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Vulvovaginal Infections Wang Yu M.D., Department Of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine Definition inflammation of the vagina(阴道) and/or vulva (外阴) 2006-11-27 Vulvovvaginal Infection 2 Defence Mechanisms • Closure of the introitus(入口) • Vaginal acidity (pH 4.5) • Glandular secretions 2006-11-27 Vulvovvaginal Infection 3 Defence mechanisms Closure of the introitus In children and virgin adults the vaginal canal is only a potential space kept closed by the surrounding muscles and provides another physical barrier 2006-11-27 Vulvovvaginal Infection 4 Defence Mechanisms Vaginal acidity (pH 4.5) Glycogen( 糖 原 ) is produced by vaginal epithelium influenced by estrogens and is converted to lactic acid by Doderlein’s bacillus (德得来因杆菌). This maintains the vaginal pH between 3 and 4 which inhibits most other organisms 2006-11-27 Vulvovvaginal Infection 5 Defence mechanisms Thick layer of vaginal squamous epithelium This is a considerable physical barrier to infection. Continual desquamation(脱落) of the superficial keratohyalin(角质透明蛋白) layer and glycogen production, both dependent upon ovarian estrogen action, combat bacteria. In children and post-menopausal patients the epithelium lacks oestrogen stimulation and is thin and easily traumatized or infected. 2006-11-27 Vulvovvaginal Infection 6 Defence mechanisms Glandular secretions from the cervix and Bartholin’s glands(前庭 大 腺 ) maintain an outward fluid current helping to clear the canal of debris. In addition, cervical secretion contains immunoglobulins, especially IgA, and there are varying numbers of polymorphs, lymphocytes and macrophages 2006-11-27 Vulvovvaginal Infection 7 Vaginal discharge-Composition Tissue fluid, cell debris, carbohydrate, lactobacilli(乳酸杆菌), lactic acid. The pH is about 4.5, a degree of acidity which inhibits the growth of organisms other than the lactobacills. 2006-11-27 Vulvovvaginal Infection 8 2006-11-27 Vulvovvaginal Infection 9 Risk factors for Vulvovaginitis • • • • • 2006-11-27 pregnant uncontrolled diabetes taking birth control pills taking antibiotics or corticosteroids previous candidal(念珠菌) infections Vulvovvaginal Infection 10 Risk factors for Vulvovaginitis • frequent sexual intercourse use douches(冲洗) • use vaginal sponges or an IUD • wear tight clothing (jeans, synthetic underwear, wet bathing suits) • AIDS 2006-11-27 Vulvovvaginal Infection 11 Incidence • 10% to 41% of women have had it at • • • • 2006-11-27 least once 75% of all women get a vaginal yeast infection at least once Bacterial vaginitis: 40% to 50% Candidal vulvovaginitis: 20% to 25%. Trichomoniasis(滴虫): 15-20% Vulvovvaginal Infection 12 Source of Vaginal Discharge Vulva: • Greater vestibular glands (前庭大腺) • Glands of vulval skin (外阴皮肤) 2006-11-27 Vulvovvaginal Infection 13 Source of Vaginal Discharge Vagina: Mainly desquamated epithelial cells which liberate glycogen. The lactobacilli metabolise the glycogen to lactic acid. Vaginal transudate (secretion from tissues and capillaries of the mature vagina) is often described: vaginal epithelium is certainly not water resistant (like transitional epithelium). There are no mucosal gland. 2006-11-27 Vulvovvaginal Infection 14 Source of Vaginal Discharge Cervix: Alkaline mucous secretion which becomes watery during ovulation Uterine glands also discharge into the vagina. 2006-11-27 Vulvovvaginal Infection 15 Clinical Features- Volume The need to wear a pad or tampon continuously suggests excessive discharge 2006-11-27 Vulvovvaginal Infection 16 Clinical Features- Onset Sudden onset means infection. Onset can be associated with the end of a pregnancy, the contraceptive pill, a course of antibiotic, a sexual adventure 2006-11-27 Vulvovvaginal Infection 17 Clinical Features- Color Normal discharge is white but stain yellow or pale brown on clothing or pads. A greenish-yellow color suggests pyogenic( 化 脓 性 ) infection, commonly accompanied by an unpleasant odour. A red or dark brown suggest blood. 2006-11-27 Vulvovvaginal Infection 18 Clinical Features- Irritation Any discharge can in time excoriate(表皮脱落) the vulva but only candidal and trichormonas cause itching(瘙痒) 2006-11-27 Vulvovvaginal Infection 19 Patient’s complain • an excessive amount of staining on the clothing • offensive smell • local irritation 2006-11-27 Vulvovvaginal Infection 20 Examination Vulva, Perineum(会阴) and thighs are inspected for signs of excoriation The vestibular glands and urethral meatus are observed and palpated 2006-11-27 Vulvovvaginal Infection 21 Examination Vaginal walls and cervix are examined through a speculum. Normal vaginal epithelium is pink, the rugae are well marked and the epithelial surface of the cervix smooth and moist. Normal discharge is like curdled milk and is white and odourless. 2006-11-27 Vulvovvaginal Infection 22 Examination A bimanual examination should always be made. 2006-11-27 Vulvovvaginal Infection 23 Examination Specimens of discharge are taken for microscopy and culture, and a cervical smear for cytology Chlamydia(衣原体) must be excluded 2006-11-27 Vulvovvaginal Infection 24 Leucorrhoea • This means an excessive amount of normal discharge – a very subjective assessment. • The patient will complain of constantly having to change her clothes but there will be no irritation and appearance will be normal. 2006-11-27 Vulvovvaginal Infection 25 Leucorrhoea • The smell will be the normal vulval odour , microscopy will reveal normal appearances and culture will grow only lactobacilli. • The patient should be reassured and given an explanation of normal physiology. No local treatment is necessary. 2006-11-27 Vulvovvaginal Infection 26 Leucorrhoea(白带) Almost 20% of all patients attending gynaecological clinics complain of vaginal discharge, indicating some form of infection. The infective agents form three groups: • Candida albicans(白色念珠菌) • Gardnerella vaginalis(加德纳尔菌) • Trichomonas vaginalis (阴道毛滴虫) 2006-11-27 Vulvovvaginal Infection 27 Inflammation • In 90% of cases the inflammation is usually relatively mild and is due to one of three agents • The remaining 10% are more serious. They may cause painful sores, tumour-like lesions, spread into the pelvis or cause generalized infection • Chlamydia trachomatis(沙眼衣原体) is a major cause of gynaecological morbidity 2006-11-27 Vulvovvaginal Infection 28 Candida Albicans This is yeast and exists in two forms – slender branching hyphae or as small globular spore which multiplies by budding. 2006-11-27 Vulvovvaginal Infection 29 2006-11-27 Vulvovvaginal Infection 30 Source of infection This organism may exist as a normal commensal in the rectum and small numbers may be found in the vagina, the acid medium suiting their survival without symptoms arising. The patients’s fingernails may harbour the yeast. Sexual transmission is also possible. Symptomatic infection is most likely to arise when there are predisposing conditions e.g. 2006-11-27 Vulvovvaginal Infection 31 Pregnancy The vagina provides a tropical micro-climate and the high concentration of sex steroids in the blood maintains an increased glycogen formation in the vaginal epithelium and may alter the local pH. 2006-11-27 Vulvovvaginal Infection 32 Immunosuppressive Therapy This includes cytotoxic drugs and corticosteroids. There is also thought to be a natural degree of immunosuppression during pregnancy 2006-11-27 Vulvovvaginal Infection 33 Glycosuria(糖尿) This may be due to undiscovered diabetes, but again a mild degree of glycosuria may exist in a normal pregnancy due to lowering of the renal threshold for sugar. 2006-11-27 Vulvovvaginal Infection 34 Antibiotic Therapy Systemic antibiotics destroy the normal bacteria thus reducing the competition for nutrients leaving the field clear C. albicans(白色念珠菌) 2006-11-27 Vulvovvaginal Infection 35 Chronic Anaemia Normal iron stores are needed to maintain an adequate immune reaction. This also entails adequate folic acid intake. The angular stomatitis(口角炎) of chronic anaemia is due to Candida infection. 2006-11-27 Vulvovvaginal Infection 36 Immune Rarely, deficient cell mediated immunity is a predisposing condition. 2006-11-27 Vulvovvaginal Infection 37 Clinical features • The patient is usually between 20 and 40 • The complaint is of irritant discharge and dyspareunia. 2006-11-27 Vulvovvaginal Infection 38 Clinical features • Examination reveals an inflamed and tender vagina and vulva with white plaques resembling curdled milk(凝乳) adhering to the vaginal wall and vulva. • Removal of the plaque reveals a red inflamed area. Post-menopausal infection is uncommon, but if it does occur after the menopause the symptoms tend to be severe. 2006-11-27 Vulvovvaginal Infection 39 Leucorrhoea is like cheese 2006-11-27 Vulvovvaginal Infection 40 Treatment • A single 500 mg clotrimazole pessary, with external application of 1% clotrimazole cream offers convenient therapy. • Oral fluconazole 150 mg or itraconazole 200 mg as a single does, or monthly for 6 months may be effective. Nystatin 500,000 i.u. orally 4X daily and Nystatin pessaries 2X day for 3 or 4 months may be added. Boilable or disposable underwear should be worn. 2006-11-27 Vulvovvaginal Infection 41 Treatment • There is now doubt about the need to treat sexual partners, formerly advised. • In persistent or recurrent infection, confirmation of the diagnosis by culture and determination of sensitivity to treatment are important. 2006-11-27 Vulvovvaginal Infection 42 Gardnerella Vaginalis – Bacterial Vaginosis For a long time a large numaber of cases of vaginitis were labeled nonspecific because of disagreement regarding the infective agent. These cases were characterized by a nonirritating, foul smelling discharge. 2006-11-27 Vulvovvaginal Infection 43 Gardnerella Vaginalis – Bacterial Vaginosis Ultimately, careful bacteriological studies have established the fact that although the discharge contains a mixture of bacteria, the one constant feature in 90% of cases is the presence of a tiny gram-negative cocco-bacillus which is a facultative anaerobe – Gardnerella vaginalis(阴道加德纳尔菌) 2006-11-27 Vulvovvaginal Infection 44 Clinical features The patient complains of a foulsmelling discharge, and examination confirms both the discharge and the odour. In appearance the discharge is thin, grayish and sometimes shows bubbles. A vaginal smear reveals the presence of ‘clue’ cells. Gram staining is usually negative but can be variable. 2006-11-27 Vulvovvaginal Infection 45 2006-11-27 Vulvovvaginal Infection 46 Treatment • Metronidazole(甲硝哒唑) 200 mg t.i.d. for 7 days or a single dose of 2 g appears to be effective. • Clindamycin( 氯林可霉素 ) vaginal cream may also be employed • Male partners should also be treated 2006-11-27 Vulvovvaginal Infection 47 Trichomonas Vaginalis Trichomonas vaginalis is a protozoan organism, which infests the vagina in the female and the urethra, prepuce and prostate in the male. It is a common cause of irritant vaginal discharge. 2006-11-27 Vulvovvaginal Infection 48 Trichomonas Vaginalis T. Vaginalis is a single-cell organism about 20Uux 10u. It is transmitted mainly during sexual intercourse but can be acquired from infected articles such as a contaminated speculum. 2006-11-27 Vulvovvaginal Infection 49 2006-11-27 Vulvovvaginal Infection 50 Clinical features • In the acute phase the patient complains of severe vaginal tenderness and pain, and an irritant discharge • The vagina is seen to be inflamed, sometimes with a patchy strawberry vaginitis, and there is a copious offensive, frothy discharge 2006-11-27 Vulvovvaginal Infection 51 Clinical features • Frequently there is a buring sensation, pruritus, dysuria and dyspareunia. • In the latent or dormant phases there are no symptoms although the presence of the organism can be demonstrated, often in a cervical smear. 2006-11-27 Vulvovvaginal Infection 52 Incidence Perhaps 18% of the female population. T.vaginalis is commonly found in patients with gonorrhoea, and has an association with cervical dysplasia. No cause-and-effect relationship has been proved. 2006-11-27 Vulvovvaginal Infection 53 Diagnosis Diagnosis is by observation of the motile organisms in a fresh smear diluted with saline and by laboratory culture. 2006-11-27 Vulvovvaginal Infection 54 Treatment • Always systemic and, if possible, including the patient’s sexual partner. • Metronidazole (甲硝哒唑) 200 mg thrice daily for a week, or 2 g orally once, avoiding concurrent alcohol ingestion. • Nimorazole (Naxogin) 2 gm as a single dose taken with food. 2006-11-27 Vulvovvaginal Infection 55 Treatment • Short courses are useful with patients whose cooperation is uncertain, but are more likely to cause nausea and gastritis. • The post-treatmet vaginal smear should be normal, but T. vaginalis can linger in the urethra, Skene’s and Bartholin’s glands, and reinfection of the vagina may call for further treatment. 2006-11-27 Vulvovvaginal Infection 56 Prevention • treatments should not be taken unless the woman had been diagnosed • Douching should be avoided because it may disturb the balance of organisms in the vagina and may spread them higher into the reproductive system. • Avoid wearing tight clothing and wear cotton underwear. 2006-11-27 Vulvovvaginal Infection 57 Prevention • Thoroughly dry oneself after bathing and remove a wet bathing suit promptly. • After a bowel movement, wipe from front to back to avoid spreading intestinal bacteria to the vagina. • Clean diaphragms, cervical caps, and spermicide applicators after use. Use condoms to avoid sexually transmitted disease As Trichomonas infection is sexually transmitted, 2006-11-27 Vulvovvaginal Infection 58 Complications Bacterial vaginosis (BV) results in pelvic inflammatory disease that result in infertility and tubal pregnancy increase in adverse outcomes of pregnancy such as premature labour,premature rupture of membranes, amniotic fluid infection and low-birth-weight infants 2006-11-27 Vulvovvaginal Infection 59 Complications trichomoniasis may increase the risk of transmission of human immunodeficiency virus, and may cause delivery of low-birth-weight or premature infants. 2006-11-27 Vulvovvaginal Infection 60 Prognosis • a disease with minor symptoms and most women respond well to medications. • It is believed that certain vaginal infections, if left untreated, can lead to more serious conditionssuch as PID(盆腔 炎),endometritis postsurgical infections and spread of the AIDS virus 2006-11-27 Vulvovvaginal Infection 61 Cervical Ectopy • An overgrowth of columnar epithelium replacing the squamous epithelium round the cervical os. It has a raw appearance and a velvety feel. • It is an ectopy(异位) of columnar epithelium and in modern terminology is so described. This is physiological and no treatment is required. 2006-11-27 Vulvovvaginal Infection 62 Aetiology: • Parturition(分娩) • Contraceptive • Persistence of a condition which is normal in infancy 2006-11-27 Vulvovvaginal Infection 63 2006-11-27 Vulvovvaginal Infection 64 Cervicitis(宫颈炎症) infection of the cervical epithelium and stroma, usually following ectopy. 2006-11-27 Vulvovvaginal Infection 65 Symptoms There may be no symptoms with any of these conditions which are observed at examination, but usually there is a complaint of discharge, and they are potential causes of post-coital bleeding(性 交 后 出 血 ). Cervicitis has never been proved to have a special liability to malignant change 2006-11-27 Vulvovvaginal Infection 66 Symptoms 2006-11-27 Vulvovvaginal Infection 67 Cryosurgery(冷冻手术) • This has been developed as an alternative to cautery(烧灼法 ) and diathermy( 透热法 ) and is useful as an outpatient procedure. • The cryoprobe temperature is reduced to about -50℃ over 2 minutes by the endothermic action of nitrous oxide, taking in its latent heat as it is decompressed after being forced at high pressure through a narrow orifice. 2006-11-27 Vulvovvaginal Infection 68 Cryosurgery • Treatment takes about 2 minutes and is almost painless. Extreme cold causes adherence between tissues and metal and 30 seconds must be allowed for thawing before the probe is removed. • The patient will have a watery discharge for 2 weeks, and coitus should be avoided for a fortnight. 2006-11-27 Vulvovvaginal Infection 69 Cryosurgery 2006-11-27 Vulvovvaginal Infection 70 Treatment • Diathermy(透热法) • LASER • Laser therapy may be employed at a via colposcopy(阴道镜) 2006-11-27 Vulvovvaginal Infection 71 Rare Causes of Cervicrtis Chancre (下疳) Secondary infection is uncommon so the characteristic hard indurated base does not form. A chancre may be popular or ulcerative in which case it looks like an erosion. On palpation it may be mistaken for cancer. A herpes simplex infection of the cervix may resemble a chancre. 2006-11-27 Vulvovvaginal Infection 72 Tuberculosis • This is a very rare condition usually secondary to tubal and uterine infection and may be proliferative or ulcerative – in appearance not unlike ectopy. • It is usually found in association with chronic pelvic inflammation and infertility, and the diagnosis is histological • It there is any doubt about the nature of a cervical lesion, a biopsy should always be taken before employing cryosurgery, diathermy or laser. 2006-11-27 Vulvovvaginal Infection 73 Endometrtis Acute inflammation may develop in response to infection following childbirth or abortion, or the insertion of a contraceptive device or as part a gonorrhoeal(淋病) infection 2006-11-27 Vulvovvaginal Infection 74 Chronic Endometritis Chronic Endometritis is a rare condition because of the frequency with which the endometrium is shed. The diagnosis is histological and there are no specific signs or symptoms, but the microscopic appearances are of infiltration mainly by plasma cells and lymphocytes. 2006-11-27 Vulvovvaginal Infection 75 2006-11-27 Vulvovvaginal Infection 76 Senile Endometritis Post-menopausal endometrium has little resistance to infection, and endometritis may arise from cervicitis or from tumour. If the cervix is stenosed by infection or tumour, the uterus becomes distended with pus and the condition is known as pyometra. Cervical dilatation will release the pus but curettage must be done to exclude malignancy and shuch a situation it is very easy to perforate the uterus. 2006-11-27 Vulvovvaginal Infection 77 Metritis Acute inflammation of the myometrium is a serious condition resulting from infection introduced during childbirth or abortion. 2006-11-27 Vulvovvaginal Infection 78 Treatment • If there is no organic cause, the menstrual irregularity may respond to sex steroid hormones. • In the woman over 40 who wishes no more family, there is much to be said for simple hysterectomy. • There may be a role here for progestogen releasing IUDs as these reduce the duration and amount of menstrual loss as well as giving excellent contraception. 2006-11-27 Vulvovvaginal Infection 79 Pelvic inflammatory disease (PID) Infection of the fallopian tubes usually involves the ovaries and peritoneum, and the combined infection is called pelvic inflammatory disease (PID). 2006-11-27 Vulvovvaginal Infection 80 Pelvic inflammatory disease (PID) It results from ascending infection by microorganisms from the vagina or cervix. Its incidence is closely related to that of sexually transmitted diseases and it is predominantly a disease of young, sexually active, women. 2006-11-27 Vulvovvaginal Infection 81 Acute PID The history is often of a prolonged period followed by the gradual onset of pelvic pain and irregular bleeding. The patient is fever and on examination there is abdominal tenderness and guarding, and extreme tenderness of the vaginal fornices(穹隆) and cervical excitation. 2006-11-27 Vulvovvaginal Infection 82 Acute PID Acute PID may follow operations, but it is usually a result of ascending infection, and may be associated with the intrauterine device. It must be treated actively to avoid the development of a chronic infection and minimize fallopian tube damage. 2006-11-27 Vulvovvaginal Infection 83 Bacteriology It is unusual to be able to isolate pathogens from the infected area, but their demonstration in the cervix points to the probable cause. N. gonorrhoea and Chlamydia trachomatis are said to be commonest, but anaerobic organisms are often found in pelvic abscesses. Bacterial vaginosis and mycoplasma have not been shown to cause acute PID. 2006-11-27 Vulvovvaginal Infection 84 Differential diagnosis • Appendicitis(阑尾炎) • Signs are mainly right sided, and the menstrual cycle is undisturbed. • Diverticulitis(憩室病) • This is a disease mainly of older women and signs are left sided. 2006-11-27 Vulvovvaginal Infection 85 Differential diagnosis • Torsion of pedicle of a cyst • There may be a history of intermittent pain over several months. A cyst should be palpable. • Tubal pregnancy • The history may be helpful, but in young women in whom salpingitis(输卵管炎) and tubal pregnancy may co-exist the distinction can be very difficult. A β-hCG pregnancy test aids diagnosis. 2006-11-27 Vulvovvaginal Infection 86 Management • A laparoscopy is advisable if there is any doubt, especially as this nearly always makes it possible to exclude tubal pregnancy. • An intrauteruterine device, if in the uterus, should be removed. After swabs have been taken from the vagina and cervix a broad spectrum antibiotic such as doxycycline, ampicillin should be given. 2006-11-27 Vulvovvaginal Infection 87 Management If acute signs and symptoms persist, a laparotomy( 剖 腹 探 查 ) should be carried out to search for abscess formation. No surgical procedure beyond drainage should be performed. 2006-11-27 Vulvovvaginal Infection 88 Chronic PID The patient complains of pelvic pain made worse during the periods which are irregular and heavy. Dyspareunia(性交痛) is common. There is a 10 fold increase in hysterectomy after PID. 2006-11-27 Vulvovvaginal Infection 89 2006-11-27 Vulvovvaginal Infection 90 Examination Some swelling may be felt but often there is little to find except tenderness in the fornices. An exact diagnosis and estimate of the degree of PID can not be made without laparoscopy( 腹 腔 镜). 2006-11-27 Vulvovvaginal Infection 91 Pathology All degrees of inflammation are met with from salpingitis( 输 卵 管 炎 ) alone to a widespread inflammatory reaction involving all the pelvic tissues. It is rare to recover any organism in chronic PID, other than in the case of tuberculosis(结核). 2006-11-27 Vulvovvaginal Infection 92 Pathology The ascending infection first attacks the tubes which are sealed off by edema and adhesions. The tubes either swell up with watery exudates forming a-hydrosalpinx(输 卵管积液) or pyosalpinx(输卵管积浓); or they become very thickened and adherent to the ovary. The ovary may also be the seat of abscess formation, and the uterus and adnexa(子宫附件), normally mobile, become fixed by adhesions. 2006-11-27 Vulvovvaginal Infection 93 2006-11-27 Vulvovvaginal Infection 94 Treatment • The course of chronic PID is not predictable, and mild degrees may resolve spontaneously. • In such cases the patient should be treated by rest, and although the infective organism may not be identified, a broad spectrum antibiotic(广谱抗生素) is usually given. 2006-11-27 Vulvovvaginal Infection 95 Treatment • Hydrosalpinx and any abscess formation must be relieved by laparotomy and drainage, and dyspareunia may be relieved by correcting the uterine retroversion with a sling operation. 2006-11-27 (输卵管积液) Vulvovvaginal Infection 96 Treatment In advanced cases however the only effective treatment is operation to remove the uterus and tubes and perhaps the ovaries as well. 2006-11-27 Vulvovvaginal Infection 97 Thanks for Your Attention Wang Yu M.D., Ph.D., Professor Department of Obstetrics & Gynecology Renji Hospital Affiliated to SJTU School of Medicine