VAGINAL HEALTH

 

Bacterial vaginosis

Bacterial vaginosis is caused by overgrowth of normal vaginal flora. Vaginal odor is the most common symptom and often the first symptom. Odor may be recognized only after sexual intercourse. The alkalinity of semen may cause a release of volatile amines from the vaginal discharge and cause a fishy odor. Increased vaginal discharge is typically mild to moderate. Vulvar irritation is less common. Dysuria or dyspareunia occur rarely.

Ask patients about risk factors that may predispose them to developing bacterial vaginosis. Predisposing factors include:

• Recent antibiotic use
• Decreased estrogen production
• Smoking
• Douching
• Use of an intrauterine device (IUD)
• Sexual activity that could lead to transmission, as evidenced by a patient having a new sexual partner, more sexual partners in the month preceding the onset of symptoms, or having more lifetime sexual partners,

Vaginal cancer

Vaginal cancer is uncommon, especially primary vaginal cancer, as most lesions are metastatic from another primary site. Metastases typically come from reproductive organs (eg, cervix, endometrium, ovary); however, they can also come from other sites (eg, colon, breast, pancreas). The duration of symptoms in vaginal cancer averages 6-12 months before diagnosis, with a range of 0-11 years. Delay in the diagnosis of vaginal carcinoma is not uncommon; this is partially due to the rarity of the disease, as well as with delays in relating patient symptoms to a vaginal origin. As expected, the longer the delay, the more advanced the cancer once the diagnosis is made, resulting in a poorer outcome.

Painless vaginal bleeding is the most common symptom, accounting for the vast majority of presentations. Bleeding is postmenopausal in most patients, which is consistent with the peak age of 60 years for squamous cell carcinoma, the most common type of vaginal cancer. Menorrhagia, intermenstrual bleeding, and postcoital bleeding have also been reported.

Vaginal discharge occurs in about one third of patients. Some patients report urinary symptoms, which are caused by an anterior lesion compressing or invading the bladder, the urethra, or both. This causes bladder pain, dysuria, urgency, and hematuria. Patients may also have pelvic pain. Posterior lesions compress or invade the rectosigmoid, which causes tenesmus or constipation.

Few patients report a vaginal mass or vaginal prolapse. As many as one quarter of patients are asymptomatic; diagnosis is made during routine pelvic examination. The cancer tends to be caught at a much earlier stage in these patients than in those who have symptoms, and their prognosis is much better.

 

vulvovaginal candidiasis

Traditionally, vulvovaginal candidiasis is not considered a sexually transmitted disease because it occurs in celibate women, and Candida itself is considered part of the normal vaginal flora; however, it is more common among sexually active women.

In acute vulvovaginal candidiasis, vulvar pruritus and burning are the main symptoms. Patients commonly complain of both symptoms after intercourse or upon urination. Dyspareunia may develop and become severe enough to lead to intolerance of intercourse. Physical findings in acute vulvovaginal candidiasis include erythema and edema of the vestibule and of the labia majora and minora. The rash may extend to the thighs and perineum. Thrush patches are usually found loosely adherent to the vulva. A thick, white, curd-like vaginal discharge is usually present.

The clinical picture of chronic, persistent vulvovaginal candidiasis differs in that it includes marked edema and lichenification of the vulva with poorly defined margins. Often, a grayish sheen made up of epithelial cells and organisms covers the area. Symptoms include severe pruritus, burning, irritation, and pain. Patients with chronic candidiasis are usually older and obese and often have long-standing diabetes.

A pelvic examination, pH testing, and other laboratory tests to exclude differential diagnoses are indicated. The cervix is typically not inflamed in vulvovaginal candidiasis, and no cervical motion tenderness or abnormal discharge from the cervical os should be observed. The diagnosis of vulvovaginal candidiasis depends on the demonstration of a species of Candida — as with a wet-mount test or potassium hydroxide preparation — and the presence of clinical symptoms. Vaginal pH usually remains normal in vulvovaginal candidiasis.

Acute vulvovaginal candidiasis is typically treated with azole antifungals that can be taken orally as a single dose or applied intravaginally, with many treatments available over the counter. Patients with recurrent vulvovaginal candidiasis often benefit from 6-month suppressive therapy with weekly oral fluconazole. 

Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. The pelvic structures that may be involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), anterior vagina (cystocele), or posterior vagina (rectocele). Many parous women may have some degree of prolapse when examined; however, most prolapses are not clinically bothersome without specific pelvic symptoms, and they may not require an intervention. Approximately 3% of patients with pelvic organ prolapse are symptomatic.

PELVIC ORGAN PROLAPSE

Although signs of pelvic organ prolapse are frequently observed, the condition seldom causes symptoms. However, vaginal or uterine descent at or through the introitus can become symptomatic. Symptoms of pelvic organ prolapse may include:

• A sensation of vaginal fullness or pressure
• Sacral back pain with standing
• Vaginal spotting from ulceration of the protruding cervix or vagina
• Coital difficulty
• Lower abdominal discomfort
• Voiding and defecatory difficulties (an anatomic kinking of the urethra may cause obstructive voiding and urinary retention)

Nonsurgical (conservative) management of pelvic organ prolapse is recommended by the American College of Obstetricians and Gynecologists' Committee on Practice Bulletins and should be attempted before surgery is contemplated. Patients with mild pelvic organ prolapse do not require surgery because they are usually asymptomatic. Pelvic muscle exercises and vaginal support devices (pessaries) are the main nonsurgical treatments for patients with pelvic organ prolapse. Kegel exercises may help improve incontinence associated with mild pelvic organ prolapse.

Quality-of-life assessment by standardized questionnaires (eg, Pelvic Floor Distress Inventory Questionnaire 20 (short form), Pelvic Floor Impact Questionnaire 7 (short form), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire) are helpful in determining appropriate treatment. A detailed sexual history is crucial, and focused questions or questionnaires should include quality-of-life measures.

TRICHOMONIASIS

Unlike chlamydia, which has a peak rate among women aged 19-24 years, the incidence of trichomoniasis is highest among women aged 40-49 years. Trichomoniasis symptoms in women range from no symptoms to severe pelvic inflammatory disease. Women with trichomoniasis frequently report an abnormal vaginal discharge (yellow/gray-green), which may be purulent, frothy, or bloody. Although frothy vaginal discharge is thought to be the classic presentation of trichomoniasis, women with trichomoniasis also commonly report:

• Abnormal vaginal odor (often described as musty)
• Vulvovaginal itching, burning, or soreness
• Dyspareunia (often the major complaint)
• Dysuria
• Postcoital bleeding
• Lower abdominal pain

Given the poor reliability of a patient's medical history and physical findings, the diagnosis of trichomoniasis depends on laboratory testing. Tests for trichomoniasis are quick and can be performed in the medical office. The Centers for Disease Control and Prevention (CDC) now recommend molecular diagnostic tests, when available, to evaluate patients at risk for trichomoniasis.

After a positive diagnosis, treatment should be instituted immediately and, whenever possible, in conjunction with all sexual partners. Expedited partner therapy is a safe and effective means of treating the sexual partners of patients diagnosed with trichomoniasis and should be practiced whenever possible. Both patient and partner should abstain from sex until pharmacologic treatment has been completed and they have no symptoms. For women, the CDC recommends oral metronidazole (500 mg) twice daily for 7 days. Tinidazole (2 g) orally in a single dose is an alternative regimen. Metronidazole gel is effective in less than 50% of patients with trichomoniasis and is not recommended to treat the disease.