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High power H&E showing the different layers of squamous cells in the cervix. From the basement membrane to the outermost layer that lies within the vagina, there are the youngest squamous cells in the basal layer, then (increasing in age) the parabasal, intermediate and the superficial layer. http://micro2tele.com/2013/01/20/histoquarterly-cervix/
Bacterial Vaginosis
alteration of normal vaginal bacterial flora that results in the loss of hydrogen peroxide producing lactobacilli and an overgrowth of predominantly anaerobic bacteria the concentration of anaerobes, as well as G. vaginalis and Mycoplasma hominis, is 100 to 1,000 times higher than in normal women. Lactobacilli are usually absent.
Bacterial vaginosis (BV) has previously been referred to as nonspecific vaginitis or Gardnella vaginitis.
Bacterial Vaginosis. One of the main symptoms is liquid discharge that gives the patient the sensation of wetness
Bubbly discharge due to bacterial vaginosis in a 28 years old patient during the 30 th weeks of pregnancy
Peterson, Eiko, Infection in Obstetrics and Gynecology : Textbook and Atlas, Georg Thiem Verlag, 2006, Page 124 http://books.google.co.id/books?id=sw_6Lozgd8QC&pg=PA122&dq=atlas+bakterial+vaginosis&hl=en&sa=X&ei= umY8UaGxDI3RrQfJ1oGoBA&redir_esc=y#v=onepage&q=atlas%20bakterial%20vaginosis&f=false
Trigger? Postulat??
repeated alkalinization of the vagina, which occurs with frequent sexual intercourse or use of douches, plays a role. After normal hydrogen peroxideproducing lactobacilli disappear, it is difficult to reestablish normal vaginal flora, and recurrence of BV is common.
Diagnosis
A fishy vaginal odor vaginal discharge are present Vaginal secretions are gray and thinly coat the vaginal walls The pH of these secretions is higher than 4.5 (usually 4.7 to 5.7) increased number of clue cells, and leukocytes are conspicuously absent
Clue cell
clue cells are superficial vaginal epithelial cells with adherent bacteria, usually Gardnerella vaginalis, which obliterates the crisp cell border when visualized microscopically
Kafi, SK, Bacterial Vaginosis, Sudan Journal of medical Science, Volume 7, 1st March 2012 http://www.sudjms.net/issues/7-1/html/10)Bacterial%20Vaginosis.htm
Diagnosis
The addition of KOH to the vaginal secretions (the whiff test) releases a fishy, aminelike odor. Culture of G. vaginalis is not recommended as a diagnostic tool because of its lack of specificity.
Treatment
Metronidazole 500mg orally twice a day for 7 days, avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter. Metronidazolegel, 0.75%, one applicator (5 g) intravaginally once or twice daily for 5 days.
Treatment
Clindamycincream, 2%, one applicator full (5 g) intravaginally at bedtime for 7 days Clindamycin, 300 mg, orally twice daily for 7 days Clindamycin ovules, 100 mg, intravaginally once at bedtime for 3 days Clindamycin bioadhesive cream, 2%, 100 mg intravaginally in a single dose Treatment of the male sexual partner has not been shown to improve therapeutic response and thereforeis not recommended.
Trichomonas Vaginitis
sexually transmitted, flagellated parasite, Trichomonas vaginalis
Trichomonas vaginalis in vaginal discharge Copyright Gary E. Kaiser, All Rights Reserved,Updated: March 3, 2001 http://faculty.ccbcmd.edu/courses/bio141/lecguide/unit3/protozoa/tricho.html
Trichomonas Vaginitis
transmission rate is high; 70% of men contract the disease after a single exposure to an infected woman, which suggests that the rate of male to-female transmission is even higher. only in trophozoite form, is an anaerobe that has the ability to generate hydrogen to combine with oxygen to create an anaerobic environment.
Trophozoite
A trophozite of Trichomonas vaginalis from culture. The four flagella and single nucleus are visible. The dark median rod is the axostyle which is characteristic of the trichomonads; approximate size = 26 m.
http://www.icp.ucl.ac.be/~opperd/parasites/tricho.htm
Diagnosis
Local immune factors and inoculum size influence the appearance of symptoms. profuse, purulent, malodorous vaginal discharge vulvar pruritus patchy vaginal erythema and colpitis macularis (strawberry cervix) pH of the vaginal secretions is usually higher than 5.0. Microscopy of the secretions reveals motile trichomonads and increased numbers of leukocytes Clue cells may be present because of the common association with BV. The whiff test may be positive.
Strawberry cervix
Treatment
Metronidazole is the DOC. 95% single-dose (2 g orally) multidose (500 mg twice daily for 7 days) The sexual partner should also be treated. Metronidazole gel do not respond to initial therapy treated again with metronidazole, 500 mg, twice daily for 7 days. If repeated treatment is not effective single 2g dose of metronidazole once daily for 5 days or tinidazole, 2 g, in a single dose for 5 days
http://www.ispub.com/journal/the-internet-journal-of-advanced-nursing-practice/volume-6-number-1/differentiation-of-the-vaginoses-bacterialvaginosis-lactobacillosis-and-cytolytic-vaginosis.html#sthash.xKhubDsF.dpbs
Vulvovaginal Candidiasis
75% at least 1 episode 45% 2 or more episode 85 90% vaginal yeast infection: Candida albicans C. glabarata, C. tropicalis resistant to th/ pruritus and inflammation minimal invasion of the lower genital tract epithelial cells toxin or enzyme Hypersensitivity
Vulvovaginal Candidiasis
symptomatic disease (>104/mL) asymptomatic patients (<103/mL)
Pregnancy and diabetes are both associated with a qualitative decrease in cell-mediated immunity, leading to a higher incidence of candidiasis.
Diagnosis
vaginal discharge that typically resembles cottage cheese.
Recurrent vulvovaginal candidiasis is defined as four or more episodes in a year. By Dr Louise Newson http://www.gponline.com/Clinical/article/1004744/Basics---Recurrent-vaginalcandidiasis/
DIagnosis
The discharge can vary from watery to homogeneously thick Vaginal soreness, dyspareunia, dysuria, vulvar burning, irritation erythema and edema of the labia and vulvar skin pH of the vagina in patients with VVC is usually normal (<4.5) The whiff test is negative.
Treatment
A presumptive diagnosis absence of fungal elements confirmed by microscopy if the pH and the results of the saline preparation evaluations are normal and the patient has increased erythema based on examination of the vagina or vulva
Treatment
Topically applied azole drugs are the most commonly available treatment for VVC and are more effective than nystatin An oral antifungal agent, fluconazole, used in a single 150-mg dose Women with complicated VVC benefit from an additional 150-mg dose of fluconazole given 72 hours after the first dose complication Women with complicated VVC benefit from an additional 150-mg dose of fluconazole given 72 hours after the first dose topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irritative symptoms
Inflamatory Vaginitis
characterized by diffuse exudative vaginitis, epithelial cell exfoliation, and a profuse purulent vaginal discharge Unknown, but Gram stain findings reveal a relative absence of normal long gram-positive bacilli (lactobacilli) and their replacement with gram-positive cocci, usually streptococci. pH of the vaginal secretions is uniformly higher than 4.5
http://books.google.co.id/books?id=sw_6Lozgd8QC&pg=PA122&dq=atlas+vaginitis&hl=en&sa= X&ei=kjQ9UbOCD8uGrAfrtICYCQ&ved=0CCoQ6AEwAA#v=onepage&q=atlas%20vaginitis&f=fals e
Treatment
2% clindamycin cream, one applicator full (5 g) intravaginally once daily for 7 days. Relapse 30% of patients, who should be retreated with intravaginal 2% clindamycin cream for 2 weeks. When relapse occurs in postmenopausal patients, supplementary hormonal therapy should be considered
Atrophic Vaginitis
Estrogen maintenance of normalnvaginal ecology Purulent vaginal discharge incresed :
o Menopause o naturally or secondary to surgical removal of the ovaries
Atrophic Vaginitis
Dyspareunia, post coital bleeding Loss of the rugae Vaginal mucosa maybe in somewhat friable in are predominance of parabasal epithelial cells and an increased number of leukocytes.
Treatment
stopical estrogen vaginal cream 1 g of each day for 1 to 2 weeks Systemic estrogen therapy should be considered to prevent recurrence of this disorder.
Cervicitis
cervix : squamous epithelium and glandular epithelium. ectocervical squamous Trichomonas, candida, and HSV Glandular epitelium N. gonorrhoeae and C. trachomatis
Diagnosis
a purulent endocervical discharge, generally yellow or green in color and referred to as mucopus Increased number of neutrophils (30 per high power field) Gram negative diplococci gonococcal endocervotis Gram negative gonococci chlamydial cervicitis
Pelvic Inflamatory
caused by micro-organisms colonizing the endocervix ascending to the disease endometrium and fallopian tubes. includes endometritis, salpingitis, and peritonitis caused by the sexually transmitted microorganisms N. gonorrhoeae and C. trachomatis BV micro-organisms, also often are isolated from the upper genital tract of women with PID.
Diagnosis
on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal tenderness, and the presence of fever. increased number of polymorphonuclear leukocyte, mucopurulent discharge Elevated C-reactive protein or erythrocyte sedimentation rate Temperature higher than 38C Positive test for gonorrhea or chlamydia Endometrial biopsy Ultrasound, radiologig test laparoscopy
Treatment
Broadspectrum Regimen A
Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or Ceftriaxone, 250 mg intramuscularly, or Equivalent cephalosporin
Plus: _Doxycycline, 100 mg orally 2 times daily for 14 days With or without: _Metronidazole, 500 mg orally 2 times daily for 14 day
Treatment
Regimen B Ofloxacin, 400 mg orally 2 times daily for 14 days, or Levofloxacin, 500 mg orally once daily for 14 days With or without: Metronidazole, 500 mg orally 2 times daily for 14 daysa
Hospitalzation
only when the diagnosis is uncertain, pelvic abscess is suspected, clinical disease is severe, or compliance with an outpatient regimen is in question
Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea
Diagnosis
based on history and physical examination alone often is inaccurate
serologic test for syphilis Darkfield examination or direct immunofluorescence testing for Treponema pallidum, culture or antigen testing for HSV, and culture for Haemophilus ducreyi.
Diagnosis
nontreponemal rapid plasma reagin (RPR) test venereal disease research laboratory (VDRL) test, confirmatory treponemal testfluorescent treponemal antibody absorption (FTA ABS) microhemagglutininT. pallidum (MHA TP), should be used to
diagnose syphilis presumptively. treponemal EIA tests, the results of which should to be confirmed with nontreponemal tests.
Treatment Syphilis
Benzathine penicillin G, 2.4 million units i.m in a single dose Latent syphilis is defined as those periods after infection with T. pallidum when patients are seroreactive but show no other evidence of disease. Patients with latent syphilis of longer than 1 year's duration or of unknown duration
benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units
Genital Wart
Manifestation of human papiloma virus (HPV) types 6 and 11 occur in areas most directly affected by coitus, namely the posterior fourchette and lateral areas on the vulva warts can be found throughout the vulva, in the vagina, and on the cervix. Minor trauma?
Treatment
specific treatment regimen depends on the anatomic site, size, and number of warts most successful in patients with small warts that have been present for less than 1 year. reduces transmission of HPV. examination of sex partners is not absolutely necessary. Recurrences more often result from reactivation of subclinical infection than reinfection by a sex partner
Modality
Efficacy (%)
Recurrence Risk
2139 1319 2765 3360 81 36 22 2995 067
Cryotherapy 6388 Imiquimod 5% creama 3372 Podophyllin 10%25% 3279 Podofilox 0.5% 4588 Trichloroacetic acid 80%90% Electrodesiccation or cautery 94 Laser 4393 Interferon 4461
Diagnosis
ELISA or a rapid assay + Western blot
a positive antibody test result confirms that a person is infected with HIV and is capable of transmitting the virus to others. Women at risk for STD, such as those with multiple sexual partners or whose partners have multiple sexual partners, should be offered HIV testing.
HPV infection and has been found to occur in high frequency in women with both HPVand HIV.
Treatment
Antiretroviral therapy guided by monitoring the laboratory parametersof HIV RNA (viral load) and CD4-cell count.
suppression of viral load, restoration or preservation of immunologic function, improvement of quality of life reduction of HIV-related morbidityand mortality patients with less than 200 CD4 T cells/ L should receive prophylaxis against opportunistic infections, such as trimethoprim-sulfamethoxazole or aerosol pentamidine for the prevention of PCP pneumonia
Acute Cystitis
Dysuria, frequency, and urgency Pyuria, hematuria Lowback pain Suprapubic tenderness
Risk
sexual intercourse, the use of a diaphragm and a spermicide, delayed postcoital micturition, and a history of a recent urinary tract infection
Diagnosis
80% Esherichia coli 5 15% Staphylococcus saprophyticus
Colonization on vagina and uretra antimicrobial agent. Trimethoprim and floroquinolone