GYN 13

• Vulvar infection


  The vulvar and perineal skin is usually resistant to common infection, but the defense is lost following constant irritation by the vaginal discharge or urine (urinary incontinence). Furthermore, there may be atrophy or degenerative changes, either in disease or following menopause when the infection is more likely.
• Types of vulvar infection

  • Due to specific infection
  • Due to sensitive reaction
  • Due to vaginal discharge or urinary contamination
• Specific infections of the vulva

  • Bacterial (pyogenic, sexually transmitted diseases)
  • Viral (condylomata accuminata, herpes genitalis, molluscum contagiosum, herpes zoster)
  • Fungal (moniliasis, ringworm)
  • Parasitic (pediculosis pubis, scabies, threadworm)
• Bartholin's glands


  Two pea sized (2 cm) glands, located in the groove between the hymen and the labia minora at 5 o'clock and 7 o'clock position of the vagina
• Causative organisms of Bartholin's gland infection

  • Gonococcus
  • Escherichia coli
  • Staphylococcus
  • Streptococcus
  • Chlamydia trachomatis
  • Bacteroides
  • Peptostreptococcus
  • Mixed types (polymicrobial)
• Pathology of Bartholin's gland infection


  The epithelium of the gland or the duct gets swollen. The lumen of the duct may be blocked or remains open through which exudates escape out.
• Possible outcomes of acute bartholinitis

  • Complete resolution
  • Recurrence
  • Abscess formation
  • Cyst formation
• Clinical features of Bartholin's gland infection

  • Initially, there is local pain and discomfort even to the extent of difficulty in walking or sitting. Examination reveals tenderness and induration of the posterior half of the labia when palpated between thumb outside and the index finger inside the vagina. The duct opening looks congested and secretion comes out through the opening when the gland is pressed by fingers.
• Treatment of Bartholin's gland infection

  1. Hot compress over the area and analgesics to relieve pain

  2. Systemic antibiotic like amoxicillin-clavulanate orally 8 hourly or appropriate antibiotic according to the bacteriological sensitivity
• Bartholin's abscess

  The end result of acute bartholinitis. The duct gets blocked by fibrosis and the exudates pent up inside to produce abscess.
• Clinical features of Bartholin's abscess

  • The local pain and discomfort become intense. The patient cannot walk or even sit. Fever is often associated. On examination, there is an unilateral tender swelling beneath the posterior half of the labium majus expanding medially to the posterior part of the labium minus. The overlying skin appears red and edematous.
• Treatment of Bartholin's abscess

  1. Rest, pain relief by analgesics, daily sitz bath, systemic antibiotic (ampicillin or tetracycline)

  2. Abscess should be drained at the earliest opportunity before it bursts spontaneously
• Bartholin's cyst


  Closure of the duct or the opening of an acinus, commonly involving the duct. The content is glairy colorless fluid—secretion of the Bartholin's gland.
• Clinical features of Bartholin's cyst

  • A small size often remains unnoticed. If it becomes large (size of hen's egg), there is local discomfort and dyspareunia. Examination reveals an unilateral swelling on the posterior half of the labium majus which opens up at the posterior end of the labium minus. Its medial projection makes the vulvar cleft 'S'-shaped. The overlying skin is thin and shiny. The cyst is fluctuant and not tender.

  
• Treatment of Bartholin's cyst

  Marsupialization: An incision is made on the inner aspect of the labium minus just outside the hymenal ring. The incision includes the vaginal wall and the cyst wall. The cut margins of the either side are to be trimmed off to make the opening an elliptical shape and of about 1 cm in diameter. The edges of the vaginal and cyst walls are sutured by interrupted catgut, thus leaving behind a clean circular opening.
• Types of vaginal infection (vaginitis)

  • Vulvovaginitis in childhood
  • Trichomoniasis
  • Moniliasis
  • Vaginitis due to Chlamydia trachomatis
  • Atrophic vaginitis
  • Nonspecific vaginitis
  • Toxic shock syndrome
• Vulvovaginitis in childhood


  Inflammatory conditions of the vulva and vagina are the most common disorders during childhood. Due to lack of estrogen, the vaginal defense is lost and the infection occurs easily, once introduced inside the vagina.
• Causes of vulvovaginitis in childhood

  • Nonspecific vulvovaginitis
  • Presence of foreign body in the vagina
  • Associated intestinal infestations (threadworm being the most common)
  • Rarely, more specific infection caused by Candida albicans or Gonococcus
• Clinical features of vulvovaginitis in childhood

  • 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.
• Investigations for vulvovaginitis in childhood

  1. Vaginal discharge is collected for direct examination, Gram stain, and culture

  2. Stool examination to exclude intestinal infestation

  3. Vaginoscopy to exclude foreign body or tumor in case of recurrent infection
• Treatment of vulvovaginitis in childhood

  1. In most cases, simple perineal hygiene will relieve the symptoms

  2. In cases of soreness or after removal of foreign body, estrogen cream is to be applied locally, every night for two weeks

  3. When the specific organisms are detected, therapy should be directed to cure the condition
• Trichomonas vaginalis


  A pear-shaped unicellular flagellate anaerobic protozoa, measuring 20 µ long and 10 µ 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 of trichomonas vaginitis

  The organism is predominantly transmitted by sexual contact, the male harbors the infection in the urethra and prostate. It is a highly contagious STI. The transmission may also be possible by the toilet articles from one woman to the other or through examining gloves.
• Pathology of trichomonas vaginitis

  In about 25% of women in the reproductive period, the parasites harbor in the vagina is in asymptomatic state. When the local defense is impaired—during and after menstruation, after sexual stimulation, and following illness, the pH of the vagina is raised to 5.5–6.5. At this level of pH, the trichomonads thrive. The organisms usually lie in between the rugae and produce surface inflammatory reaction when the defense is lost.
• Clinical features of trichomonas vaginitis

  • Sudden profuse and offensive vaginal discharge often dating from the last menstruation, irritation and itching of varying degrees within and around the introitus, urinary symptoms like dysuria and frequency of micturition, history of previous similar attacks.
• Examination findings in trichomonas vaginitis

  • Vaginal discharge: Thin, gray, greenish-yellow, frothy and offensive. The vulva is inflamed with evidences of pruritus. 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 a 'strawberry'.
• Diagnosis of trichomonas vaginitis


  Identification of the trichomonas is done by hanging drop preparation. If found negative even on repeat examination, the confirmation may be done by culture. NAATs are 3–5 times more sensitive than wet preparation. NAAT can be done with vaginal discharge or urine.
• Treatment of trichomonas vaginitis

  Metronidazole 200 mg thrice daily by mouth for 1 week or a single dose regimen of 2 g. Tinidazole single dose 2 g PO is equally effective. The husband should be given the same treatment schedule for 1 week. Patients should be screened with NAAT in 3 months due to high reinfection rates. The husband should use condom during coitus irrespective of contraceptive practice until the wife is cured.
• Candida albicans


  A gram-positive yeast-like fungus that causes candida vaginitis (moniliasis).
• Risk factors for candida vaginitis


  • Not provided in the study material
• Clinical features of candida vaginitis


  • The patient complains of vaginal discharge with intense vulvovaginal pruritus. The pruritis is out of proportion to the discharge. There may be dyspareunia due to local soreness. On examination, the discharge is thick, curdy white and in flakes, (cottage cheese type) often adherent to the vaginal wall.
• Differential diagnosis of vaginal discharge characteristics
• Contraceptive practice should be used until the wife is cured of Candida vaginitis (moniliasis)
• Candida vaginitis (moniliasis)


  Vaginal infection caused by the yeast-like fungus Candida albicans
• Candida albicans


  • Gram-positive yeast-like fungus
• Risk factors for candida vaginitis

  • Diabetes
  • Pregnancy
  • Broad-spectrum antibiotics
  • Combined oral pills
  • Immunosuppression—HIV
  • Drugs—steroids
  • Thyroid, parathyroid disease
  • Obesity
• Vaginal discharge in candida vaginitis

  Thick, curdy white and in flakes, (cottage cheese type) often adherent to the vaginal wall
• Vulvovaginal pruritus in candida vaginitis

  Intense, out of proportion to the discharge
• Dyspareunia may occur due to local soreness in candida vaginitis
• On examination, the vaginal walls may have punctate hemorrhagic spots and 'strawberry' appearance in trichomonas negatives