The lecture has been given on Oct. 6th, 2010 by Dr. Hanaa.

1. Vulvovaginitis &vavinal discharge

2. vaginitis Etiology The most common causes vary by patient age. Children: In children, vaginitis usually involves infection with GI tract flora (nonspecific vulvovaginitis). A common contributing factor in girls aged 2 to 6 yr is poor perineal hygiene (eg, wiping from back to front after bowel movements; not washing hands after bowel movements; fingering, particularly in response to pruritus). Chemicals in bubble baths or soaps may cause inflammation. Foreign bodies (eg, tissue paper) may cause nonspecific vaginitis with a bloody discharge. Sometimes childhood vulvovaginitis is due to infection with a specific pathogen (eg, streptococci, staphylococci, Candida sp; occasionally, pinworm).

3. Women of reproductive age: In these women, vaginitis is usually infectious. The most common types are bacterial vaginosis ,candidalvaginitis and trichomonalvaginitis which is sexually transmitted. Normally in women of reproductive age, Lactobacillus sp is the predominant constituent of normal vaginal flora. Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), thereby preventing overgrowth of pathogenic bacteria. Also, high estrogen levels maintain vaginal thickness, bolstering local defenses. Factors that predispose to overgrowth of bacterial vaginal pathogens may include the following: An alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli Poor hygiene Frequent douching

4. Postmenopausal women: Usually, a marked decrease in estrogen causes vaginal thinning, increasing vulnerability to infection and inflammation. Some treatments (eg, oophorectomy, pelvic radiation, certain chemotherapy drugs) also result in loss of estrogen. Decreased estrogen predisposes to atrophic vaginitis. Poor hygiene (eg, in patients who are incontinent or bedridden) can lead to chronic vulvar inflammation due to chemical irritation from urine or feces or due to nonspecific infection. Bacterial vaginosis, candidalvaginitis, and trichomonalvaginitis are uncommon among postmenopausal women but may occur in those with risk factors.

5. Women of all ages: At any age, conditions that predispose to vaginal or vulvar infection include fistulas between the intestine and genital tract, which allow intestinal flora to seed the genital tract, and pelvic radiation or tumors, which break down tissue and thus compromise normal host defenses. Noninfectious vulvitis accounts for up to 30% of vulvovaginitis cases. It may result from hypersensitivity or irritant reactions to hygiene sprays or perfumes, menstrual pads, laundry soaps, bleaches, fabric softeners, fabric dyes, synthetic fibers, bathwater additives, toilet tissue, or, occasionally, spermicides, vaginal lubricants or creams, latex condoms, vaginal contraceptive rings, or diaphragms

6. Physiological discharge Normal vaginal discharge is white, becoming yellowish on contact with air, due to oxidation. It consists of desquamated epithelial cells from the vagina and cervix, mucus originating mainly from the cervical glands, bacteria and fluid, which is formed as a transudate from the vaginal wall. More than 95 per cent of the bacteria present are lactobacilli. The acidic pH is maintained by the lactobacilli and through the production of lactic acid by the vaginal epithelium metabolizing glycogen. Physiological discharge increases due to increased mucus production from the cervix in mid-cy-cle. It also increases in pregnancy and sometimes when women begin using a combined oral contraceptive pill.

7. Symptoms and Signs Vaginitis causes vaginal discharge, which must be distinguished from normal discharge. Normal discharge is common when estrogen levels are high—eg, during the first 2 wk of life, because maternal estrogen are transferred before birth (slight bleeding often occurs when estrogen levels abruptly decrease), and during the few months before menarche, when estrogen production increases. Normal vaginal discharge is commonly milky white or mucoid, odorless, and nonirritating; it can result in vaginal wetness that dampens underwear. Discharge due to vaginitis is accompanied by pruritus, erythema, and sometimes burning, pain, or mild bleeding. Pruritus may interfere with sleep. Dysuria or dyspareunia may occur. In atrophic vaginitis, discharge is scant, dyspareunia is common, and vaginal tissue appears thin and dry.

8. Diagnosis Vaginitis is diagnosed using clinical criteria and in-office testing. First, vaginal secretions are obtained with a water-lubricated speculum, and pH paper is used to measure pH in 0.2 intervals from 4.0 to 6.0. Then, secretions are placed on 2 slides with a cotton swab and diluted with 0.9% NaCl on one slide (saline wet mount) and with 10% K hydroxide on the other (KOH wet mount).

9. The KOH wet mount is checked for a fishy odor (whiff test), which results from amines produced in trichomonalvaginitis or bacterial vaginosis. The saline wet mount is examined microscopically as soon as possible to detect trichomonads, which can become immotile and more difficult to recognize within minutes after slide preparation. The KOH dissolves most cellular material except for yeast hyphae, making identification easier. If clinical criteria and in-office test results are inconclusive, the discharge may be cultured for fungi or trichomonads.

10. Other causes of discharge are ruled out. If children have vaginal discharge, a vaginal foreign body is suspected. Cervical discharge due to cervicitis (eg, due to pelvic inflammatory disease [PID]) can resemble that of vaginitis; abdominal pain, cervical motion tenderness, or cervical inflammation suggests PID. Discharge that is watery, bloody, or both may result from vulvar, vaginal, or cervical cancer; cancers can be differentiated from vaginitis by examination and Papanicolaou (Pap) tests. Vaginal pruritus and discharge may result from skin disorders (eg, psoriasis, tineaversicolor), which can usually be differentiated by history and skin findings.

11. Vaginal candidiasis Over three-quarters of women have at least one episode of vaginal candidiasis. A few women have frequent recurrences. The organism is carried in the gut, under the nails, in the vagina and on the skin. The yeast Candida albicans is implicated in more than 80 per cent of cases; C. glabrata, C. krusei and C. tropicalisaccount for most of the rest. Sexual acquisition is rarely important, although the physical trauma of intercourse may be sufficient to trigger an attack in a predisposed individual. The classical presentation is with itching and soreness of the vagina and vulva,with a curdy, white discharge, which may smell yeasty, but in some cases there may be itching and redness with a thin, watery discharge. The pH of vaginal fluid is usually normal, between 3.5 and 4.5. Microscopy and culture of the vaginal fluid can confirm a diagnosis . Asymptomatic women from whom Candida is grown on culture do not require treatment.

13. • HIV

14. • Immunosuppressive therapy, e.g. steroids

15. • Diabetes mellitus

16. • Vaginal douching, bubble bath, shower gel, tight clothing,

17. • Increased oestrogen

18. • Pregnancy

19. • High-dose combined oral contraceptive pill

20. • Underlying dermatosis, e.g. eczema

22. Vaginal creams and pessaries can be prescribed at a variety of doses and durations of treatment. For uncomplicated Candida, a singledosetreatment, such as clotrimazole 500 mg, is adequate. Some women have a preference for oral therapy, particularly if treatment is required at the time of menstruation. A single 150 mg tablet of fluconazole is usually effective, but its activity is limited to C. albicans strains. Longer courses of treatment are needed when there are predisposing factors that cannot be eliminated, such as steroid therapy.

23. If recurrences occur frequently, it is worth performing a full blood count to check for anaemia and checking thyroid function, but usually these are normal. Many clinicians prescribe treatment to be taken once or twice a month for 6 months to suppress recurrences.

24. (a) Normal: lactobacilli - seen as large Gram-positive rods - predominate. Squamous epithelial cells are Gram negative with a large amount of cytoplasm.

25. Hyphae and Spores in CandidalVaginitis

26. Bacterial vaginosis Bacterial vaginosis is the commonest cause of abnormal vaginal discharge in women of childbearing age. Studies in antenatal clinics and gynaecology clinics show a prevalence of approximately 12 per cent in the UK. It is commoner in women of Afro-Caribbean origin and in those who have an intrauterine device (IUD). Higher prevalence is generally reported in women undergoing elective termination of pregnancy. It is probably commoner in women with STIs, but has been reported in virgins, and it may be particularly common in lesbian women.

27. The condition often arises spontaneously around the time of menstruation and may resolve spontaneously in mid-cycle. When BV develops, the predominantly anaerobic organisms that are usually present in the vagina at low concentration increase in concentration up to a thousand- fold. This is accompanied by a rise in vaginal pH to between 4.5 and 7.0, and ultimately the lactobacilli may disappear. The organisms most commonly associated with BV are Gardnerellavaginalis, Bacteroides (Prevotella) spp., Mobiluncus spp. and Mycoplasma hominis.

28. principal symptom of BV is an offensive fishy smelling discharge; it is characteristically thin, homogeneous and adherent to the walls of the vagina and may be white or yellow. The smell is particularly noticeable around the time of menstruation or following intercourse; however, semen itself can give off a weak fishy smell.

29. The diagnosis is commonly made in clinical practice using the composite (Amsel) criteria: • vaginal pH > 4.5, • release of a fishy smell on addition of alkali (10% potassium hydroxide), • a characteristic discharge on examination, • presence of 'clue cells' on microscopy. 'Clue cells' are vaginal epithelial cells so heavily coated with bacteria that the border is obscured.

30. BV can also be diagnosed from a Gram-stained vaginal smear. Large numbers of Gram-positive and Gram-negative cocci are seen, with reduced or absent large Gram positive bacilli (lactobacilli) . Culture of a high vaginal swab yields mixed anaerobes and a high concentration of Gardnerellavaginalis. However, Gardenella vaginalis can be grown from cultures taken from up to 50 per cent of women with normal vaginal flora. Its presence is not, therefore, diagnostic of BY.

31. The simplest and cheapest treatment for BV is metronidazole 400 mg twice a day for 5 days, or 2 gas a single dose. Topical preparations are available in the form of metronidazole gel 0.75% or clindamycin cream 2%. Initial cure rates are over 80 per cent, but up to 30 per cent of women relapse within 1 month of treatment

32. It is now established that women with BV are at a greater risk of second trimester miscarriage and preterm delivery during pregnancy, which may result in perinatal mortality or cerebral palsy. "omen with a prior history of second trimester loss or idiopathic preterm birth should be screened for BV and treated with metronidazole early in the second trimester. It has also been demonstrated that treating women with BV with metronidazole prior to termination of pregnancy reduces the subsequent incidence of endometritis and pelvic inflammatory disease (PID). Women with BV are also at increased risk of infections after surgery.

33. Trichomoniasis This sexually transmissible infection can be carried asymptomatically for several months before causing symptoms. The incidence has been falling in the UK over the last 20 years. In men it is often carried asymptomatically, but may present as non-gonococcal urethritis (NGU). In women it causes a vulvovaginitis that can be severe, accompanied by a purulent, sometimes offensive, vaginal discharge. In many cases BV develops as well.

34. Examination shows a yellow or green vaginal discharge with inflammation sometimes extending out onto the vulva and adjacent skin. Punctatehaemorrhages can occur on the cervix, giving the appearance of a 'strawberry cervix'. The diagnosis is confirmed by culture, preferably in a specific medium such as Fineberg-Whittington. Microscopy of vaginal secretions mixed with saline has 60 per cent sensitivity for detecting the organism. Numerous polymorphonuclear cells are seen and the motile organism is identified from its shape and four moving flagellae.

35. Trichomonads on Wet Mount

36. Treatment is with metronidazole, either 2 g as a single dose or 400 mg twice a day for 5 days. The woman should be advised to send her sexual partner(s) for treatment before resuming intercourse together. Trichomoniasis has occasionally been identified in the upper genital tract of women with PID but is probably not an important cause of genital tract pathology. It can be isolated from the bladder. Occasionally persistent trichomoniasis is seen. This may be due to poor compliance with medication, poor absorption or a resistant organism.

37. Review the history to rule out reinfection from an untreated partner. The usual approach is to use higher doses of metronidazole, initially 400 mg three times a day, increasing to 1 g per rectum or intravenously twice a day. Neurological toxicity may be encountered with high doses. Unfortunately, alternative treatments are limited, but include arsphenaminepessaries and clotrimazole, which has an inhibitory effect on Trichomonasvaginalis.

38. Vaginal discharge in children Vaginal infections are common in childhood and mostly not related to sexual abuse. Streptococcal infections are the commonest cause. Shigella spp. can cause a haemorrhagic chronic vaginitis, often with nc history of diarrhoea. Recurrent vaginal infections should lead to suspicion of a fo reign body. An examination under anaesthesia may be necessary to exclude or remove the cause. Pinworms (Enterobiusvermicularis) are common and migrate from the anus at night, causing intense irritation and inevitable scratching by the child. The clue to the diagnosis is the nocturnal pattern infestations

39. . A Selotape test can be performed to look for eggs if the worms have not been witnessed at night. If sexual abuse occurs leading to infection with Chlamydia or gonorrhoea, a generalized vaginitis occurs. Adequate testing can therefo re be performed from vaginal swabs, negating the need to observe the cervix with the aid of a speculum. Other conditions affecting the vagina Other causes of discharge include atrophic vaginitis, toxic shock syndrome, Bartholin's abscess and

40. Atrophic vaginitis is common in postmenopausal women. Over the 5 years following the cessation of menstruation, the vaginal epithelium atrophies and the lactobacilli are once again replaced by typical skin commensal organisms. This can lead to superficial dyspareunia and vaginal soreness. The treatment of choice is oestrogen replacement with either topical dienoestrol cream or systemic therapy.

41. Occasionally a true bacterial vaginitis is encountered due to a Streptococcus or other organism. It responds to appropriate antibiotic therapy. Toxic shock syndrome is a rare condition associated with the retention of tampons or foreign bodies in the vagina. An overgrowth of staphylococci producing a toxin causes systemic shock with fever, diarrhoea, vomiting and an erythematous rash. There is a 10 per cent mortality rate. More frequently a foreign body or retained tampon merely causes an offensive discharge.