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Vulvo-Vaginal Infections

Bambhania, Radhika

Vulvo-Vaginal Infection

Lesions/ Ulcers

Discharges

Normal Vaginal Flora


Usually seen in the normal asymptomatic reproductive aged women. Anaerobes > Aerobes Production of lactic acid and hydrogen peroxide Antibiotic compounds- bacteriocins Secretion of leukocyte protease inhibitor.

Vaginal pH
Ranges between 4-4.5 Lactibacillus species- lactic acid, fatty acids and other organic acids Amino acid fermentation by anaerobic bacteria Importance of Glycogen - Increases vaginal pH (6-7.5) after menopause

Altered flora
Post menopausal women not receiving estrogen replacement and young girls have LOW Lactobacillus. Changes accured during 1st part of the menstrual cycle. Treatment with a broad spectrum antibiotics may result inflammation of Candida albicans. Total abdominal hysterectomy increases prevalence of Bacteroides fragilis + E.coli + Enterococcus species.

GENITAL ULCERS
1. 2. 3. 4. 5. Ulcers vs. Erosions Herpes Simplex Virus Infection Syphilis Chancroid Granuloma Inguinale Lymphogranuloma Venereum

HERPES SIMPLEX INFECTIONS


Herpes simplex virus Most prevalent genital ulcer chronic viral disease Resides in dorsal root ganglion HSV-1 associated with oral lesions HSV-2 associated with genital lesions Mild and unrecognized in women Most (65%) with active women are women.

Symptoms
Burning/severe pain with vesicular lesions May have dysuria 3 stages: 1. Vesicle with/wo pustule formation, lasts a week 2. Ulceration 3. Crusting Lesions seen on vagina, cervix, bladder and rectum.

Virus infects the epidermal cells

Develops into CRUSTS, secondarily infected.

Erythematous and papule formation

Covering disrupts, leaving a painful ULCER

Cell death+ cell wall lysis= blister form

Cont. symptoms
1st exposure: initial stage is longer. New lesions formation, longer time to healing (2-3 weeks), pain for 7-10 days Previously exposed: less painful, time to healing- 2weeks 2/3 patients show prodrome prior to onset. - heralding paresthesias: pruritus or tingling Clinical manifestation in women with recurrences are limited, only about a week of symptoms.

Diagnosis
Gold standard : tissue culture Polymerase chain reaction Serologic type-specific glycoprotein based assay

Treatment
For analgesia: NSAIDS or Acetaminophen with codein lidocaine ointment Patient education: refrain from sexual activities even during prodrome period. Latex condom use to reduce risk for herpetic transmission.

Anti-viral Therapy
First Clinical Episode of Genital Herpes
Acyclovir 400 mg three times daily for 7 to 10 days
Acyclovir 200 mg five times daily for 7 to 10 days Famciclovir 250 mg three times daily for 7 to 10 days Valacyclovir 1 g twice daily for 7 to 10 days

OR
OR OR

Episodic Therapy for Recurrent Diseases


Acyclovir 400 mg three times daily for 5 days Acyclovir 800 mg twice daily for 5 days Acyclovir 800 mg three times daily for 2 days Famciclovir 125 mg twice daily for 5 days Famciclovir 1g twice daily for 1 day Valacyclovir 500 mg twice daily for 3 days Valacyclovir 1 g once daily for 5 days OR OR OR OR OR OR

If episodes recur at intervals of 2-3 months, a woman may elect daily suppressive therapy which reduces recurrences by 70-80 percent.

Oral Suppressive Therapy Options


Acyclovir 400 mg twice daily Famciclovir 250mg twice daily OR OR

Valacyclovir 0.5 to 1 gm once daily

Suppressive therapy may eliminate recurrences and decreases sexual transmission of virus by about 50%.

SYPHILIS
Sexually transmitted disease Treponema pallidum Spirochete,capable of infecting almost any organ or tissue in the body

Risk factors
Lower socioeconomic groups Adolescents Early onset of sexual activity A large number of lifetime sexual partners

PRIMARY SYPHILIS
Hallmark lesion: chancre Abundant spirochetes Painful, isolated non-tender ulcers with raised rounded borders, integrated base Cervix, vagina or vulva, mouth or around anus Mean incubation period: 3weeks Spontaneously heal in 6 weeks without treatment

SECONDARY SYPHILIS
Hallmark lesion: Maculopapular rash that involves whole body, including palms, soles and mucous membranes. Rash shades spirochetes. Warm, moist body areas: condylomata lata - broad, pink or gray-white, highly infectious plaques

LATENT SYPHILIS
During the first year following secondary syphilis without treatment, termed early latent syphilis. Not really contagious. Late Latent Syphilis: period greater than 1 year after the initial infection. Secondary signs and symptoms.

TERTIARY SYPHILIS
May appear up to 20 years after latency. Known as Gumma. Cardiovascular, CNS and musculoskeletal involvement Cardiovascular and neurosyphilis is common in females than males

Diagnosis
On presence of lesion: -Dark-field examination or direct fluorescent antibody testing When asymptomatic: 1. Venereal Disease Research Laboratory (VDRL) 2. Rapid plasma reagin (RPR) tests - if any of above test positive; treponemal specific test 1. Fluorescent treponemal antibody-absorption (FTA-ABS) 2. Treponema pallidum particle agglutination (TPPA)

For population screening, RPR or VDRL testing is appropriate. But for diagnosis confirmation in a woman with a positive non-treponemal antibody test result or with a suspected clinical diagnosis, then FTA-ABS or TP-PA testing should be selected.

Treatment
Primary, secondary, early latent ( <1 year) syphilis
Benzathine penicillin G, 2.4 million units IM once FOR PENICILIN ALLERGIC, NON PREGNANT WOMEN:
Doxycycline 100 mg orally twice daily for 2 weeks Tetracycline 500 mg orally four times daily for 2 weeks OR

Late latent, tertiary, and cardiovascular syphilis


Benzathine penicillin G, 2.4 million units IM weekly times 3 doses FOR PENICILIN ALLERGIC, NON-PREGNANT WOMEN: Doxycycline 100 mg orally twice daily for 4 weeks

CHANCRIOD
Classic STI Mainly in Black and hispanic males Haemophilus ducreyi No systemic presentation. Incubation period is 35 days.

Symptoms
Erythematous papule that becomes foul smelling pustular and within 48 hours, becomes painful ulcers Ulcers have soft, nacrotic base. Autoinoculation causes multiple lesions. In women: fourchette, vestibule, clitoris, and labia Unilateral or bilateral tender inguinal lymphadenopathy Large and fluctuant = Buboes

Drawing depicts the differences in clinical appearance among chancroid, syphilis, and genital herpes.

Diagnosis
Definitive diagnosis: growth of H. ducreyi on special media, sensitivity <80%. Identification of gram-negative, non-motile rods on a Gram stain of lesion contents.

Treatment
Recommended Treatment for non-pregnant women
Azithromycin 1 g orally Ceftriaxone 250 mg intramuscularly
Ciprofloxacin 500 mg orally twice daily for 3 days Erythromycin base 500 mg orally three times daily for 7 days

OR OR
OR

GRANULOMA INGUINALE
Also known as Donovanosis Calymmatobacterium (Klebsiella) granulomatis Mildly contagious Requires repeated exposures A long incubation period

Symptoms
highly vascular, beefy red ulcers that bleed easily on contact Ulcers may end up becoming keloid scars

Diagnosis
Donovan bodies in a Wright-Giemsa staining.

Treatment
Recommended treatment
Doxycycline 100 mg twice daily for a minimum of 3 weeks Azithromycin 1 g orally once a week Ciprofloxacin 750 mg orally twice daily Erythromycin base 500 mg orally four time daily Trimethoprim-sulfamethoxazole DS orally twice daily OR OR OR OR

LYMPHOGRANULOMA VENERUM
Chlamydia trachomatis, serotypes L1, L2, and L3 Mainly found in lower socio-economic groups among sexually promiscuous persons 3 days to 2 weeks

Symptoms
1. 2. 3. Three stages: Small vesicle or papule Inguinal or femoral lymphadenopathy Anogenitorectal syndrome Mainly seen on fourchette,posterior vaginal wall and cervix "groove sign during the 2nd stage is characteristic.

In the third stage of LGV, a patient develops rectal pruritus and a mucoid discharge from rectal ulcers Rectal bleeding, rectal pain, crampy abdominal pain with distantion and fever are reported.

Diagnosis
Clinical evaluation with exclusion of other etiologies Positive chlamydial testing.

Treatment
Doxycycline, 100 mg orally twice daily for 21 days Patient education to refrain sexual activity for 60days

VAGINAL DISCHARGES

BACTERIAL VAGINOSIS
Common and complex clinical syndrome due to altered vaginal flora. Also known as : Haemophilus vaginitis Corynebacterium vaginitis Gardnerella or anaerobic vaginitis Significant reduction of Lactobacillus species. Not a sexually transmitted disease.

Risk Factors
Oral sex Douching Black race Cigarette smoking Sex during menses IUDs Early age of sexual intercourse New/multiple sexual partners Sexual activity with other women

Diagnosis
Non irritating, malodorous vaginal discharge is characteristics but not always present. No abnormalities in the cervical exam. CRITERIA: 1. Microscopic evaluation of a saline wet prep of vaginal secretion. 2. Determination of the vaginal pH 3. Release of volatile amines produced by anaerobic metabolism (whiff test)

Clue cells- vaginal cells with attached bacteria

Vaginal pH >4.5 Trichomonas vaginalis should be ruled out. Pregnant women with BV risk for premature rupture of the membranes preterm labor and deliver Chorioamnionitis postcesarean endomentritis

Treatment
Metronidazole 500mg orally BID for 7days Metronidazole gel 0.75% intravaginally OD for 5days Clindamycin cream 2% intravaginally at HS for 5days

Candidiasis
Candida albicans Normal flora of the mouth, rectum, and vagina More commonly in warmer climates and in obese patients Immunosuppression, diabetes mellitus, pregnancy, and recent broad-spectrum antibiotic use

Diagnosis
Pruritus, pain, and swelling Vulvar erythema and edema with excoriations Cottage cheese-like discharge

Treatment
Intravaginal agents : Butoconazole 2% cream Clotrimazole 1% cream Oral agent: Fluconazole 150 mg oral tablet once Primary treatment for prevention of recurrent infection is oral fluconazole, 100 to 200 mg weekly for 6months Non-albicans recurrent infection: 600-mg boric acid gelatin capsule intravaginally daily for 2 weeks

TRICHOMONIASIS
Trichomonas vaginalis 3 days to 4 weeks incubation period Vagina, urethra, endocervix, and bladder Men are asymptomatic

Symptoms
Vaginal discharge is typically described as foul, thin, and yellow or green Dysuria, dyspareunia, vulvar pruritus, and pain. Hallmark lesions: "strawberry spots on vagina and cervix

Diagnosis
Diagnosed by microscopic identification of parasites in a saline preparation of the discharge. Vaginal pH is often elevated. Culture in Diamond media is most sensitive.

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

Gonococcal infections
Neisseria gonorrhoeae Gram-negative coccobacillus that invades columnar and transitional epithelial cells, becoming intracellular.

Risk factors
Age less than 25 years the presence of other sexually transmitted infections a history of previous gonococcal infection new or multiple sexual partners lack of barrier protection drug use commercial sex work

Symptoms
Profuse odorless,non-irritating, and white-toyellow vaginal discharge Infect the Bartholin and Skene glands, the urethra

Diagnosis
Gold standard: Culture on chocolate agar or Thayer martin agar NAATs are available Ideal specimens are recovered from the endocervix

Treatment
Ceftriaxone 125 mg IM / Cefixime 400 mg orally / Ciprofloxacin 500 mg orally / Ofloxacin 400 mg orally / Levofloxacin 250 mg orally

Chlamydia trachomatis
Second most prevalent of the sexually transmitted disease. Found in individuals younger than 25 years. Organism is dependent on host cells for survival, esp. in Lymphogranuloma Venereum (LGV)

Symptoms
Endocervical glandular infection Mucopurulent discharge, endocervical secretions Prominent Dysuria and urethritis. Endocervical tissue is commonly edematous and hyperemic.

Diagnosis
Microscopic inspection of secretion reveals 20 or more leukocytes per high-power field. Culture NAAT Enzyme-linked immunosorbent assay (ELISA)

Treatement
Primary treatment : Azithromycin 1 g orally once Alternative regimens:
1. 2. 3. 4. Erythromycin base 500 mg orally QID for 7 days Erythromycin ethyl succinate 800mg orally QID for 7 days Ofloxacin 300 mg orally twice for 7 days Levofloxacin 500 mg orally for 7 days OR Doxycycline 100 mg orally twice daily for 7 days

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