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Villegas, Jose Bernabe GYNECOLOGY

Vinluan, Joseph David Dr.


Wong, Deo Adiel August 22, 2007
Yague, Glenn Section 3 – D
Yang , Caprice

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Case # 11
A 22-year old single nulligravid factory worker in Taiwan con-
sulted because of vulvar pruritus for 4 days. On PE, there were
multiple warty growths, 0.7 – 1.5 cm diameter, on the fourchet and
medial aspect of the labia majora and minora. On speculum
examination, the vaginal mucosa was hyperemic. The cervix was
smooth with yellowish green foul discharge. IE: Cervix – firm, long,
closed; Uterus – normal in size; Adnexae - (-)mass/tenderness.
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1. What additional information (on the genital warts) should be inquired


about?
a. Character of the lesion: How did the patient notice the warty
growths? When did they start to appear? At their onset, did they
have the same appearance as in the present or did they
progressively change in shape, texture, size, color or odor, and
increase in number? Were there any discharges from the lesions?

b. Occupational History: This includes inquiry about her sexual


partner’s occupation. Certain occupations such as sexual workers
increase the risk of acquiring STDs. Does her partner’s occupation
involve engaging in sexual intercourse with customers?

c. Medical History: Medical conditions that suppress the immune


system, such as DM and HIV infection, increase the risk of acquiring
any infection, including STDs. People with normal immune systems
may be able to ward off infections better than immunosuppressed
people. Poor nutrition and hygiene may also be a source of the
infection.

d. Sexual History: Asking, without judgment, about specific sexual


practices enables physicians to identify potential health risks and
needed screening tests. The Centers for Disease Control and
Prevention recommends asking about the "five Ps": partners,
practices, prevention of sexually transmitted diseases (STDs), past
history of STDs, and prevention of pregnancy. Thus, in eliciting

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information, possible questions such as the following would be of much
help.

Are you having or have you ever had sex with men or women?

How many partners have you had in the past six months? past five years?

Does your partner have sex with someone other than yourself?

What kind of sexual contact do you have?

Oral, including mouth on vagina, anus, or penis?

Vaginal penetration, including with hands, latex sex toy, or penis?

Anal penetration, including with hands, latex sex toy, or penis?

Have you had sexual contact with someone who uses injection drugs or a
man who has sex with other men?

Do you use barrier protection like condoms or gloves during sexual contact?
What kind?

Has she had any previous history of warts or STD?

Has she had any other symptoms such as vaginal ulcers, excoriations,
discharge, dryness, itchiness, abnormal odor emanating from her genitalia?

Has she experienced any pain on urination or during sexual intercourse?

Does her partner also have or had genital warts or some other form of STD?

What additional information (on the vaginal discharge) should be inquired


about?
A patient who complains of vaginal discharge, itching, frequent urination
and/or irritation should be evaluated for vaginitis. The first step is to obtain a directed
history. The patient should be asked about specific symptoms and their duration, any
previous diagnosis and previous treatment and its effects. A general medical review,
dermatologic review, social history and contraceptive history can also be helpful.

It is also important to inquire about abdominal or pelvic pain, fever, recurrent


or resistant infections, urinary symptoms, menstrual history, pregnancy and sexual
practices. The nature of the discharge (i.e., amount, consistency, color, odor,
accompanying pruritus) may also provide important clues. Dysuria is a common

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symptom of vaginitis. It is usually external and is defined as pain and burning when
urine touches the vulva. In contrast, internal dysuria, defined as pain inside the
urethra, is usually a sign of cystitis.

A physical examination can help to identify the anatomic site of involvement


(vulva, vagina or cervix). Inspection of the external genitalia for inflammation,
lesions, masses, atrophic tissue and enlarged lymph nodes is important. The
physician should also assess the patient for uterine or tubo-ovarian tenderness and
perform a speculum examination to detect erythema, edema or lesions. The pooled
vaginal discharge should be assessed for color, consistency, volume and adherence
to the vaginal walls.

Because the diagnostic tests and treatments for cervicitis are different from
those for vaginitis, it is important to differentiate these conditions. Several clues can
help to rule out cervical infection as the cause of a vaginal discharge. Almost 90
percent of symptomatic or asymptomatic women with chlamydial cervicitis meet at
least two of the following criteria: (1) younger than 24 years, (2) sexual intercourse
with a new partner in the previous two months, (3) presence of mucopurulent
cervicitis, (4) cervical bleeding induced by swabbing the endocervical mucosa and
(5) no form of contraception. If cervicitis is suspected, cultures for Chlamydia
species and Neisseria gonorrhoeae should be obtained.

If the findings of the history and/or physical examination suggest that the
patient has vaginitis, a sample of the vaginal discharge should be obtained for gross
and microscopic examination. Standard office examinations include a wet-mount
preparation using saline, a slide prepared with 10 percent potassium hydroxide
(KOH), a "whiff" test to detect amines and a litmus test of the pH level of vaginal
fluid.

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Diagnosis of Vaginitis

Evaluation of patients with suspected vaginitis. (KOH = potassium hydroxide)

2. What is the probable diagnosis?


Our patient presented with vulvar pruritus for 4 days and on
physical examination, there were multiple warty growths, 0.7 – 1.5cm
in diameter, on the fourchet and medial aspect of the labia majora and
minora. These presenting signs are indicative of Genital Warts.

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On speculum exam, the vaginal mucosa of our patient was
hyperemic. The cervix was smooth with yellowish green foul discharge
which is suggestive of Trichomonas Vaginitis.

External genital warts area a manifestation of human


papillomavirus (HPV) infection. The non-oncogenic HPV types 6 and
11 are usually responsible for external genital warts. The warts tend to
occur in areas most directly affected by coitus, namely the posterior
fourchet and lateral areas on the vulva. Less frequently, warts can be
found throughout the vulva, in the vagina, and on the cervix. They are
highly contagious. More than 75% of sexual partners develop this
manifestation of HPV infection when exposed.

Trichomonas vaginitis is caused by the sexually transmitted,


flagellated parasite, Trichomonas vaginalis. Transmission rate is high.
The parasite, which exists only in trophozoite form, is an anaerobe that
has the ability to generate hydrogen to combine with oxygen to create
an anaerobe environment. It often accompanies Bacterial Vaginosis,
which can be diagnosed in as many a 60% of patients with
thichomonas vaginitis.

3. Give differential diagnoses.


On physical exam, the patient had multiple warty growths and yellowish green foul
discharge was noted.
The differential diagnosis of warts are the following:

A. Molluscum contagiosum: a benign viral disease of the skin that is caused


by a member of the poxvirus group, molluscum contagiosum virus (MCV).
The virus is one of the largest that causes human disease, measuring 240-
320 nm in diameter. The lesions have a waxy appearance and a central
umbilication. They may appear migratory, as individual lesions usually
spontaneously resolve over weeks, while new lesions appear elsewhere.
Bateman first described the disease in 1817. The term molluscum was used
to describe the pedunculated appearance, and the term contagiosum was
used to connote that the disease is transmissible.
B. Bowenoid papulosis consists of rough papular eruptions and is considered
a carcinoma in situ. Eruptions can be red, brown, or flesh colored and may
regress or become invasive.
C. Seborrheic keratoses previously were considered a benign skin
manifestation. These consist of rough plaques and have an infectious and an
oncogenic potential.
D. Buschke-Lowenstein tumor (giant condyloma) is a fungating, locally
invasive, low-grade cancer attributed to HPV.
E. Condylomata lata: Typical early lesions are usually less than 20, round,
discrete, nonpruritic, and symmetric macules distributed on the trunk and

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proximal extremities. Red papular lesions also may appear on the palms,
soles, face, and scalp and may become necrotic. Patchy and nonpatchy
alopecia may occur. In intertriginous areas, papules may coalesce to form
highly infectious lesions called condylomata lata. Lesions usually progress
from red, painful, and vesicular to "gun metal grey" as the rash resolves.
Mucous patches are superficial mucosal erosions, usually painless, that may
develop on the tongue, oral mucosa, lips, vulva, vagina, and penis.

Vaginitis is defined as the spectrum of conditions that cause vulvovaginal symptoms


such as itching, burning, irritation, and abnormal discharge.

The most common causes of vaginitis in symptomatic women are bacterial vaginosis
(BV) (22-50%), vulvovaginal candidiasis (17-39%), and trichomoniasis (4-35%); yet,
7-72% of women with vaginitis may remain undiagnosed. Accurate diagnosis may be
elusive and must be distinguished from other infectious and noninfectious causes.

A complex balance of microorganisms maintains the normal vaginal flora. Important


organisms include lactobacilli, corynebacteria, and yeast. Hormones further
influence this microenvironment. A state of decreased estrogen, as occurs in
prepuberty and postmenopause and following oophorectomy, can result in an altered
risk of infection.

The normal postmenarchal and premenopausal vaginal pH is 3.8-4.2. At this pH,


growth of pathogenic organisms usually is inhibited. Disturbance of the normal
vaginal pH can alter the vaginal flora, leading to overgrowth of pathogens. Factors
that alter vaginal environment include feminine hygiene products, contraceptives,
vaginal medications, antibiotics, sexually transmitted diseases (STDs), sexual
intercourse, and stress.

• Bacterial vaginosis: characterized by thin, homogenous, malodorous white-to-


grey vaginal discharge and pruritus. Vaginal pain or vulvar irritation is
uncommon. Bacterial vaginosis: BV discharges are frothy and white to grey.
The discharge appears adherent to the vaginal mucosa. As many as 50% of
women with BV are asymptomatic. For diagnosis of BV, 3 out of the following
4 criteria must be present:
a. Homogenous, white, adherent discharge
b. Vaginal pH higher than 4.5
c. Release of fishy odor from vaginal discharge with potassium hydroxide
d. Clue cells on wet mount
• Vaginal candidiasis: Pruritus is the most common symptom of vaginal
candidiasis. This is accompanied by thick, odorless, white vaginal discharge
(with an appearance similar to cottage cheese) that can be minimal. Usually,
associated vulvar candidiasis is present, commonly with vulvar burning,
dyspareunia, and vulvar dysuria (burning sensation when urine comes into
contact with vulva skin). Erythema and swelling of the labia and vulva with
satellite lesions (discrete pustulopapular lesions). Vaginal erythema with

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adherent thick, cottage cheese–like vaginal discharge (the cervix usually
appears normal)

T vaginalis infection: Many patients (20-50%) are asymptomatic. Symptoms include


profuse vaginal discharge that can be white, gray, yellow, or green. The yellow and
green colors are due to the presence of WBCs. Dysuria (20%), pruritus (25%), and
postcoital bleeding due to cervicitis are other possible symptoms. The vulva may
appear erythematous and edematous, with excoriation. Look for homogenous
vaginal discharge that can be white, gray, yellow, or green. Small punctate cervical
and vaginal hemorrhages with ulcerations may be observed. "Strawberry cervix" or
"colpitis macularis" is very specific for Trichomonas infection, and 2-5% of patients
will have this finding on examination. Diagnosis of Trichomonas infection based on
clinical signs and symptoms is unreliable, so laboratory confirmation is mandatory.

4. What diagnostic procedures are necessary?


Appearance of vaginal secretions is assessed, pH of the secretions is
measured, and microscopy with isotonic sodium chloride solution and 10%
potassium hydroxide (KOH) is performed along with a whiff test.

Diagnosis should be inferred by placing a small cotton swab into the


endocervical canal and the cervical mucus is extracted. The cotton swab is
inspected against a white or black background to detect the green or yellow color of
the mucopus. In addition, touch the ectropion with a cotton swab or spatula to see if
it is friable or easily induced to bleed. Ectocervical secretions on the other hand
should be obtained using a large swab. Since the cause of cervical epithelium
depends on the epithelium affected, the former procedure will be presumptive of the
organism causing inflammation (mostly gram-positive cocci, e.g. streptococci in
ectocervix; trichomonas, candida, and herpes in endocervix).

Both secretions are placed on a slide and Gram-stained. The observation of


more than 30 leukocytes per oil immersion field is highly suggestive of chlamydia
and gonorrhea. The acetic acid test is done by soaking acetic acid into suspicious
lesion. This can enhance the degree of suspicion in lesions without classic features.
The method involves applying a 3-5% acetic acid–moistened gauze pad for 5-10
minutes on suspected lesions of the cervix, labia, or perianal area. Inconspicuous,
flat, genital lesions that might be difficult to assess become visible. Dysplastic and
neoplastic tissues turn white (acetowhite). False-positive results are common and
can result from anything that causes parakeratosis (eg, candidiasis, psoriasis, lichen
planus, healing epithelium, sebaceous glands). This technique can be combined
with the use of colposcopy to examine cervical lesions. The acetic acid test is
reserved only for suspicious lesions and should not be used for routine screening.
Histopathology can elucidate diagnosis in most cases. Verrucae consist of
acanthotic epidermis with papillomatosis, hyperkeratosis, and parakeratosis.
Elongated rete ridges may point to the center of the wart and dermal capillary
vessels may be thrombosed. Koilocytes are indicative of HPV infection. These are

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large keratinocytes with an eccentric, pyknotic nucleus surrounded by a perinuclear
halo. Immunohistochemical staining with the peroxidase-antiperoxidase technique
stains cells infected by viral particles. Certain screening tests are available with a
relatively high sensitivity and specificity; they include the following: ViraPap,
ThinPrep Pap and Hybrid capture II.

5. Give treatment options.


The primary goal of treatment for genital warts is their removal. For most
patients, treatment could bring about wart-free periods. However, if the warts are left
untreated, they could spontaneously remit, remain the same, or even multiply in
number and increase in size. The treatment of genital warts could possibly diminish
but not entirely remove HPV, the main cause. Whether the reduction in HPV viral
DNA, resulting from treatment, impacts future transmission remains unclear. No
evidence indicates that the presence of genital warts or their treatment is associated
with the development of cervical cancer.

Treatment of genital warts should be chosen on the basis of the preference of


the patient, costs, and the experience of the physician. No definitive data suggests
that one is superior to any other and no single treatment is ideal for all patients or all
warts. The use of locally developed and monitored treatment algorithms has been
associated with improved clinical outcomes and should be encouraged. Because of
uncertainty about effects of treatment on future transmission of HPV and the
possibility of spontaneous resolution, an acceptable alternative for some persons is
to forego treatment and wait for spontaneous resolution. On the other hand, if the
patient showed no substantial improvement, a change of therapy is suggested. The
majority of genital warts respond within 3 months of therapy. The response to
treatment and its side effects should be evaluated throughout the course of therapy.

Recommended Regimens for External Genital Warts


Patient-Applied:
Podofilox 0.5% solution or gel. An antimitotic drug that destroys warts, is relatively
inexpensive, easy to use, safe, and self-applied by patients. They should apply
podofilox solution with a cotton swab, or podofilox gel with a finger, to visible genital
warts twice a day for 3 days, followed by 4 days of no therapy. This cycle may be
repeated, as necessary, for up to four cycles. The total wart area treated should not
exceed 10 cm2, and the total volume of podofilox should be limited to 0.5 mL per
day. The majority of patients experience mild-to-moderate pain or local irritation after
treatment.

Imiquimod 5% cream. Is a topically active immune enhancer that stimulates


production of interferon and other cytokines. Patients should apply imiquimod cream
once daily at bedtime, three times a week for up to 16 weeks. The treatment area
should be washed with soap and water 6–10 hours after the application. Local
inflammatory reactions are common with the use of imiquimod; these reactions
include redness and irritation and are usually mild to moderate.

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Conservatively, follow-up is not required for patients using self-administered therapy.
However, it might be useful several weeks into therapy to determine the
appropriateness of medication use and the response to treatment.

Physician-Administered:
Cryotherapy with liquid nitrogen or cryoprobe causes thermal-induced cytolysis.
Physicians must be trained on its proper use because over- and undertreatment
might result in complications or low efficacy. Pain after application of the liquid
nitrogen, followed by necrosis and sometimes blistering, is common. Local
anesthesia (topical or injected) might facilitate therapy if warts are present in many
areas or if the area of warts is large. Repeat applications every 1–2 weeks.

Podophyllin resin 10%–25% in a compound tincture of benzoin. A small amount


should be applied to each wart and allowed to air dry. The treatment can be
repeated weekly, if necessary. To avoid the possibility of complications associated
with systemic absorption and toxicity, two important guidelines should be followed: 1)
application should be limited to <0.5 mL of podo-phyllin or an area of <10 cm2 of
warts per session, and 2) no open lesions or wounds should exist in the area to
which treatment is administered. Some specialists suggest that the preparation
should be thoroughly washed off 1–4 hours after application to reduce local irritation.

Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90% are caustic


agents that destroy warts by chemical coagulation of proteins. Although these
preparations are widely used, they have not been investigated thoroughly. TCA
solutions have a low viscosity comparable with that of water and can spread rapidly
if applied excessively; therefore, they can damage adjacent tissues. Both TCA and
BCA should be applied sparingly and allowed to dry before the patient sits or stands.
A small amount is put only to the warts and allowed to dry, at which time a white
“frosting” develops. If an excess amount of acid is applied, the treated area should
be powdered with talc, sodium bicarbonate (i.e., baking soda), or liquid soap
preparations to remove unreacted acid.

Surgical removal either by tangential scissor excision, tangential shave excision,


curettage, or electrosurgery. Surgical therapy has the advantage of usually
eliminating warts at a single visit. However, such therapy requires substantial clinical
training, additional equipment, and a longer office visit. After local anesthesia is
applied, the visible genital warts can be physically destroyed by electrocautery, in
which case no additional hemostasis is required. Care must be taken to control the
depth of electrocautery to prevent scarring. Alternatively, the warts can be removed
either by tangential excision with a pair of fine scissors or a scalpel or by curettage.
Because the majority of warts are exophytic, this procedure can be accomplished
with a resulting wound that only extends into the upper dermis. Hemostasis can be
achieved with an electrocautery unit or a chemical styptic. Surgical therapy is most
beneficial for patients who have a large number or area of genital warts. Carbon
dioxide laser and surgery might be useful in the management of extensive warts or

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intraurethral warts, particularly for those patients who have not responded to other
treatments.

Alternative Regimens
Interferons, both natural or recombinant, have been used for the treatment of
genital warts. They have been administered systemically (i.e., subcutaneously at a
distant site or IM) and intralesionally (i.e., injected into the warts). Systemic
interferon is not effective. The efficacy and recurrence rates of intralesional
interferon are comparable to other treatment modalities. Administration of
intralesional interferon is associated with stinging, burning, and pain at the injection
site. Interferon is probably effective because of its antiviral and/or immunostimulating
effects. Interferon therapy is not recommended as a primary modality because of
inconvenient routes of administration, frequent office visits, and the association
between its use and a high frequency of systemic adverse effects.

Because of the shortcomings associated with all available treatments, some


clinics employ combination therapy. No data support the use of more than one
therapy at a time to improve efficacy of treatment, and some specialists believe that
combining modalities might increase complications.

For the concomitant Trichomoniasis:


Recommended Regimens
Metronidazole 2 g orally in a single dose or
Tinidazole 2 g orally in a single dose
Alternative Regimen
Metronidazole 500 mg orally twice a day for 7 days

References:
Harrison’s Principles of Internal Medicine 16th edition
Berek et al., eds. Novak’s Gynecology. 14th ed. USA: Lippincott Williams & Wilkins.
2007.
http://www.aafp.org/afp/20060715/279.html
http://www.aafp.org/afp/20000901/1095.html
http://www.cdc.gov/std/treatment/2006/genital-warts.htm
http://www.cdc.gov/std/treatment/2006/vaginal-discharge.htm#vagdis3

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