Vaginitis Vaginosis Vaginal Infection

most common cause for females to seek a medical doctor – around 60%
vaginal infections have numerous symptoms, which include: abnormal vaginal discharge, foul smell, itching, irritation, burning, painful intercourse, painful urination, asymptomatic – without any of the above mentioned symptoms.

Three different types of organisms can infect the female genital tract, and cause vaginitis/vaginosis.

These are:

1) Bacteria – bacterial infection

2) Yeast – candidiasis – yeast infection

3) Trichomonas - trichomoniasis

Candidia, the species of yeast that causes yeast infections, also known as vaginitis and/or candidiasis.

Bacterial Vaginosis

bacterial vaginosis – the most common type of vaginal infection
causes of bacterial vaginosis is an excess of one or more types of bacteria
there is simply an imbalance of the natural flora / natural bacteria that are normally found in the vagina
this normal flora is changed in bacterial vaginosis
the vagina normally contains a variety of bacteria that help keep the vagina healthy, for example by preventing pathogenic bacteria from growing in the vagina by overpopulating them
one particularly important bacterium is lactobacillus, which keeps the vagina slightly acidic
the acidity of the vagina helps to reduce the growth of other harmful bacterium, as well as other organisms, such as yeast and trichomonas
women with bacterial vaginosis have a large increase in the number of harmful, not normal bacteria in the vagina, and a decrease of the normal bacteria, such as lactobacillus
bacterial vaginosis usually happens in females who have had multiple partners, recently changed partners, and in women who started having intercourse at an early age
bacterial vaginosis however; can also be found in women who have never had intercourse, but at much lower levels
more than half of all women have no symptoms
symptomatic women with bacterial vaginosis have increased vaginal discharge
vaginal discharge is white to grey with a milky thick consistency that can even stain undergarments
unpleasant foul smelling discharge – ‘fishy smell'
this smell is usually increased following intercourse
diagnosis is usually by characteristics of the vaginal discharge
itchiness and irritation do not occur with bacterial vaginosis – therefore if you have these symptoms – look for another cause – yeast vaginosis or trichomonas
bacterial infections require antibiotics

Yeast Infections

Yeast Vaginosis

yeast infections are another form of vaginitis
yeast infections are caused by a fungus called Candida – infection with Candida is referred to Candidiasis
symptoms of yeast infection include:
cottage cheese-like vaginal discharge
itching
vaginal discharge has no smell in yeast infections
a burning sensation during intercourse is usually felt with yeast infections
treatment of yeast infections usually entails over-the-counter products

Trichomoniasis

trichomoniasis is a sexually transmitted disease caused by a parasite
trichomonad is the parasite that causes trichomoniasis
trichomoniasis accounts for 5-15% of all vaginal infections / vaginosis
transmitted by sexual intercourse
women with trichomoniasis usually will have a green-yellow vaginal discharge
foul smelling discharge
vulvar irritation
itching
burning
painful intercourse
painful urination
trichomoniasis requires specific antibacterial treatment

Diagnosis of these infections includes the following:

Health care providers detect these infections as follows:

• assessment of the color and appearance of the vaginal secretions – normal secretions are clear or white

• vaginal acid level is measured using pH paper

• doing a sniff test – which consists of adding the chemical potassium hydroxide to the vaginal secretions – this produces characteristic smells for each of the infections

• examination of the vaginal secretions under a microscope may be done if the previous tests do not reveal anything – cells of the bacteria, trichomonad, yeast may be seen

• a Pap smear may also reveal the causative organism

Treatment of these infections is essential in order to prevent complications such as PID pelvic inflammatory disease. Pelvic inflammatory disease can subsequently lead to infertility, constant and chronic pelvic pain, and ectopic pregnancies.

The main treatment of bacterial vaginosis is with metronidazole, an antibiotic.

pH Test of Vaginal Secretions

pH measurement unreliable with blood or semen present
this is done by applying a small amount of vaginal fluid/secretions from the side of the vaginal wall to a piece of pH paper
normally, the vagina has a pH that is acidic <4.5
yeast infections cause the pH to be lower or normal
Tichomonas vaginalis infection causes an elevation of the pH

Wet Mount

microscopic examination of vaginal fluids/secretions while being mixed with normal saline or 10% KOH
normal saline slide will show vaginal flora, bacteria, immune cells, epithelial cells
KOH is used to lyse cells and allow for any yeast/fungi to be seen

KOH Whiff Test

swab of vaginal fluid/secretions dipped into 10% KOH is passed under the nose
KOH liberates the amines produced by bacteria, like Trichomonas
With bacteria, the smell will be strong, and ‘fishy-like’

Human Papilloma Virus (HPV)
Vaginal Infections – Genital Warts

Diagnosis of warts is done through inspection
In the near future, HPV DNA testing will be available to diagnose harmful bacteria versus benign ones. In addition, a new HPV vaccine will come into to play soon, and be available to females aged 12-14, in order to form immunity to HPV and prevent not only warts, but more importantly cervical cancer.

The reason for Pap smears, colposcopy, are to reveal the presence of cellular changes due to HPV viral infections. HPV viruses produce a special protein once inside host cells, the E2 protein. This protein binds to a cell cycle regulator known as the retinoblastoma protein, and subsequently, inhibits the cell from stopping its growth. The cells therefore replicate uncontrollably, leading to localized warts.

Genital Wart Treatments

Imiquimod 5% cream also known as Aldara, is an immune modulator / cytokine inducer which is applied 3 times per week for 3 months. Side effects are mainly skin irritation
Podofilox 5% solution applied twice a day for 4 weeks
Dermatologist applied Podophyllin , tricholoroacetic acid (TCA) , liquid nitrogen
Last resort is surgical removal

Herpes Simplex Virus

Diagnosis of herpes is through viral culture, detecting the DNA through PCR, and/or through detecting antibodies for herpes through ELISAs.

Treatment of Herpes

The first episode is treated with Acyclovir 400 mg three times a day (or famciclovir / valacyclovir)
Recurrent herpes is treated with acyclovir 400 mg three times a day for about 5 days (or famciclovir / valacyclovir)
Patient with more than six attacks of herpes a year, should consider continous prophylaxis with acyclovir 400 mg twice a day (or famciclovir / valacyclovir) everyday in order to prevent the herpes from flaring

What else can vaginal itch or vaginitis be?:

Vaginal itch can also be termed infectious vaginitis. This means CANDIDA (Yeast infection), BACTERIAL VAGINOSIS (basically asymptomatic except for abnormal discharge and odour), Gardnerella vaginalis, and TRICHOMONAS VAGINITIS (which is a STD, sexually transmitted disease).

NON-INFECTIOUS VAGINITIS is a termed used for vaginitis not caused by bacteria, fungi, yeast, or trichomonas. These include ATROPHIC VAGINITIS, which is seen in post-menopausal females, due to loss of tissue structure and composition of the vagina secondary to loss of estrogen which maintains the vagina.Also CHEMICAL and IRRITANT effects on the vagina can cause vaginitis.

SYMPTOMS ASSOCIATED WITH VAGINITIS:

Symptoms of vaginitis include:

DISCHARGE – Quantity, Colour, Consistency, etc
                        - curd-like “cottage cheese” suggests Yeast
                        - profuse thin greyish discharge suggests Gardnerella (BACTERIAL VAGINITIS)
                        - greenish suggests Trichomonas

ODOUR (Bacterial Vaginosis smells fishy, Trichomonas smells rancid, no smell with yeast infections)

ITCHINESS (suggestive of Yeast infection)

PAIN WITH INTERCOURSE (Yeast and Trichomonas infections)

PAIN WITH URINATION (occurs in Yeast and Trichomonas infections, not in Bacterial Vaginosis)

POST-INTERCOURSE SPOTTING (atrophic vaginitis, post-menopausal vaginitis)

GENITAL INFLAMMATION and SWELLING (suggestive of Yeast infection)

RED FLAGS (things to watch out for that mean something more serious is occuring):

ABNORMAL VAGINAL BLEEDING - which is worrisome for cancer of the vagina or vulva

FEVER - seen with infections that have entered the bloodstream and are severe

PELVIC PAIN - must worry about pelvic inflammatory disease, in which the female genital tract may have become infected

WEIGHT LOSS - similar to abnormal vaginal bleeding, must worry about a cancer or systemic process

DOES DISCHARGE CHANGE WITH CYCLE ? - if present, this may be just physiological discharge
RECENT CHANGE IN DETERGENTS, SOAPS, LUBRICANTS - if present, this is likely irritant vaginitis
RECENTLY BEEN IN HOT TUBS OR SAUNAS? - these pose a risk for Trichomonas infection
PREVIOUS INSTANCES AND HOW TREATED? - may be a recurrence of past poorly or not completely removed infection
LAST MENSTRUAL PERIOD, MIGHT YOU BE PREGNANT?
- increases risk of Yeast infection AND may influence decision to treat or not to treat if pregnant
USE OF BIRTH CONTROL PILL? - leads to an increase in the risk of yeast infections
DO YOU DOUCHE? - can lead to irritant vaginitis
SEXUAL HISTORY - this helps to rule out sexually transmitted diseases, STDs – such as Trichomonas, Gonorrhea, and Chlamydia)

ARE YOU SEXUALLY ACTIVE?

HOW MANY PARTNERS?

SAFE SEX? TYPES OF CONTRACEPTION? - intrauterine devices, IUDs, can increase the risks of having an infection

VISUAL PROBLEMS? - sign of an infection often

JOINT PAIN? - sign of infection often - post-infectious arthritis, also known as Reiters and Reactive Arthritis

PAST MEDICAL HISTORY

Past medical history is important as it may point to the infection and causes, as similar infections usually occur. Previous INSTANCES AND Treatments, Sexually Transmitted Diseases (STDs). Trichomonas is an STD. Having Trichomonas increases therisk of Gonnorhea and Chlamydia infections. DIABETES and IMMUNOSUPPRESSION increases the risk of having yeast infections.

MEDICATIONS THAT CAN PREDISPOSE YOU TO VAGINITIS

BIRTH CONTROL PILL (increases the risk of yeast infections), STEROIDS (causes immunosuppression which can lead to yeast infections), ANTIBIOTICS (increases the risk of Yeast infections since antibiotics kill normal vaginal bacterial flora that help prevent yeast from growing), SMOKING is believed to contribute to vaginitis

LABS/INVESTIGATIONS: CERVICAL AND VAGINAL SWABS FOR:

There are numerous investigations and laboratory tests that can be done to identify the cause of vaginitis and vaginal itch. The KOH WET MOUNT test is an examination of vaginal tissue and discharge under the microscope with the addition of KOH (potassium hydroxide). This shows the presence of hyphae and spores if there is an infection with yeast. The WHIFF TEST is a test for the smell of the discharge and liquid of the vagina. If there is a fishy smell, amine odour, with the addition of KOH, then there is BACTERIAL VAGINOSIS or TRICHOMONAS. Measuring the pH reveals some information. Normally it is usually less than 5 is normal. If less than 5, most likely a Yeast infection (i.e. normal). If pH is ~ 6 then Gardnerella or Trichomonas infection. SALINE WET MOUNT can be used to visualize the cells of the vagina. If there are CLUE CELLS, these are seen with Gardnerella infection. FLAGELLATED ORGANISMS, bugs with tails, and lots of white blood cells are seen with Trichomonas infections. Sexually transmitted diseases tests are used to rule out a gonnorrhea or chlamydia infection. URINALYSIS, which is an analysis of the urine is done to rule out a possible Urinary track infection. URINE B-hCG is done to rule out a possible pregnancy.

MANAGEMENT AND TREATMENT OF VAGINITIS, VAGINAL ITCH, VAGINAL INFECTIONS:

Management and treatment of Vaginitis, Vaginal itch, and Vaginal infections requires numerous issues. EDUCATION is essential. This consists of HYGEINE and SAFE SEXUAL PRACTICES. SYMPTOMATIC RELIEF with DOUCHING. ANTIFUNGALS should be used if there is a yeast infection. VARIOUS “AZOLES” IN SUPPOSITORIES or CREAMS are used for 1-7 days. ORAL FLUCONAZOLE can be used as a single dose therapy. NYSTATIN is used if the patient is pregnant. ANTIBIOTICS are used for GARDNERELLA OR TRICHOMONAS. These include TOPICAL OR ORAL METRONIDAZOLE, CLINDAMYCIN, or AMPICILLIN OR AMOXICILLIN if the patient is PREGNANT. HORMONAL THERAPY FOR ATROPHIC VAGINITIS (Estrogen and Progesterone topical or in oral pill forms. Also can be injected.)