Pembimbing – dr. Miko Ssanto, Sp.OG Kepaniteraan Obstetri dan Ginekologi RS Sumber Waras- FK UNTAR Flora normal Asymptomatic caused by aerobic or facultative & obligate anaerobic. Aerobic species is dominant 10:1 Produces lactic acid H2O2 & other antimicrobial compounds (bacteriocins- peptides attach to vaginal epithelial cells) Vagina secrets leukocyte protease inhibitor (protecting tissue from inflammatory products and infection) Upper reproductive tract is not sterile explains the potential acceleration of local acute infection (GO) Vaginal pH- 4-4.5 – normal Said to originate from lactobacillus species production of lactic acid + fatty acids etc. Other bacteria can contribute protein catabolism & anaerobic bacteria contribute by amino acid formation Glycogen- nutrient for species in vaginal ecosystem; menopause causes glycogen decrease making pH increase 6-7.5 (asymptomatic) FSH- +ve correlation with pH Estrogen replacement therapy postmenopausal women can restore lactobacillus sp. Menstrual fluid can also provide nutrient to flora (causes overgrowth) Women with symptomatic Gonococcal upper reproductive tract usually during mens or after Broad spectrum AB may cause inflammation due to candida sp. Hysterectomy with cervix removal changes flora Post op- anerob bacteriodes fragillis Aerob Enterococus & E.coli Bacterial Vaginosis Vaginal flora overgrown of Anaerobic sp. Gardnerella vaginalis, Ureaplasma, Urealyticum, Mobiluncus sp., Mycoplasma homonis & preuotella sp. There is significant reduction in lactobacillus sp (H2O2 decrease). (Weather or not reduction is a result or cause of BV is unclear) Risk factor Smoking sex during mens Oral sex IUD Douching New or multiple partners Black race Sexual activity with other women Early age of intercourse BV Diagnosis Irritating (-) Order (-) Discharge +/- Vagina non-erythematous Non abnormalities in cervical examination
95% +ve 2. Release of Amines (produced by anerobic metabolisim) KOH Bau amis (fishy). Wiff test 3. Vaginal pH >4.5 (due to decrease in acid production) Male partners do not need to be treated Introduction of lactobacilli, acidifying vaginal gels, probiotics – can help Metronidazole 500 mg PO 2x – 7 days Leukorrhea Leukorrhea: whitish yellow discharge of mucous from vagina Infection – Vaginitis BV-foul discharge odor Normal discharge- valvular burning irritation or itching vaginitis
7-70% of women have no definite cause imp to offter STD screening
NaCl prep
KOH 10% osmotic swelling lysis of squamous cell membrane.
fungal buds & hyphae seen clearly
pH analysis (upper vaginal wall) Fungal infection Candida most common (C. tropicalis, C. Uncomplicated- sporadic & infrequent, mild- glabrata) moderate symptoms severity for non Can be asymptomatic immunocomprmised Seen in warmer climates, immunosupression, Recurrent- 4x/year fluconazole DM, pregnancy, recent abuse 100/150/200 mg intravaginally 1-4-7 day Symptoms: Complicated Pruritus, pain, valvular erythema & edema. +/- moderate –severe symptoms from possibly excoriation other species than albicans Vaginal discharge cottage cheese Reccurent cases Microscopic- KOH 10%- Haifa +blastospora Immunocompramised (suppression) (yeast bud) Recurrent thx: Culture not routine but can be done for fail in Suppressive maintenance- fluconazole 100-200 empiric treatment mg Non-albicans not responsive to azole 600mg boric acid –gelatin capsule intravaginally daily for 2 wk Trichomonas Vaginalis - Protozoa Incidence increase with patient age Most men asymptomatic mainly seen in Women (70% who’s male partners will have in their urinary tract) Co-infection is frequent – GO Ventricle transmission – during birth is possible Diagnosis- incubation – 3 days – 4 wk. can affect vagina, urethra, endocervix & bladder 50% women asymtomatic Colnizatoin can persist for months –years Foul smell, thin, yellow –green – Discharge Symptoms Dysuria Dyspareunia Pain Vaginal spotting Valvular pruritus (erythematous, edematous, excoriated)