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![pH of vagina is raised
• During menstruation when the cervical & the endometrial
discharge ,[alkaline] tends to neutralize the vaginal acidity
• After abortion & labour when the alkaline lochia has a similar
effect
• An excessive cervical discharge , such as occurs in
endocervicitis, has the same effect
• Antibiotics & barrier contraceptives also make vaginal
secretion more alkaline & conduce to increased secretion](https://image.slidesharecdn.com/vaginaldischarge-241110061954-b6f1bc18/75/vaginal_discharge8757865321245432233-pptx-5-2048.jpg)
vaginal_discharge8757865321245432233.pptx
- 1.
- 2. BIOLOGY OF VAGINA •In a healthy adult women of childbearing age vaginal contents consist of white coagulated material comprising: • Squamous cells • Doderlein’s bacilli • Coagulated secretion
- 3. DODERLEIN’S BACILLI These aregram+ve organisms which are sugar fermenting. These convert glycogen lactic acid This bacilli is almost the only organism which will grow in the upper 2/3rd of vagina But saprophytic & parasitic organisms can be demonstrated in neighbourhood of vulva These appear in vagina of newborn within 9 hrs after delivery Although usual time for them to appear is 15hrs Probably vagina of newborn is inoculated during parturition
- 4. Superficial cornified cellsof vaginal mucosa glycogen under oestrogen stimulation &continously desquamated Due to break down of cells glycogen is liberated doderlein’s bacilli Lactic acid
- 5. pH of vaginais raised • During menstruation when the cervical & the endometrial discharge ,[alkaline] tends to neutralize the vaginal acidity • After abortion & labour when the alkaline lochia has a similar effect • An excessive cervical discharge , such as occurs in endocervicitis, has the same effect • Antibiotics & barrier contraceptives also make vaginal secretion more alkaline & conduce to increased secretion
- 6. • Vaginal contentsmostly derived from squamous cells of vaginal mucosa • Some contribution comes from cervical &endometrial mucosa • In a healthy woman these secretions are small
- 7. Characteristics of normalvaginal fluid • Watery • White in colour • Nonodorous • pH around 4 • Microscopically : squamous epithelial cells lactobacilli,few gram-ve bac &anaerobes are present without WBC & RBC.
- 8. Components of vaginalsecretion comes from • Sweat & sebaceous glands of vulva & racemose glands of bartholin’s • Characterstic odour --- apocrine glands of vulva • Trasudate of vaginal epithelium & desquamated cells of cornified layer – strongly acidic • Mucous sec. Of endocervical glands – alkaline • Endometrial glandular sec.
- 9.
- 10. LEUCORRHOEA • It isstrictly defined as an excessive normal vaginal discharge The term leucorrhoea should fulfil the following criteria: • The excess secretion is evident from persistent vulval moistness or • staining of the undergarments or • Need to wear a vulval pad • Non purulent microscopically & macroscopically • Non offensive • Non irritant & never causes pruritus
- 11. • Purulent dischargesdue to infections such as: • gonorrhoea , • trichomoniasis , • moniliasis & • the discharges caused by urinary fistulae are of different type & should be excluded from the term leucorrhoea.
- 12. • An inc.in the normal vaginal secretion occurs physiologically at: • Puberty • During pregnancy (inc vascularity of FGT) • At ovulation(peak rise of oestrogen-inc cervical gland activity) • Premenstrual phase of menstrual cycle(inc secretion from hypertrophied endometrial gland)
- 13.
- 14. Cervical leucorrhoea Mucous dischargefrom endocervical glands inc : • Chronic cervicitis • Cervical erosion(endocervical epithelium encroach onto ectocervix • Mucous polyp • ectropion
- 15. When Excess mucoussecretion from cervix occur It undergo little change in vagina & appear as mucoid discharge at vulva
- 16. Non pathogenic vaginalleucorrhoea • In this the discharge originates in the vagina itself as a transudation through vaginal walls • Inc vaginal secretions occurs in local congestive states such as: • Pregnancy • Acquired retroversion & prolapse of uterus • Chronic pelvic inflammatory ds • Chronic constipation
- 17. Diagnosis • Leucorrhoea mustbe distinguished from specific vaginitis & cervicitis • Following examinations should be done: 1. Vulval inspection reveals: White or creamy discharge No evidence of pruritus
- 18. 2. Bimanual includinga speculum examination reveals: • Either a negative pathology • Associated pelvic lesions 3. To exclude infective nature: • Microscopic examination for detection of pus cells
- 19. • If puscells not detected than it is considered as case of true leucorrhoea • If pus cells are detected than further investigations are to be carried out to identify the organism • These include : • Hanging drop prepration • Clue cells • Gram stains • Culture
- 20. Treatment Following guidelines areprescribed: • Improvement of general health • Surgical treatment for cervical factors like electrocautery, cryosurgery • Pelvic lesions require appropriate therapy for pathology
- 21. • Pill usersmay have to stop pill temporarily, if symptom is annoying • Local hygiene has to be maintained
- 22. Trichomonas vaginitis • Itis caused by organism Trichomonas which is a protozoa. • This organism ingress the vagina when the pH is raised as during a menstrual period Discharge – • profuse , • thin , creamy or • slightly green in colour , • irritating & frothy
- 23. Treatment • Metronidazole –200mg oral TDS for 7 days for both partners • They should be advised to abstain from intercourse or use condom during therapy • Recent modality – 2g for 1 day only • Tinidazole – 300mg twice daily for 7 days • Secnidazole – 1000mg single dose for 2 days • In early pg – vineger douch to lower pH , betadine gel trichofuran suppositories
- 24. Monilial vaginitis • Fungalinfection caused by Candida(yeast) • Commanly occurs in immunocompromised individual • Discharge – thick curdy white flaky pruritic
- 25. diagnosis • Gram staining •KOHmount (10%) • Culture in SDA • Pap smear – red stained hyphae & red spores
- 26. Treatment • Intravaginal applicationof antifungals as vaginal pessaries or creams for 3 – 6 days Fluconazole 150 mg single dose If reccurent infection – fluconazole oral 150 mg every 72 hrs for 3 days & then weekly for few weeks clotrimazole- 100 mg vaginal tab for 7 days 1% cream for 7 – 10 days miconazale 2% cream for 7 days s
- 27. Bacterial vaginosis • Itis called vaginosis rather than vaginitis because it lead to alteration in vaginal flora rather than due to any specific infection Decrease in no. Of lactobacilli Increase in no. Of anaerobic bac Lactobacilli dec pH release H2o2 toxic to other bac no. Of aerobic & anaerobic bac inc
- 28. discharge • White ,milky •Non viscous • Fishy odour • Adherent to vaginal wall • pH is more than 4.5
- 29. Diagnosis • Presence ofclue cells • Inc. In no. Of Gardnerella vaginalis • Dec. In no. Of lactobacilli • Gram stain & culture
- 30. Treatment • Metronidazole 500mgBD for 7 days (superior to clindamycin) • Ampicillin & cephalosporin are also effective • Clindamycin 2% cream is effective in 85% • Clindamycin oral 300mg for 7 days • Ornidazole 500mg vaginal tab for 7 days • Lacteal (LA 5% W/V 0.1% glycogen) neutralizes the vaginal pH– 5ml applied daily for 7 days
- 31. ECOFLORA CAPSULE • Itcontain Lactobacillus rhamnosus GR-1 & reuteri Rc-14. • Effective – gram-ve • Antiinflammatory • Resistant to spermicides • Secrete collagen binding proteins that prevent pathogen adhesion
- 32. Adhere to epithelialcells prevent adhesion of other pathogen produce H2O2 maintain pH in vagina
- 33. • 1 to2 capsule daily for 30 days • Followed by 1 capsule daily for another 30 days • Contraindicated during pg
- 34. Common causes ofvaginitis & abnormal vaginal discharge CAUSE NATURE INFECTIVE •Trichomonas vaginitis •Monilial vaginitis •Bacterial vaginosis •cervicitis •Frothy yellow discharge •Curdy white in flakes , pruritic •Gray white , fishy odour & non pruritic •Mucoid discharge ATROPHIC postmenopausal •Discharge is not prominant •Irritation is prominant FOREIGN BODY •Forgotten pessary •Mechanical irritation Offensive , copious ,purulent , often blood stained
- 35. CAUSE NATURE Chemical •Douches ,latex condoms •Chemical irritation or allergy Soreness is pronounced than discharge Excretions •Contamination with urine or faeces Offensive discharge with pruritus Neoplasms Fibroid polyp Genital malignancy Serosanguious , often offensive
- 36. PRURITUS VULVA • itis an itching sensation with a desire to scrach the vulva. • Vulvar irritation is not the same as pruritus,but it is a painful condition associated with burning. • Prolonged or severe pruritus can lead to vulval irritation through scratching and abrasions.
- 37. MECHANISM OF ITCHING Possiblemechanisms are mediated through: • Special sensory innervation of the area • Underlying vascular instability Result in production of histamine like substance Induction of itching
- 38. Aggravation at nightbecause of • Absence of distraction of mind • Tired CNS • Local warmth & lack of aeration
- 39. AETIOLOGY 1. Vaginal discharge– either due to trichomonas vaginalis or candida albicans or both are the commonest cause of pruritus vulva It accounts for 80% cases of pruritus vulva Purulent discharge produces irritation or pain & tenderness rather than pruritus
- 40. 2. Cervical causelike cervicitis ,erosion etc. 3. Vulval parasitic infections like pediculosis, threadworm infection scabies 4. vulval disease like condyloma acuminata , granulomas& vulval cancer etc
- 41. 5. Viral infections herpesgenitalis genital warts 6. STD gonorrhoea Trichomoniasis
- 42. 7. Allergic to drugs Soaps Detergents Antiseptics Nylonundergarments Condom & diaphragm 8. Contact dermatitis
- 43. 9. Non neoplasticepithelial disorders of vulva • Squamous hyperplasia • Lichen sclerosis
- 44. 10. neoplastic disordersof vulva • Paget’s ds • Invasive carcinoma of vulva 11. Urinary Bacilluria glycosuria incontinence
- 45. Systemic diseases 1. Medicalds diabetes jaundice chronic liver ds 2. Deficiency states Fe def anaemia vit A & B12 def
- 46. 3. Generalized &localized dermatitis psoriasis eczema 4. Psychological scratching habit may develop due to mental anxiety sexual frustration
- 47. clinically • Woman developsitiching sensation & begin to scratch • Persistant & prolong scratching • Abrasions inflammation & irritation with soreness • Pt may lose sleep & become irritable
- 48. MANAGEMENT & TREATMENT •DETAILED H/O: • Age of onset • Intensity of itching • Duration • Associated vaginal discharge • Contraceptive practice • Relation with psychologic upset • Allergic to nylon soap detergents etc.
- 49. GENERAL EXAMINATION • Lookfor features of malnutrition anaemia • Evidence of fungal infection in interdigital folds of fingers & toes • Examine for diabetes mellitus Thyroid disorder Haematological ds
- 50. LOCAL EXAMINATION • EXTENTOF LESION TO BE NOTED • If itching area is predominantly anal then cause is probably threadworn ,tinea etc • If itching area is predominantly on vulval area then cause may be: • Trichomoniasis • Moniliasis • Glycosuria • Non-neoplastic & neoplastic vulval cause
- 51. SPECIAL INVESTIGATIONS • Microscopicexam of vaginal discharge to detect Candida or Trichomonas • Urine for sugar protein & pus cells • Blood-Hb, postprandial glucose • LFT&RFT • Stool – for ova ,cysts& parasites • Biopsy either random or toluidine blue is to be taken to note type skin changes & exclude malignancy
- 52. TREATMENT • Antihistamines &sedation may allay the symptoms • Hydrocortison or eurax ointment often helps • Fungal infection--- nystatin cream or with imidazole group of antifungal
- 53. • Trichomonas infection---oralmetronidazole • Perianal pruritus---oral nystatin • If skin is hard & tend to crack then a cream Zno-40parts , olive oil-60parts or cod liver oil helps to soften the skin
- 54. • To breakthe scratch habit---injection of absolute alcohol sc 0.5-1ml • But has disadvantage • Ball’s operation---comprises division of cutaneous nerves by a circular incision around the vulva (performed rarely)
- 55. • Lately interferonas an ointment is used 4000 units/g QID for 5 weeks Im 20 lac units daily for 10 days yielded90% cure rate side effects of systemic use---fever, myalgia ,headache