Mc Cance (814-815)

The vagina is an elastic fibromuscular canal, 9 to 10 cm long in a reproductive-

aged female, which extends up and back from the introitus to the lower portion of
the uterus. As Figure 22-5 shows, it lies between the urethra (and part of the
bladder) and the rectum. Mucosal secretions from the up- per genital organs,
menstrual fluids, and products of concep- tion leave the body through the vagina,
which also receives the penis during coitus. During sexual excitement the vagina
lengthens and widens and the anterior third becomes con- gested with blood.

The vaginal wall is composed of four layers:1. Its lining is a mucous membrane
of squamous epithe-

lial cells. (Types of epithelium are described and illus- trated in Chapter 1, Table
1-7.) This layer thickens and thins in response to hormones, particularly estrogen.
The squamous epithelial membrane is continuous with the membrane that covers
the lower part of the uterus. In women of reproductive age, the mucosal layer is ar-
ranged in transverse wrinkles, or folds, called rugae (singular, ruga) that permit
stretching during coitus and childbirth.

2. Fibrous connective tissue containing numerous blood and lymphatic vessels.

3. Smooth muscle.4. Connective tissue and a rich network of blood vessels.

The upper part of the vagina surrounds the cervix, the lower end of the uterus (see
Figure 22-5). The recessed space around the cervix is called the fornix of the
vagina. The pos- terior fornix is deeper than the anterior fornix because of the
angle at which the cervix meets the vaginal canal. In most women this angle is
about 90 degrees. A pouch called the cul- de-sac separates the posterior fornix and
the rectum.

Its elasticity and relatively sparse nerve supply enhance the vaginas function as
the birth canal. During sexual arousal the vaginal wall becomes engorged with
blood, like the labia mi- nora and clitoris. Engorgement pushes some fluid to the
sur- face of the mucosa, enhancing lubrication. The vaginal wall does not contain
mucus-secreting glands; rather, secretions drain into the vagina from the
endocervical glands or enter from the vestibule, from the Bartholin and Skene
glands.

Two factors help maintain the self-cleansing action of the vagina and defend it
from infection, particularly during the reproductive years: (1) an acid-base balance
that discourag- es the proliferation of most pathogenic bacteria and (2) the
thickness of the vaginal epithelium. Before puberty, vaginal pH is about 7
(neutral) and the vaginal epithelium is thin. At puberty, the pH becomes more
acidic (4 to 5) and the squa- mous epithelial lining thickens. These changes are
maintained until menopause (cessation of menstruation), at which time the pH
rises again to more alkaline levels and the epithelium thins out. Therefore,
protection from infection is greatest during the years when a woman is most likely
to be sexually active. Between puberty and menopause, vulnerability to in- fection
varies somewhat with cyclic changes in pH and epi- thelial thickness. Both
defenses are greatest when estrogen levels are high and the vagina contains a
normal population of Lactobacillus acidophilus, a harmless resident bacterium that
helps maintain pH at acidic levels. Any condition that causes vaginal pH to rise,
such as douching or use of vaginal sprays or deodorants, low estrogen levels, or
destruction of L. acidophi- lus by antibiotics, lowers vaginal defenses against
infection.

Mc Cance (858-860)

Vaginitis is infection of the vagina. The major causes of vagi- nitis are sexually
transmitted pathogens (see Chapter 24) and Candida albicans. The incidence of
sexually transmitted vagi- nitis remains highest in young women 15 to 24 years of
age.72

The development of vaginitis is related to loss of local de- fense mechanisms, such
as skin integrity, immune reaction, and particularly vaginal pH. The pH of the
vagina depends on cervical secretions and the presence of normal flora that help
maintain an acidic environment. A neutral or alkaline pH normally occurs before
puberty, after menopause, and dur- ing pregnancy. The acidic nature of vaginal
secretions during the reproductive years provides protection against a variety of
sexually transmitted pathogens. Therefore, variables that alter the vaginal pH or
the bactericidal nature of secretions (see Chapter 22) may predispose a woman to
infection. These variables include douching; use of soaps, spermicides, femi- nine
hygiene sprays, or deodorant menstrual pads or tampons; and conditions
associated with increased glycogen content of vaginal secretions, such as
pregnancy or diabetes. Antibiotics often destroy normal vaginal flora, facilitating
overgrowth of C. albicans, causing a yeast vaginitis.

Normally, vaginal discharge is a clear, milky, or cloudy secretion with a slippery

or clumpy texture. It is nonirritat- ing, has a mild inoffensive odor, and turns
yellow after dry- ing. Throughout the menstrual cycle, the amount and texture of a
womans discharge will change in response to hormonal fluctuation. Vaginal
secretions increase at the time of ovula- tion, during pregnancy, and with sexual
arousal; just before menstruation, vaginal discharge becomes thick and sticky.
Although the amount of vaginal discharge alone is not an in- dication of infection,
any other change in discharge may indi- cate a problem. Infection is suggested
with a marked change in color or if the discharge becomes copious, malodorous,
or irritating.

Diagnosis is based on history, physical examination, and examination of the

discharge by wet mount. Treatment in- volves developing and maintaining an
acidic environment, relieving symptoms (usually pruritus), and administering an-
timicrobial or antifungal medications to eradicate the infec- tious organism. If the
infection can be sexually transmitted, a womans partner also will be treated.

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NORMAL VAGINAL PHYSIOLOGY AND FLORA In reproductive aged women,

normal vaginal discharge consists of 1 to 4 mL fluid (per 24 hours), which is white or
transparent, thick, and mostly odorless. This physiologic discharge is formed by
mucoid endocervical secretions in combination with sloughing epithelial cells, normal
bacteria, and vaginal transudate. The discharge may become more noticeable at
times, such as during pregnancy, use of estrogen-progestin contraceptives, or at
midmenstrual cycle close to the time of ovulation. It can be somewhat malodorous
and accompanied by irritative symptoms [4]. Microscopic examination reveals a
predominance of squamous cells and rare polymorphonuclear leukocytes (PMNs)
(table 2).

The pH of the normal vaginal secretions is 4.0 to 4.5; the acidic pH is due to lactic
acid, which is produced by from glycogen by Lactobacillus species and by vaginal
epithelium under the control of estrogen. The acidic environment is hostile to growth
of pathogens (bacterial and viral) and inhibits adherence of bacteria to vaginal
squamous epithelial cells.

The microbiology of the vagina is complex, containing 10 9 bacterial colony forming

units per gram of secretions, and potentially dozens of different isolates. The most
abundant normal isolates are lactobacilli [5], diphtheroids, and S. epidermidis. Age,
phase of the menstrual cycle, sexual activity, contraceptive choice, pregnancy,
presence of necrotic tissue or foreign bodies, and use of hygienic products or
antibiotics can disrupt the normal ecosystem.

Under the influence of estrogen, the normal vaginal epithelium cornifies and
produces glycogen, which acts as a substrate for lactobacilli, thereby protecting
women against infection from a number of pathogens. In contrast, the endocervix is
lined with columnar epithelium and is more susceptible to infection with certain
pathogenic organisms. These differences explain, in part, why cervicitis occurs in the
absence of vaginitis and vice versa.
In premenarchal and postmenopausal women in whom estrogen levels are low, the
vaginal epithelium is thin and the pH of the normal vaginal secretions is 4.7 or more.
The higher pH is due to reduced colonization of lactobacilli and less glycogen in
epithelial cells. (See "Clinical manifestations and diagnosis of vaginal atrophy".)

GENERAL DIAGNOSTIC APPROACH Both the history and findings on physical

examination are relatively nonspecific. Nevertheless, certain features often suggest a
particular diagnosis (table 3), which should be confirmed in the office by microscopic
examination of vaginal secretions and, if necessary, culture.