EXAMINATION OF A PATIENT WITH PRUITUS VULVAE,CAUSES AND TREATMENT

 EXAMINATION OF A PATIENT WITH PRUITUS VULVAE

a.       General exam must include dermatologic inspection of face, mucous membrane ,hands, wrist, elbow, trunk and knee.

b.                 Lack for evidence of systemic dzs  e.g Dm, renal dz, hepatic dz and haematological dz

c.                  Inspection of vulva. 

INVESTIGATIONS:

Urine microscopy,culture and sensistivity

Do a urinalysis and PCV

Clinical photography

Coloscopy, using either acetic acid or 1% aqueous solution of toluidine blue (to mek the lesion clearer to the vision)

Biopsy and histology

TREATMENT        

Depends on cause

Use steroid anti-histanmines, sedatives oestrogen creams, nystatin creams/imidazole metronidazole interferons.

Lesion may be excised surgically.

VULVO-VAGINTIS

Vaginal discharge consequent to infections of the vagina is one of the most common symptoms seen in gyneacology OPD. The 3 most common causes include:

Fungal (candidiasis)

Protozoan (trichomoniasis)

General (bacterial vaginosis)

Vulvovaginitis affects all age group from premenarchial to post menopausal.

VAGINAL DISCHARGE: May be physiological or pathological. Normal physiologic vaginal discharge consist of transudates from the vaginal wall, squanes containing glycogen, polymorphs, lactobacilli, cervical mucus, residual menstrual fluid, and contributions, from the greater and lesser vestibular glands. Vaginal secretions vary with oestrogen levels and don’t automatically mean infection. Between puberty and menopauses, the presence of lactobacilli maintains the vaginal PH 3.8 and 4.2. This protects against infection. Before puberty and after menopause, the higher PH and urinary and faecal contamination increase the risks infection. Vaginal atrophy seen prior to puberty, during pregnancy, post-partum/lactation, and following the menopause also increases the risk of infection, vaginal bleeding and vaginal discharge. The acid PH of the vagina, its normal bacterial flora, presence of glycogen and osetrogenization provide natural defense mechanism for the lower genital tract. Physiological vaginal discharge is white follicular, curdy, odour less and does not cause itching burning sensation or other discomforts.

FACTORS THAT IMPAIR THE DEFENCE MECHANISM

1.       Age: Infection are more likely in childhood and post-menopausal patients. In childhood, there is vaginal atrophy, increased PH, foecal and urinary contamination due to poor hyiene and proximity of the vagina and anus. There is lack of protective hair on the labia majora and lack of labial fat pads; lack of oestrogenization. This make the vulva and vaginal skin easily traumatized by medication and clotting.

          For post-menopausal women: low levels of oestrogen atrophy of the vulva and vaginal low concentration of lacto-bacilli; low glycogen store. They are prone to infections, vaginal discharge, trauma and atrophic vaginitis.

2.       MENSTRUAL CYCLE: during this period there is an increase in alkalinity. Hence increasing infection.

3. Pregnancy and puerperium: Due to the increase in PH of the vaginal fluids, and also due to trauma on delivery.

4. Oestrogen containing oral contraceptives: Also cause an increase in PH.

5. Presence of foreign bodies in the vagina: e.g beads and cotton wool in children and forgotten tampons in adults this is associated with toxic shock syndrome.

6. Presence if IUCD

Pathological causes

These can be

1.       infective

2.       non-infective

INFECTIVE: called vaginitis ( or vulvovagnitis because it always affects the vulva it can be due to specific and non-specific organisms.

Vulvovagnitis: This is the inflammation and irritation of the vulva and vagina, which can by microbiologic agents.

Vulvo-vaginal problems in pre-pubertal Girls

a.                 Non specific

b.                 Specific

i.        Respiratory pathogens (group A, B streptococcus strep pneumonia, Noiseria Meingitids, branchmella cetarrhalis, Staph aureus, H. influenae

ii.       Enteric shigella, yersinia, other Flora

iii. STDs: Neisseria gonorrhoea, Chlamydia trachomatis, herpes simplex trichomonas

iv.      Pin worms

v.       Foreign bodies

vi.      Polyps and tumours

vii.     Systemic illness: measles, chicken pox scarlet fever vulval skin diseases: lichen slerosis, psoriasis contact dermatitis. Trauma

Psychosomatic vaginal complaints

miscelancous: draining pelvic abscesses, prolapsed uterus, ectopic

ureter

Adolescent females and reproductive women

Infectious vulvovaginal commonest causes

Bacterial vaginosis (40-50%) candidiasis

Vulvovaginal candidiasis (20-25%)

Trichomoniasis (15-20%)

Less common causes (i) Atrophic vaginitis with primary infection (ii) foreign body with secondary infection (iii) HIV-associated vaginal infections

Non infectious vulvovagintis

i.                   Ulcerative vaginitis associated woth staphylococcus toxic shock syndrome.

ii.                 Atrophic vaginitis

iii.              Contact dermatitis

iv.               Eczema

v.                 Lichen simplex chronic

vi.              Psoriasis

vii.            Lichen planus

viii.         Traumatic dermatitis.

CANDIDIASIS

This is a common cause of vulvovaginitis causative agents are C. albicans (60-80%)

                                      C. glabrata (20%)

                                      C. tropicalis (6-23%)

These organisms can be carried in the vagina, buccal cavity and skin major reservoirs in the G.T

PREDISPOSING FACTORS      

a.     DM

b.     Reduced immunity

c.      Pregnancy

d.     Antibiotics use

e.      Coticosteroids

f.       Obesity

g.     Oestrogen containing oral contraceptives

h.     Iron deficiency anaemia

i.       Use of tight filtting under garments

j.       Summer seasons.

The role of sexual transmission is debatable. However, sexual partners of women with recurrent candida vaginitis are more likely to have oral and ejaculate cultures of the organism.

SYMTOMPS

Thick curdy, whitish discharge adhering to the vaginal kin and accompanied by itching and labial pain. Itching may occur at mid cycle and after menses. However, some patients seem to remit at mid cycle.

There may be dyspareunia

DIAGNOSIS.

Clinical: Erthema of the vagina and labia minora, which may extend perianally and unto the thighs. There may be oedema of the vulva with red popules or fissures at the posterior fourchette. The PH of the vaginal fluid usually below 5 (normal 3.5-.5)

Microscopy: A wet mount under microscopy will show hyhae and spore. It can also be cultured on glucose agar and sabouraud agar. Swabs to be cultured are put in stuarts transport medium.

TREATMENT: Use of imidazole, fluconazole, niconazole, teconazole)

Cotrimazole: 100mg vaginal suppository for 6-7 nights or 200mg tabs of vaginal suppository for 3 nights.

Or 1% cream of cotrimazole one applicator full x 7 nights

Niconazole: 200mg vaginal suppositories for 7 nights or 2% cream, one applicator full for 7 nights. POLYENE anti fungals (e.g Nystatin) given as 100000 1.11 vaginal suppository for 14 nights.

TRIAZOLE ANTIFUNGALS: fluconazole given 150mg capsule, once orally.

GENTIAN VIOLET: 1% applied to the and vagina; 2 occasions 72 hours apart.

FOR RECCURENT INFECTION: investigate to rule out DM. give polyenes and imidazoles as above over a prolonged period (e.g 3 weeks) or

Flu conazole caps daily until a good result is achieved.ketoconazole 200mg bd orally for 7-14 days

For pregnant women: polyenes and imidazoles, but avoid first trimester.

PREVENTTION

Good hygiene

Daily washing with blank soap and water.

Avoidance of close-fittings underwear and nylon pants.

Washing of underwears with water of above 80%

TRICHOMONIASIS

Causative agent: it is caused by a flagellated protozoan T. vaginalis. They are sexually transmitted, and may mask the presence of gonaccal infections. Cervical cytology can be highly abnormal in the presence of T. vaginalis cervical smear may be repeated after adequate tests

Clinical features:   

Itching and burning senation

Dyspareunia

Frothy vagina discharge, which is foul smelling may white green or brownish. There may be dysuria and urethral discharge may occur. There could be vulval and congestions vaginal skin is reddish purple.

DIAGNOSIS

CLINICAL: Examine the vulva and vagina. The cervix may appear reddish with contact bleeding and is described as astrabery cervix.

Vaginal PH is always 5 (5-6)

Microscopy of the discharge suspended in adrop of normal saline shows a motile flagellated protozoan.

Trichomonas can also be isolated by culture.

TREATMENT

Use of metronidazole for both partners 500mg bd x ⁷/₇

Or 400mg tbs x ^5-7/₇

Or 2g stat

For treatment failure

Metronidazole 2g daily for 3-5 days

Or 500mg orally bd x ^5-7/₇

Vaginal cotrimazole

For pregnant women

Treat after 1^st trimester with Metronidazole 2g stat

BACTERIAL VAGINOSIS

It was formerly called non-specific vaginitis. It results from complex atteration of the microbial flora of the vagina. It seems to result from an increased concentration of Gardnerlla vaginalis and anaerobic organism e.g bacteroides, mobilencus species and mycoplasma hominis with an absence of normal H₂O₂ producing lactobacilli. The over growth results in an elevanted vaginal PH and production of amines which cause the typical malodour the patient experience(fishy small)

Bacterial vagnosis occurs in 5-15% of college (university) students, 10-25% of pregnant women, and 33-37% of women attending STD clinics.

Bacterial vagnosis has been associated with post-partum endometritis premature labour, premature ROM, irregular menstrual bleeding and salpingitis.

Symptoms

Malodourous vaginal discharge the odour is described as offensive fishy small . This discharge can be scanty or profuse. It is usually grey or yellow in colour PH of vaginal discharge is between 5 and 6

There is itching

There may be slight abdominal discomfort

There may be prolonged menses

There could be vulval excoriation and punctuate haemorrhage

SOURCE OF INFECTION

Seen in sexually active patients

DIAGNOSIS

          On wet mounts due cells are seen; reduced number of lactobacilli. There is mixed bacterial population including Gardneralla vaginalis and mobilencus .

          A drop of 10% KOH added to a sample of the discharge on a glass slide releases the fishy odour. The due cell is vaginal epithelial cell coated with bacteria

ole is the treatment of choice: 200mg tds x 7/7 or 500mg bd x 5-7/7 or 2g stat

Topical  application of Metronidazole gel can be used clindamycin can also be used (orally or as a cream). 

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Posted by : Unknown July 08, 2015 Tags : NEWS

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