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APGO educational topic 35 vulvar and
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vaginal disease vulvar and vaginal
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conditions occur frequently and can be
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distressing with serious consequences
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vaginitis gynecology visits are very
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common with over 10 million office
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visits per year the percent of American
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women who reported symptoms in the past
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year was 8 percent for Caucasian women
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and 18 percent for African American
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women the objectives of this video are
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to formulate a differential diagnosis
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for vulval vaginitis interpret a wet
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mount microscopic examination describes
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the variety of dermatological disorders
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of the vulva and finally discussed steps
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in the evaluation and management of a
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patient with vulva vaginal symptoms
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let’s meet dr. vulva vagina when a
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patient presents with Volvo vaginitis
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symptoms I am having itching burning
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irritation and discharge what are the
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most common causes that are at the top
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of the differential diagnosis bacterial
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vaginosis is the cause 20 to 25 percent
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of the time volvo vaginal candidiasis 17
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to 39% and trichomonas 4 to 35 percent
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taking a careful history will often help
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to narrow the diagnosis a thick white
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discharge with itching is the classic
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presentation for yeast a thin white
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discharge with a fishy odor is the
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classic presentation for bacterial
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vaginosis and a yellow frothy discharge
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with odor is the classic presentation
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for trichomonas the cornerstone of
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diagnosis is the wet mount a dry
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speculum was placed in the vagina and a
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specimen of vaginal discharge of swabs
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be careful not to get cervical mucus
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which will alter the ph of the specimen
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the pH is a very helpful triage point
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normal pH and a reproductive age woman
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is between three point eight to four
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point five a pH of less than four point
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five is usually east
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whereas pH greater than four point five
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is usually bacterial vaginosis or
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trichomonas here is a wet mount
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photograph of a normal vaginal
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epithelial cell with nice smooth borders
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in contrast here is the classic clue
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cell a bacterial vaginosis
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note the stippled borders of the cell
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adding a few drops of potassium
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hydroxide to the vaginal discharge
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produces an amine or fishy odor this is
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commonly referred to as a positive whiff
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test
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bacterial vaginosis is a polymicrobial
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infection characterized by a lack of
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balance in the vagina
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there is overgrowth of anaerobic or
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and a lack of normal lactobacilli the
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diagnosis is made clinically when a
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patient has abnormal vaginal discharge
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pH greater than four point five positive
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whiffed tests and our presence or clue
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cells treatment is with oral or topical
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metronidazole or topical clindamycin
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here is a wet mount slide showing the
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characteristic budding high fee of vulva
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vaginal candidiasis or yeast it is often
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helpful to add some potassium hydroxide
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to the slide in order to better
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visualize the yeast candida albicans is
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the organism of 90% of cases other
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organisms include Canada glabrata and
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Canada tropicalis vulva vaginal
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candidiasis is more common in women who
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are pregnant diabetic or obese on
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antibiotics corticosteroids or oral
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contraception other practices that keep
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the vaginal area warm and moist such as
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wearing tight clothing wet swimsuits or
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habitual use of panty liners diagnosis
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is by wet mount visualization of blasto
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spores or pseudohyphae
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or a positive yeast culture treatment is
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with vaginal and medes all such as
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mikanos electra Mosel or taco nozzle or
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single dose oral fluconazole lastly
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here’s the characteristic wet mount
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finding of the trichomonas organism with
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his characteristic flagella the
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trichomonas organism is transmitted via
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sexual contact but can also survive in
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swimming pools and hot tubs it is
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associated with PID and dermatitis and
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could facilitate HIV transmission the
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diagnosis is by the wet mount and women
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diagnosed with trichomonas should also
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be screened for other STDs especially
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gonorrhea and chlamydia treatment is
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with oral metronidazole or tech notice
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all the partners should be treated as
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well many patients presenting with
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vaginitis symptoms will also have
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associated vulvar itching complaints
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this is a good time to take a quick
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moment to review anatomy 101 mixing up
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the distinction between vulva and vagina
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is something that can instantaneously
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mark someone as an amateur in this
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business
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don’t forget vulva is the labia majora
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labia minora vestibule and perineum on
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the outside vaginas on the inside many
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patients assume that itching equals
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yeast but this is definitely not the
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case in a report of 200 new patients
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presenting to evolve our specialty
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clinic the etiology for the itchy vulva
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was contact dermatitis in 20% of the
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cases
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recurrent yeast 20%
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like in sclerosis or like in simplex
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chronic is 11 percent bacterial
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vaginosis 7% valve our vestibule itis
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13% and atrophic vaginitis 13 percent
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since contact dermatitis is such a
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common source of all very itchy it’s
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important to realize with the common
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vulvar irritants consist of shampoos and
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body washes with fragrance creative
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underwear 100% cotton underwear is the
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best and don’t forget to ask about maxi
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pads and panty liners it is important to
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discuss these vulva comfort care
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measures and to offer tips for breaking
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the itch scratch cycle it’s important to
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emphasize that if the itching does not
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get better a topical steroids or does
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not seem to make sense the number apps
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you should be performed the biopsy will
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evaluate for dysplasia and cancer and
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can also diagnose benign volver
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conditions we will conclude this video
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by discussing the B’nai involve our
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conditions of lichens chlorosis like
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complainers and lichen simplex chronic
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as’ like in sclerosis is a benign
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chronic dermatological condition
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characterized by marked inflammation
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epithelial thinning and distinct dermal
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changes here is a photograph of lincoln
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sclerosis note the obliteration of the
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labia minora and the cigarette paper
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quality of the skin patients will often
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experience vulva itching and burning
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treatment is with topical
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corticosteroids it is important to note
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that women with lichen sclerosis are at
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increased risk of developing squamous
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cell carcinoma of the vulva lichen
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planus is a rare inflammatory skin
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condition that can affect the skin oral
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cavity vulva and vagina women can
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experience chronic vulva burning and
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itching insertional dyspareunia and
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perfuse vaginal discharge note that
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lichen planus can affect both the vulva
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and the vagina
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whereas lichen sclerosis only affects
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the vulva lichens simplex chronic hiss
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is a bit of a mouthful and describes the
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skin changes that occur with the itch
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scratch cycle here is a photograph of
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contact dermatitis
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note the erythema of the labia majora
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with scratching there is mechanical
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irritation which leads to epidermal
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thickening and an inflammatory cell
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infiltrate which makes the skin itchy
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earth thus the cycle treatment for like
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on simplex chronic is is also topical
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corticosteroids as well as counseling on
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how to avoid skin irritants and the
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importance of breaking
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scratch cycle this concludes the video
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on Volvo retinitis we reviewed the
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common symptoms wet prep findings and
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treatments for yeast material vaginosis
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and trichomonas and discussed the
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complexity of diagnosing and treating
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the achieve ova
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