Vulvitis

Learning outcomes:
At the end of this unit the student nurse should be able to:
Define the related concepts
Discuss the causes
Describe the pathophysiology.
Outline the clinical manifestations.
Describe the types/classification/stages.
Name the surgical procedures
Recognise the possible complications.

1
Vulvitis
Def:Inflammation of the vulva
Pathophysiology and Etiology
• Causative Factors
• Infections- Trichomonas, molluscum contagiosum, bacteria, fungi, herpes
simplex virus (HSV), human papilloma virus (HPV; genital warts).
Irritants.
• Urine, feces, vaginal discharge.
• Close-fitting, synthetic fabrics.
• Chemicals, such as laundry detergents, vaginal sprays, deodorants,
perfumes, some soaps, chlorine, dryer sheets and bubble bath.
• Carcinoma

2
Pathophysiology and Etiology cont
• Chronic dermatologic conditions, such as psoriasis or eczema.
• Predisposing Factors
• Diabetes mellitus and dermatologic disorders.
• Atrophy due to menopause

3
 Clinical Manifestations
• Pruritus – acute at night, aggravated by warmth, often associated with
candidal infections.
• Reddened, edematous tissue, ulceration.
• Pain, burning, dyspareunia.
• Exudate – profuse and purulent – involving vaginitis.
• Lesions of molluscum contagiosum are multiple
• Lesions of HSV:vesicles with an erythematous base, clustered in linear
pattern.
• Lesions of HPV : flesh-colored, irregular, raised, soft warty-like growths
Diagnostic Evaluation
• Vulvar smears and cultures – show infections organism.
• Biopsy of vulvar tissue – to rule out malignancy and chronic dermatologic
conditions.
4
 Management
• Oral or tropical anti-infectives (antibiotics, antifungals, antivirals)- to treat infectious
agents.
• Extremely low-dose topical steroids -to treat inflammation.
• Vaginal estrogen- to treat vaginal atrophy associated with menopause.
• Treatment of underlying disorder.
• Molluscum contagiosum - treated by scalpel excision, electrical cautery, or curette
or may be left untreated, allowing spontaneous resolution.
• Complications
• Scarring and chronic discomfort.
• Transmission of STD to partner.
• Nursing Assessment
• Question patient about medical history, symptoms, sexual activity.
• Determine use of chemical-containing products on undergarments or directly on
vulva.
• Examine the genitalia and lymph nodes.
5
 Nursing Diagnosis
• Acute Pain related to vulvar inflammation.
Nursing Interventions
Relieving Pain
• Administer prescribed medications
• and instruct patient on their use, method of application, and adverse effects.
• Instruct use of sitz baths,
• Instruct her to sitting in or over warm water for 15 to 20 minutes, 3-4 times daily.
• Patient may also use cool compress to soothe the vulva.
• Instruct patient about nature of condition (eg, chronic recurrent or curable)
• and expectations for symptoms after treatment.

Patient Education and Health Maintenance

• Teach patient hygienic principles.
- Wipe from front to back after voiding.
- Use cotton with warm water and bland soap for cleansing, rinse, and pat dry.
- Patient may use fragrance-free hypoallergenic wet wipes.
Avoid the following:
6
 Patient Education and Health Maintenance continued…
• Chronic moisture; and to change bathing suit after swimming.
• Use of chemical irritants,e.g. sprays, perfumed,deodorant soaps, laundry detergents,
static-control dryers sheets, and bubble bath.
• Use of mechanical irritants, such as tight clothing, synthetic fabrics and
undergarments.
• and to replace them with loose-fitting cotton undergarments.
• Teach about use of sitz bath and cool compress at home and to avoid scratching.
• infections, such as Trichomonas, molluscum contagiosum,
• and HSV sexually transmitted;
• Partner needs to seek treatment before intercourse is resumed.
• Assist patient with health communication techniques to inform partner.
• Educate about STD prevention and encourage screening.

7
References
• Sandra, M.N.(2010) Lippincott: Manual of Nursing practice.(9th Ed)
Lippincott: New york.
• Brunner,L,S.,& Suddaarth,(1992).The textbook of Adult Nursing:
London ,Chapman Hall.

8
 Bartholin Cyst or Abscess
Bartholinitis: an infection of the greater vestibular gland,causing cyst or
abcess formation
Pathophysiology and Etiology
• These glands lie on both sides of the vagina at the base of the libia minora;
they lubricate the vagina.
• If they become obstructed secondary to infection, abscess or cyst formation
may occur.
• Abscess or cyst may spontaneously rupture or enlarge thus, become painful.
• Most are sterile or abscess/cellulitis caused by mixed vaginal flora.
• May also be caused by sexual transmission of infection (gonorrhea or
chlamydia).
.

9
Bartholin cyst continues
Clinical Manifestations
• Asymptomatic cyst.
• Pain, erythema, tenderness, swelling.
• Edema, cellulitis, possible abscess formation
Diagnostic Evaluation
• Culture, if draining or upon excision- to identify infectious organisms.
• Biopsy-if is older than 40 years or recurrent-to rule out carcinoma

10
11
 Management
• May be treated conservatively with warm soaks or sitz baths if small or
asymptomatic;
• Antibiotics - if cellulitis is present.
• Incision and drainage; provides relief, but may recur
alternatively, a wood catheter, Foley catheter, or Jacobi ring
(called fistulisation).
Healing occurs around catheter and it is removed after 2 to 4 weeks.
Thus, provide a new opening to the gland.
• Marsupialization, for recurrent abscesses.
- cyst is incised and sutured open to incision edges.
- healing occurs from within the area of the abscess.

12
 Management continued…
• Other methods of treatment : excision with a carbon dioxide laser, and
needle aspiration .
• Recurrence up to 20% of patients with all methods
Complications
Scarring from recurrent infection and rupture.
Nursing Assessment
• Obtain history sexual activity, including new partners and history of
STDs.
• Inspect labia minora for warmth, erythema, swelling.
• Assess for signs of other STDs – rash, genital ulcers, vaginal
discharge.

13
 Nursing interventions
Relieving Pain
• Administer pain medications and antibiotics,
• apply warm soaks or to use sitz bath 3-4 times daily for 15 to 20 minutes to
promote comfort and drainage.
• Encourage patient to limit activity as pain may exacerbated by activity.
• incision and drainage, if indicated.
• For marsupialization: apply ice packs intermittently for 24 hours to reduce edema
and provide comfort and.
• thereafter, warm sitz baths,and perineal heat pack,

14
 Patient Education and Health Maintenance

Advise about the following:

• the partner to be tested and treated prophylactically if STIs suspected.
• to abstain from intercourse until cyst or abscess has resolved.
• To completed all her antibiotics.
• Review principles of perineal hygiene with patient.
• Discuss STDs and methods of prevention – abstinence, monogamy, proper
use of female or male condoms.
• Encourage patient to follow up for recurrent abscess to rule out malignant
lesions.
• Tell her that surgical treatment is commonly necessary for recurrences.

15
References
• Sandra, M.N.(2010) Lippincott: Manual of Nursing practice.(9th Ed)
Lippincott: New york.
• Brunner,L,S.,& Suddaarth,(1992).The textbook of Adult Nursing:
London ,Chapman Hall.

• Sandra,M.N.(2010)Lippincott:Manual of Nursing practice.(9th

Ed)Lippincott:New york.
• Mogothlane,S.mots
• chedish C. ,Mokgadi,M.,Joyce ,M.,& Young,A.(2014)Juta ‘s complete
text book of medical Surgical Nursing.Cape Town:Lebone Publisher

16
 Vaginal Fistula
Abnormal opening between vagina and another hollow opening.
Pathophysiology and Etiology
Causes
• Obstetric injury, especially in long labors and in countries with inadequate
obstetric care.
• Pelvic surgery (rare) – hysterectomy or vaginal reconstructive procedures.
• Carcinoma(rare) – extensive disease or complication of treatment such as
radiation therapy.
Types
• vesicovaginal fistula is an opening between the bladder and vagina.
• Rectovaginal fistula is an opening between the rectum and vagina.
• Ureterovaginal fistula is an opening between the ureter and vagina.
• Urethrovaginal fistula is an opening between the urethra and vagina.
• Vaginoperineal fistula is an opening between the vagina and perineum.
17
 Clinical Manifestations
• Vesicovaginal – most common type of fistula.
- Constant trickling of urine into vagina.
- Loss of urge to avoid because bladder is continuously emptying.
- may cause excoriation and inflammation of vulva.
• Rectovaginal
- Fecal incontinence and flatus through the vagina; malodorous.
- May present as vulvar cancer.
• Ureterovaginal fistula – rare
- Urine in vagina but patient still voids regularly.
- May cause severe UTIs.
• Urethrovaginal fistula.
-Dysuria
- Urine in vagina on voiding.
• Vaginoperineal fistula – pain and inflammation of perineum.
18
Diagnostic Evaluation
• Methylene blue test – instilled in the bladder via catheter, a tampon is placed in the
vagina.
- Methylene blue appers in vagina via vesicovaginal fistula.
- Methylene blue does not appear in vagina via ureterovaginal fistula.
• indigo carmine is injected intravenously (IV). If dye appears in vagina, this indicates
ureterovaginal fistula.
• Cystoscopy with retrograde pyelography.
• Intravenous pyelography (IVP) – helps to detect ureteral fistulas.
Management
• Fistulas recognised at time of delivery should be corrected immediately.
• Historically, surgeries were delayed 8 to 12 weeks to allow recovery from infection or
inflammation.
• However, early excision and repair within 1 to 2 weeks of urine leakage has become
common.
• Surgical closure of opening via vaginal route is most common in developing nations.
In developed nations, laparoscopic, vaginal, or abdominal, or robot-assisted routes
may be used.
19
 Management continued…
• Fecal or urinary diversion procedure - for large fistulas.
• Rarely, a fistula may heal without surgical intervention.
Medical approach.
Prosthesis to prevent incontinence and allow tissue to heal;
This is for patient who not legible for surgical procedure.
Prosthesis is inserted into vagina and connected to drainage tubing leading to
a leg bag.
Complications
• Hydronephrosis,
• pyelonephritis, and
• possible renal failure with ureterovaginal fistula.
• Risk for vaginal infection and pelvic organ infection from rectovaginal fistula.

20
21
Nursing Diagnosis

• Obtain obstetric, gynaecologic,and surgical history.

• Monitor intake and output and voiding pattern.
• Assess drainage on perineal pads.
• Watch for signs of infection ( fever, chills, flank pain).

22
Nursing diagnoses
• Risk for infection related to contamination of urinary tract by vaginal flora or
contamination of the vagina by rectal organisms.
• Impaired Urinary Elimination related to fistula.
Nursing Interventions
Preventing Infection
• Encourage frequent sitz baths.
• Preform vaginal irrigation, as ordered,
• Teach patient about the procedure.
• Administer prescribed antibiotics to reduce pathogenic flora in the intestinal tract.
• A single dose of gentamycin IVI before surgery may prescribed.
• maintain patient on clear liquids, as prescribed, to limit bowel activity for
several days.
- Encourage rest.
- Administer warm perineal irrigations to accelerate healing and increase
comfort.
23
Maintaining Urinary Drainage
• use of perineal pads or incontinence products preoperatively.
After vesicovaginal repair:
- Maintian proper drainage from indwelling catheter (intermittent flushing with
sterile normal saline) to prevent pressure on newly sutured tissue (usually for
about 7 days postoperatively).
- Administer vaginal or bladder irrigations gently because of tenderness at
operative site.
- Maintain strict intake and output records.

24
After vesicovaginal repair cont:

• -IV fluids or oral fluid intake - to maintain good bladder flow.

• Prophylactic antibiotics to prevent infection.
• Teach patient the use of prosthetic device after surgery.
• Encourage patient to express feelings about he altered route of
elimination,
• and share them with a significant other.

25
 Patient Education and Health Maintenance
•Teach patient to :
• Report signs of infection early.
• Clean perineum gently.
• Follow surgeon’s instructions on when to resume sexual intercourse
and strenuous activity.
• follow-up regularly.
Expected Outcomes
• No sign of infection – afebrile, no complaints of flank pain or difficulty
voiding
• Clear urine flows from catheter postoperatively;
• Voids without difficulty after catheter removal.

26
 Pathophysiology and Etiology
• May be caused by sexually transmitted organisms or overgrowth of
vaginal flora.
• Normal vaginal secretion because of estrogen secretion and acidity
inhibit the growth pathogens.
• Such conditions as diabetes, pregnancy, stress, coitus, and
menopause alter normal vaginal environment.
• Types of vaginitis
- Simple
- bacterial vaginosis
- Trichomonas
- Candida albicans
- Atrophic.
27
• Continent urinary diversion is an internal reservoir that a surgeon
creates from a section of the bowel. Urine flows through the ureters
into the reservoir and is drained by the patient. ... Continent urinary
diversion consists of two main types, continent cutaneous reservoir
and bladder substitute.
• Duct ectasia of the breast or mammary duct ectasia or plasma cell
mastitis is a condition in which the lactiferous duct becomes blocked
or clogged.This is the most common cause of greenish discharge.
Mammary duct ectasia can mimic breast cancer. It is a disorder of
peri- or post-menopausal ag

28
References
• Sandra, M.N.(2010) Lippincott: Manual of Nursing practice.(9th Ed)
Lippincott: New york.
• Brunner,L,S.,& Suddaarth,(1992).The textbook of Adult Nursing:
London ,Chapman Hall.

• Sandra,M.N.(2010)Lippincott:Manual of Nursing practice.(9th

Ed)Lippincott:New york.
• Mogothlane,S.mots
• chedish C. ,Mokgadi,M.,Joyce ,M.,& Young,A.(2014)Juta ‘s complete
text book of medical Surgical Nursing.Cape Town:Lebone Publisher

29
Vaginitis
Is a inflammation of the vagina caused by infectious pathogens.
Types of Vaginitis
Simple Vaginitis (Contact Vaginitis)
Description
• An inflammation of the vagina, with discharge; due to mechanical, chemical,
allergic, or other non-infectious irritation, poor hygiene, imbalance of vaginal
flora
• Urethritis commonly accompanies vaginitis due to proximity of the urethra to
the vagina.
Predisposing factors
• contact allergens, excessive perspiration, synthetic underclothing, poor
hygiene, foreign bodies (tampons, condoms, spermicides, condoms with
spermicides, diaphragms that have been left in too long).
30
Vaginitis continues
Clinical Manifestations
• Increased (yet minimal) vaginal discharge with itching, redness, burning,
and edema.
• Voiding and defecation aggravate the above symptoms.
Management
• Stimulate the growth of lactobacilli (Doderlein’s bacilli) through
consumption of yogurt with live active cultures.
• Current evidence does not support douching.
• Foster cleanliness by meticulous care after voiding and defecation.
• Discontinue use of causative agent.

31
Bacterial Vaginosis
Description
• Inflammation of the vagina commonly referred to as nonspecific vaginitis
because it is not caused by Trichomonas, Candida, or gonorrhoea.
• It is not considered an STD.
• Caused by Gardnerella vaginalis
• Manifestations
• Vaginal discharge with odor.
• Itching and burning
• May be asymptomatic.
• “Clue” cells present on microscopic examination of saline slide.
• fishy odor.

32
Management
• Treatment only recommended for symptomatic woman.
• Metronidazole PO for 7 days
• or topical clindamycin or metronidazole.
• Alcohol intake should be avoided during Flagyl treatment and for 24 hours
after completion to avoid nausea and vertigo.
• Studies have demonstrated that metronidazole is not teratogenic.
• Treating partners is not recommended.
• Clindamycin cream weakens latex condoms.
• Data does not support douching.

33
Trichomonas Vaginalis
Description
• STD. a condition produced by a protozoan (pear-shaped and motile) that
thrives in an alkaline environment.
• Recurrence may occur due to low levels of antimicrobial resistance.
Manifestations
• yellow-green discharges .
• pruritus, dyspareunia, and spotting.
• Red, speckled (strawberry) hemorrhages on the cervix.
• vulvar edema,
• dysuria.
• Motile organisms visible on saline microscopy.

34
Management
• Destroy infective protozoa by taking oral metronidazole 2g or tinidazole 2g.
• Note: Treatment during pregnancy is acceptable.
• Prevent reinfection by treating partner concurrently, even though male may be
asymptomatic.
• Avoid alcohol during treatment.
• Rescreen after three months due to possibility of low-level antimicrobial resistance.

35
References
• Sandra, M.N.(2010) Lippincott: Manual of Nursing practice.(9th Ed)
Lippincott: New york.
• Brunner,L,S.,& Suddaarth,(1992).The textbook of Adult Nursing:
London ,Chapman Hall.

• Sandra,M.N.(2010)Lippincott:Manual of Nursing practice.(9th

Ed)Lippincott:New york.
• Mogothlane,S.mots
• chedish C. ,Mokgadi,M.,Joyce ,M.,& Young,A.(2014)Juta ‘s complete
text book of medical Surgical Nursing.Cape Town:Lebone Publisher

36
Candida Albicans

A fungal infection caused by Candida albicans.

Associated factors :
• Steroids therapy
• Obesity
• Pregnancy
• Antibiotics therapy

37
 • Diabetes mellitus
• Oral contraceptives
• Frequent douching
• Chronic debilitative diseases
Characteristics
• C. albicans is a normal inhabitant of the intestinal tract and therefore a
frequent contaminant of the vagina.
• Because the fungus thrives in an environment rich carbohydrates, it is seen
commonly in patients with poorly controlled diabetes.
• Also commom is observed in patients who have been on antibiotic or steroid
therapy for a while (reduces natural protective organisms in vagina).
Clinical manifestations
• thick and irritating vaginal discharges ;
• white or yellow patchy, cheese like particles adhere to vaginal walls
• Itching.

38
• burning, soreness, vulvar edema,
• excoriations, fissures, dyspareunia,
• frequency, and dysuria.
• Microscopic examination will reveal hyphae, buds, pseudohyphae.
• Vaginal pH is normal (<4.5).
Management
• Apply antifungal vaginal cream (clotrimazole, miconazole, or ketoconazole),
suppository, or tablet for 1 -14 nights,
• Oral fluconazole in single dose.
• Oral fluconazole- contraindicated in pregnancy;(Use topical creams instead).
• Incorporate live-culture yogurt into diet to enhance lactobacillus colonization
and improve microorganism balance in vagina.

39
• Treat the symptomatic or uncircumcised partner with balanitis by applying
antifungal cream under the foreskin nightly for 7 nights.
• For severe or recurrent cases, use systemic antifungal, such as weekly
fluconazole for suppression therapy.
Atropic Vaginitis
Description
• A common postmenopausal occurrence due to atrophy of the vaginal mucosa
secondary to decreased estrogen levels; more susceptible to infection.
Manifestations
• Vaginal itching,
• dryness, burning , dyspareunia, and vulvar irritation.
• Vaginal bleeding
• Dry and slightly paler vaginal mucosa .
Management
• Vaginal estrogen .
• The condition reverses itself under treatment.
40
• Treat infection with antibiotics.
• Systemic estrogen therapy to treat additional menopausal symptoms,
Progesterone - to prevent endometrial hyperplasia.
Clinical Manifestations
Signs and symptoms vary with etiology or causative organism.
• Vaginal itching, irritation, burning.
• Odor, increased or unusual vaginal discharge.
• Dyspareunia, pelvic pain, dysuria.
• Asymptomstic.
Diagnostic Evaluation
• History and physical examination.
• Wet smear for microscopic examination.

41
Diagnostic evaluation

Vaginal pH ( not diagnostic, but may indicate infection) – use Nitrazine paper.
- Normal pH: 4.0 to 4.5
- Bacterial vaginosis: >4.5.
- Trichomonas: >4.5.
• Pap smear – detect ,Carcinoma ,bacterial vaginitis and Trichomonas. not a
diagnostic tool for vaginitis due to low sensitivity.
• Vaginal smear = BV + Candida,
• Vaginal swab(PCR) to identify the following organisms/agents:
• Chlamydia trachomatis (CT)
• Trichomonas Vaginalis(TV)
42
Management
• Anti-infectives (oral or vaginal preparations).
• Estrogen replacement (systemic or vaginal preparations) for atrophic
vaginitis.
• Evaluation and treatment of sexual partners for STDs, such as
Trichomonas.
• Vaginal recolonization with lactobacilli through ingestion of yogurt
with active cultures.

43
References
• Sandra, M.N.(2010) Lippincott: Manual of Nursing practice.(9th Ed)
Lippincott: New york.
• Brunner,L,S.,& Suddaarth,(1992).The textbook of Adult Nursing:
London ,Chapman Hall.

• Sandra,M.N.(2010)Lippincott:Manual of Nursing practice.(9th

Ed)Lippincott:New york.
• Mogothlane,S.mots
chedish C. ,Mokgadi,M.,Joyce ,M.,& Young,A.(2014)Juta ‘s complete
text book of medical Surgical Nursing.Cape Town:Lebone Publisher

44