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Vaginal discharge is mainly composed of water with electrolytes, microorganisms, epithelial cells, and organic compounds such as fatty acids, proteins, and carbohydrates. Smaller amounts of fluid are derived from Bartholin's glands, cervix, endometrium, and fallopian tubes. Cellular elements represent sloughed cells from cervical columnar and vaginal squamous epithelium. White blood cells are present only in small s, among women without vaginitis. Estrogen and the pH are two important factors that influence the types of bacteria present in the vaginal flora. Vaginal lactic acid content provides an acidic pH of less than 4.

Lactic acid is produced from the metabolism of Lactobacillus and by vaginal epithelial cells through the breakdown of glycogen. The low pH favors the growth of acidophilic organisms such as Lactobacillusbut it inhibits the growth of most other bacteria.

Lactobacillus appears central in limiting the growth of other bacteria. The combination of a halide ion such as chloride present in abundance in the vagina with peroxidase, present in endometrial and vaginal fluid, 22 and H 2 O 2 produced by certain strains of Lactobacillus forms a potent inhibiting system for certain bacteria in the vagina 23 and of HIV and other virus in vitro. Between 5 and 10 microorganisms can be recovered form the vagina of women, and most of the focus has been on the of bacteria recovered.

Table 1 describes the frequency and concentration of microorganisms recovered by culture from the vagina of pregnant women, stratified by Gram-stain criteria. For one half of the women without G. From theseit is possible to appreciate the total dominance of Lactobacillus species in the vagina of women with normal vaginal flora.

TABLE 1. The normal vaginal flora, H 2 O 2 -producing lactobacilli and bacterial vaginosis in pregnant women. Clin Infect Dis ;16 Suppl 4 :S The prevalence of Lactobacillus is ificantly decreased in BV cases in which Lactobacillus species are no longer the dominant microorganisms. In BV, the concentration of G. Women in this report with intermediate flora had a similar prevalence and concentration of Lactobacillus and G. When the complex balance of microorganisms changes, potentially pathogenic endogenous microorganisms that are part of the normal flora, such as Candida albicans in cases of candidiasis and G.

Little is known about factors that contribute to the overgrowth of normal flora. Pathogenic exogenous sexually transmitted microorganisms such as Trichomonas vaginalisN. Diagnosis of vaginitis cannot be based solely on the presence or absence of symptoms. A wide range of symptoms occurs among women with vaginitis that provides great overlap with the symptoms that occur in women with no infection or vaginitis.

Physical and laboratory parameters and not symptoms must be used to establish a diagnosis of vaginitis by physicians. Except for certain individuals with typical and well-spaced symptoms of candidiasis, self-diagnosis is even more inaccurate. The diagnosis of vaginitis is largely based on microscopic criteria.

Syndromal diagnosis and treatment is inaccurate and not acceptable in any modern medical setting. If a diagnosis cannot be established with certainty, selected cultures and a repeat examination should be performed several days later, at least for symptomatic women with suspected vaginitis to make a specific diagnosis and for symptomatic women with a pd normal discharge to further exclude vaginitis. The vulva should be inspected for the geographic erythema or fissures that can occur with candidiasis and contact dermatitis, for the white epithelium of lichen sclerosis, for hypertrophic epithelia of neurodermatitis, and for other lesions e.

A thin vaginal discharge is often present at the introitus of women with trichomoniasis or BV. Patients with excessive vulvar tenderness should be scrutinized for vestibulitis, particularly if they have pain with penetration during intercourse.

In vestibulitis, the vestibular area at 4 and 8 o'clock just external to the hymeneal ring is typically red and tender to even slight touch. Normal vaginal discharge is usually white and clumpy, and it pools in the vagina. In contrast, the discharge from BV is gray and homogeneous i. Characteristics of vaginal discharge.

During the early estrogen-dominant phase of the menstrual cycle, a clear mucous endocervical discharge is normal. In the later progesterone phase of the cycle, cervical mucus is thick, scant, or not visible. Vaginal discharge on the ectocervix needs to be wiped from the cervical portio with a cotton swab to examine for a purulent appearance from vaginal discharge.

The presence of a purulent discharge in the endocervical canal should prompt a diagnosis of cervicitis. Simple office analysis of the vaginal discharge is helpful and inexpensive. The pH paper should have a range between 4 and 6. The pH should be tested by placing a drop of the vaginal discharge on pH paper or rubbing the paper on the vaginal wall.

Cervical mucus must be avoided, because it has a basic pH. A normal pH virtually excludes BV. The fish odor is caused by the volatilization of mostly trimethylamine, which is a byproduct of anaerobic metabolism. An approximately ratio of vaginal discharge to normal saline is mixed on a glass slide and covered with a coverslip to make a saline wet mount.

The microscopic examination should be performed within a few minutes of preparing the slide. Based on the appearance and chemical determinations, the most likely characteristic to be identified by microscopy is sought Fig.

The most likely features in patients with a pH 4.

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Women pussy Seattle Washington analysis of several microscopic features is the key to an accurate diagnosis. A few WBCs can be present in the vagina as a result of physiologic cervical discharge, particularly premenstrually, but the normally does not exceed the of vaginal epithelial cells. A large of WBCs suggests trichomoniasis, cervicitis, or occasionally candidiasis. The discharge of women with candidiasis or a normal discharge usually contains a predominance of large rods, which are gram positive if stained.

These large rods can be seen on wet mount preparation and represent lactobacilli. In contrast to patients with normal Lactobacillus flora, those with BV, trichomonal infection, and DIV usually have a predominance of cocci or small coccobacillary form and none or only a few Lactobacillus morphotypes.

These small bacteria are particularly numerous in BV. The trichomonad is a motile, flagellated microorganisms that is slightly larger than a WBC. Fully motile trichomon are easily identified by their characteristic undulating swimming motion. About one half of women with trichomoniasis on culture have too few trichomon to be detected by direct microscopy.

Fortunately, most of these patients are asymptomatic. The clue cell is a vaginal epithelial cell to which such a large of bacteria attach that the cell border is obscured and has a serrated appearance. Clue cells are most objectively identified by observing the absence of a straight cell border through the x objective.

Hyphae have a characteristic branching appearance that can usually be identified in the x objective. The entire surface of the coverslip should be scanned, because even in symptomatic women, hyphae may be clumped in only one area of the slide. Buds from yeast can also be identified by experienced microscopists. Vaginal Gram stains can be used in place of the wet mount to detect WBCs, predominant bacterial flora, and yeast forms. The Gram stain is not useful for detecting trichomon.

Patients with BV have a predominance of small gram-negative bacillus flora e. Gardnerella spp. Lactobacillus morphotypes. A Gram stain is useful to identify normal, intermediate, and BV flora. Vaginal bacterial cultures are of limited benefit to diagnose vaginitis. Cultures should be used only in specific circumstances.

Cervical tests for N. Women pussy Seattle Washington and chlamydial infections are also common among women with trichomoniasis. DNA detection tests i. Vaginal cultures for Candida organisms are useful for women with suspected candidiasis but normal KOH preparation. Candida cultures should be obtained from women without hyphae on the KOH smear who have pruritus, an erythematous vulvar rash, vulvar fissures, or white vulvar plaques and from those unresponsive to antifungal medication.

Trichomonas cultures on Diamond's media can be obtained in cases of a purulent vaginal discharge when repeated microscopic examinations fail to identify the organism. Vaginal cultures for G. Women with a physiologic discharge usually have no vulvar abnormality and a white floccular clumpy vaginal discharge.

The discharge is very thick, and it tends to pool in the inferior portion of the vagina.

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The vaginal and cervical epithelial surfaces are a normal pink color. The pH of normal discharge is usually less than 4. The most striking microscopic finding is an abundance of vaginal epithelial cells and large rods representing normal gram-positive lactobacilli Fig. No clue cells, trichomon, or mycelia are seen, and only a few WBCs and short rod bacteria are present on microscopy. Cervical mucus can cause a large amount of discharge, particularly in women with a large surface area of cervical columnar epithelium. Such women typically have excessive discharge midcycle.

Examination of the cervix at midcycle reveals a large amount of clear cervical mucus and usually a large area of columnar epithelium. Gram stain of the cervical discharge reveals only an occasional WBC. The microscopic appearance of vaginal discharge in these women is that of the physiologic vaginal discharge. Cervical gonococcal and chlamydial testing should be obtained to exclude their presence. Women with a physiologic discharge should be reassured that the discharge is normal and that therapy is not needed.

Symptomatic patients who still suspect they have infectious vaginitis should be reexamined in 1 to 2 weeks. Long-term use of tampons should be avoided to prevent vaginal ulceration. Although the practice should generally be discouraged, some women insist on douching, in which case, mild vinegar solutions or water should be used.

However, the repeated drying effect of multiple douches may increase the amount of discharge, and douching with commercial preparations may cause abnormal shifts in vaginal flora. Cryocautery, laser cautery, electrical cautery, and silver nitrate application treatment of a normal columnar epithelium usually are unnecessary for an excessive normal cervical discharge.

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Symptoms usually only result when these organisms proliferate to large s. The true incidence of vulvovaginal candidiasis is unknown. Women who carry C. Symptoms reflect the host immune response. Diagnosis without the benefit of microscopy or culture indicates that one half of women diagnosed with candidiasis instead have other conditions. Postmenopausal women given estrogen replacement can have candidiasis. The frequency of intercourse is related to candidiasis.

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Candidiasis appears weakly related to high-dose estrogen contraceptive pills. Antibiotics have been strongly related to candidiasis, 40 and this association may be especially important for women with recurrent infection. Diet may play little in the role of candidiasis. Uncontrolled diabetes is associated with candidiasis, particularly with unresponsive infections.

Recurrence of typical severe symptoms such as pruritus and vulvar irritation often represent candidiasis, but atypical or minimal symptoms are incorrectly self-diagnosed in about one half of cases. Uncomplicated candidiasis refers to sporadic infrequent episodes with mild to moderate symptoms in a normal, nonpregnant woman.

Virtually all uncomplicated infections are caused by C. Complicated candidiasis refers to recurrent infection, infection with severe symptoms or infection in women who are pregnant, diabetic, or immunosuppressed. Many cases of complicated infection are caused by non- albicans species. Topical azole therapy remains the first choice to treat infrequent acute candidiasis. Azoles are fungistatic by their inhibition of ergosterol and membrane synthesis. Candida organisms are killed by the host lymphocytes through cell-mediated immune mechanisms. Only a limited fungicidal effect can be achieved by a high concentration of azoles that produce direct membrane damage.

Topical azoles are effective, well tolerated, and relatively inexpensive. The products available include buconazole Femstatclotrimazole Gyne-Lotrimin, Mycelexmiconazole Monistatand terconazole Terazol. A wide range of doses in cream and suppository forms are available Table 2. For some preparations, the treatment interval has been increased to twice daily or the dose has been increased from to mg while the length of medication was reduced concurrently from 7 to 3 days.

Cure rates for the 3-day course have been equal to longer courses for uncomplicated candidiasis. There is no suggestion that the cure rates differ between various different azoles or between the suppository and the cream form. TABLE 2. I do not recommend single-dose therapy, because clinical experience suggests that 1-day courses are less effective than published reports indicate.

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