's complaints appear to exce ed the physical and microscopic findings, the possibility of inappropriate expec tations, inaccurate or psychological dysfunction should be taken into account.