Makassar, 2 April 2019

PBL REPORT
MODULE 4 Whitish
BLOCK REPRODUCTION

Arranged by :
group 8
Ade Apriani ratnasari 11020150049
Fatimah Marwah 11020160059
Muhammad sothyan Fajrin 11020160018
Resky karnita goddess 11020160072
Dwi Deno zubiranto 11020160038
Ridha Mardhatillah 11020160048
Siti Khadijah Nawir 11020160058
Goddess daughter pratiwi 11020160068
A. Nashira iswalaily 11020160078
Sulfiani 11020160088
tutor:
dr. Yusriani Mangerangi M.Kes

MEDICAL SCHOOL
MUSLIM UNIVERSITY OF INDONESIA
MAKASSAR
2019
SCENARIO 2 :

A woman, aged 35 years, P3A0, came to the clinic with complaints of

whitish since 1 month ago. Discharge from the vagina white as milk and
clotted, smelling, and itchy. History hormonal acceptors INJ 4 weeks 3
months ago

KEYWORDS

- A woman 35 years
- P3A0
- Whitish since 1 month ago
- Discharge from the vagina white as milk and clotted, smelling, and
itchy
- History hormonal acceptors INJ 4 weeks 3 months ago
-

QUESTION

1. Explain the definition and classification of whiteness!

2. Explain Mechanism whiteness!
3. Explain the cause of vaginal discharge!
4. Mention the signs and symptoms of vaginal discharge!
5. Mention predisposing risk factors and whiteness!
6. Describe the relationship history of injection acceptors on the scenario!
7. Describe the steps diagnosis!
8. Any disease that causes vaginal discharge?
9. What is the differential diagnosis of scenario?
10. How whitish prevention?
11. Perspective of Islam under the scenarios!

ANSWER QUESTIONS
1. Explain the definition and classification of whiteness!
Fluor albus (vaginal discharge, leukorrhea, vaginal discharge) is the
term used for a discharge from the female genitalia instead of
blood. Whitish is a condition that is often experienced by women
throughout the life cycle starting from adolescence, the reproductive
years or menopause. Whitish very risky in teenagers that need
special attention. This time, girls experience puberty is marked by
menstruation. In some people when menstruating may experience
vaginal discharge. Whitish divided into 2 types of normal or
physiological vaginal discharge and abnormal or pathological.
a. Physiological vaginal discharge is a discharge sometimes in
the form of mucus which contains epithelium with leukocyte
rare, whereas the content of leukositnya many pathological
vaginal discharge. Whitish physiological influenced by
hormonal changes, which usually occurs at the time before
and after menstruation, around the secretion phase between
days 10-16 of the menstrual cycle, when aroused,
pregnancy, fatigue, stress and taking hormonal drugs such
as birth control pills.
b. Pathological whitishis a lot of fluid exudate containing
leukocytes. This happens because the body's reaction to
injury (injury). The lesion is usually caused by infection with
microorganisms such as fungi (Candida albicans), parasites
(Trichomonas), and parasites (E. coli, Staphylococcus,
Treponema pallidum). Fluor Albus also be caused by a
foreign object, benign neoplasms, lesions, precancerous and
malignant neoplasms.

Physiology Pathology
odorless smelling
Clear cloudy
leukocytes rarely leukocytes many
The hormone estrogen Infection pathogens (bacteria, fungi,
viruses)
coital stimulation physical trauma
Before and after menstruation hormonal contraceptives
Stress or fatigue Foreign object
Newborns (BBL) Vaginal pH changes
pre menopause Reproductive organ abnormalities
many mucus
many epithelial
Not accompanied by complaints

References:
 Persia, A. Gustia, R. Bahar, E. 2015. Use of Panty Liner
relationship with Fluor Albus incident on High School
Students in Padang Based Guided Interview (questionnaire).
Padang: Andalas Medical Journal. 509 pages.
 Marhaeni, GA 2016. Discharge in Women. Denpasar: Scale
Husada Journal Vol 13 No 1. Page 30.
 Abrori, Hernawan AD, Ermulyadi. 2017. Factors Associated
With Pathologic Whitish Genesis SMAN 1 Simpang Hilir

2. Explain Mechanism whiteness!

A. Normal vaginal discharge

Normal vaginal discharge may occur during the premenstrual, at

around the secretion phase between 10-16 days of menstruation.
Physiological vaginal discharge occurs due to the influence of estrogen
and progesterone are produced during the process of ovulation. After
ovulation, increased vascularization of the endometrium which causes the
endometrium becomes swollen. Endometrial glands become winding
influenced by the hormones estrogen and progesterone from the corpus
luteum to secrete a clear fluid known as whitish

B. Abnormal vaginal discharge

Lactobacillus acidophilus is the dominant bacteria in the vaginal

ecosystem. Lactobacillus helps maintain normal vaginal pH (3.5 to 4.5) by
producing lactic acid, which balances the ecosystem vagina.2

Whitish caused by changes in pH around the genital organ which

originally acidic becomes more alkaline. acidic pH in the female genital
serves as a defense mechanism against genital pathogens in the area,
which turned into alkaline pH is not only causing pathogens can mengivasi
genital area but also normal floras that exist in the genital area becomes
pathogenic. The existence of these conditions cause the vagina to remove
secretions that depend on the cause or microorganisms that cause vaginal
discharge. Manifestations of discharge depending on the cause of vaginal
discharge.

Biokomuniti vaginal ecosystem is a dynamic and complex that consists

of different elements that influence each other. One component of the
vaginal ecosystem is full of endogenous vaginal microflora, consisting of
gram-positive and gram-negative aerobic, facultative and obligate
anaerobic bacteria. Synergistic and antagonistic action between
endogenous vaginal microflora together with other components, resulting
remained stable ecological system that leads to vaginal ecosystem health.
Some of the factors / conditions that result in changes in the balance of
causing imbalance in the vaginal ecosystem and changes in vaginal
microflora. In equilibrium, the vaginal ecosystem is dominated by
Lactobacillus bacteria that produce organic acids such as lactic acid,
hydrogen peroxide (H2O2), and bacteriocins.
Lactic acid such as organic acid produced by Lactobacillus lanilla,
plays an important role in maintaining the pH remains below 4.5 (between
3.8 to 4.2), which is not the appropriate place for bacterial growth of
pathogenic microorganisms, especially for the vagina , The ability to
produce H2O2 is another mechanism that causes the live Lactobacillus
dominant than obligate anaerobic bacteria lacking the enzyme catalase.
Hydrogendominant peroxide contained in the normal vaginal ecosystem
but not in bacterial vaginosis. The third mechanism of defense is a
bacteriocins produced by Lactobacillus, which is a low molecular weight
protein that inhibits the growth of bacteria, especially Gardnerella
vaginalis.
G. vaginalis itself is also a variable rod anaerobic gram
experiencing hiperpopulasi thereby replacing the normal vaginal flora from
being acidic becomes alkaline. This change is due to a reduced number of
Lactobacillus that produce hydrogen peroxide. Lactobacillus itself is a
large trunk anaerobic bacteria that help keep the acidity of the vagina and
inhibit other anaerobic microorganisms to grow in the vagina.
Vaginal discharge is a common and normal in women of childbearing age.
Under normal conditions, the glands of the cervix produce a clear liquid
that comes out, mixed with bacteria, vaginal cells are separated and
secretion from the glands of Bartolini. In women, vaginal discharge is a
thing of the body's natural self-cleaning, as a lubricant, and the defense of
various infections. Under normal conditions, the vaginal discharge appears
clear, cloudy white, or yellowish in color when it dries on clothes, has a pH
of less than 5.0 is composed of epithelial cells that mature, normal number
of leukocytes, without fungi, Trichomonas, without a clue cells.
In bacterial vaginosis can occur symbiosis between G. vaginalis as
forming amino acids and facultative anaerobic bacteria in the vagina along
with that change amino acids to amines that raise the pH of the vaginal
secretions up an appropriate atmosphere for the growth of G.
vaginalis.Beberapa amines are known to cause skin irritation and add the
release of epithelial cells and cause body odor discharge that comes out
of vagina.Basil-basil accompanying anaerobic bacterial vaginosis among
Bacteroides Bivins, B. and B. disiens Capilosus that can be isolated from
genitalia.G infection. vaginalisattached to the vaginal epithelial cells in
vitro, and then add the desquamation of vaginal epithelial cells, causing
the body to the wall attachment vagina.Organisme duh is not invasive and
limited local inflammatory response can be evidenced by the small number
of leukocytes in the vaginal secretions and by histopathologic examination.
The emergence of bacterial vaginosis nothing to do with sexual activity or
have had Trichomonas infection.

The immune system against the whiteness:

A. Immune System in Normal vaginal discharge

 Ecosystem vaginal mucosa consists of stratified squamous
epithelium covered by layers of mucous continuously lubricated by fluid
servicovaginal (CVF), which contains product epithelial cells, such as
mucus and antimicrobial molecules B-defensin, lipocalin, Elafine and
secretion leukocyte protease inhibitor (SLPI) [ 1,2], IgA and IgG antibody
produced by plasma cells mucosa. CVF constantly lubricate the
epithelium, maintain the fluidity of the ecosystem and is the first line of
defense against exogenous pathogens colonization through mucus trap
microbial activity and facilitate its binding to the antibody

B. The immune system in pathological whitish

Sex hormone is the main regulator of this interaction: the hormone

regulates the production of antimicrobial peptides (beta-defensins, alpha
defensins, SLPI) and pro-inflammatory cytokines (IL-6, IL-8)

When the dominance of Lactobacillus lost and microbial diversity

increases, changes in immunity and homeostasis epithelium often arise,
induced by a variety of mechanisms, such as: (a) the production of
cytokines and chemokines proinflammatory, (b) the recruitment of immune
cells (c) reduction in the viscosity of CVF, because production degrading
enzymes mucin (including sialidase, α-fucosidase, α-and β-galactosidase,
N-acetyl-glukosaminidase, and glycine and arginine aminopeptidases.
Changes in the physical / chemical in the vaginal ecosystem ultimately
affect the barrier properties of the CVF and epithelium genital and improve
the risk of infection is sexually transmitted pathogens

Reference: M. Torcia 2019. Interplay among Vaginal Microbiome, Immune

Response and Viral Sexually Transmitted Infections. Department of
Clinical and Experimental Medicine, University of Florence, 50139
Florence, Italy; Page 1-2
3. Describe the cause of vaginal discharge!

Fluor albus physiological in women normally only found on porsio

vaginal area. Pathological secretions usually found on the lateral and
anterior wall of the vagina.
Fluor albus physiological found at:
a) Newborns up to the age of approximately 10 days: here is why is the
effect of estrogen on the uterus and vagina placenta to the fetus.
b) Before or after menstruation.
c) Adult women when stimulated before and during coitus, caused by
spending the transudation of vaginal walls. This relates to the
readiness to accept the penetration of the vagina intercourse.
d) Ovulation, secretions from the glands of the uterine cervix becomes
more dilute.
e) gestation
f) Stress and fatigue
g) Hormonal Contraception
h) Spending cervical secretions from glands also increased in women
with chronic disease, and in women with uterine porsionis ectropion
Fluor albus pathological found at:
1) irritation:
Irritants such as semen, lubricant, condoms, soap, antiseptic
liquid for bathing., Cleaning the vagina, the pants are tight and do not
absorb perspiration colored toilet paper.

2) Tumors or other abnormal tissue

Tumor or cancer will cause fluor albus pathological due to
interference with normal cell growth that is excessive, causing the cells
 to grow very rapidly abnormally and easily broken, resulting in decay
and bleeding due to rupture of blood vessels that grow to provide food
and O2 in the tumor cells or cancer.
In such circumstances there will be spending a lot of fluids and
stinking due to the decay process and is often accompanied by fresh
blood.
3) Foreign object
Tertinggalnya foreign bodies such as condoms or a particular
object that is used during intercourse, the ring pessary used women
with uterine prolapse can stimulate the vagina caian spending
excessively. If this stimulus will cause injury is likely to occur
concomitant infection of the normal flora in the vagina so that the
resulting fluorine albus.

4) Radiation
5) fistula
6) Other causes:
1. Psychology: psychosomatic Volvovaginitis
2. Unknown: "Desquamative inflammatory vaginitis"
7) Infection
a. bacterium
There are the normal vaginal flora composed of "good"
bacteria that function in the balance of the ecosystem while
maintaining acidity / pH normal as well as some other bacteria in
small amounts such as Gardnerella vaginalis, Mobiluncus,
Bacteroides, and Mycoplasma hominis.
Some circumstances such as pregnancy, the use of spiral /
IUD (intrauterine device), sexual intercourse, promiscuity can lead
to an imbalance of the normal vaginal flora in which the growth of
bacteria "evil" becomes redundant. Whitish caused by bacteria
called bacterial vaginosis Gardnerella / BV.
 Whitish usually watery, grayish white in color and smelled
fishy (fishy odor). The smell wafted over stabbing after sexual
intercourse and cause menstrual blood smells bad. If found
irritation such as itchy vaginal area is usually milder than the
discharge caused by fungi and parasites.

 Gardanerrella vaginalis
Gardnerella vaginalis can cause bacterial vaginosis in
women. One of the Haemophilus species, growing, small, circular,
gray colonies, under a microscope looks gram-negative, but
actually coined the cell wall of gram-positive, epithelial cells which
encase the bacteria.These bacteria are usually filled with a vaginal
epithelial cells forming a typical formation and called clue cells.
Gardanerrella produce amino acid that is converted into amine
compounds that cause a fishy smell like fish. These infections
cause itching and annoying. Liquid color gray, watery, frothy and
bermau fishy. These bacteria also can trigger venereal diseases
such as syphilis and gonorrhea
b. mushroom
Whitish fungal infections caused by Candida albicans is
generally triggered by factors from both inside and outside the body
such as the use of birth control pills, certain drugs such as steroids,
antibiotics, low immunity, climate, heat and humidity. Secretions that
come out are usually yellowish-white, like the head of the milk
(cottage cheese), distinctive smell and cause intense itching in the
intimate areas of the vulva and surrounding so-called vulvovaginitis.
Itching is often a predominant complaint is felt.

 Candida albicans

Issued usually viscous liquid, milky white as milk rupture or

like cheese, and often accompanied by itching. Vagina looks red
due to the inflammatory process. With 10% KOH looked yeast cells
(blastospora) and pseudo hyphae (pseudohyphae). Some
circumstances can be a fertile place for fungal growth are
pregnancy, diabetes mellitus, users of the contraceptive pill. Couple
patients usually also will suffer from this fungus. The situation is
mutually transmitted between spouses referred to as ping-pong
phenomenon.
 c. Parasite
Trichomonas vaginalis parasite infections included in the
group of sexually transmitted diseases (STDs) for transmission
primarily occurs through sexual intercourse but also through
contact with toiletries, lip toilet that has terkontaminasi.Keputihan
form of yellow-green discharge, thick, frothy and smells bad
(malodorous). Sometimes vaginal discharge occurs causing itching
and irritation in the intimate area.
 Trichomonas vaginalis
These parasites berbetuk oval and feather mempuyai
shakes and can move rapidly spinning. This movement can be
monitored with a microscope. Modes of transmission of this disease
with intercourse. Rarely can also be transmitted via toiletries, such
as towels or toilet lip.

References:
- Badaryati, Emi. 2012. Factors Affecting Behavior Prevention and
Treatment of Pathologic Whitish At High School Students orEqual in
KotaBanjarbaru2012. Depok: FKM UI. Page 10.
- Jawetz, Melnick, Adelberg. Medical Microbiology. 25. Issue EGC:
Jakarta
4. List the signs and symptoms of vaginal discharge!
 a. Physiological whitish
The characteristics of the physiological vaginal discharge
is a clear liquid, sometimes creamy white, odorless, and
without complaints, such as itching, pain, and burning and
few in number. fluid that comes out sometimes in the form
of mucus which contains epithelium with leukocyte rare.
b. Pathological whitish
Distinctive whitish pathological is there are a lot of
leukocytes, numerous, arise constantly, color change
(usually yellow, green, gray, and like milk), accompanied
by complaints (itching, burning, and pain) and smell
(musty, fishy and foul).

References:

- Prawirohardjo, Sarwono. Obstetrics. Issue 5 Jakarta: PT Bina Library

Prawirohardjo Sarwono.
5. Mention predisposing risk factors and whiteness!

 Predisposing factors (underlying, originator)

There are two things to be a motivating factor vaginal discharge that

is infectious and non-infectious factors.

1) Factors that infection of bacteria, fungi, parasites, and viruses.

2) Non-infectious namely:

- The entry of foreign objects into the vagina, either intentionally

or unintentionally to injure the vaginal epithelium,

- The area around the vagina moist,

- Body condition of stress, such as body condition is always

tense or anxious,

- Urinary incontinence,

- Poor personal hygiene or less appropriate:

 o Sitting and squatting on the ground carelessly,

o Lack of maintaining personal hygiene during

menstruation, often do not replace the pads during

menstruation.

o Underwear that absorbs sweat less,

o Rarely change underwear,

o Wash the genitals with dirty water (water is less clean),

o Rinse excessive wear.

 Risk factor (characteristics, habits, signs or symptoms that appear in

an individual or population prior to developing a disease)

custom not maintain good hygiene with the reproductive organs

such as washing with dirty water, rinse excessive wear, using a pair that

does not absorb sweat, rarely change underwear and rarely replace the

pads.

Attitude (behavior) to keep their genitalia such as washing with

unclean water, use soap excessive vaginal cleaning, use underwear that

does not absorb sweat, rarely change underwear, do not frequently

change pads during menstruation can trigger the onset of infection that

cause vaginal discharge

Environment, Is in hot tropical regions causes excessive sweating,

sweat makes the body becomes moist, especially in the genital organs. As

a result, bacteria and fungi can multiply so disturbed ecosystems in the

vagina that can cause odor and infection. That's necessary in balancing

the ecosystem by doing personal hygiene, to avoid the onset of infection

that can cause vaginal discharge

douchingan act to wash or clean the vagina with water or a mixture

consisting of water, vinegar, baking soda and iodine. Interest douching

actually for therapeutic purposes is to clean the vagina due to surgery and

to provide a useful antiseptic to reduce bacterial growth. Douching can

disturb the balance of the vaginal flora (normal organisms that live in the

vagina) and the acidity of a healthy vagina. In a healthy vagina artifacts

good bacteria and bad bacteria. Balance between the two types of

bacteria to help maintain the acidity level of the existing environment so

that the vagina does not need "help" from outside. Engineering from the

outside it can cause excessive growth of bad bacteria that can lead to

infection or bacterial vaginosis.

References: Elmia Kursani, HM (2015). Factors that affects occurrence of

Flour Albus (Whitish) Teen Putridi SMA PGRI Pekanbaru 2013. Maternity
and Neonatal Journal Volume 2 No. 1, 31.

6. Describe the relationship history of injection acceptors on the

scenario!

In the study Syahlani et al (2013), that the use of hormonal

contraception injections, pills and implants can cause vaginal discharge
due to estrogen and progesterone levels contained by such hormonal
contraception. The occurrence of whitish in injectable hormonal
contraceptive use in accordance with the theory Sulistyawati (2013)
because the hormone progesterone alter vaginal flora and pH, so the
mushrooms are easy to grow and cause a vaginal discharge. Old picture
of the type of hormonal contraceptive use, most of the respondents who
use contraception more than three years of 72 people (74%), while less
than three years as many as 25 people (26%).

According to research Fakhidah (2014), that the incidence of

vaginal discharge can be affected by duration of use of hormonal
contraceptives because of hormonal imbalance in the female body. The
instability of the ecosystem of the vagina will cause vaginal discharge, the
stability of the vaginal ecosystem can be affected secretion (discharge
from the uterus), hormonal status (puberty, pregnancy, menopause),
foreign objects (IUD, tampons, and a drug that is inserted through the
vagina), diseases caused by relationship sex, drugs (contraceptives), diet
(mostly carbohydrates, lack of vitamins)

There is a connection with the use of this type of hormonal

contraceptive vaginal discharge incidence of family planning acceptors.
This is in line with research Syahlani et al (2013) found no association
between hormonal contraceptive use with whitish events in Puskesmas
Pekauman Banjarmasin. Hormonal contraception is contraception where
estrogen and progesterone to provide feedback on the pituitary gland
through the hypothalamus, causing obstacles to the follicles and ovulation
Adverse effects of excess estrogen, side effects that often occur are
nausea, fluid retention, headaches, pain in the breast, and fluor albus, or
white. In addition to the side effects of excess estrogen, progesterone also
has side effects if an overdose can cause irregular bleeding, increased
appetite with weight gain, acne (pimples), alopsia, sometimes the breasts
shrink, fluor albus (white), hypomenorrhea. Fluor albus are sometimes
found on hormonal contraception with progesterone in high doses, due to
increase in infection with candida albicans. Thus we are obliged to
maintain cleanliness and hygiene in the genital region. Discharge can be
prevented by maintaining the cleanliness of the genitalia, choose the right
underwear, avoid infection risk factors such as changing sexual partners,
as well as gynecological examination regularly. Fluor albus are sometimes
found on hormonal contraception with progesterone in high doses, due to
increase in infection with candida albicans. Thus we are obliged to
maintain cleanliness and hygiene in the genital region. Discharge can be
prevented by maintaining the cleanliness of the genitalia, choose the right
underwear, avoid infection risk factors such as changing sexual partners,
as well as gynecological examination regularly. Fluor albus are sometimes
found on hormonal contraception with progesterone in high doses, due to
increase in infection with candida albicans. Thus we are obliged to
maintain cleanliness and hygiene in the genital region. Discharge can be
prevented by maintaining the cleanliness of the genitalia, choose the right
underwear, avoid infection risk factors such as changing sexual partners,
as well as gynecological examination regularly.

The use of injectable contraceptives and contraceptive pill is a

contraceptive method that is very popular in Bangladesh. Contraceptive
injections and pills containing estrogen and progesterone, Depo-Provera
(DMPA) is used by over 15 million women over 90 countries. Thus
Candida albicans thrive, because contraceptives containing estrogen and
progesterone, which can increase the vaginal glycogen is converted into
lactic acid by lactobacilli. Thus the excessive growth of Candida species
occurs due to a decrease in pH. Found the relationship between hormonal
contraceptive use with whitish events in Puskesmas Pekauman
Banjarmasin. The use of hormonal contraceptives may cause increased
incidence of fluor albus. Injectable hormonal contraceptives and pills have
side effects occurrence of discharge. Thus we must maintain the
cleanliness and health. in the genital region. Discharge can be prevented
by maintaining the cleanliness of the genitalia, choose the right
underwear, avoid infection risk factors such as changing sexual partners,
as well as regular gynecological examination

Reference: Syahlani, A., Redjeki, SSD, and Rini. 2013. Relationships

Hormonal Contraceptive Use and Knowledge Capital On Reproductive
Organs Treatment With Whitish Genesis Puskesmas Wilyah Pekauman In
Banjarmasin. Dynamics of Health. Vol. 12. No. 12. December 17. 2013.

7. Describe the steps diagnosis!

The diagnosis is made by history, physical examination, examination and

laboratory tests
Figure 1. Table differences in clinical findings on discharge

1) anamnesis
That must be considered in the history are:
a. Age
Should be considered related to the effects of estrogen. Babies of
women or in older women, vaginal discharge (leukorrhea / fluor
albus), which may be due to the effect of high estrogen and a
physiological discharge. Women of reproductive age should be
considered the possibility of an STI (Sexual Disease) and other
infectious diseases
b. In women with older age have to think about the possibility of
occurrence of malignancies, especially cervical cancer
c. Contraceptive methods used
On the use of hormonal contraceptives may increase the secretion
of cervical glands. This situation can be exacerbated by a fungal
infection. The use of IUD (Intra Uterine Device) also can cause
infection or irritation of the cervix meragsang cervical gland
secretion is increased
d. sexual contact
To anticipate the result leukorea PHS, such as gonorrhea, genital
wart, genital herpes, and so on. Things need to be asked is the last
sexual contact and with whom do
e. behavior
Patients who live in dormitories or with friends the possibility of
contracting an infectious disease that causes leukorea big enough.
Examples of bad habits is the exchange of toiletries or towels
f. The nature of whiteness
Things that should be asked is the amount, odor, color and
consistency, turbid / clear, presence / absence of blood, its
frequency and how long the event took place. It needs to be asked
 in detail because by knowing these things can be predicted
likelihood aetiology
g. Ask the patient the possibility of pregnancy or menstruation
In both these circumstances, vaginal discharge usually happens is
that the physiological
h. The incubation period
When the acute onset of vaginal discharge can be expected due to
infection or chemical influences or influence the physical stimulation

2) Physical examination and inspection In

General physical examination should be performed to detect the
possibility of chronic disease, renal failure, urinary tract infections, and
other infections that might be associated with whiteness. Kusus
examination should be done is an examination of the genitalia,
including inspection and palpation of external genitalia, speculum
exam to look at the vagina and cervix, as well as bimanual pelvic
examination. To assess the liquid wall of the vagina, avoid
contamination with cervical mucus.
In infections due to Gonococcus, abnormalities that can be
encountered is red eksternum urethral orifice, edema and secretions
mukopurulen, Labio labia can be swollen, red, and tenderness.
Bartholin gland sometimes come inflamed and painful when walking or
sitting. On examination with a speculum visible red cervical erosion
and mucopurulent secretions.
Trichomonas vaginalis on the vaginal walls were red and swollen.
Sometimes a small abscess formed on the walls of the vagina and
cervix that appear as red granulation and is known as a strawberry
appearance. When secretions expelled many can irritate the groin or
around the external genitalia.
 Gardnerella vaginalis infection gives an overview colored vulvar
and vaginal hyperemia, secretions attached to the wall of the vagina,
and is seen as a thin layer or sparkling. On examination of the cervix
can be found erosions of mucus mixed with blood from the os
internum.
In vaginal candidiasis can be found inflammation of the vulva and
vagina, the vaginal wall membranes often are small, white, which if
raised scars rather bloody.
At the beginning of cervical cancer will be visible red patches with
a surface that is not slippery. This picture can be developed into a
granular, bumpy, and ulcerative accompanied necrotic tissue. In
addition, thick secretions appeared brown and foul-smelling. In
advanced cervical cancer, cervical necrosis, bumpy, ulcerative and
bergranuler surface, provide a picture like cauliflower.
Foreign bodies can be seen with the object irritant, such as IUDs,
vaginal tampons, pessaries, condoms were left behind, and so on.

3) Laboratory examination
Several laboratory tests can be done:
a. determination of pH
Determination of the pH with pH indicator (3.0-4.5)
b. Wet stock assessment
Ratings are taken for wet mount examination with 10% KOH and
examination of wet mount with saline. Trichomonas vaginalis will
be obvious with saline as a parasite oval with flagelanya and rapid
movement, while Candida albicans can be seen clearly with 10%
KOH looked yeast cells (blastospora) or pseudo hyphae.
Nonspecific vaginitis caused by Gardnerella vaginalis in the
preparation can be found a few groups of basil, leukocyte that is
not how much, and many epithelial cells largely mottled surface.
 These cells are called clue cells that are characteristic of
Gardnerella vaginalis infection

c. gram
Neisseria gonorrhoeae illustrates the intra and extracellular
gonococcus. Gardnerella vaginalis gives an overview of small-
sized trunks of gram negative that can not be numbered and many
epithelial cells with coccobacillus, without being discovered
lactobacilli
d. Culture
With the culture of germs will be found with certainty, but often do
not grow germs and should be cautious in interpretation
e. serology
This examination can be used to detect genital herpes and human
papilloma virus with ELISA (Enzyme-Linked Immunosorbent
Assay)
f. Pap Smear Test
These checks are intended to detect the presence of malignancy
in the cervix
Reference: Ramayanti. Microorganisms Pattern Fluor Albus Pathological
Caused By Infection in Patients with Gynecological Outpatient Clinic
General Hospital Dr. Kariadi Semarang. Department of Obstetrics &
Gynecology, Faculty of Medicine, University of Diponegoro. Retrieved on
March 31, 2019: http://eprints.undip.ac.id/12387/1/2004PPDS3634.pdf.

8. Any disease that causes vaginal discharge?

1. inflammation of the cervix

Inflammation of the cervix or uterus (can be referred to as cervicitis)
is one of the problems of the reproductive organs that can cause
vaginal discharge. Some other symptoms are pain in the lower
back. This is usually caused by inflammation triggered by a sexually
transmitted disease, allergic reactions to contraceptive implanted in
 the uterus, or allergic reactions to condoms and lubricants used
during sexual intercourse.

2. Infectionmushroom
Vaginal discharge can also be caused by a fungal infection of the
vagina. It is usually experienced by women who have
diabetes,pregnant, Antibiotics or birth control pills. Changes in vaginal
pH can cause fungal infections. In addition, mushrooms can also be
caused by a lack of cleanliness or underwear that is too damp.

3. Vaginal Trichomoniasis
Vaginal trichomoniasis is one form of infectious diseases that occur in
the vagina. One symptom of this disease is a yellowish discharge from
the vagina and itching. It usually occurs three to 28 days after infection.
 That's some kind of disease that must watch out for the ladies if you
experience unusual vaginal discharge. If experience should
immediately consult a doctor. Whitish and diseases above can be
prevented by maintaining vaginal hygiene and safe sex.

Reference: Prawirohardjo, Sarwono. Wiknjosastro, Hanifa. 2011.

Science Ingredients. Third Edition. The first mold. Jakarta: PT. Bina
Library Prawirohardjo Sarwono.
9. What is the differential diagnosis of scenario?

a) candidiasis vulvovaginalis
Vulvovaginalis Candidiasis is a yeast infection of the vagina and
vulva caused by several types of Candida, the most common is
Candida albicans, can be asymptomatic or symptomatic.
Vulvovaginalis recurrent candidiasis Candidiasis is
vulvovaginalis that occurred as much as four or more episodes
within a 12 month period.

Etiology

KVVR and KVV often caused by C.albicans, although non-

albicans species can be found as an organism Candida
penyebab.1 agent derived from Candida genus of the family
Cryptococcaceae, order Moniliales of the phylum Fungi
Imperfecti. In 1877 Grawitz suggests that this genus is a
dimorphic fungus. Martin then split the genus into several
species. It has been known 163 species of Candida, although
 only 20 species are known pathogens in humans. Candida
fungal cells are round or oval with a size of 2-5 X 3-6 u u u up 2
to 5.5 X 5 to 28.5 U.14 fungus forms a pseudo hyphae
(pseudohyphae) which is a series blastospora (blastokonidia)
extending without septa, which can also be branched. Based on
these forms it is said that Candidaresembling yeast (yeast like).
Candida cell walls composed mainly of β- glucan, mannan,
chitin and a number of proteins and fats. Mannan is a major
component of the antigen. Candida can grow on the medium
with a pH that is spacious, but growth would be better at a pH
between 4.5 to 6.5.

Faktor predisposing

Some of the factors identified as predisposing factors of KVVR,

among others:
1. Sex hormones
Age is an important factor in the prevalence of KVVR. The high

female sex hormones during reproductive years increases the

likelihood of the occurrence of Candida infection. Estrogens

increase the attachment of yeast organisms in the vaginal mucosa

cells. Cytosolic receptors or attachment system to the female

reproductive hormones have been known in C.albicans led to

increased formation of miselial / hyphae.

2. Contraception
Here including oral contraceptives, protective or KDR (intrauterine).
KVVR contraceptives influence on the content associated with
estrogen which stimulates the organism Candida for persistent
vaginal ecosystem.
 3. Obesity, carbohydrate intake is poor glycemic control in diabetic
patients KVVR stimulating events. The correlation between higher
BMI (body mass index) and genital Candida infection has been
associated with increased glucose tolerance, whereas other studies
did not find a correlation between the IMB and KVVR. But the
effects of obesity on KVV / KVVR can not be excluded.

pathogenesis

Candida is an opportunistic pathogen that can cause disseminated

infection in the host with a weak immune defense. There is no

definite pathogenic factor for Candida, but there are several
virulence factors that affect its ability to infect. The combination of
these factors will affect the host defense system. Postulated that the
pathogenesis of KVVR is a complex interaction between the
virulence of Candida and immunologic factors.
Several virulence factors for KVVR among others:
1) Germ tube formation as a virulence factor Germ tube formation
(GTF) is considered as a major pathogenic factor of KVV / KVVR, is
essential in Candida attachment to the mucosal surface and ability
to invade. C.albicans has a greater ability to adhere to epithelial
cells compared to non-albicans strains such as C.tropicalis,
C.krusei and C.parapsilosis. This could explain why non-albicans
strains rarely cause KVVR. In the electron microscope examination
in vivo and in vitro seen that C.albicans after the formation of
hyphae and GTF will penetrate the layers of the stratum in the
epithelium and stroma cells. After the organisms invade the
mucosa, it will be protected from the occurrence of phagocytosis
and immune defense mechanisms as well as the activity of the
antifungal agent. In some locations, yeast will form a place for
recurrence. Phagocytosis is regarded as an important defense
factor in Candida infections. An in vitro study states that the GTF
 can change the hydrophobicity of yeast cells and thereby decrease
or inhibit phagocytosis. It also causes genital persistence of
organisms in ecosystems
2) Adhesions on the line the mucosal
Blastokonidia surface Candida mannoprotein may mediate
attachment to epithelial cells. Cytosol for estrogen receptors are
also present in C.albicans. Expression of cell surface receptors and
antigens to form filaments of Candida cells contribute as virulence
factors. Fibrin can work as a receptor C.albicans. It is not clear
where the receptor that acts for the attachment of Candida with
mucosal line. There was no relationship between receptor
expression and / or activation and clinical manifestations in cases
KVVR.

3) Enzymes as a virulence factor

There are at least three proteinase associated with intracellular
compartments C.albicans. The optimal pH is 5 to intracellular and
2.2 to 4.5 in the form of secretions, the pH is lower than vaginal
secretions found on KVVR case. Proteinase secreted acid will be
inactive at neutral pH. At pH 7.5 occurred irreversible enzyme
denaturation. Pathogenic effects of proteinase is limited to cases of
acute inflammation of the vagina, in patients with increased vaginal
pH and glycolysis neutrophils. Proteinase secretion in vitro is an
ingredient found in C.albicans, C.tropicalis, while only a few are
found in C.parapsilosis. For other Candida species proteinase rare
or absent. This may explain why only three species of Candida are
becoming common pathogen in humans. Although C. albicans was
isolated from KVV cases have increased proteolysis activity in vitro,
the role of this enzyme in KVVR still unclear. Proteinase may
increase the capacity of GTF in C.albicans and therefore increase
the penetration of the mucosal line.
 clinical features
Symptoms associated with genital Candida infections can vary from
case to case. Uncomfortable vaginal symptoms such as acute
pruritus and vaginal secretions is an image commonly found.
Secretions described as milk, can vary from wet to a homogeneous
thick secretions. Pain in the vagina, irritation, a feeling of a flaming
vulva, dispareuni, and external dysuria usually found. Odor if found
usually minimal and not offensive. From the examination will be
found vulva and labia majora swollen and erythematous, often with
peripheral pustulopapular discrete lesions. Typical symptoms
usually occur
a week after the menstrual period.Frustrations in women because
of frequent recurring symptoms because of the assumption that no
effective treatment is also a typical symptom. Symptoms are not
always associated with positive Candida culture at KVV or KVVR.
Therapy
Treatment consisted of topical application imidasol or triasol, like
mikonasol, klotriimasol, butokonasol, or terjonasol. These drugs
can be prescribed as creams, suppositories, or both. Duration of
treatment varies depending on the drug selected. flukonasol single
dose of 150 mg orally have higher levels of progress.

b) bacterial vaginosis

A. DEFINITION
Bacterial vaginosis (bacterial vaginosis / BV) is the most common
cause symptoms of vaginal discharge in women of reproductive age.
Bacterial vaginosis (BV) is a condition of abnormal vaginal marked
ecological changes by shifting the balance of vaginal flora in which the
dominance of Lactobacillus replaced by anaerobic bacteria, including
Gardnerella vaginalis, Mobiluncus, Prevotella, Bacteroides, and
Mycoplasma sp.

B. EPIDEMIOLOGY

BV prevalence and distribution vary among the entire population of the

world. Several studies have reported a high prevalence of BV in the
population of the African race, Afro-American and Afro-Caribbean. The
prevalence of BV obtained by 32% among Asian women in India and
Indonesia. The age group most established in the age group 25-44 years
by 74.3%.

C. ETIOLOGY

BV is a clinical syndrome due to the change of Lactobacillus spp.

producing hydrogen peroxidase (H2O2) in the normal vagina with high
concentrations of anaerobic bacteria, for example, that Bacteroides spp.,
Mobiluncus spp., Gardnerella vaginalis (G. vaginalis), and Mycoplasma
hominis (M.hominis). It causes a decrease in the concentration of H2O2
which is generally characterized by the production of a lot of vaginal
discharge, colored gray to yellow, thin, homogeneous, smelling, and there
is an increase in vaginal pH.

D. Pathophysiology

In the microbiological environment of the vagina, is naturally present

bacteria that act as guardians of the vaginal ecosystem and prevent
interference from the external environment that may affect the
environment of the vagina. Normal vaginal flora is dominated by
Lactobacillus that produce hydrogen peroxide, which is Lactobaciluss
crispatus, Lactobasilus acidofilus and Lactobasilus rhamnosus. Hydrogen-
producing lactobacilli can be found at 96% of normal vaginal and only 6%
in women with VB.
This hydrogen-producing lactobacilli also has the ability to produce
organic acids (lactic acid) that maintain the vaginal pH <4.7 with the use of
glycogen in the vaginal epithelium as the substrate, in addition lactobacilli
also produce bacteriocins, a protein that can inhibit other bacterial
species. Lactobacillus that does not produce hidogen found by 4% in
normal women and by 36% in women with VB. VB characterized by
hydrogen-producing lactobacilli hilangnyanya peroxidase and the rapid
growth of anaerobic species. It is not known exactly where the events that
preceded, if there are factors that can lead to death so that the anaerobic
bacteria lactobacilli is growing rapidly or anaerobic bacteria to the
numerous causes of lactobacilli disappear.
The basic question that is VB pathogenesis is still not answered until
now. A number of biochemical changes have also been described, normal
vaginal epithelium covered by a thin layer of mucin. In VB this protective
layer was replaced by G. vaginalis biofilm produced. β defensin-1 and
concentration of secretory leukocyte protease inhibitor also reduced in VB.
Interleukin (IL) 1 α, 1β and receptor 1 agonists increase, IL8 (primary
leukotaktik cytokines) is reduced. There was an increase on the 70 kD
heat shock proteins, lytic enzyme sialidase, matrix metalloproteinase 8
and fosfolidase A2, nitric oxide and endotoxin are also found in the vagina
with VB. All of this can eliminate the normal protective mechanisms and
increase the occurrence of inflammatory processes.

Table 1.1 Diagnostic criteria vagintis

diagnostic criteria Normal bacterial vaginosis

 Vaginal pH 3.8 to 4.2 > 4.5

Vaginal fluid White, clear, smooth Thin, homogeneous, white,

gray, sticky, often multiply

Ujiwhiff - +

tang - +

Main complaint - Vaginal discharge, foul

odor (probably added
unwell after intercourse),
the possibility of itching

microscopic examination Lactobacilli, epithelial Clue cells with kokoid

cells attached bacteria, no
WBCs

Diagnoses - Vaginosis trichomonas,

Candida Vulvovaginitis

E. predisposing factors

1. IUD Users
Amsel et al, and Holst et al found VB is more common in women
who use an IUD compared to no use (18.8% vs 5.4%, p <0.0001 and 35%
vs 16%, p <0.03). In a retrospective study conducted by Avonts et -kawan
report BV increased among users of oral contraceptives IUD than this may
be caused by the tail of the IUD is in endocervical or vaginal
environmental causes for the development of anaerobic bacteria andG.
vaginalis , Which may play a role in the occurrence of VB in women who
use an IUD.
2.douching
The use of vaginal douching which is a product to keep hiegene women
can lead to VB. Said douching habits can change vaginal ecology,
research conducted by Onderdonk and friends - comrades expressed
douches containing povidone iodine more mepunyai inhibitory effect on
vaginal lactobacilli than containing brine or acetic acid.

3.immunosuppression
4.Diabetes mellitus
5.Hormonal changes (eg pregnancy)
6.The use of broad-spectrum antibiotic therapy
7.Obesity.

F. CLINICAL SYMPTOMS

1.Smell

The smell that is usually described as fishy odor caused by the

production of amines (trimetalamin, putrescine and kadaverin) by
anaerobic bacteria. Amen Volatilasi increases with increasing pH, so that
patients often feel the complaint is worsened if there is an increase
alkanin, for example after sexual intercourse (for their semen) or during
menstruation.

2.Itching (pruritus)
3.whitish
Grayed
4.dyspareunia
5.dysuria

G. DIAGNOSIS
Amsel criteria
 Amsel et -kawan basic advocate VB based their diagnosis at least
three signs - signs: vaginal secretions homogeneous white, vaginal fluid
pH> 4.5. the fishy odor of vaginal fluids spilled 10% KOH (whiff test), as
well as on microscopic examination found Clue cells
a. vaginal secretions
VB vaginal secretions on white, attached to the wall of the vagina,
the number increased slightly to moderate compared to normal
women.

b. Examination of vaginal fluid pH.

normal vaginal pH ranges between 3,8- 4.1, while the pH in patients
VB usually 4.7 to 5.5.

c. Vaginal malodor (whiff test) malodor in the vagina is the most

common symptom in women with VB, to help aid the detection of
malodor for clinicians do whiff test, a positive result if the scent of
the typical form of fishy odor after drops of 10% KOH.
d. Examination of Cells Clue
clue cellss a vaginal squamous epithelial cells covered a lot of
bacteria that illustrate the uneven edges.

H. MANAGEMENT (Plan)
 Non-Pharmacological:
1. Maintaining personal hygiene, especially the vaginal area
2. Avoid using towels simultaneously

3. Avoid the use of soap to cleanse the vaginal area that could shift the
number of normal flora, can change the pH conditions of the feminine
area
4. Maintain Ideal Weight

 Pharmacology:
 Management of bacterial vaginosis
- Metronidazole 500 mg orally 2 times daily for 7 days
- Metronidazole pervagina 2 x daily for 5 days
- Clindamycin cream 2% pervagina 1 x daily for 7 days

I. COMPLICATIONS

Risk facilitate getting a disease other STDs, namely gonorrhea,

chlamydia, trichomoniasis, genital herpes and HIV, in addition VB said
also can cause infertility tuba, two studies conducted in Glasgow and
Bristol find the mean infertility tubal higher in patients VB than those who
do not VB suffer.

J. PROGNOSIS

Prognosis is generally bonam.

K. PREVENTION
Actions that can be done to prevent the occurrence of BV for example:
1. Avoiding the use of vaginal douching and other women hygiene
products, such as disinfectants giver vagina, vagina fasteners and
dryer.
2. Cleanse the outside of the vagina enough with soapy water.
3. Using condoms during sexual intercourse
4. Clean up properly after use contraception (such as diaphragms,
cervical caps and spermicides).

C.Trikomoniasis

Definition

Trikominiasis is a sexually transmitted disease caused by trichomonas

vaginalis. In women the infection of TV especially causes vaginitis,
urethritis, while in the male lead. The disease is characterized by the
release of vaginal discharge in women and urethral discharge in pria.18
Etiology

Trichomonas vaginalis is an oval-shaped protozoan 4-32um length and

width from 2.4 to 14.4 um, have flagella 5 flagelnya fourth yng located
anteriorly, while the fifth flagellum undulating membranes berinkoporasi
with parasit.18

Epidemiology

Trikominiasis prevalence in males was reported around 5-29%. Lower

prevalence of men than women. Because infection in men often
asimtomatik.18

pathogenesis

T. vaginalis causes inflammation in the walls of the channel urogenoital by

way of the invasion until it reaches the epithelial and sub-epithelial tissue.
The average incubation period of 4 days to 3 weeks. In advanced cases
there are parts with granulation tissue evident. Necrosis can subepithelial
layer which spread to dipermiukaan epithelium. In the vagina and uretyra
parasites living off the remains of cells, germs and other substances
contained in the secretions.

symptoms of Trichomoniasis

If it occurs in women, trichomoniasis affects the vagina and urinary or

urethral discharge channel. In men, trichomoniasis invade the urethra,
penis area (eg foreskin), and prostate gland.

The role of Trichomonas vaginalis

Adherence of the epithelial cells of the urogenital tract is a critical step in

the pathogenesis. Events adhesions depend on time, temperature, and
pH. Cell surface TV

Symptoms in women:

- Lower abdomen ached.

- Appears pain or discomfort while urinating or having sex.
 - whitishbecomes lumpy, watery, frothy, oryellowish and greenish
and smells fishy,
- Arising pain, swelling and itching in the area of femininity.
Sometimes the itching has also appeared in the inner thigh.

Symptoms in men:

- Frequency urinate more often than usual, and accompanied by

pain.
- Appeared white discharge from the penis.
- Appears pain, swelling, and redness in the area of the tip of the
penis. The pain could also arise during urination or ejaculation.

Typically, trichomoniasis symptoms will appear within a month since

someone started to get infected. However, about half of people with
trichomoniasis do not experience any symptoms.

diagnosis

Trikominiasis Diagnosis Diagnosis based on history, physical examination,

and supported by laboratory tests.

anamnesis

TV infection in women often present with vaginal discharge greenish-

yellow foamy, smelly, itching, pain, dyspareunia, and dysuria, whereas the
complaint in men is He keluahan gonokokkus nin non chlamydial urethritis.
Complaints include urethritis urethral discharge, dysuria, and itching of the
urethra. Can be purulent urethral discharge until mucoid. Most infections
are symptomatic are intermittent and recover without treatment.

Physical examination

In women
On physical examination can be found

1. Looks purulent vaginal discharge

2. Erythema of the vulva or vagina
3. Colpitis muscularis or strawberry cervix that appear in the form of
patches macular lesions were diffuse or localized erythema of the
cervix.
4. Lower abdominal pain
In males
Clinical signs in men is rare kecualj in case of complications. The
clinical signs that appear related to local inflammation such as
balanitis and balanopistitis

Laboratory

Repsentatif yamg clinical specimens for laboratory tests include

urine, vaginal fluids, endocervical, semen and urethral swabs.
microscopic examination
Microscopic examination can use a wet mount, Gram, Giemsa,
Papanicolau, immunoperoxidase. Painting with Papanicolau
staining can be used routinely to detect TV in women who are
asymptomatic. Sensitivity and specificity was detected by staining
Papanicolaou reported 65% and 95-97%.

Culture

Culture is the gold standard for the diagnosis of infections TV.

Cultures of microorganisms is done in the medium diamond.

Rapid diagnostic examinations (rapid test)

Currently available rapid test for the detection of TV in women but

not yet exist for men. There are 2 types of rapid test that checks the
microbial Vpill Affirm that uses oligonucleotide probes and The
 OSOM Trichomonas Rapid Test which is a test strip
immunokromatografi.

Nucleic acid amplification test (NAAT)

NAAT methods, such as polymerase chain reaction (PCR) to be an

alternative in the diagnosis of infection due to the low sensitivity TV
wet mount and the limited availability of culture medium. In male
urine specimens is more sensitive than urethral swabs.

Management

Treatment options for trichomoniasis is nitromidazole class of drugs

(metronidazole, tinidazole, ornidazole, carnidazole and nimorazole).
Center for disease control and preventiob (CDC) recommends
metronidazole and tinidazole for the treatment trikominiasis. High-
dose metronidazole and old will increase the risk of side efej which
include nausea, vomiting, headache, rash, dry mouth, metallic taste
and flavor. Serious side effects can occur eosonifilia, leukopenia,
palpitations, confusion, and peripheral neuropathy.

complication

In women complications biosa adneksitis, piosalping, endometritis,

cervical erosion, low birth weight babies, and infertility, whereas in
men could be complications of non-gonococcal urethritis,
prostatitis ,, balanoposthitis, epididymitis, urethral structures
disease, and infertility.

Prevention

Effective prevention is to avoid unhealthy sexual contact and use

condoms correctly and consistently. Sexual activity is stopped
temporarily until people with trikominiasis got the full treatment and
 be asimtomtik. Reinfection can be prevented by providing the p-
engobatan complete at the same time to a sex partner.

References:

1. Elmia Kursani, HM (2015). Factors that affects occurrence of Flour

Albus (Whitish) Teen Putridi SMA PGRI Pekanbaru 2013. Maternity
and Neonatal Journal Volume 2 No. 1, 31.
2. Babic M, Hukic M. Candida albicans Species And Non Alcans
Etiological As Agent Of Vaginitis In Pregnant And Non-Pregnant
Women. Bosnian Journal of Basic Medical Sciences. 2010; 10 (1): 89-
97 16.
3. Ramayanti. Microorganisms Pattern Fluor Albus Pathological Caused
By Infection in Patients with Gynecological Outpatient Clinic General
Hospital Dr. Kariadi Semarang. Department of Obstetrics &
Gynecology, Faculty of Medicine, University of Diponegoro. Retrieved
on March 31,
2019:http://eprints.undip.ac.id/12387/1/2004PPDS3634.pdf,

10. How whitish prevention?

1. Keeping the genitals clean and dry

The vagina is anatomically located between the urethra and anus.

Genitals are cleaned from back to front can increase the risk of entry of
bacteria into the vagina. The entry of germs into the vagina causing
infection that can cause vaginal discharge. The way is wipe carefully from
front to back so that the germs that are in the anus can not enter into the
vagina.

2. Maintain cleanliness of underwear

 Not ironed underwear can be a tool transfer germs from the air into
the genitals. Bacteria, fungi, and parasites may die with heating so as to
avoid ironing clothes in infectious germs through underwear.

3. Do not exchange towels

Towels are media spread of bacteria, fungi, and parasites. The

towels that have been contaminated with bacteria, fungi, and parasites
when used can cause the bacteria to infect users towel so that the use of
towels for one person.

4. Avoid tights

Tights can cause the genitals to be warm and humid. Genital humid
weather can increase the colonization of bacteria, fungi, and parasites.
Increased colonization of bacteria can increase the infection could trigger
a whitish, then avoid wearing tight pants too long.

5. Avoid vaginal washing

Vaginal washing products can kill the normal flora in the vagina.
Ecosystems in the vagina undisturbed for vaginal washing product is
alkaline, causing the bacteria to thrive. Vaginal washing products used
must comply with the normal pH of the vagina, which is 3.8 to 4.2 and in
accordance with the doctor's instructions.

6. Wash hands before washing genitals

Hands can be a mediator of the bacteria causing the infection.

Wash your hands before touching the genitals to avoid displacement of
the germs that cause infection.

7. Frequently changing pads

Replace the pads at least 3-4 times a day to avoid moisture.

8. Managing stress

Stress can increase adrenal hormones which causes constriction of

blood vessels. Narrow blood vessels cause the flow of estrogen into the
vagina is inhibited so as to avoid the stress can reduce the whiteness.

9. Faithful in pair

Always faithful to the couple. Avoid promiscuity or use condoms to

prevent the transmission of infectious diseases

References:Badaryati, Emi. 2012. Factors Affecting Behavior Prevention

and Treatment of Pathologic Whitish At High School Students orEqual in
KotaBanjarbaru2012. Depok: FKM UI. Page 10.

11. The Islamic Perspective on Scenario

Whitish (ifrazat)is generally clear mucus, out of the female

reproductive organs, but notmadzi and semen,Either because of
lust or when normal activity. Whether it is normal or because of
illness. The scholars explain the law whitish (ifrazat) as ruthubah
(mucus always wet the female reproductive organs).
Wadi: thick white liquid that comes out after urination or after an
exhausting job, such as heavy exercise. Wadi is unclean by
agreement of the scholars that he was obliged to be washed. He is
also an ablution cancellatio as urinary and madzi.
Madzi: thin and sticky liquid, which comes out when the emergence
of lust, both when making out with a woman, as a preliminary
before jima ', or seeing and imagining something that leads to jima'.
The exit is not radiated and the body does not become tired after
removing it. Sometimes the discharge is not felt. He also defiled by
agreement of the scholars of hadith Ali that would come where he
 ordered them to mencucinya.Mani: thick liquid that smells like flour
dough, out with radiated so that was out, come out when jima 'or
ihtilam (dream jima') or masturbation ( wal 'iyadzu billah), and the
body will feel tired after removing it. "

First, discharge status is unclean. This is the opinion of Imam al-

Shafi'i according to one explanation, as-Saerozi; Syafiiyah schools
cleric, al-Qodhi Abu Ya'la; cleric Hambali schools, and several other
scholars.
Second, whitish includes sacred liquid. These Hanafiyah
opinion, the opinion of al-Shafi'i imam according to another
statement, al-Baghawi, ar-Rafii; Syafiiyah schools scholars, and the
Ibn Qudaamah; madzhab cleric Hambali.
Ibn Qudaamah - schools cleric Hambali - explains,

.‫ذي‬VV‫به الم‬VV‫ أش‬,‫د‬VV‫ه الول‬VV‫ق من‬VV‫رج ال يخل‬VV‫ه في الف‬VV‫ه نجس; ألن‬VV‫ أن‬,‫دهما‬VV‫ أح‬:‫االن‬VV‫وفي رطوبة فرج المرأة احتم‬
,‫اع‬VV‫و من جم‬VV‫لم وه‬VV‫ه وس‬VV‫ طهارته; ألن عائشة كانت تفرك المني من ثوب رسول هللا صلى هللا علي‬:‫والثاني‬
;‫ لحكمنا بنجاسة منيها‬,‫ وألننا لو حكمنا بنجاسة فرج المرأة‬,‫ وهو يالقي رطوبة الفرج‬,‫فإنه ما احتلم نبي قط‬
‫ه ال‬VV‫و نجس; ألن‬VV‫ ما أصاب منه في حال الجماع فه‬:‫ وقال القاضي‬.‫ فيتنجس برطوبته‬,‫ألنه يخرج من فرجها‬
‫ال‬VV‫ كح‬,‫ذي‬VV‫ني دون الم‬VV‫رج الم‬VV‫تدت خ‬VV‫هوة إذا اش‬VV‫إن الش‬VV‫ ف‬,‫ل‬VV‫ح التعلي‬VV‫ وال يص‬.‫و نجس‬VV‫ وه‬,‫يسلم من المذي‬
‫االحتالم‬

"In the discharge out the problems of the female reproductive organs,
there are two opinions,

[1] discharge status is odious because it comes from the pubic who are
not elements of the creation of a child. As madzi.

[2] whitish sacred status. Because 'Aisha never scrape semen from the
shirt the Prophet sallallaahu' alaihi wa sallam former jima '. Considering
there is not any Prophet who have wet dreams. So the meaning of the
seminal fluid is a liquid that mixes with his wife pussy wet liquid. Because
if we menghukumi whiteness as an unclean thing, we should also