Yara saleh outline Approach Bacterial vaginosis Vulvovaginal candidiasis PID Physiologic Discharge clear white flocculent odourless discharge pH 3842 smear contains epithelial cells Lactobacilli ID: 932608
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Slide1
Vaginal infections & PID
Yara
saleh
Slide2outline
Approach
Bacterial vaginosis
Vulvovaginal candidiasis
PID
Slide3Physiologic Discharge
• clear, white, flocculent,
odourless
discharge; pH 3.8-4.2
• smear contains epithelial cells, Lactobacilli
• increases with increased estrogen states: pregnancy, OCP, mid-cycle, PCOS, or
premenarchal
• if increased in
perimenopausal
/postmenopausal woman, consider investigation for other effects of excess estrogen (e.g. endometrial cancer).
Slide4Vaginal discharge
1) History taking :
Discharge
( amount /consistency/
colour
/duration/
odour
)
first time and Associated symptoms(pain, itching, fever, bleeding ,
burnning
,
externl
dysuria,pain
during intercourse
)
Obtain history of the following
:
•Prior similar episodes
•Sexually transmitted infection
•Sexual activities
•Douching practice
•Antibiotic use
•General medical history
•Systemic symptoms such as lower abdominal pain, fever, chills, nausea, and vomiting.
Slide5Vaginal discharge
Visual inspection
: the gross characteristics of the vaginal discharge seen on
speculum
examination.
Vaginal pH
: Normal vaginal pH is an acidic
<4.5
.
Performed using pH-dependent Nitrazine paper. Normal vaginal discharge leaves the paper yellow, whereas an elevated pH turns the paper dark.
Slide6Microscopic examination (Wet prep)
: For WBC, pseudo-
hyphae
,
trichomonads
, and clue cells.
Normal saline preparation
: microscopic examination of discharge ( clue cells of BV)
KOH preparation
: dissolves cellular debris leaving pseudohyphae of candida.Whiff Test ; performed by adding several drops of 10% potassium hydroxide to a sample of vaginal discharge. A strong fishy odor is indicative of a positive test result. Such a result may suggest either
trichomoniasis
or bacterial
vaginosis
Slide7Causes of vaginal discharge
Non infective
Infective causes
1-physiological
- menstrual cycle
- pregnancy
- sexual excitement
- emotional stress
- nutritional status
-Medications
2. Cervical polyps
3. Foreign bodies (Retained tampon)
4.
Valvular
dermatitis
5. Genital tract malignancy
6. Fistulae
A-Non-sexually transmitted
infections
- Bacterial vaginosis
candida vaginitis
b. Sexually transmitted infections
- chlamydia trachomatis
-
neisseria
gonorrhoeae
- trichomonas vaginitis
- Syphilis
- HSV
- HPV
- HIV
Slide8Vaginitis differential
Bacterial
vaginosis
Candida
vaginitis
Trichomonas
vaginitis
-STD-
Slide9Bacterial vaginosis
The
commonest cause
of abnormal vaginal discharge
While a definitive cause is
not
determined,
depletion of the lactobacilli
dominant in the healthy vaginal flora is observed
((Not a true infection, but alteration in concentration of normal vaginal bacteria (anaerobic species >lactobacilli))). Seen commonly in postmenopausal females due to decreased estrogen
Slide10Risk factors
Douching
Black race
Smoking
Having a new sexual partner
Receiving oral sex.
Slide11symptoms
Vaginal discharge typically
thin, grayish-white
with
no
obvious
inflammation
.
‘
fishy’ odorThe vaginal pH is elevated >4.5
Slide12Wet prep
“
Clue cells
” on a
saline
preparation
A
positive “whiff ”test
is elicited when
KOH is placed on the discharge, releasing a fishy odor.
Slide13treatment
Oral or intravaginal treatments with
metronidazole
or clindamycin
No need to treat partner
Slide14Vulvovaginal candidiasis
This condition occurs when yeast of the Candida species, most frequently
C. albicans
, cause vulval and vaginal inflammation.
Risk factors
include:
diabetes mellitus
, systemic antibiotics,
pregnancy
, obesity, and decreased immunity.
Slide15Clinical features
Itching and burning
On speculum:
Vaginal discharge
is typically
curdy and white
. The vaginal epithelium is frequently edematous and
inflamed
.
Wet mount: pseudohyphae on a KOH prep.Vaginal pH is normal <4.5.
Slide16treatment
Up to
30-40% of asymptomatic
women may have
C. albicans
grown on a vaginal swab. These women
do not need treatment even if they are pregnant
.
A
single oral dose of fluconazole or vaginal “azole” creamsRecurrent infection (4/1y): treat the acute episode (3 days of fluconazole) followed by a maintenance regimen (fluconazole 150 mg weekly for 6 months) to treat further recurrences.asymptomatic sexual partner does not need to be treated.
Slide17Slide18Pelvic Inflammatory Disease
It’s an
inflammation
of the female
upper genital tract
(uterus, tubes, ovaries, ligaments) caused mostly by
ascending infection
from the vagina and cervix.
The most common initial organisms are
chlamydia and gonorrhea. With persistent infection, secondary bacterial invaders include anaerobes and gram-negative organisms.The inflammation may be present at any point along a continuum that includes endometritis, salpingitis and peritonitis.
Slide19Risk factors
Age <35 (especially in teens)
Multiple sexual partners
Unprotected intercourse
IUCD
Nulliparity
History of STD
Pregnancy is
protective
as it forms thick cervical mucous that occludes the way for the bacteria.
Slide20Cervicitis
:
The initial infection starts with invasion of
endocervical
glands with
chlamydia
and gonorrhea. A
mucopurulent
cervical discharge or friable cervix may be noted. Cervical cultures will be positive, but symptoms are usually absent.
Acute
salpingo-oophoritis
:
Usually after a menstrual period with
breakdown of the cervical mucus barrier
, the pathogenic organisms ascend through the uterus causing an
endometritis
; then the bacteria enter the oviduct where acute
salpingo-oophoritis
develops.
Chronic PID
:
If the
salpingo-oophoritis
is not appropriately treated, the body’s immune defenses will often overcome the infection but at the expense of persistent adhesions and scarring.
Tubo
-ovarian abscess (TOA):
If the body’s immune defenses cannot overcome the infection, the process worsens, producing an inflammatory mass involving the oviducts, ovaries, uterus, bowel, and
omentum
.
Slide21diagnosis
Minimal criteria
: Sexually active young woman, Pelvic or lower abdominal
pain
,
Tenderness
: cervical motion or uterine or adnexal
Supportive criteria
(but not necessary for diagnosis):
Fever
, Abnormal vaginal
mucopurulent discharge
,
Presence of abundant
WBC
on vaginal fluid saline microscopy,
Elevated ESR, Positive lab findings of cervical N. gonorrhoeae or C. trachomatis.
Slide22Acute salpingo-oophoritis
Bilateral lower abdominal-pelvic
pain
Often after menses.
P/E
: Bilateral abdominal
tenderness
, cervical motion tenderness and
mucopurulent discharge
.Investigations: High WBC and ESR, positive culture, Normal U/S
Slide23Differential diagnosis
Adnexal torsion
Ectopic pregnancy
Appendicitis
Endometriosis
Diverticulitis
IBD
Slide24management
Outpatient treatment
:
Criteria: absence of inpatient criteria
Antibiotics:
Ceftriaxone
IM x 1 plus
doxycycline
po bid for 14 days with/without metronidazole po bid for 14 days
Slide25management
Inpatient treatment
is essential with severe cases:
Criteria
: Appendicitis cannot be ruled out; failed outpatient therapy; unable to tolerate oral medications; severe illness, high fever, nausea/vomiting; tubo-ovarian abscess or pregnancy
Antibiotics
: (1)
Cefotetan
IV q12 h +
doxycycline po or IV q 12 h or (2)
clindamycin
+
gentamicin
IV q 8 h
Slide26management
Hospitalized patients
can be considered for
discharge
when their
fever is less than 37.5° for more than 24 hours
, the
WBC count is decreasing
, rebound tenderness is absent, and repeat examination shows
marked improvement of abdominal tenderness.Sexual partners of women with PID should be evaluated and treated for urethral infection caused by Chlamydia or gonorrhea, treatment with doxycycline if sexual contact with partner in the last 6 days.
Slide27Tubo-ovarian abscess
End stage
process of acute PID
Accumulation of pus in the adnexae forming an inflammatory mass
involving the oviducts, ovaries, uterus, or omentum
Slide28TOA
Severe
bilateral pain (lower abdominal pain, back and rectal pain) , nausea, vomiting.
P/E
: septic patients, high fever, elevated heart rate, decreased blood pressure, peritoneal signs, grunting, rigidity, bilateral adnexal masses.
Investigations:
elevated WBCs and ESR, +ve cervical and blood culture
On CT: bilateral complex pelvic masses.
Slide29Differential Diagnosis
Diverticular Abscess
Appendiceal Abscess
Adnexal Torsion
Slide30management
Admit
IV
clindamycin + Gentamycin
75%
of women respond to ABs alone within 72 hours.
Failure of medical therapy
suggests the need for
drainage
of the abscess. Although drainage may require surgical exploration, percutaneous drainage, guided by imaging studies (U/S or CT) should be used as an initial option if possible.
Slide31Chronic pid
Chronic bilateral pain
, infertility, dyspareunia, ectopic pregnancy, abnormal bleeding,
NO nausea or vomiting.
P/E
: cervical motion
tenderness
and bilateral adnexal tenderness,
no discharge, no fever or tachycardia.
Investigations: normal WBCs and ESR, -ve culture, - on US: hydrosalpinx. Diagnosis is by laparoscopy by visualization of pelvic adhesions
with
pus collection in cul de sac.
Slide32management
It’s
difficult
but involves:
Analgesia
and
adhesion lysis
which might be helpful in
fertility.
If severe and unresponsive pain: TAH-BSO with ERT (estrogen replacement therapy)
Slide33complications
Infertility
Ectopic pregnancy
Fitz-Hugh Curtis syndrome
Dyspareunia
Abnormal bleeding.
Slide34Thank you!