Vulvitis

The vulva is the external genital organ of the

female.
The vulva includes the labia, clitoris, and
entrance to the vagina (the vestibule of the
vagina).
• Vulvitis is a condition of inflammation of
the vulva.

• Vulvitis may be caused by a number of

different infections.
Because the vulva is also often inflamed
when there is inflammation of the vagina,
vaginitis is sometimes referred to as
vulvovaginitis. Vulvitis can affect women
of all ages.
 Causes
• Vulvitis may be caused by one, or more,
of the following:
• Vulvitis due to specific infection:
 Bacterial, pyogenic (non-gonococcal),
STI, tubercular (vulval tuberculosis).
Viral: Condylomata acuminate (genital
warts), herpes genitalis(HPV),
molluscum contagiosum (pox virus),
herpes Zoster(HZV).
Fungal: Moniliasis, ringworm.
 Parasitic: Pedicu1osis pubis, scabies,
threadworm
• Allergic: Vulvitis due to sensitive
reaction (allergic vulvitis). Allergies
particularly to soaps, colored toilet paper,
vaginal sprays, laundry detergents,
bubble baths, shampoos and hair
conditioners, vaginal sprays, deodorants,
• douches, and powders, douches that are
too strong or used too frequently , hot tub
and swimming pool water.
• Low estrogen levels: In young girls and
postmenopausal women, the condition
may be caused by low estrogen levels.
• Contamination: Vulvitis due to vaginal
discharge and urinary contamination.
• Due to the most area, the favors growth
of the organism like candida albicans or
trichomonas vaginalis.
• Poor hygiene.
• Diabetic women face increased risk of
developing vulvitis because the high sugar
content of their cells increase susceptibility
to infections.

| 70 | Gynecological Nurs ng
• As estrogen levels drop during
perimenopause, vulvar tissues become
thinner, drier, and less elastic increasing a
woman's chance of developing vulvitis.
• Young girls who have not yet reached
puberty are also at possible risk due to the
fact that adequate hormone levels have
not yet been reached.
• Any woman who is allergy-prone has
sensitive skin, or who has other infections
or diseases can develop vulvitis.
 Sign and symptoms

• Redness and swelling on the labia and

other parts of the vulva
• Excruciating itching

• Clear, fluid-filled blisters (present when

the vulva is particularly irritated)
• Sore, scaly, thickened, or whitish patches
(more prevalent in chronic vulvitis) on
the vulva
• Acute vulvitis: Marked edema,
erythema of the vulva, burning, and
pruritus, pain
may be so severe that the patient can
neither sit nor walk. Ulceration, pustules or
vesicle formation may be present.
• Chronic Vulvitis: Edema may be
minimal, purities, excoriation, ulcerative
lesion may destroy the vulva
Common vulvitis due to specific infection

Vulval cellulitis: Unhygienic condition

associated with even minor scratching on the
vulva cause intense cellulitis. The causative
organism is staphylococcus aureus. The
vulva is swollen, red, tender and profuse
exudation.
 The patient complains of intense pain,
itching, and problem in micturition. The
treatment is effective by systemic
antibiotics, local hot compress, and
analgesics.
• Contact Vulvitis: Contact vulvitis is a
skin problem that causes vulvar/vaginal
itching and burning when there is no
infection. This occurs when the vulvar
skin becomes very sensitive to products
called contact irritants.
 Examples include things such as laundry
detergents, fabric softeners, body soaps, and
feminine hygiene products (such as douches,
vaginal deodorants, pads or wipes). Regular and
continued use of these products over a period of
time cause irritation, burning and/or itching.
Sign and symptoms of contact vulvitis:
Mild to severe itching an or burning on the
vulva. Vulvar redness and swelling. Raw
feeling due to the vulvae irritation.et
feeling due to the oozing of the irritated
skin surface.
Vulva pain, in more advanced cases, the
insertion of a tampon, speculum, or with
intercourse.
Pre-Pubertal vulvitis: It is caused by
group A- beta-hemolytic streptococcus,
candid species, and pinworms.
The child may have symptoms of dysuria,
vulvar pain, pruritis or bleeding. Treatment
includes cephalosporin or antibiotics for 2-
4 weeks.
• Furunculosis: The infection affects the
hair follicles of the mons and labia
majora caused by staphylococcus aureus.
If it is recurrent, glycosuria should be
excluded.
Treatment is effective with systemic and
local antibiotics and local cleanliness.
• Moniliasis/ Candidiasis: It is the fungal
infection caused by qandida Albicans usually
secondary to vaginal moniliasis. Primary
vulvitis may occur in diabetes, pregnancy,pt.
taking broad spectrum antibiotic or pills.
• The use of tight-fitting nylon underwear
encourage reccurante infection. The whole
vulva is inflamed and looks like that a raw
beef. There is intense pruritis and associates
urinary problems. Use Fungicidal creams as a
treatment.
• Vulval ringworm: It is caused by Tinea
cruris. The lesions look bright red and
Circumscribed. Treatment is very
effective with imidazole (clotrimazole or
micronazole) cream.
• Vulval Psoriasis: This itchy and
sometimes sore condition does not
involve the vagina. There is an
erythematous, well-defined rash
involving the labia, perianal skin.
• Lichen Sclerosus: This is a relatively
rare, but significant condition. It causes
vulvitis only and does not involve the
vagina. The very characteristic rash is a
white plaque which may involve any part
of the vulva or perianal skin. Woman may
complain of intense itching, discomfort,
bleeding, excoriations (abrasion of skin)
and dysuria.
• lf untreated, shrinkage and scarring of the
vulva with loss of the labia and clitoris
and stenosis of the introitus may occur.
There is a small but real association with
carcinoma of the vulva. Treatment
consists of topical corticosteroid cream
such as 2.5 % hydrocortisone, applied
nightly to the vulva for 6 weeks.
• If improvement is noted, the dose may be
lowered to 1% hydrocortisone and
continue for 4-6 weeks. Thereafter, strict
attention to hygiene and use of
petroleum-based ointments are
recommended.
• Atrophic vulvovaginitis: Patients who
have low estrogen levels due to
menopause may develop vulvovaginal
symptoms of varying severity. The
commonest is vaginal dryness which
inhibits sexual intercourse. The fragility
of the epithelium may result in very small
but painful fissures which make
intercourse painful.
In patients with an underlying atrophic problem,
vulval dermatitis may appear at times of estrogen
deficiency, and in addition to difficulties with sexual
intercourse, the patient may experience itching or a
dermatitis rash. Examination reveals a pale, flat, dry
mucosal surface often with tiny fissures around the
introitus.
 Diagnosis

• Complete medical history

• Physical examination
• Blood tests
• Urinalysis
• Tests for sexually transmitted diseases
(STDs)
• Pap test
 Complications
• The symptoms of the vulvitis can lead to
depression and psychosexual problems if
left untreated.
• If left untreated, Infected elated vulvitis
can be passed on to sexual partners and
can lead to balanitis (inflammation o the
glans penis) in males.
• Itching of the vulva may he a sign of
genital warts (HPV - human
papillomavirus ), vulvar dystrophy
(defective structure), or vulvar dysplasia
(a precancerous condition).
• Sexually transmitted diseases (STDs),
which can cause vulvitis, may lead to
other problems. such as infertile.
 Treatment

Self-help treament:
• Stopping the use of any products that may
be a contributing factor.
• The vulva should be kept clean, dry, and
cool.
• Always remember to ipe frol front to back.
• Cold compresses
| 72 | Gynecologic I Nursing
• Learning to reduce stress.
• Eating an adequate and nutritious diet.
• Making sure you get enough sleep at
night.
• Sitz baths with soothing compounds (to
help control the itching).
 Specific treatment

Specific treatment for vulvitis will be

determined by based on age, overall health
and medical history, the severity of the
symptoms, cause of the condition, tolerance
for specific medications, procedures, or
therapies, expectations for the course of the
condition, opinion or preference.
• The treatment for vulvitis varies
according to cause.
• Apply steroid ointments use: Apply a
thin layer to areas of discomfort; decrease
redness, swelling, itching, burning,
cortisone cream may be used two or three
times a day on the affected area for up to
1 week.
• If the vulvitis is due to a fungal infection,
treat by antifungal creams.
• If treatment of vulvitis does not work,
further evaluation may include biopsy of
the skin to rule out the potential of vulvar
dystrophy (a chronic vulvar skin
condition) or vulvar dysplasia, a
precancerous condition.
 Prevention from vulvitis
• Practice good personal hygiene, including
keeping your genital area clean and dry,
and wiping from front to back after
urinating or having a bowel movement.
• This helps to prevent vaginal infections,
which ultimately leads to the prevention
of vaginal itchiness.
• Avoid certain products such as scented
bath soaps, feminine hygiene sprays,
• colored toilet paper, bubble baths, and
vaginal douches; the chemicals in these
items (dyes, fragrances) may cause
irritation.
 Wear white cotton panties (underwear),
avoidance of underwear made of silk or
nylon because these materials are not very
absorbent and restrict airflow.
• Avoid wearing extremely tight-fitting
pants or shorts, which may cause
irritation by constantly rubbing against
the skin and reducing airflow.
• Use condoms during sexual activities
( safer sex).
• Change out of wet bathing suits or
exercise clothes as soon as possible; the
moisture (from the water or from your
own sweat) and/or heat can contribute to
your itchiness.
• Cleansing the parts three or four times a
day with quite warm water
• If you have diabetes, keep your blood
sugar under control.
• If you are overweight, work to get your
weight in check.
• \For itchiness that is related
 Bartholin’s glands cysts and abscess

The Bartholin's glands are essential female

reproductive system. The organs' main
function is to secrete mucus to ensure
vaginal and vulval lubrication.
The Bartholin's glands are prone to infections
and abscess formation, which may result in
vestibular pain and dyspareunia. Bartholin's
glands are two pea-sized glands (very small,
round glands) that are
• The Bartholin's glands are essential
female reproductive system. The organs'
main function is to secrete mucus to
ensure vaginal and vulval lubrication.
• The Bartholin's glands are prone to
infections and abscess formation, which
may result in vestibular pain and
dyspareunia
Bartholin's glands are two pea-sized glands
(very small, round glands) that are located
next to the vaginal entrance. The glands sit
on either side Of the opening of the vagina.
A small amount of Infection of female
reproductive system mucus-like fluid is made in
the glands and leaves through a duct to keep the
entrance to These glands may help provide fluids
for lubrication during sexual intercourse.

| 73 |
Bartholinitis
• Infection of the Bartholin's gland is
knowm as Bartholinitis.
• Causative organisms, such as E.
transmitted diseases (STDs), such as
chlamydia or gonorrhea, may cause
infection that can lead to a Bartholin’s
infection.
• If bacteria get into the gland, swelling
infectin and obstruction may ot remains
open through which exudates escape out.
• The infection may resolute completely.
In others, the infection subsides only to
recur in the future. In such cases, the
gland becomes fibrotic.
• Too often, the duct lumen heals by
fibrosis with closure of the orifice, pent
up secretion of the gland, formation of
Bartholin cyst. The infection may
resolute completely or an abscess is
formed.
 Pathophysiology
Cysts arc common complications of the Bartholin's gland, affecting the
ductal region due to outlet blockage. When the Bartholin's gland duct
orifice becomes obstructed, the glands produce a buildup of mucus. This
build-up leads to a cystic dilation 'of the duct and cyst formation.
Infection of this cyst is likely to result in Bartholin's gland abscess. Duct
cyst is not required for the development of an abscess. abscesses are
almost three times more common than duct cysts. Bartholin's abscess
cultures often show polymicrobial infection.
 Clinical features

Bartholin's infection will often cause local

pain discomfort during any activity that
puts pressure on the area, such as walking,
sitting down, or having sexual intercourse.
• People who have a Bartholin's infection
will typically experience pain on one Side
of the vagina only the side of the infected
gland.
• It may also be associated with feeling the
unwell and high temperature.
• On examination, there is a unilateral
tender to the touch.
• The skin over them appears red and
edematous.
• Women may have a discharge from the
vagina, which is usually unrelated to the
abscess.
• The duct opening looks congested and
secretion comes out through the opening
when gland is pressed by fingers the fluid
will drain out.
 Treatment of Bartholinitis

• Hot compression over the area.

• Analgesics to relieve pain.

• A systemic antibiotic like ampicillin 500
mg orally 8 hourly.
• Appropriate antibiotic according to the
bacteriological sensitivity test.
 Bartholin's cyst

• A cyst is an abnormal, sac like structure

that can be found any where in the body.
Cysts usually contain a liquid or
semisolid substance and have an outer
walls known as the capsule.
 Clinical features

Bartholin's cysts which remain small and

do not become infected may not give any
symptoms and do not usually need any
treatment.
• But if cysts become large (size of hen's
egg), they can cause local discomfort/to
interfere during sitting, walking, and
dyspareunia.
• Unilateral swelling on the posterior half
of the labium majus which opens up at
the posterior end of the labium minus.
• The overlying skin is thin and shiny.

• A cyst is fluctuant and not tender.

• Women may have a discharge from the
vagina, which is usually unrelated to the
abscess.
• A Bartholin's cyst or abscess usually only
affects the gland on one side.
 Diagnosis

• History
• Patients with cysts may present with
painless labial swelling. Abscesses may
present spontaneously or after a painless
cyst with the following symptoms:
• Acute, painful unilateral labial swelling
• Dyspareunia (painful intercourse)
• Pain with walking and sitting
• Sudden relief of pain followed by discharge
(highly suggestive of spontaneous rupture)
 Physical examination

The following physical examination

findings are seen in Bartholin cysts
• Patients may have a painless, unilateral
labial mass without signs of surrounding
cellulitis.
| 75 |
• If large, the cyst may be tender. Discharge
from ruptured cyst should be nonpurulent.
Bartholin's cysts and abscesses have
characteristic appearances and can be
Sometimes a biopsy.
• The cyst is painful (often indicating an
abscess). A fever develops. The cyst
interferes with walking or sitting.
 Treatment

• A simple sitz bath may help the cyst go away

on its own. Simply fill a tub with 3 to g of

water (enough to cover your vulva), and

gently sit. Do this several times a day for

three or days. The cyst may burst and drain

on its own.
• Marsupialization:

• Make a small cut in the cyst and stitch the

inside edges of the cyst surface of the

vulva.
• This procedure is done in an outpatient

operating room. Sometimes anesthesia is

needed.

• On examination shows that have an STI, or

if cyst is infected, prescribe an antibiotic.

She also prescribe topical medications.

 Bartholin's Abscess

A Bartholin's abscess can occur when one

of the Bartholin's glands, located on either
side oftht vaginal opening, becomes
infected. When the gland is blocked, a cyst
will usually form.
If the cyst becomes infected, it can lead to a
Bartholin's abscess. Bartholin's abscess is
the end resultci acute batholiths.
 Causes of Bartholin's abscess

• A Bartholin's cyst develops when the duct

exiting the Bartholin's gland becomes
blocked.
• The fluid produced by the gland then
accumulates, causing the gland to swell
and form a cyst.
• An abscess occurs when a cyst becomes
infected.
• Bartholin's abscesses can be caused by
any of a number of bacteria.
• It is common abscesses to involve more than
one type of organism. Bacteria, such as E.
coli, and transmitted diseases (STDs), such
as chlamydia or gonorrhea, may cause the
infections can lead to a Bartholin's abscess.
• If bacteria get into the gland, swelling,
infection' obstruction may occur.
• Other bacteria species that play a role in
abscess development include Klebsiella
Neisseria sicca, Staphylococcus aureus,
Streptococcus species.
• If bacteria get into the gland, swelling,
infection' obstruction may occur.
• Other bacteria species that play a role in
abscess development include Klebsiella
Neisseria sicca, Staphylococcus aureus,
Streptococcus species.
 Symptoms

A Bartholin's abscess usually causes a lump

to form under the skin on one side of the
vagina.

A Bartholin's abscess will Often cause pain

during any activity that puts pressure on the
such as walking, sitting down, or having sexual
intercourse.
• People who have a Bartholin's abscess will
typically experience pain on one side vagina
only the side of the infected gland.
• It may also be associated with feeling the
unwell and high temperature.
• On examination, there is a unilateral
tender to the touch.
• The skin over them appears red and
edematous.
• Women may have a discharge from the
vagina, which is usually unrelated to the
abscess.
 Diagnosis

• Bartholin's abscess based on symptoms

and a physical examination. During the
exam, they will:
• Check for lumps in the vagina.
• Measure temperature to check for fever.
• Take a cervical swab to test for STIs.
• If the abscess has spontaneously ruptured,
a purulent discharge may be noted. If
completely drained, no obvious mass may
be observed.
• Abscesses cause severe pain and
sometimes fever.
• Cysts may become infected, forming a
painful abscess.
• They are tender to the touch.
• The skin over them appears red.
 Prevention

• It is not always possible to prevent a

Bartholin's abscess from developing. To
reduce the risk of an nfected gland:

• Use condoms to avoid STIs, such as

chlamydia and gonorrhea.
• Practice good genital hygiene and only
clean the outside of the vagina.
• Maintaining a healthy urinary tract may
also help prevent Bartholin's cysts and
abscesses from developing.
• Drink plenty of fluids throughout the day,
and avoid waiting a long time to urinate.
 Treatment
• Sitz baths can ease pain and discomfort.

They may also help very small abscesses

to rupture and drain. To take a sitz bath,

fill a bathtub with several inches of warm

water. Sit down in the water for 15

minutes.
• Repeat this treatment several times daily

for at least 3 to 4 days, or until symptoms

subside.
• Marsupialization: A procedure called

marsupialization can help prevent recurrent

Bartholin's abscesses. Sometimes, the doctor

may insert a catheter for a few days to speed

up the drainage process.

• If abscesses still recur after

marsupialization, it may be necessary to

remove the Bartholin's glands.

• Analgesics: Painkillers can help make

activities, such as sitting and walking,

more manageable. Infection of female

reproductive system | 77 |
• To treat a mild fever: drink plenty of
fluids, keep the room temperature at a
comfortable level, take ibuprofen, use
cold compresses on the forehead. Call a
doctor if body temperature exceeds 102 F
or if the fever persists for more than 3
days.
• Antibiotics (ampicillin 500 mg orally 8
hourly)may help in the early stages but a
small procedure is often needed to drain
the pus.
• Incision and drainage of the abscess
under general anesthesia. After incision
daily dressing is required until cavity
heals.
• The main aim of treatment is to remove
the pus (to treat the abscess) and to create
a new opening or duct to prevent
blockage (and therefore a cyst or abscess
forming) in the future.

• Send pus for bacteriological examination

and sensitivity test.
 Complications

• The most common complication of treatment

of Bartholin abscess is a recurrence.
• A theoretical risk exists for the development
of toxic shock syndrome with packing.
• Nonhealing wounds may occur.
• Bleeding, especially in patients with
coagulopathy, may be a complication.
• Prognosis
• If abscesses are properly drained, most
abscesses have a good outcome. \
• Recurrence rates are generally reported to
be less than 20%.
 Vaginitis
Vaginitis is a common gynaecological problem found in
women of all ages, with most women having at least one
form of vaginitis at some time during their lives.
It sometimes linked to more
VULVITIS Vulvjtis is an inflammation of the vulva(the
visible external genitalia) occurs in women of all ages.
Vulvitis is not a disease, but refers to the inflammation of the
soft folds of skin on the outside of
> VULVITIS Vulvjtis is an inflammation of the vulva(the visible external genitalia) occurs in women of
all ages. Vulvitis is not a disease, but refers to the inflammation of the soft folds of skin on the outside
of
>I
diseases.
Vaginitis is defined as the spectrum of
conditions that cause vulvovaginal symptoms
such as itching, burning, irritation, and abnormal
discharge.

Infection of Female Reproductive System

 Causes

• Although most vaginal infections are

caused by bacterial vaginosis,
trichomoniasis, moniliasis, chlamydia
trichromatic, allergic reactions, and
irritations, atrophic vaginitis.
• In approximately of affected women, this
condition occurs secondary to
vulvovaginal candidiasis or
trichomoniasis is the most common and
important cause of vaginitis in the
childbearing period.
• Atrophy vaginitis associated with
menopause due to estrogen deficiency.
• Vulvovaginitis in childhood due to lack of
estrogen, the vaginal defense is lost and
the infection occurs easily, foreign body in
the vagina, associated intestinal
infestations (threadworm being the most
common), rarely, the more specific
• infection caused by candida albicans or
gonococcus may be implicated.
• Allergies: latex, sperm, douching,
hygiene products.
• Chemical irritation: soaps, hygiene
products, douching, spermicides.
• Changes in hormone levels due to
pregnancy, breastfeeding.
• Infection of sexual intercourse.
 Risk factors

Type of vaginitis

• Bacterial vaginosis: Low socioeconomic

status, vaginal douching, smoking, use of an
intrauterine contraceptive device,
new/multiple sex partners, unprotected sexual
intercourse, homosexual relationships,
 Risk factors

frequent use of higher doses of spermicide

nonoxynol
• Trichomoniasis: Low socioeconomic
status, multiple sex partners, lifetime
frequency of sexual activity, other
sexually transmitted infections, lack of
barrier contraceptive use, illicit drug use,
smoking.
• Vulvovaginal candidiasis: Vaginal or
systemic antibiotic use, diet high in refined
sugars, uncontrolled diabetes mellitus
Atrophic vaginitis: Menopause, other
conditions associated with estrogen deficiency,
oophorectomy, radiation therapy,
chemotherapy, immunologic disorders,
premature ovarian failure, endocrine disorders,
antiestrogen medication.
• Irritant dermatitis: Contact Soaps,
tampons, contraceptive devices, sex toys,
pessary, topical products, douching,
fastidious cleansing, medications,
clothing.
• Allergic dermatitis: Contact Sperm,

douching, latex condoms or diaphragms,

tampons, topical products, medications,

clothing, atopic history

 Signs and symptoms

Allergic symptoms can be caused by

spermicides, vaginal hygiene products,

detergents, and fabric softeners.

Inflammation of the cervix (opening to the

womb) from these products often 79 |

is associated with abnormal vaginal
discharge, but healthcare providers can
tell them apart from true vaginal infections
by doing lab tests.
 The most common symptoms of
vaginitis are burning and itching outside
of the vagina ( the vulva).
 When present, symptoms are often
nonspecific. All women have:
• Purulent or mucopurulent vaginal
discharge and/or
• Intermenstrual or postcoital bleeding
Some women also have one or more of
the following:
• Dysuria, urinary frequency
• Dyspareunia
The vulva may become red and swollen,
but also may not change in appearance at
Often, vaginal discharge will turn white
and lumpy.
 Diagnosis

• The initial evaluation typically consists of

a history, physical examination,
microscopy and cervical tests for sexually
transmitted infections.
• Physical examination: The physical
examination assesses the degree of
vulvovagnal inflammation, characteristics
of the vaginal discharge, and presence of
lesions or foreign bodies.
Other potentially significant findings
include signs of cervical inflammation and
pelvic motion tenderness. \
Vulva:
Findings of the vulvar examination can
help guide further evaluation and diagnosis.
• Normal vulva are consistent with BV or
leukorrhea.
• Erythema, edema, or fissures suggest
candidiasis, trichomoniasis, or dermatitis.
• Atrophic changes are caused by
hypoestrogenic and suggest the
possibility of atrophic vaginitis.
• Changes in vulvovaginal architecture (eg,
scarring) may be caused by a chronic
inflammatory process, such as erosive lichen
planus, as well as lichen sclerosis cr mucous
membrane pemphigoid rather than vaginitis.
Pain with the application of pressure from
a cotton swab ("Q-tip test") on the labia the
vaginal introitus may indicate an
inflammatory process.
• Speculum examination is performed to
evaluate the vagina, any vaginal
discharge, and cervix.
• The vagina is examined for the following
lesions:
• A foreign body (eg, retained tampon or
condom) is easily detected and is
associated with vaginal discharge,
intermittent bleeding or spotting, and/or at
unpleasant odor due to inflammation and
secondary infection.
• Removal of the foreign body is generally
adequate treatment. Antibiotics are rarely
indicated
• Vaginal warts are skin-colored or pink and
range from smooth flattened papules a
verrucous, papilliform appearance.
• When extensive, they can be associated
vaginal discharge, pruritus, bleeding,
burning, tenderness, and pain.
• Granulation tissue or surgical site infection
can cause vaginal discharge bleeding after
hysterectomy or after childbirth.
• inflammatory changes associated with
malignancy in the lower or upper genital
tract can result in vaginal discharge;
spotting is more common in this setting
than in infectious vaginitis.
• The presence of multifocal rounded macular
erythematous lesions (like a spotted rash or
bruise), purulent discharge, and tenderness
suggests erosive vulvovaginitis, which can be
caused by trichomoniasis or one of several
noninfectious inflammatory etiologies.
Vaginal discharge: The characteristics of the vaginal
discharge may suggest the type of infection if
present. Trichomoniasis is classically associated with
a greenish-yellow purulent discharge; candidiasis
with a thick, white, adherent, "cottage cheese-like"
discharge; and bacterial vaginosis with a thin,
adherent discharge.
Inflammation and/or necrosis related to
malignancy of the lower or upper genital tract
can result in watery, mucoid, purulent, and/or
bloody vaginal discharge. However, the
appearance of the discharge is unreliable and
should never form the basis for diagnosis.
• The bimanual examination is performed to
assess for tenderness and/or abnormal
anatomy.
• Women with vaginitis who also have
pelvic or cervical motion tenderness are
further evaluated for pelvic inflammatory
• disease.

• While bimanual examination can also

identify pelvic muscle spasm and tenderness
reflecting pelvic muscle dysfunction, these
entities are not usually associated with
abnormal vaginal discharge.
 Investigation:
• Culture of the discharge collected by
swabs.
• Wet smear
• Vavinoscopy is needed to exclude a
foreign body or tumor in the case with
recurrent infection.
 Complication

• Pelvic inflammation disease.

• HIV infection.
• Persistent discomfort.
• Infertility.
 During pregnancy:
• Risk of miscarriage.
• Preterm birth.
• Preterm rupture of membranes.
• Low birth weight.
• Post-abortion endometritis
 Treatment

• Treatment depends on the type of

vaginitis are diagnosed with, but typically
treatment includes any or all of the
following: a pill, a cream, or a gel that is
applied to the vagina.

• | 81 |
 Predisposing risk factors

• Unsafe sex when a partner is infected

• Multiple sexual partner

• Early sexual intercourse age below 19

years
• Low socioeconomi status
• Previous STI

• Incomplete STI medication treatment

 Clinical Features

• Painful on vaginal examination.

• Cervix is congested and enlarged with a

swollen mucous membrane pouting at
external os.
• The cervix is tender on touched or
moved.
• Mucopurulent discharge in endocervical
canal or on an endocervical swab
• Endocervical bleeding by the passage of
a cotton swab.
 Prognosis

• Cervicitis will usually be cured when the

course of therapy is complete.
• Severe cases, however, may last for a few
months, even after the therapy is
complete.
•
• If the cervicitis was caused by a sexually
transmitted disease, both partners should
be treatec with medication.
• If not treated progress to a state of
chronic cervicitis.
 Diagnosis

A significant proportion of women with

cervicitis are asymptomatic. Cervicitis in
these women may be detected
incidentally during physical examination.
When present, symptoms are often
nonspecific. History of mucopurulent
vaginal discharge (abnormal vaginal
discharge), intermenstrual vaginal
bleeding, sexual history (dyspareunil
postcoital bleeding).
On speculum examination reveals thick
vaginal discharge.
Investigation:

• High vaginal/cervical swab culture

• Herpes simplex virus culture type 1 and

2 if lesion present
 Treatment

• The goal of treatment;

• Treat infection

• Prevent complication

• Prevent the spread of infection

•
• Appropriate antibiotics should be
prescribed according to the causative
organism.
 Chronic Cervicitis

Chronic cervicitis is the commonest lesion

found in women attending gynecological
outpatient may follow an acute attack or usually
chronic from the beginning. It occasionally
follows and repeated injury from pessaries,
tampons and unsatisfactory contraceptive
appliances
 Etiology

• As a result of a various sexually transmitted

disease such as Chlamydia, N gonorrhea, etc.
• It is also caused by ilTitation using a cervical
cap or diaphragm.
• By using of chemicals like spermicidal.
• It can probably arise as a result of vaginal
organisms becoming pathogenic.
• It occasionally follows chronic and
repeated injury from pessaries, tampons.
• It is usually the result of pubertal
cervicitis which is associated with
laceration of the cervix and with
cellulitis.
• Organisms can linger in the glands of the
endocervix for many years, the condition
of chronic cervicitis does not usually
represent an active inflammatory state.
• It is a result of injury and inflammation.
 Clinical features

• Chronic cervicitis is usually a histological

diagnosis without clinical significance.
Only when the Injury and reaction are
severe do they cause symptoms;
• Mucopurulent discharge.
• Low backache which is partly relieved by
rest.
• Aching in the lower abdomen and pelvis.
• Deep-seated dyspareunia.
• Spotting or bleeding after sexual
intercourse
• Menorrhagia and congestive
dysmenorrhoea.
• Infertility
• Discomfort with urination
• On examination
• The cervix may be tender to touch or on
movement.
• Speculum examination reveals mucoid or
mucopurulent discharge escaping out
through the cervical os.
• There may be enlargement, congestion or

ectropion of the cervix. Tenderness to

touch.

• Pain when the cervix is moved.

• Investigation
• Cervical discharge and high vaginal swab

for culture

• Herpes simplex virus and human

papillomavirus culture
• Cervical scrape cytology to exclude

malignancy is mandatory prior to

treatment.
 Preventive measures

• Annual gynecological examination

including Pap smear is helpful for early
rule out of disease.
• Wear cotton underpants. Avoid underpants
made from non-ventilating materials.
• Use of condom during intercourse to

prevent STl .

• Keep the perineal area dry and clean.

 Treatment

• There is no place of antibiotic therapy

except gonococcal or proved cases of

chlamydial infection.

| 85 |
• Electric or diathermy cauterization: the destruction of tissue by heat applied with electric current.
• Laser or cryosurgery: the destruction of abnormal tissue by applying freezing
• Chemical cauterization: the destruction of abnormal cells with silver nitrate.
• Hysterectomy: If the condition of cervicitis is so severe that it cannot be satisfactoily with diathermy, cryosurgery or cone
excision and further childbearing is not hysterectomy is usually performed.
• Complications
• If left untreated, cervicitis may lead to complications. These may include:
• Reinfection Other STDs May develop upper genital infection ( PID) Tuboovarian abscess Infertility Ectopic pregnancy Chronic
pelvic pain Cervicitis is an inflammatory disorder that primarily affects the endocervical glands. Sexually transmitted infections
are the most common cause; irritation from foreign bodies is another Neisseria gonorrhoeae and Chlamydia trachomatis are
the two most common causes of acute uncertain how much Mycoplasma genitalium contributes to cervicitis, but this
organism is likely responsibleft! substantial minority of cases. The cardinal signs are purulent or mucopurulent discharge and
easily induced bleeding (friability) from \ endocervix. Associated symptoms include abnormal vaginal discharge,
dysuria/urinary frequency, intermenstrual or postcoital bleeding. The clinical diagnosis of cervicitis is based upon the presence
of mucopurulent cervical discharge and friab?i Diagnostic evaluation for potential causative organisms includes assays for
chlamydia and gonorrhea, as El: evaluation of vaginal fluid for trlchomonas vaginalis and bacterial vaginosis. Endometritis
Endometritis refers to inflammation of the Normal endometrium Inflammation and infection endometrium, the lining of the
endometrium uterus. It is shed at regular intervals during menstruation. The cavity of the uterus is protected against bacterial
invasion by the defense mechanisms of the vagina and cervix. However after delivery, or abortion or after menopause, the
defense mechanism is weakened and endometritis is more likely at this time.
• You sent Today at 6:40 PM
Causes Endometritis is caused by infections such as chlamydia, gonorrhea, tuberculosis or mixture of normal vaginal bacteria. Endometritis is more likely to
occur after miscarriage or childbirth, especially after a long labor or caesarian section. A medical procedure that involves entering the uterus through the cervix
will increase the risk of developing endometritis. This includes a D&C, hysteroscopy, and placement of an Intrauterine device (IUD). Endometritis can occur at
the same time as other pelvic infection such as acute salpingitis, acute cervicitis and many sexually transmitted infection (STIs). Types of endometritis Acute
endometritis: Acute endometritis is characterized by infection. The organism isolated is most after polymicrobial. The most common cause of infection is after
abortion, after delivery medical instrumentation or multiple vaginal examinations, reltention of the placental fragment. Chronic endometritis: It is indeed rare
for chronic endometritis to occur during the reproductive period even following acute endometritis. This is because of cyclic shedding of the infected
endometrium and the infected constant drainage of the infected material. Such conditions are IUD, infected polyp, retained prod acts uterine malignancy,
•endometrium burns due to radium. Patients suffering from chronic endometritis may have an underlying cancer of cervix or endometrium. It may be seen up
to 10 % of. all endometrial biopsies performed for irregular bleeding. The most common organism are Chlamydia trachomatis, Neisseria gonorrhea, and
streptococcus. Pyometra: is an accumulation of the pus in the uter ne cavity. Two conditions must coexist to develop pyometra the first of which is the resen e of
Infection, the second is blockage of cervix. It is manifested by lower abdo •nal, suprapubic pain, rigors fever discharge pus on introduction of a sound into the
terus. In pre*ence of pyometra, the uterus is enlarged, feels soft and tender. Atrophic endometritis (senile endometritis) Following menopause, due to
deficiency of estrogen, the defense of the uterocericovaginal canal is lost. There is no periodic shedding of the endometrium. Ak a result, or anisms of low
virulence can ascend up to infect the atrophic endometrium. The clinical features of the post-menopausal women complain of vaginal discharge, at times
offensive or even lood-s ained pelvic exam. Pathology After childbirth or abortion, extensive thrombosis occurs in the I rge bl od vessels and the blood clot
provides a suitable focus for the growth of bacteria, the ut rine w Il is edematous a normal involution is delayed. The infection may spread directly the wall of
the uterus caus ng p r• oniti of cellulitis in the broad ligament, the spread may take place along the thrombo ed vyi to pr duces an extensive thrombo-phlebitis
or pyemia as the result of detachment of infe ted bl od clo the organism. Infection of fema e repr ductive system | 87 |
• You sent Today at 6:41 PM
• Pain during sexual intercourse Pain coming and going in periods Abdominal pain Lower back pain Fever
Nausea Vomiting Criteria for diagnosis of salpingitis Abdominal direct tenderness, with or without rebound
tenderness. Tenderness with the motion of cervix and uterus, adnexal tenderness. Plus Temperature more
than 38.C Leucocytosis ( >10, 000/mm3 ) Purulent material from the peritoneal cavity by Laparoscopy or
by culdocentesis. Pelvic abscess or tubo- ovarian mass on bimanual examination or on sonography.
Diagnosis/ laboratory findings By Pelvic examination, blood tests and mucus swab a doctor can diagnose
salpingitis. A smear of the cervical discharge nearly always reveal infection and may etiology (organism),
but culture confinnation is essential. Culdocentesis usually produces cloudy fluid, which should be sent for
cell count WBC/ml is associated with PID). If abdominal x-ray films show evidence of free air under the
diaphragm, laparotc. mandatory. Ultrasonic scanning is useful in the patient who is too tender to examine
properly to ill! ectopic gestation, or reveal abscesses. Treatment Salpingitis is most commonly treated with
antibiotics. Start antibiotic after taking discharge swab for the culture-sensitive test. Admission if
temperature > 39-degree centigrade, toxic look, rebound tenderness• response by 72 hours oral
antibiotic. Intravenous antibiotic and fluid are given. Surgical treatment of salpingitis is very rare but may
need for surgical operation patient who suffers repeated and recurrent attacks. Application of the dry heat
on the lower abdomen may give some relief, but analgesic require. Keeping the patient in an upright
position will encourage vaginal discharge. Wash vagina after defecation and urination.
• You sent Today at 6:42 PM
Pain during sexual intercourse Pain coming and going in periods _Abdominal pain Lower back pain Fever Nausea Vomiting
Criteria for diagnosis of salpingitis Abdominal direct tenderness, with or without rebound tenderness. Tenderness with the
motion of cervix and uterus, adnexal tenderness. Plus Temperature more than 38.C Leucocytosis ( >10, 000/mm3 ) Purulent
material from the peritoneal cavity by Laparoscopy or by culdocentesis. Pelvic abscess or tubo- ovarian mass on bimanual
examination or on sonography. Diagnosis/ laboratory findings By Pelvic examination, blood tests and mucus swab a doctor can
diagnose salpingitis. A smear of the cervical discharge nearly always reveal infection and may suggest, etiology (organism), but
culture confirmation is essential. Culdocentesis usually produces cloudy fluid, which should be sent for cell count WBC/ml is
associated with PID). If abdominal x-ray films show evidence of free air under the diaphragm, laparotom mandatory. Ultrasonic
scanning is useful in the patient who is too tender to examine properly to rulä ectopic gestation, or reveal abscesses. Treatment
Salpingitis is most commonly treated with antibiotics. Start antibiotic after taking discharge swab for the culture-sensitive test.
Admission if temperature > 39-degree centigrade, toxic look, rebound tenderness' response by 72 hours oral antibiotic.
Intravenous antibiotic and fluid are given. Surgical treatment of salpingitis is very rare but may need for surgical operation
patient who suffers repeated and recurrent attacks. Application of the dry heat on the lower abdomen may give some relief,
but require. Keeping the patient in an upright position will encourage vaginal discharge. Wash vagina after defecation and
urination.
• You sent Today at 6:43 PM
• Complications Infertility Damaged oviducts increase the risk of ectopic pregnancy. Other complications
are: Infection of ovaries and uterus Infection of sex partners An abscess on the ovary Oophoritis
Inflammation of one or both ovaries. The inflammation usually occurs with salpingitis (infection of the
fallopian tube), pelvic inflammatory disease or other infections. The ovaries are a pair of internal
reproductive organs that produce eggs and hence oophoritis may affect fertility. The affection of the
ovary from tubal infection occurs by the following routes. Directly from the exudates contaminating the
ovarian surface producing perioophoritis. Through lymphatic of the mesosalpinx and mesovarium
producing interstitial oophoritis. Through the rent of the ovulation producing interstitial oophoritis. If
the organisms are severe, an abscess is formed and the tubo — ovarian abscess results. In others, the
ovaries may be adherent to the tubes, intestine, omentum and pelvic peritoneum producing tubo —
ovarian mass (TO mass). Such a mass is usually bilateral. Bloodborne- mumps. Causes Oophoritis is
generally caused by gonorrhea or chlamydia bacteria that move from the vagina or cervix into the
uterus, fallopian tubes, and ovaries. Mumps Mycoplasma pneumonia Pelvic Inflammatory Disease
Sexually Transmitted Disease Staphylococcal infection Streptococcal infections Sign and Symptoms
Pelvic pain Lower back pain Fever Side tenderness Tenderness on internal examination Treatment
Medical treatment of outpatient is appropriate for patients those who are hemodynamically stable,
sufficiently reliable to return for follow-up care. If tolerant of oral medication, and Infection of female
reproductive system | 91 |
• You sent Today at 6:43 PM
• without clinical suspicion of a tubo-ovarian abscess (TOA). Antibiotic
Antimicrobial must be comprehensive and should cover all likely pathogens.
cephalosporin with broad spectrum, gram negative activity; higher efficacy
against organisms. Inpatient treatment is required for patients who have
already failed outpatient treatment, are pregnant, are infected with HIV or
otherwise immunocompromised, are exhibiting evidence of a TOA are
hemodynamically unstable or appear septic, or are unable to tolerate oral
medications. Surgical Care Oophoritis may be managed with surgery when
medical treatment fails . improve symptoms after 48-72 hours. Factors that
influence the choice of surgery includetl extent of the abscess, degree of
immunocompromise of the patient, and preservation. fertility for future
childbearing potential. Surgical options may include: laparoscopy with drainage
of the abscess, removal of adnexa, Total abdominal hysterectomy and bilateral
salpingo-oophorectomy (TAWBSO).