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Normal Vaginal Flora:


(+): lactobacillus spp,Staphylococcus aureus,Staphylococcus epidermidis, Group B

Streptococcus, Enterococcus faecalis, Staphylococcus spp

(-): Ecoli, Klebsiella spp, Proteus spp, Enterobacter spp, acinetobacter spp, citrobacter spp,
pseudomonas spp


(+) cocci: Peptostreptococcus spp, Clostridium spp

(+) bacilli: Lactobacillus spp, Propionibacterium spp, Eubacterium spp, Bifidobacterium spp

(-): Bacteroides spp, Prevotella spp, Bacteroides fragilis group, Fusobacterium spp, Veillonella

Yeast: Candida albicans and other spp

Within this vaginal ecosystem, some microorganisms produce substances such as lactic acid and hydrogen
peroxide that inhibit nonindigenous organisms (Marrazzo, 2006). In addition, several other antibacterial
compounds, termed bacteriocins, provide a similar role and include peptides such as acidocin and lactacin.
Moreover, some species have the ability to produce proteinaceous adhesions and attach to vaginal epithelial

For protection from many of these toxic substances, the vagina secretes leukocyte protease inhibitor. This
protein protects local tissues against toxic inflammatory products and infection.

Vaginal pH:
4.0 - 4.5, it is believed to result from

- lactobacillus species production of lactic acid, fatty acids, and other organic acids.
- anaerobic bacteria produce amino acid fermentation, organic acid production.
- Glycogen as the food for the normal flora.

In menopause women : ↓/- glycogen ⇒ pH 6.0 -7.5

References: William obsgyn, access medicine, slide lectures

Bacterial Vaginosis (BV)
This common and complex clinical syndrome reflects abnormal vaginal flora. include Haemophilus vaginitis,
Corynebacterium vaginitis, Gardnerella or anaerobic vaginitis, and nonspecific vaginitis.

Also associated with significant ↓/- of normal H O – producing lactobacillus species

2 2

RF: new/multiple sexual activity, oral sex, douching, black race, smoking, sex during menses, IUD, Early age
of sexual intercourse

DX: wet prep- use cotton swab to take vaginal discharge sample and mix it with few drops of saline

Result: Clue cells, Squamous cells are covered with bacteria to the extent that cell borders are blurred and
nuclei are not visible

Whiff test: add 10% KOH to fresh sample vaginal secretion⇒ release volatile amines that have a fishy

Characteristic: pH>4.5, becoz disminished acid production by bacteria

Outcome: Vaginitis, endometritis, postabortal endometritis, pelvic inflammatory disease unassociated with
Neisseria gonorrhoeae or Chlamydia trachomatis, and acute pelvic infections following pelvic surgery,
especially hysterectomy


Table 3-3 Recommended Treatment of Bacterial Vaginosis

Agent Dosage

Metronidazole 500 mg orally twice daily for 7 days

Metronidazole gel 0.75% 5 g (1 full applicator) intravaginally once daily for 5 days

Clindamycin cream 2% 5 g (1 full applicator) intravaginally at bedtime for 5 days

Herpes Simplex Virus Infection chronic viral infection

There are two types of herpes simplex virus, HSV-1 and HSV-2. Type 1 HSV is the most frequent cause of
oral lesions. Type 2 HSV is found more typically with genital lesions.

Infected patients can shed infectious virus while asymptomatic, and most infections are transmitted sexually

RF: Sexually active, 65% women

Symptoms: incubation= 1 week

References: William obsgyn, access medicine, slide lectures

- burning, severe pain
- frequency urination and/or dysuria
- infect viable epidermal cells→ erythema and papule formation
- Blisters← cell death and cell wall lysis
- Viremia: Low grade fever, malaise, cephalalgia

3 stages of lesions are: (1) vesicle with or without pustule formation, which lasts about a week; (2)
ulceration; and (3) crusting.


- gold standard = tissue culture, high specificity but low sensitivity. 50 % + in recurrent disease.


- Serologic type-specific glycoprotein G–based assays ≈ detect HSV 1 and 2 antibody; >96%


Initiate the treatment after physical examination.

First Clinical Episode of Genital Herpes

Acyclovir 400 mg 3x/day x 7 to 10 days or 200 mg 5x/day x 7 to 10 days

Famciclovir 250 mg 3x/day x 7 to 10 days
Valacyclovir 1 g 2x/day x 7 to 10 days
Episodic Therapy for Recurrent Disease

Acyclovir 400 mg 3x/day x 5 days or 800 mg 2x/day x 5 days

Famciclovir 125 mg 2x/day x 5 days or 1g 2x/day x 1 day
Valacyclovir 500 mg 2x/day x for 3 days or 1 g 1x/day x 5 days.

Oral Suppressive Therapy Options

Acyclovir 400 mg 2x/day

Famciclovir 250 mg 2x/day
Valacyclovir 0.5 to 1 g 1x/day

is a sexually transmitted infection caused by the spirochete Treponema pallidum, which is a slender
spiral-shaped organism with tapered ends

RF: low socioeconomic groups, adolescent, early sexual activity, large number sexual partners

References: William obsgyn, access medicine, slide lectures

Primary syphilis

- Hallmark lesion is termed: chancre= spirochetes are abundant

- it is an isolated nontender ulcer with raised rounded borders and an uninfected but integrated base

- Commonly found on the cervix, vagina, or vulva, but may also form in the mouth or around the anus

- This lesion may develop 10 days to 12 weeks after exposure, with a mean incubation period of 3

Secondary Syphilis

- Associated with bacteremia

- Develops 6 weeks- 6 months after chancre

- Hallmark= maculopapular rash of palms, soles, and mucous membranes. In warm, moist body areas,
this rash may produce broad, pink or gray-white, highly infectious plaques called condylomata lata

- Viremia +

Latent Syphilis : period > 1 year after initial infection

Tertiary Syphilis : untreated syphilis up to 20 years after latency

DX: dark-field examination/ direct fluorescent antibody testing of lesion exudate. treponemal-specific tests
may be selected: (1) fluorescent treponemal antibody-absorption (FTA-ABS) or (2) Treponema pallidum
particle agglutination (TP-PA) tests

Treatment :

Primary, secondary, early latent (<1 year) syphilis

Benzathine penicillin G, 2.4 million units IM once

Alternative oral regimens (penicillin-allergic, nonpregnant women):

Doxycycline 100 mg orally twice daily for 2 weeks

Tetracycline 500 mg orally four times daily for 2 weeks


Vaginitis is the diagnosis given to women who present complaining of abnormal vaginal discharge with vulvar
burning, irritation, or itching mostly caused by bacterial vaginosis, candidiasis, and trichomoniasis

References: William obsgyn, access medicine, slide lectures

Table 3-15 Summary of Characteristics of Common Vaginal Infections
Category Physiologic Bacterial Vaginosis Candidiasis Trichomoniasis Bacterial
(normal) (streptococcal,
E coli )

Chief None Bad odor, increased Itching, burning, Frothy discharge, bad Thin, watery
complaint after intercourse discharge odor, dysuria, pruritis, discharge, pruritis

Discharge White, clear Thin, gray or white, White "cottage Green-yellow, frothy, Purulent
adherent, often increased cheese like" adherent, increased

KOH "whiff Absent Present (fishy) Absent May be present Absent


Vaginal pH 3.8–4.2 >4.5 <4.5 >4.5 >4.5

Microscopic N/A "Clue cells", slight Hyphae and buds Trichomonads Many WBCs
findings increase in WBCs, clumps in 10-percent KOH (protozoa with 3-5
of bacteria (saline wet solution (wet flagella) may be seen
mount) mount) moving on saline wet

E coli = Escherichia coli; KOH = potassium hydroxide; N/A = not applicable; WBC = white blood cell.

Fungal Infection

>>> caused by candida albicans

RF: warmer climates, obese, imunosupres, diabetes mellitus, pregnancy, sexual transimited, orogenital sex.


References: William obsgyn, access medicine, slide lectures

Butoconazole 2% cream 5 g intravaginally for 3 days a

Clotrimazole 1% cream, 5 g intravaginally 7 to 14 days a

Miconazole 2% cream, 5 g intravaginally for 7 days a

Nystatin 100,000-unit tablet intravaginally for 14 days

Tioconazole 6.5% ointment, 5 g intravaginally once a

Terconazole 0.4% cream, 5 g intravaginally for 7 days Or 0.8% cream, 5 g intravaginally for 3 days

Oral agent

Fluconazole 150 mg oral tablet once


Women>men; in men asymptomatic; 70 percent of male partners of women with vaginal trichomoniasis will
have trichomonads in their urinary tract.

DX: incubation 3-4 weeks, vagina, urethra, endocervix, and bladder can be infected

Symptoms: liat table atas Additionally, dysuria, dyspareunia, vulvar pruritus, and pain may be noted.

In Vulva - erythematous, edematous, and excoriated.

In Vagina- subepithelial hemorrhages or "strawberry spots"

Treatment :

Primary therapy

Metronidazole single 1-g dose orally

Tinidazole single 2-g dose orally

Alternative regimen

Metronidazole 500 mg orally twice daily for 7 days


Neisseria gonorrhoeae

In women is asymptomatic

RF: age < 25 years

References: William obsgyn, access medicine, slide lectures
Presence of other STI

History of previous gonococcal infection

New/multiple sex partners

Lack barrier protection

Drug use, and commercial sex work.


- present as vaginitis or cervicitis.

- w/ the Cervicitis: profuse odorless, nonirritating, and white-to-yellow vaginal discharge.

- if infect the bartholin and skene glands, lead to ascending to upper Reproductive tract infection.

DX: Coccobacillus (-); invade columnar and transitional epithelial cells, becoming intracellular.


Ceftriaxone 125 mg IM

Cefixime 400 mg orally

Ciprofloxacin 500 mg orally

Ofloxacin 400 mg orally

Levofloxacin 250 mg orally

Haemofilus Vaginalis Vaginitis

- basil (-)

- leukorea: putih keabu-abuan; kadang kuning, dan disertai bau tidak sedap

- gejal; gatal-gatal

- ditularkan melalui intercourse

- DX: pada sediaan ditemukan basil, dengan leukosit jarang, banyak epithel yang ada bintik-bintiknya= clue cell

References: William obsgyn, access medicine, slide lectures


Usually prepubertal girls; complains: ulvar discomfort, dysuria, and itching.
Usually in prepubertal girls
- Appearance: vesicles or papules form on bright red edematous skin
- In chronic cases→ scaling, skin fissuring, and lichenification.
- children may develop diaper dermatitis as a result of urine and stool exposure
- Significant pruritus may develop from contact or allergic vulvitis.

Treatment :
- keep the skin dry
- 1 or 2 x/day sitz bath (+ baking soda 2 sdm in warm water and soaking for 20 min)
- Topical creams, lotions, and ointments
- If itching is severe →
oral hydroxyzine hydrochloride 2 mg/kg/d divided in four doses
or 2.5-percent topical hydrocortisone cream twice daily for 1 week.

LICHEN SCLEROSUS Hypoestrogenism or with



Symptom: intense itching, discomfort, bleeding, excoriations, and dysuria

References: William obsgyn, access medicine, slide lectures

Vulva→hypopigmentation; atrophic, parchment-like skin; and occasional fissuring.
Lession →simetrical, Form an hour glass appearances around vulva & perinaal
DX: by visual inspection
Treatment: topical corticosteroid cream e.g 2.5-%hydrocortisone 6 weeks

The dose may be lowered to 1 % continue for 4-6 weeks

Infection → Vulvitis
A β-hemolytic Streptococcus→ bright beefy-red vulva and introitus, dysuria, vulvar pain, pruritus, or
Treatment : 1 generation penicillin/cephalosporin or other for 2-4 weeks

Candida species- rare in prepubertal

Dx: visual inspection of a reddened, raised rash with well-demarcated borders and
occasional satellite lesions. Microscopic examination of a vaginal sample
prepared with 10-percent potassium hydroxide (KOH) will help identify hyphae
Treatment: 2x/day clotrimazole, miconazole, or butaconazole for 10 to 14 days or
until the rash is cleared.
and pinworms/Enterobius vermicularis
→vulvar itching, particularly at night.
Nocturnal pruritus, 1 cm threadlike white worms that often exit the anus at night
DX: inspecting the area during night with flashlight identify worms exiting the anus.
Scotch-tape test entails pressing a piece of tape to the perianal area in the
morning, affixing the tape to a slide, and visualizing eggs with microscopy
Treatment : mebendazole 100 mg orally

•Vulvitis dapat dibagi menjadi 3 golongan:

b.Orificium uretra eksternum, Gl. Parauretra  GO
c.Bartholin: Bartholinitis

2.Timbul bersama-sama atau sebagai akibat dari vaginitis  Vulvovaginitis

3.Permulaan atau manifestasi dari penyakit umum:

References: William obsgyn, access medicine, slide lectures

–Penyakit kelamin (PMS): GO, sifilis, dsb
–Virus: limfogranuloma venerum, herpes, kondiloma

•Penyebab: gonorhea, streptokokus dan Coli.
•Bartholinitis akut: kelenjar kemerahan, nyeri, penangangan dengan pemberian antibiotik.
•Abses Bartholin: kelenjar Bartholin berisi pus, penanganan dengan insisi abses.
•Jika infeksi berulang-ulang  kista Bartholin, penanganan dengan ekstirpasi kista atau marsupialisasi.

References: William obsgyn, access medicine, slide lectures