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By
Prof. Dr.
Professor of Obest. & Gynecology
Tanta University
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.

The 5th World Conference on Vaginitis
3 - 1 May 2008
Ritz Carlton
Istanbul,Turkey
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
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.
Complications
persistent discomfort
Superficial skin infection (from
scratching)
Complications of the causative condition
as gonorrhea and candida infection
Trichomonas Vaginitis
Causative organism:
Unicellular flagellated protozoan (Trichomonas
vaginalis) that causes up to10-30% of vaginitis.
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.
CLINICAL PICTURE:
1- Asymptomatic
2- Acute
3- chronic
SYMPTOMS:
1-Discharge, copious, greenishyellow, frothy and foulsmelling (fishy odor).
2-Pruritis,Edema, Erythema,
especially in acute stage.
3-Urinary symptoms may be
present due to urethrocystitis.
Profuse purulent frothy vaginal discharge
Thin, water, cervical discharge of
trichomonas infection
SIGNS:
Vulvar edema and erythema
Strawberry Cervix (2-3% of cases)
Punctate hemorrhages or Petechiae
Prof.Dr. Amal E. Mahfouz
External Exam
Frothy" Discharge seen around the cervix
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.
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.

The antibiotic Paromomycin cream is an
effective, alternative treatment option for
women with hard-to-treat vaginal
trichomoniasis
Candidiasis
Candida albicans,is a common organism
found in the vagina of healthy women.
Hyphe
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-compromised patients (AIDs).

Poor hygiene .

Corticosteroids intake.

Pregnancy due 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

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 .
Clinical Picture
1) Discharge: thick "curdy" while,
not malodorous unless mixed
with infection.
2) Vulvar itching: vagina has no
itch receptors, so pruritus is felt
distally onto the vulva in 90% of
patients.
3) Erythema of vulva: with
edema of labia minora and
excoriation due to scratching.
Thrush Patches

Situations That Mimic Vaginal Candidal Infection
 Condition





Possible Cause
Contact dematitis
Soaps, deodorants, detergents,
spermicides, vaginal lubricants, perfumed cleansing wipes
Irritant vulvitis
Excessive use of minipads
Vulvo-vaginitis
Adverse reaction to vaginal
antifungal
Change in vaginal mucus That occurs at ovulation
Coitus-related vaginitis
Allergy to partner’s sperm
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.

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.
 Fluconazole is a potent antifungal known to act
against most candida species (particularly candida
albican) has demonstrated effective action against
both oral and vaginal candidiasis even in cases
resistant to nystatin or clotrimazole.

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.
 Fluconazole taken once a week for six
months was found to reduce the frequency
of recurrent vaginal Candida infections by
more than 90%.
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 .
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 .
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
vaginal cream, contains butoconazole
nitrate 2%, an imidazole derivative with antifungal
activity.
GYNAZOLE
Bacterial Vaginosis
The term vaginosis indicates lack of
an inflammatory reaction (absence
of white blood cells in the
discharge.
The
causative
organisms
Hemophilus
(Gardnerella vaginalis).

is
vaginalis
It is gram -ve, anaerobic, commashaped rods.
Incubation period: 5-10 days after
inoculation.

Three points help confirm bacteria as the
source of vaginitis:
(1)
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)
Honey-colored pus-like vaginal discharge characteristic
of either group B streptococcus or Staphylococcus aureus
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.
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.
Diagnosis

Vaginal PH: 5- 5.5 .

Wet mount preparation of
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
 Gram
stain smear reveled gram
–ve bacilli.
 Cultures
on Casman's blood
agar the colonies of Gardnerella
are identified
hemolysis.
 Whiff
by
diffuse
B
test: positive for fishy
odor when alkaline KOH solution
is added.
 Pap
smear
indicate Cocobacillary shift of vaginal flora.
Gram Stain - Bacterial
Vaginosis
Treatment
 Metronidazol
500 mg bid for 7 days.
 Metronidazol
oral 2gm single dose.
 Metronidazol
gel vaginally bid for 5 day.
 Clindamycin
cream 2% per vagina for 7 days.
 Ampicillin
or Amoxicillin 500 mg qid for 7 days
(not as effective).
 Intravaginal
for 7-10 days.
sulphonamides 1 tab or applicator bid
Differential Diagnosis of Vaginal Infections
Candida
Vaginitis
Vulvovaginiti
Trichomonas
s
Diagnostic
Criteria
Normal
Bacterial
Vaginosis
Vaginal pH
3.8 – 4.2
> 5.4
5.4
<5.4 (usually)
Thin, white
(milky), gray
Yellow, green,
frothy
White, curdy,
cottage cheese
Absent
fishy
fishy
Absent
Lactobacilli
epithelial cells
Clue cells
adherent
cocci, no
WBC's
Discharge
Amine odor
"whiff" test
Miroscopic
White, thin,
floccuent
Trichomonad
WBC's
/hpf >10
Budding yeast,
hyphae ,
pseudohyphae
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.
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.
Clinical Picture
I Genital symptoms:
•Dryness
•Burning
•Itching
•Vulvar pruritus
•Feeling of heaviness
Yellow malodorous discharge
II Urinary Symptoms:
1. Dysuria
2. Frequency
3. urinary tract infection
4. Stress incontinence
5. Hematuria
Diagnosis
 History
of used perfumes or lubricants,
which contain irritant compounds.
 Vagina
shows signs of atrophy, pale,
smooth, and shiny with patchy erythema and
increased friability.
 Introitus
becomes narrow with decreased
vaginal depth.
 Pelvic
examination causes pain, vaginal
bleeding and spotting.
Examination of External Genitalia

Decrease elasticity of the
skin.

Decrease pubic hair.

Dryness of labia.

Fusion of labia minora.

Vulvar dermatosis.
sclerosus Lichen

Signs of vulvar irritation caused
by urinary incontinence.

Cystocele, rectocele, or uterine
prolapse, may accompany atrophic
vaginitis.

Urethral polyp, or caruncle may
be present.
Vulvar irritation
Urethral polyp
Prof.Dr. Amal E. Mahfouz
Rectocele
Cystocele
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.
 Vaginal ultrasonography, shows thin endometrial
lining (4-5mm)
 No evidence of trichomonas, candida or
bacterial vaginitis.
Treatment
 Estrogen
replacement therapy oral or
vaginal.
 Moisturizers
and lubricants.