Cervicitis and Vaginitis by

Prof. Dr. Tarek Karkor Professor of obs & gyn Alexandria university
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Bacterial Vaginosis
nonspecific vaginitis or Gardnella vaginitis. It is an alteration
of normal vaginal bacterial flora that results in the loss of hydrogen peroxideproducing aerobic lactobacilli and an

overgrowth of predominantly anaerobic bacteria .

The most common form of vaginitis . repeated alkalinization of the vagina, which occurs with
frequent sexual intercourse or use of douches, plays a role.

 women with BV are at increased risk for pelvic

inflammatory disease (PID) , postabortal PID , postoperative cuff infections after hysterectomy ,and abnormal cervical cytology . Pregnant women with BV are at risk for premature rupture of the membranes , preterm labor and delivery, chorioamnionitis, and postcesarean endometritis . In women with BV who are undergoing surgical abortion or hysterectomy, perioperative treatment with metronidazole eliminates this increased risk.

Diagnosis
A fishy vaginal odor, which is particularly noticeable

following coitus. Vaginal secretions are gray and thinly coat the vaginal walls. The pH of these secretions is higher than 4.5 (usually 4.7 to 5.7). Microscopy of the vaginal secretions reveals an increased number of clue cells, and leukocytes are absent. The addition of KOH to the vaginal secretions (the whiff test) releases a fishy, aminelike odor.

Treatment
Metronidazole, an antibiotic with excellent activity against
anaerobes but poor activity against lactobacilli, is the drug of choice for the treatment of BV. A dose of 500 mg administered orally twice a day for 7 days should be used. Patients should be advised to avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter. Metronidazolegel, 0.75%, one applicator (5 g) intravaginally once or twice daily for 5 days, may also be prescribed. Clindamycincream, 2%, one applicator full (5 g) intravaginally at bedtime for 7 days Clindamycin, 300 mg, orally twice daily for 7 days Many clinicians prefer intravaginal treatment to avoid systemic side effects such as mild to moderate gastrointestinal upset and unpleasant taste. Treatment of the male sexual partner has not been shown to improve therapeutic response and therefore is not recommended. 5

Trichomonas Vaginitis
Trichomonas vaginitis is caused by the sexually
transmitted, flagellated parasite, Trichomonas vaginalis. The transmission rate is high; 70% of men contract the disease after a single exposure to an infected woman. The parasite, which exists only in trophozoite form, is an anaerobe that has the ability to generate hydrogen to combine with oxygen to create an anaerobic environment. It often accompanies BV, which can be diagnosed in as many as 60% of patients with trichomonas vaginitis.
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Diagnosis
trichomonas vaginitis often is asymptomatic. Trichomonas vaginitis is associated with a profuse, purulent,
malodorous vaginal discharge that may be accompanied by vulvar pruritus. Vaginal secretions may exude from the vagina. In patients with high concentrations of organisms, a patchy vaginal erythema and colpitis macularis (strawberry cervix) may be observed. The pH of the vaginal secretions is usually higher than 5.0. Microscopy of the secretions reveals motile trichomonads and increased numbers of leukocytes. Clue cells may be present because of the common association with BV. The whiff test may be positive.
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 Morbidity associated with trichomonal vaginitis may

be related to BV. Pregnant women with trichomonas vaginitis are at increased risk for premature rupture of the membranes and preterm delivery. Because of the sexually transmitted nature of trichomonas vaginitis, women with this infection should be tested for other sexually transmitted diseases (STDs), particularly Neisseria gonorrhoeae and Chlamydia trachomatis. Serologic testing for syphilis and human immunodeficiency virus (HIV) infection should also be considered.

Treatment
Metronidazole is the drug of choice for treatment of vaginal
trichomoniasis. Both a single-dose (2 g orally) and a multidose (500 mg twice daily for 7 days) regimen are highly effective and have cure rates of about 95%. The sexual partner should also be treated. Metronidazole gel, although highly effective for the treatment of BV, should not be used for the treatment of vaginal trichomoniasis.

Vulvovaginal Candidiasis
An estimated 75% of women experience at least one episode

of vulvovaginal candidiasis (VVC) during their lifetimes. Candida albicans is responsible for 85% to 90% of vaginal yeast infections. Other species of Candida, such as C. glabrata and C. tropicalis, can cause vulvovaginal symptoms and tend to be resistant to therapy. Candida are dimorphic fungi existing as blastospores, which are responsible for transmission and symptomatic colonization, and as mycelia, which result from blastospore germination and enhance colonization and facilitate tissue invasion. Factors that predispose women to the development of symptomatic VVC include antibiotic use , pregnancy , and diabetes . Pregnancy and diabetes are both associated with a qualitative decrease in cell-mediated immunity, leading to a higher incidence of candidiasis.
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Uncomplicated
Sporadic or infrequent Mild to moderate symptoms Candida albicans Immunocompetent

Complicated
Recurrent symptoms Severe symptoms Non-albicans Candida Immunocompromised

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Diagnosis
vulvar pruritus associated with a vaginal discharge that
typically resembles cottage cheese. The discharge can vary from watery to homogeneously thick. Vaginal soreness, dyspareunia, vulvar burning, and irritation may be present. External dysuria (splash dysuria) may occur when micturition leads to exposure of the inflamed vulvar and vestibular epithelium to urine. Examination reveals erythema and edema of the labia and vulvar skin. Discrete pustulopapular peripheral lesions may be present. The vagina may be erythematous with an adherent, whitish discharge. The cervix appears normal. The pH of the vagina in patients with VVC is usually normal (<4.5). Fungal elements, either budding yeast forms or mycelia, appear in as many as 80% of cases. increase in the number of inflammatory cells in severe cases. The whiff test is negative.
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 Topically applied azole drugs are the most commonly

Treatment

available treatment for VVC and are more effective than nystatin . An oral antifungal agent, fluconazole, used in a single 150mg dose, has been approved for the treatment of VVC. It appears to have equal efficacy when compared with topical azoles in the treatment of mild to moderate VVC . Patients should be advised that their symptoms will persist for 2 to 3 days so they will not expect additional treatment. Women with complicated VVC benefit from an additional 150-mg dose of fluconazole given 72 hours after the first dose. Patients with complications also can be treated with a more prolonged topical regimen lasting 10 to 14 days. Adjunctive treatment with a weak topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irritative symptoms.
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 Clotrimazole
1% cream, 5 g intravaginally for 714 days 100-mg vaginal tablet for 7 days 100-mg vaginal tablet, two tablets for 3 days 500-mg vaginal tablet, single dose Miconazole 2% cream, 5 g intravaginally for 7 days 200-mg vaginal suppository for 3 days 100-mg vaginal suppository for 7 days Nystatin 100,000-Units vaginal tablet, one tablet for 14 days
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Recurrent Vulvovaginal Candidiasis

defined as four or more episodes in a year. These women
experience persistent irritative symptoms of the vestibule and vulva. Burning replaces itching as the prominent symptom in patients with RVVC.

The treatment of patients with RVVC consists of inducing a

remission of chronic symptoms with fluconazole (150 mg every 3 days for 3 doses). Patients should then be maintained on a suppressive dose of this agent (fluconazole, 150 mg weekly) for 6 months. On this regimen,

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Cervicitis
The cause of cervical inflammation depends on the
epithelium affected.

The ectocervical epithelium can become inflamed by the

same micro-organisms that are responsible for vaginitis. In fact, the ectocervical squamous epithelium is an extension of and is continuous with the vaginal epithelium. Trichomonas, candida, and HSV can cause inflammation of the ectocervix. Conversely, N. gonorrhoeae and C. trachomatis infect only the glandular epithelium .

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Diagnosis
The diagnosis of cervicitis is based on the finding of a purulent
endocervical discharge, generally yellow or green in color and referred to as mucopus After removal of ectocervical secretions with a large swab, a small cotton swab is placed into the endocervical canal and the cervical mucus is extracted. Placement of the mucopus on a slide that can be Gram stained will reveal the presence of an increased number of neutrophils (30 per high-power field). The presence of intracellular gramnegative diplococci, leading to the presumptive diagnosis of gonococcal endocervicitis, also may be detected. If the Gram stain results are negative for gonococci, the presumptive diagnosis is chlamydial cervicitis. Tests for both gonorrhea and chlamydia, preferably using nuclei acid amplification tests, should be performed. The microbial etiology of endocervicitis is unknown in about 50% of cases in which neither gonococci nor chlamydia is detected.
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 Neisseria gonorrhoeae endocervicitis

Ceftriaxone, 125 mg intramuscularly (single dose), or Ciprofloxacin, 500 mg orally (single dose)a, or Chlamydia trachomatis endocervicitis Azithromycin, 1 g orally (single dose), or Doxycycline, 100 mg orally twice daily for 7 days, or Ofloxacin, 300 mg orally twice daily for 7 days, or Levofloxacin, 500 mg orally for 7 days

Treatment of cervicitis consists of an antibiotic regimen

recommended for the treatment of uncomplicated lower genital tract infection with both chlamydia and gonorrhea . It is imperative that all sexual partners be treated with a similar antibiotic regimen. Cervicitis is commonly associated with BV, which, if not treated concurrently, leads to significant persistence of the symptoms and signs of cervicitis.
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