Prof. Dr. Professor of Obest. & Gynecology Tanta University

1. Vaginitis By Prof. Dr. Professor of Obest. & Gynecology Tanta University Amal E. Mahfouz

2. Vaginitis WHAT IS VAGINITIS? It is a term applied to any kind of vaginal inflammation that cause abnormal discharge and pruritis . It is one of the most common reasons for a women to seek Gynecological care.

3. The 5th World Conference on Vaginitis1 - 3 May 2008Ritz CarltonIstanbul,Turkey

4. Classification of Vaginitis according to the age VULVO-VAGINITIS • Occur in children usually caused by gonococi and chlamydia INFECTIVE VAGINITIS • Occur in child-bearing age ATROPHIC VAGINITIS • In post-menopausal women VULVO-VAGINITIS

5. Causes of Vaginitis 1- ALLERGIC VAGINITIS:caused by spermicidal creams, bath oils or soaps. 2- INFECTIOUS VAGINITIS: A-Trichomoniasis(30%of cases). B-Candidiasis(candida albicans) 20-30 %. C- Bacterial vaginosis(Gardnerella vaginitis) 40-50%. D- Miscellaneous organisms (herpes simplex, HPV, gonorrhea &$). 3- ATROPHIC VAGINITIS: 4-Parasitic vaginitis:caused by Entropius Vermicularis 5-Foreign Body Vaginitis:retained tampons or condoms cause malodorous vaginal discharges.

6. Complications persistent discomfort Superficial skin infection (from scratching) Complications of the causative condition as gonorrhea and candida infection

7. Trichomonas Vaginitis Causative organism: Unicellular flagellated protozoan (Trichomonas vaginalis) that causes up to10-30% of vaginitis.

8. SITES AFFECTED: * Vagina, skene ducts & lower urinary tract. MODES OF INFECTION. 1-Sexual intercourse 2-Vulvo-vaginal contamination by bath, towels or wet bathing suits. • The disease is worse immediately after menstruation and most acute during pregnancy.

9. CLINICAL PICTURE: 1- Asymptomatic 2- Acute 3- chronic SYMPTOMS: 1-Discharge, copious, greenish-yellow, frothy and foul-smelling (fishy odor). 2-Pruritis,Edema, Erythema, especially in acute stage. 3-Urinarysymptoms may be present due to urethro-cystitis. Profuse purulent frothy vaginal discharge   Thin, water, cervical discharge of trichomonas infection

10. SIGNS: • Vulvar edema and erythema • Strawberry Cervix (2-3% of cases) • Punctate hemorrhages or Petechiae Prof.Dr. Amal E. Mahfouz

11. External Exam Frothy" Discharge seen around the cervix

13. LAB: 1- Vaginal pH > 5.0 2- Skiff Test positive - Fishy odor of discharge when KOH added. 3- Wet preparation(from vaginal vault, not endocervix). - Motile pear shaped Trichomonads with flagella (70%). 4- Gram Stain - White Blood Cells over 10 per high powered field. 5- Culture of Trichomonas vaginalis - Grown on Kupfierberg medium.

14. TREATMENT 1-Single dose of oral metronidazol (2gm). 2- Metronidazol 500mg bid for 7 days. 3- Intravaginal metronidazol supp. 500mg (bid) for 7 days. 4- Secnidazol (2 gm) oral single dose. N.B. Treatment of both partners is mandatory.

15. The antibiotic Paromomycin cream is an effective, alternative treatment option for women with hard-to-treat vaginal trichomoniasis

16. Hyphe Candidiasis Candida albicans,is a common organism found in the vagina of healthy women.

18. Predisposing causes: • Antibiotics which cause reduction of phagocytosis of the candida, or reduction of antibodies to the organism. High-risk antibiotics that more commonly lead to candidal infection are reportedly ampicillin, tetracyclines, clindamycin, and cephalosporins. • Diabetes, glucosuria and sweets eaters leads to glycogen deposition in the vaginal epithelium. • Immuno-compromisedpatients (AIDs).

19. Poor hygiene. • Corticosteroidsintake. • Pregnancydue to increase glycogen content of the vagina. • Hormonal contraception containing 75-150 micrograms of estrogen are most likely to cause the problem; low-dose products are seldom implicated

20. Certain types of clothing may predispose for Candida. Females should be cautioned to avoid wearing tight-fitting clothes and synthetic underwear. Frequent coitus and the use of intrauterine devices may also be contributing factors.

21. Clinical Picture • Discharge:thick "curdy" while, not malodorous unless mixed with infection. • Vulvar itching:vagina has no itch receptors, so pruritus is felt distally onto the vulva in 90% of patients. • Erythema of vulva:with edema of labia minora and excoriation due to scratching.

22. ThrushPatches

23. Situations That Mimic Vaginal Candidal Infection ConditionPossible Cause Contact dematitis Soaps, deodorants, detergents, spermicides, vaginal lubricants, perfumed cleansing wipes Irritant vulvitisExcessive use of minipads Vulvo-vaginitisAdverse reaction to vaginal antifungal Change in vaginal mucusThat occurs at ovulation Coitus-related vaginitisAllergy to partner’s sperm

24. Diagnosis • PH 4 – 4.7. • Microscopic examination of discharge with KOH reveled hyphae or budding yeast. • Increase lactobacilli in the smear. • Candida is recovered form the stool and oral cavity of 75% of women.

25. Treatment • Gentian violet 1-2% solution: is one of the oldest and most reliable treatment for candidiasis. • Oral Fluconazol 150 mg single dose. • Oral Ketoconazol 200 mg bid for 5 days. • Recurrent infection is due to harbouring of the fungus in the GIT.

26. Fluconazole is a potentantifungalknown to act against most candida species (particularly candida albican)has demonstrated effective action against both oral andvaginal candidiasiseven in cases resistant to nystatin orclotrimazole. One of it's side effects is liver toxicity although that appears to be more common in patients with concomitant health issues and seems to be reversible on stopping the drug.

27. Fluconazole taken once a week for six months was found to reduce the frequency of recurrent vaginal Candida infections by more than 90%.

28. Antifungal vaginal medications Antifungal creams Antifungal tablets Antifungal suppositories Miconazole • An antifungal synthetic derivative of imidazole. • Miconazole selectively affects the integrity of fungal cell membranes. • It is used topically and by intravenous infusion.

29. Clotrimazole • An imidazole derivative with a broad spectrum antimycotic activity. • It inhibits biosynthesis of the sterol ergostol, an important component of fungal cell membranes. • Its action leads to increased membrane permeability and disruption of enzyme systems bound to the membrane.

30. Tioconazole • A synthetic imidazole derivative. • It inhibits cell wall synthesis, damaging the fungal cell membrane, altering its permeability, and promoting loss of essential intracellular elements. Butoconazole GYNAZOLE vaginal cream, contains butoconazole nitrate 2%, an imidazole derivative withantifungalactivity.

31. Bacterial Vaginosis The term vaginosis indicates lack of an inflammatory reaction (absence of white blood cells in the discharge. The causative organisms is Hemophilus vaginalis (Gardnerella vaginalis). • It is gram -ve, anaerobic, comma-shaped rods. Incubation period:5-10 days after inoculation.

32. Three points help confirm bacteria as the source of vaginitis: The discharge is thin, homogeneous, white, and resembles skim milk adhering to vaginal walls. (2) The pH is above 4.5 (normal vaginal pH is 3.8-4.4). (3) When a sample of the discharge is mixed with 10% KOH, it will produce a typical "fish-like" odor (this is indicative of an increase in anaerobic activity, which yields amines such as cadaverine and putrescine)

33. Honey-colored pus-like vaginal discharge characteristic of either group B streptococcus or Staphylococcus aureus

34. Sequelae of Infection • Increase risk of septic abortion. • Premature rupture of membrane. • Preterm labor: due to production of phospholipase A2 by the micro-organism which in turn initiate labor. • Post-cesarean section endomyometritis. • Post hysterectomy pelvic cellulitis.

35. Clinical Picture DISCHARGE: • Vary from scant to profuse (less than trichomoniasis). • Non inflammatory discharge (No W.B.Cs). • Homogenous thick in consistency (like thin flour paste). • Gray in color, malodorous especially during sexual intercourse. Irritative symptoms:pruritis and burning, less than with trichomonas infection.

36. Diagnosis • Vaginal PH: 5- 5.5 . • Wet mountpreparationof discharge in saline, revealed typical appearance of clue cells (epithelial cells stippled with bacteria attached to its border. • There is absence of lacto bacilli. Clue Cell

37. Gram stainsmear reveled gram –ve bacilli. • Cultures on Casman's blood agarthe colonies of Gardnerella are identified by diffuse B hemolysis. • Whiff test:positive for fishy odor when alkaline KOH solution is added. • Pap smearindicate Coco-bacillary shift of vaginal flora. Gram Stain - Bacterial Vaginosis

38. Treatment • Metronidazol500 mg bid for 7 days. • Metronidazol oral2gm single dose. • Metronidazol gelvaginally bid for 5 day. • Clindamycin cream2% per vagina for 7 days. • Ampicillinor Amoxicillin500 mg qid for 7 days (not as effective). • Intravaginal sulphonamides1 tab or applicator bid for 7-10 days.

39. Diagnostic Criteria Normal Bacterial Vaginosis VaginitisTrichomonas Candida Vulvovaginitis Vaginal pH 3.8 – 4.2 > 5.4 5.4 <5.4 (usually) Discharge Thin, white (milky), gray Yellow, green, frothy White, curdy, cottage cheese White, thin, floccuent Amine odor "whiff" test Absent fishy fishy Absent Miroscopic Lactobacilliepithelial cells Clue cellsadherent cocci, no WBC's TrichomonadWBC's /hpf>10 Budding yeast, hyphae, pseudohyphae Differential Diagnosis of Vaginal Infections

40. Atrophic Vaginitis • This term is used to describe atrophic changes in the vulva and vagina as well as urethra and bladder. Incidence: • Affect 10-40% of postmenopausal women.

41. Risk Factors • Menopause • Surgical oophorectomy. • Ovarian destruction by radiation or chemotherapy • Postpartum due to loss of placental estrogen • During lactation. • Anti-estrogic druges e.g. Tamoxifen, Depot provera and LHRH antagonist. • Other risk factors are cigarette smoking and absent coital cavity.

42. Clinical Picture • I Genital symptoms: • Dryness • Burning • Itching • Vulvar pruritus • Feeling of heaviness • Yellow malodorous discharge

43. II Urinary Symptoms: • Dysuria • Frequency • urinary tract infection • Stress incontinence • Hematuria

44. Diagnosis • Historyof used perfumes or lubricants, which contain irritant compounds. • Vagina showssignsof atrophy, pale, smooth, and shiny with patchy erythema and increased friability. • Introitusbecomes narrow with decreased vaginal depth. • Pelvic examinationcauses pain, vaginal bleeding and spotting.

45. sclerosus Lichen Examination of External Genitalia • Decrease elasticity of the skin. • Decrease pubic hair. • Dryness of labia. • Fusion of labia minora. • Vulvar dermatosis.

46. Vulvar irritation Urethral polyp Cystocele Rectocele • Signs of vulvar irritationcaused by urinary incontinence. • Cystocele, rectocele, or uterine prolapse, may accompany atrophicvaginitis. • Urethral polyp, or caruncle may be present. Prof.Dr. Amal E. Mahfouz

47. Laboratory Findings • Increase serum FSH & LH. • PAP smear from upper third of the vagina show increase proliferation of parabasal cells, decrease superficial cells. • Increase vaginal PH >5. • Vaginalultrasonography, shows thin endometrial lining (4-5mm) • No evidence of trichomonas, candida or bacterial vaginitis.

48. Treatment • Estrogen replacement therapy oral or vaginal. • Moisturizers and lubricants.

49. Thank You