VAGINITIS & PID

DR. SUZAN AI KAFY

MD. FRCSC.

 NORMAL VAGINAL PHYSIOLOGY AND FLORA :

Normal vaginal discharge consists of 1 to 4 mL fluid (per 24

hours).
White or transparent, thick, and mostly odorless.
Is formed by mucoid endocervical secretions in combination
with sloughing epithelial cells, normal bacteria, and vaginal
transudate.
The discharge may become more noticeable ( during
pregnancy, use of estrogen-progestin contraceptives,
midmenstrual cycle close to the time of ovulation.
The pH of the normal vaginal secretions is 3.5 to 4.5.
Dozens of different bacterial isolates.
Lactobacillus
Diphtheroids
S. epidermidis

Vaginal discharge is a frequent presenting complaint.

The three most common diseases associated with vaginal

discharge are trichomoniasis, bacterial vaginosis, and

candidiasis.
Vaginal pH testing can be very helpful in the diagnosis of
vaginitis.
The normal vaginal pH is usually 3.5 to 4.5.
Estrogen causes deposition of glycogen in mature
epithelial cells, which is then converted by bacterial
enzymes to glucose.
The glucose is anaerobically fermented to lactic acid,
which gives the vagina a pH of 3.5 to 4.5

Causes of vaginitis
Infectious vaginitis :
Common causes
Bacterial vaginosis (40 to 50 percent of cases)
Vulvovaginal candidiasis (20 to 25 percent of cases)
Trichomoniasis (15 to 20 percent of cases)
Less common causes
Foreign body with secondary infection
Desquamative inflammatory vaginitis
Streptococcal vaginitis (group A)
Ulcerative vaginitis associated with Staphylococcus aureus
and toxic shock syndrome
Idiopathic vulvovaginal ulceration associated with HIV.

Causes of vaginitis
Noninfectious vaginitis :
Chemical or other irritant
Allergic, hypersensitivity, and contact dermatitis
(lichen simplex)
Traumatic vaginitis
Atrophic vaginitis
Postpuerperal atrophic vaginitis
Desquamative inflammatory vaginitis (steroidresponsive)
Erosive lichen planus
Collagen vascular disease, Behcet's syndrome,
Idiopathic vaginitis

GENERAL DIAGNOSTIC APPROACH

History : Symptoms of vaginitis include
abnormal vaginal discharge
pruritus, irritation
Burning
soreness
odor
less commonly, dyspareunia

dysurea

GENERAL DIAGNOSTIC APPROACH

Physical examination :
Appearance
cervical motion tenderness.
The vulva usually appears normal in bacterial

vaginosis.
Erythema, edema, or fissure formation suggest
candidiasis, trichomoniasis, or dermatitis.

Diagnostic studies
Vaginal pH:
Vaginal pH is the single most important finding.
A strip of pH paper is applied to the vaginal sidewall.
A pH above 4.5 in a premenopausal woman suggests
infections such as
bacterial vaginosis or trichomoniasis (pH 5 to 6)
helps to exclude candida vulvovaginitis (pH 4 to 4.5).
Vaginal pH may be altered (usually to a higher pH)

by contamination with lubricating gels, semen,

douches, and intravaginal medications.

Vaginal discharge processing:

wet prep is generally sampled with a cotton-tipped swab.
The sample of vaginal discharge is mixed with one to two drops of

0.9 percent normal saline solution on a glass slide. Cover slips are
placed on the slides, which are examined under a microscope at
low and high power.

Under the microscope, observe for presence and number of white

blood cells (WBCs), trichomonads, candidal hyphae, or clue cells.

Trichomonads are motile, pear-shaped organisms with active

flagella, larger than a WBC but smaller than epithelial cells, that
are usually seen swimming or thrashing around in the wet prep.

Clue cells are epithelial cells that have bacteria adhered to their

surface, obscuring their borders and causing a stippled

appearance.
Yeast or hyphae also may be seen on the wet prep.

Diagnostic studies
The KOH prep is made by adding a drop of 10 percent
potassium hydroxide KOH solution to a drop of saline

suspension of the discharge.

The KOH lyses epithelial cells in 5 to15 minutes and
allows easier visualization of Candidal hyphae.
Another diagnostic procedure is the "whiff" test,

which is done by placing a drop of KOH on a slide of

the wet prep and smelling for a foul, fishy odor.
The odor is indicative of anaerobic overgrowth or
infection.(BV)

Diagnostic studies
Microscopy:
Candidal buds or hyphae
Motile Trichomonas
Epithelial cells studded with adherent coccobacilli
(clue cells)
Polymorphonuclear cells (PMNs).
The saline should be at room temperature and
microscopy should be performed within 10 to 20
minutes
Excess WBCs without evidence of yeast, trichomonads, or

clue cells suggests cervicitis.

Candida Albicans

Trichomonas

Clue Cell (BV)

Bacteroides species; anaerobic Peptostreptococcus species; Fusobacterium sp. and
Atopobium vaginae

Diagnosis BV
BV can be clinically diagnosed by finding 3 of the
following 4 signs and symptoms:
1-A homogeneous, off-white creamy discharge that
adheres to the vaginal walls
2-clue cells
3-pH >4.5
4-fishy odor after the addition of 10% KOH (whiff test)

Vaginal culture:
For Candida or Trichomonas , if microscopy is negative
because microscopy is not sufficiently sensitive to exclude
these diagnoses in symptomatic patients.

Cervical culture:
For cervicitis, typically due to Neisseria gonorrhoeae or
Chlamydia trachomatis, if you see a purulent vaginal
discharge, fever, or lower abdominal pain (PID).
Sexual behaviors that result in STD-related vulvovaginitis

(eg, trichomoniasis, herpes simplex virus) increase the odds

of acquiring other STDs.
The presence of high risk behavior or any sexually
transmitted disease requires screening for HIV, hepatitis
B, and other STDs.

Diagnostic
Criteria

Normal

Bacterial
Vaginosis

Vaginal pH

3.8 - 4.2

> 4.5

Discharge

White,thin,
flocculent

Thin, white,
gray

Amine odor
"whiff" test

Absent

Fishy

Microscopic

Lactobacilli,
epithelial cells

Trichomonas
Candida
Vaginitis
Vulvovaginitis

4.5

< 4.5 (usually)

Yellow, green,
White, curdy,
frothy
"cottage cheese"

Fishy

Absent

Clue cells,
Budding yeast,
Trichomonads,
adherent cocci,
hyphae,
WBCs >10/hpf
no WBCs
pseudohyphae

Treatment
Candida:
Butoconazole (Femstat)*
(Femstat)* 2 percent cream 5 g/day for 3 days or 1 day for sustained release

formulation
(Gynazole) 2 percent cream 5 g/day for a single dose
Clotrimazole (Gyne- lotrimin, Mycelex)* 1 percent cream 5 g/day for 7 to 14
days
100 mg vaginal tablet 1/day for 7 days
Miconazole (Monistat) 2 percent cream 5 g/day for 7 days
100 mg vaginal suppository 1/day for 7 days
200 mg vaginal suppository 1/day for 3 days
1200 mg vaginal suppository 1 suppository
Tioconazole (Vagistat) 6.5 percent cream 5 g in a single dose
Terconazole (Terazol) 0.4 percent cream 5 g/day for 7 days
80 mg vaginal suppository 1/day for 3 days
Nystatin (Mycostatin) 100,000 U vaginal tablet 1/day for 14 days
Fluconazole (Diflucan)

Trichomonas / BV
Metronidazole
PO 500 mg bid x 7 days OR 2 gms single dose.
PV
Clindamycin 300 mg po bid x 5 days for BV.

Treat the partner in Trichomoniasis

Atrophic vaginitis
Lubricating /moisturizing gel.
Low dose Estrogen :
- Systemic
- Local

Pelvic inflammatory disease (PID)

PID
Pelvic inflammatory disease (PID) is a general term that refers

to Upper genital tract infections that involve the

endometrium (endometritis)
fallopian tubes(salpingitis)
and pelvic peritoneum

These infections result from ascending spread of lower genital

tract infection

It is a common and serious complication of some sexually

transmitted diseases(STDs), especially chlamydia and

gonorrhea.

PID can damage the fallopian tubes and tissues in

and near the uterus and ovaries.

Untreated PID can lead to serious consequences

including
infertility
ectopic pregnancy
abscess formation
and chronic pelvic pain.

How common is PID

Each year in the United States, it is estimated that

more than 1 million women experience an episode of

acute PID.
More than 100,000 women become infertile each
year as a result of PID
A large proportion of the ectopic pregnancies
occurring every year are due to the consequences of
PID.
Annually more than 150 women die from PID or its
complications.

Risk factors for PID include:

Multiple sexual partners (the more partners, the greater the

risk)
being sexually active before age 20 (women)
current or past STDs
New sexual partner within 3 months
Non use of barrier contraceptives
douching more than once or twice a month
use of intrauterine device (IUD) contraceptionit may slightly increase the risk of PID
(this risk is lowered when women are tested and treated for
infections before getting an IUD)

The most common etiologic agents in PID are:

Neisseria gonorrhoeae
Chlamydia trachomatis
Anaerobic bacterial species found in the vagina,

particularly Bacteroides spp

Anaerobic gram-positive cocci, (Peptostreptococci),
E. coli
Mycoplasma hominis

Complications of PID
can be prevented with early treatment.
Without treatment, PID can cause infertility, ectopic

(tubal) pregnancy, chronic pelvic pain, and abscesses.

Infertility occurs in up to 20% of women with PID and is

caused by the development of scar tissue that partially or

totally blocks the fallopian tubes.
Ectopic pregnancies occur when a fertilized egg attaches
to the fallopian tube, instead of in the uterus. If not
caught and treated early, ectopic pregnancies can be
fatal.
Scarring can also lead to chronic pelvic pain

Complications of PID
The most serious complication of PID is the

rupture of an abscess or of the walls of one

of the infected organs.

This requires immediate medical attention.

This may cause bacteria to pour out into the abdominal

cavity, causing a general abdominal infection, known as

peritonitis.
Bacteria can also get into the bloodstream (a condition
known as sepsis)leading to septic shock
Rupture of an abscess will cause a sharp increase in
symptoms. Intense lower abdominal pain will be
followed by nausea, then weakness and possibly
fainting.

PID: History and Examination

Symptoms suggestive of PID include:
Abdominal pain (usually bilateral and in the lower
quadrants)
Dyspareunia
Abnormal Vaginal discharge
Menometrorrhagia
Dysuria
Onset of pain in association with menses
Fever, and/or chills
Nausea or vomiting

PID: History and Examination

Women with endometritis may present
with:
vaginal discharge or
intermenstrual bleeding, and
have uterine tenderness on pelvic exam

PID: Additional Considerations

PID is difficult to accurately diagnose, in part,

because manifestations range from mild to quite

severe
All young, sexually active women presenting with
lower abdominal pain should be carefully evaluated
for the presence of salpingitis and endometritis
Routine bimanual and abdominal exams should be
done on all women with an STD, since some women
with salpingitis or endometritis will not complain of
lower abdominal pain.

Diagnosis of PID Additional considerations

Enlargement or induration of one or both fallopian tubes
a tender pelvic mass
direct or rebound abdominal tenderness may also be

present.
Temperature may be elevated but is normal in many
cases
In general, clinicians should err on the side of
overdiagnosing and treating milder cases.
Some women have chlamydial infection of the upper
genital tract without apparent clinical manifestations of
PID (i.e., silent salpingitis).

Diagnosis of Acute PID CDC Criteria

Minimum findings:
Cervical motion tenderness and uterine and adnexal

tenderness
along with WBCs seen on vaginal wet mount
Additional supportive criteria
to increase the specificity:
- Oral temperature higher than 101F (38.3C)
- Abnormal cervical or vaginal mucopurulent discharge
- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level
- Laboratory documentation of cervical infection with
N gonorrhoeae or C trachomatis

Diagnosis of PID Laboratory Tests

1. Gram-stained endocervical smear (to quantify

PMNs/1000x field
and to look for intracellular Gram-negative diplococci)
2. Endocervical and rectal cultures for N.gonorrhoeae
3. Culture of endocervical swab or first void urine for C.
trachomatis
4. Wet prep for WBCs
5. If menses is late or if the patient is not using reliable
contraception
- check pulse and blood pressure (supine and seated);
- obtain serum or sensitive urine pregnancy test if ectopic
pregnancy is suspected.

Table 3. Diagnostic Criteria for PID

Minimum Criteria
Uterine or adnexal tenderness or Cervical motion tenderness
Additional Criteria
Oral temperature >38.3C (>101F)
Abnormal cervical or vaginal mucopurulent discharge
Presence of WBCs on saline microscopy of vaginal secretions
Lab documentation of cx gonococcal or chlamydial infection
Elevated C-reactive protein level
Elevated erythrocyte sedimentation rate
Specific criteria
Endometrial bx with histopathologic evidence of endometritis
Laparoscopic abnormalities consistent with PID
Transvaginal U/S or MRI study showing thickened, fluid-filled tubes, with or
without free pelvic fluid or tubo-ovarian complex

Treatment PID
broad spectrum antimicrobial coverage should be
provided to cover gonorrhea, chlamydia, and anaerobes.
Patients should be advised to:
Rest for 1 to 3 days or until symptoms have resolved or

pain is significantly improved (pain score decreased by

50%)
Abstain from sexual intercourse until follow-up
cultures are negative (usually a minimum of 2 weeks).
An IUD should be removed in moderate to severe cases
of PID.

PID Hospitalization Criteria

Diagnosis uncertain
Surgical emergency not R/O
Suspected pelvic abcess
Pregnancy
Adolescent or noncompliant
Unable to eat
Temperature > 38o C
Outpatient failure or cannot keep f/u

Outpatient Treatment of PID: CDC Treatment

Guidelines 2002

Regimen A
Either of the following:
- Ofloxacin 400 mg orally twice a day for 14 days
- Levofloxacin 500 mg orally once daily, with or without
Metronidazole
500 mg orally twice a day for 14 days.
Regimen B
Any of the following:
- Ceftriaxone 250 mg IM once,
- Cefoxitin or Cefotetan 2 g IM plus Probenecid, 1 g orally in a single
dose,
[Other parenteral third-generation cephalosporins (e.g., ceftizoxime
or cefotaxime),]
plus
- Doxycycline 100 mg orally twice a day for 14 days, with or without
Metronidazole 500 mg orally twice a day for 14 days

Inpatient Treatment of PID: CDC Treatment

Guidelines 2002
Regimen A
Either of the following:
Cefotetan 2 g IV every 12 hours,
Cefoxitin 2 g IV every 6 hours, plus Doxycycline 100 mg
orally or IV every 12 hours.
Regimen B
Clindamycin 900 mg IV every 8 hours, plus
Gentamicin loading dose IV or IM (2 mg/kg of body
weight) followed by a maintenance dose (1.5 mg/kg)
every 8 hours.

MANAGEMENT OF SEX PARTNERS

Examination and urethral smear and culture for

gonorrhea and chlamydia for all sex partners within the

preceding 4 weeks, regardless of symptoms.

Empirically treat partners with cefixime and

doxycycline or azithromycin to cover C. trachomatis and

N. gonorrhoeae,regardless of the apparent etiology of the
PID.

Cases should be reported to the state/local health

department

Sequelae of Pelvic Inflammatory Disease

Rrecurrence occurs in up to 25% ofcases
- Infertility (12% to 50%)
- Ectopic Pregnancy (6 to 10 fold increase)
- Chronic Pelvic Pain (18%)
Psychological Problems: devastating

THANK YOU