(1) Vulvovaginitis in childhood.
(2) Trichomoniasis.
(3) Moniliasis.
(4) Vaginitis due to Chlamydia trachomatis.
(5) Atrophic vaginitis.
(6) Non-specific vaginitis.
(7) Toxic shock syndrome.
(1) VULVOVAGINITIS IN CHILDHOOD
Inflammatory conditions of the vulva and vagina are
the commonest disorders during childhood. Due to
lack of estrogen, the vaginal defence is lost and the
infection occurs easily, once introduced inside the
vagina.
Etiology
Non-specific vulvovaginitis.
Presence of foreign body in the vagina.
Associated intestinal infestations—threadworm
being the commonest.
Rarely, more specific infection caused by Candida
albicans or Gonococcus may be implicated.
Clinical Features:
The chief complaints are pruritus
of varying degree and vaginal discharge. There may
be painful micturition.
Inspection reveals soreness of the vulva. The labia
minora may be swollen and red. If a foreign body is
suspected, a vaginal examination with an aural or nasal
speculum may help in diagnosis.
Investigations:
Vaginoscopy is needed to exclude foreign body or
tumor in a case with recurrent infection.
Treatment:
In most cases, the cause remains
unknown. Simple perineal hygiene will relieve the
symptoms. In cases of soreness or after removal
of foreign body, estrogen cream is to be applied
locally, every night for two weeks. When the specific
organisms are detected, therapy should be directed to
cure the condition.
(2) TRICHOMONAS VAGINITIS
Vaginal trichomoniasis is the most common and
important cause of vaginitis in the childbearing period.
Causative Organism:
It is caused by Trichomo-
nas vaginalis, a pear-shaped unicellular flagellate
protozoa. It measures 20µ long and 10µ wide (larger
than a WBC). It has got four anterior flagellae and
a spear-like protrusion at the other end with an
undulating membrane surrounding its anterior two-
third. It is actively motile.
Mode of Transmission
The organism is predominantly transmitted by sexual
contact, the male harbors the infection in the urethra
and prostate. The transmission may also be possible
by the toilet articles from one woman to the other or
through examining gloves. The incubation period is
3–28 days.
Clinical Features
(a) There is sudden profuse and offensive vaginal
discharge often dating from the last menstruation.
(b) Irritation and itching of varying degrees within
and around the introitus are common.
(c) There is presence of urinary symptoms such as
dysuria and frequency of micturition.
(d) There may be history of previous similar attacks.
Women with trichomoniasis should be evaluated for
other STDs including N. gonorrheae, C.trachomatis,
and HIV.
On Examination
(a) There is thin, greenish-yellow and frothy offensive
discharge per vaginum.
(b) The vulva is inflamed with evidences of pruritus.
(c) Vaginal examination may be painful. The vaginal
walls become red and inflamed with multiple
punctate hemorrhagic spots. Similar spots are also
found over the mucosa of the portio vaginalis part
of the cervix on speculum examination giving the
appearance of ‘strawberry’.
Diagnosis
(a) Identification of the trichomonas is done by
hanging drop preparation (p. 110). If found
negative even on repeat examination, the
confirmation may be done by culture.
(b) Culture of the discharge collected by swabsin
Diamond’s TYM or Feinberg Whittingtonmedium.
Treatment
The treatment is very much effective with
metronidazole. Metronidazole 200 mg thrice daily by
mouth is to be given for 1 week. A single dose regimen
of 2 g is an alternative. Tinidazole single 2 gm dose
PO is equally effective. The husband should be given
the same treatment schedule for 1 week. Resistance to
metronidazole is extremely rare. The husband should
use condom during coitus irrespective of contraceptive
practice until the wife is cured.
(3) CANDIDA VAGINITIS (MONILIASIS)
Causative Organism
Moniliasis is caused by Candida albicans, a gram-
positive yeast-like fungus
Microscopic views of candid albicans
Pathology
Predisposing factors for Candida vaginitis
™ Diabetes : • ↑ Glycogen in the cells, glycosuria
™ Pregnancy : • ↑ Vaginal acidity, glycosuria
• ↑ Glycogen in the cells
™ Broad spectrum antibiotics : • ↓ Acid forming
lactobacillus
™ Combined oral pills
™ Immunosuppression– HIV
™ Drugs–steroids
™ Thyroid, Parathyroid disease: • Obesity
Clinical Features
The patient complains of vaginal discharge with
intense vulvovaginal pruritus. The pruritis is out of
proportion to the discharge. There may be dyspa-
reunia due to local soreness.
On examination:
(a) The discharge is thick, curdy white and in flakes,
(cottage cheese type) often adherent to the vaginal
wall
(b) Vulva may be red and swollen with evidences of
pruritus.
(c) Vaginal examination may be tender. Removal of
the white flakes reveals multiple oozing spots.
Treatment:
Corrections of the predisposing
factors should be done, if possible. Local fungicidal
preparations commonly used are of the polyene or
azole group. Nystatin, clotrimazole, miconazole,
econazole are used in the form of either vaginal
cream or pessary.
One pessary is to be introduced high in the vagina
at bedtime for consecutive 2 weeks. In severe cases,
additional use of pessary in the morning is advocated.
The treatment should be continued even during
menstruation. Single dose oral therapy with fluconazole
(150 mg) or itraconazole is also found effective.
Associated intestinal moniliasis should be treated
by fluconazole 50 mg daily orally for 7 days. Hus-
band should be treated with nystatin ointment
locally for few days following each act of coitus.
The use of condom is preferred.
Resistance to these drugs is not known. The
systemic antifungal drugs fluconazole and itraconazole
are effective in a single dose oral therapy.
(4) ATROPHIC VAGINITIS (SENILE VAGINITIS)
Vaginitis in postmenopausal women is called
atrophic vaginitis. The term is preferable to senile
vaginitis.
Views of vaginal atrophy
Clinical Features
(a) Yellowish or blood stained vaginal discharge.
(b) Discomfort, dryness, soreness in the vulva.
(c) Dyspareunia.
On examination
(a) Evidences of pruritus vulvae.
(b) Vaginal examination is often painful and the walls
are found inflamed.
Diagnosis:
Senile endometritis may co-exist and
carcinoma body or the cervix should be excluded
prior to therapy
Treatment
Improvement of general health and treatment
of infection if present should be done. Systemic
estrogen therapy may be considered if there is
no contraindication. This improves the vaginal
epithelium, raises glycogen content, and lowers
vaginal pH.
Intravaginal application of estrogen cream by an
applicator is also effective. About one-third of the
vaginal estrogen is systemically absorbed.
(5) TOXIC SHOCK SYNDROME (TSS)
TSS is commonly seen in menstruating women
between 15 and 30 years of age following the use of
tampons (polyacrylate). Other condition associated
with TSS is use of female barrier contraceptives
(diaphragm). It is characterized by the following
features of abrupt onset :
x Fever >38.9°C.
x Diffuse macular rash, myalgia.
x Gastrointestinal:Vomiting, diarrhea.
x Cardiopulmonary:Hypotension, adult respiratory
distress syndrome.
x Platelets: < 100,000/mm3
.
x Renal : ↑ BUN (> twice normal).
x Hepatic : Bilirubin, SGOT, SGPT rise twice the
normal level.
x Mucous membrane (vaginal, oropharyngeal) :
Hyperemia.
pathological features
are due to liberation
of exotoxin by Staphylococcus aureus. It may lead
to multiorgan system failure. Blood cultures are
negative.
Treatment
Correction of hypovole-
mia and hypotension with intravenous fluids and
dopamine infusion is done in an intensive care
unit. Parenteral corticosteroids may be used. Blood
coagulation parameters and serum electrolytes are
checked and corrected. Infection is controlled by
b-lactamase resistant antistaphylococcal penicillin
(cloxacillin, clindamycin and oxacillin) for 10–14
days. The tampon should be removed. Cotton tampons
are the safest. Mortality following TSS is 6–10 percent.
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