Distinguished future physicians welcome to Stomp on Step 1 the only free videos series
that helps you study more efficiently by focusing on the highest yield material.
I’m Brian McDaniel and I will be your guide on this journey through vulvovaginal infections.
This is the 3rd video in my playlist covering all of microbio.
Vulvovaginitis (AKA Vaginitis) is inflammation of the lower genital tract.
It is usually due to infection, but there are a wide variety of causes.
During this video we will focus on the 3 most important causes of vulvovaginitis for the
medical board exam (trichomonas, candida and BV).
However, you should know that other types of vaginitis include mechanical irritation,
allergic reactions (to soaps or feminine products) and a variety of other infections.
Atrophic Vaginitis is a common cause of vaginitis in post-menopausal women and we will cover
that in a later video in the GYN section.
Gonorrhea and Chlamydia present primarily with cervicitis, but it can also cause vulvovaginitis.
G/C will be covered later in its own video.
We will start with a few different tests that we will use to differentiate between the different
infections.
Wet Prep (AKA Wet Mount Test) is a microscopic examination of vaginal discharge used to differentiate
between different types of vulvovaginitis.
The vaginal specimen is obtained using a speculum and a que tip similar to how one gets a pap
smear.
Then the specimen is rubbed onto a glass slide.
One half of the slide has a drop of saline added to it while the other half of the slide
has a drop of 10-20% KOH (Potassium hydroxide) added to it.
When Saline is added it makes it easier to view clue cells for BV & flagellated motile
cells for trichomonas.
The KOH kills bacteria and vaginal cells leaving only yeast cells.
This makes it easier to view the psuedohyphae and budding yeast present during vulvovaginal
candidiasis.
KOH is also alkalotic so it can be used for a “Whiff Test.”
In this scenario when the alkalotic KOH is added to a sample containing BV it will create
an amine or fishy smell.
This is a similar principle behind how the smell of BV can increase after unprotected
sex since semen is alkalotic.
The normal vaginal pH for a reproductive age woman is about 4, while the normal vaginal
pH before puberty and after menopause is about 7.
During puberty there is an estrogen guided increase in the growth lactobacilli flora.
These bacteria break down glycogen into lactic acid which lowers pH from about 7 to about
4.
Now that you know the normal values you can apply it to diseases.
Usually, Bacterial Vaginosis & Trichomonas have alkalotic pH (>4.5 in reproductive age
women) while candida has normal pH (<4.5).
pH paper can be tested by using pH paper on vaginal discharge.
You can see here at the top right corner that I give BV a high yield rating of 3 on a scale
from 1 to 10.
If you want to learn more about that rating system you can go to my website or click on
this orange box here if you are watching this video on a computer.
Bacterial Vaginosis (AKA BV) is a polymicrobial infection caused by the overgrowth of normal
flora.
The key bacteria in this infection is gram negative Gardnerella Vaginalis.
Clue cells are visible on the saline portion of a wet prep.
A Clue Cell is a sloughed mucosal squamous epithelial cell covered in many adherent coccoid
bacteria (Gardenerella Vaginalis).
Here is a picture comparing normal squamous epithelial cells with a few scattered lactobacill
to squamous cells that are covered in thousands of adherent garenerella bacteria.
Here is one more pic.
You can see on the left we have a normal squamos epithelial cell with a few WBCs.
On the right we have the darker Clue cells.
Finally I have a photomicrograph to look at in case you see that on your test.
A thin/watery gray-white discharge is present A fouls smell is present and often described
as an Amine Odor or Fishy Smell.
This smell is intensified after unprotected intercourse or when KOH is added (AKA Positive
Whiff Test).
Alkalotic pH (>4.5 in reproductive age woman) Minimal itching and inflammation/erythema
is present.
Few leukocytes visible on microscopy Treatment = topical Metronidazole or oral
metronidazole if that doesn’t work.
Clindamycin is another option
If you have been following along with my microbio section you will know that I already have
a video on Fungi & Candida.
I’m not going to go over that same material here, but I will covere some information that
is specific to vaginal candidiasis.
Vulvovaginal Candidiasis (AKA Yeast Infection) is an overgrowth of ubiquitous fungi.
The most common subtype of candida infections in the vaginal tract is Albicans, but you
also see Glabrata and Tropicalis (especially if it is resistant to treatment).
Mostly happens in patients with altered flora (immunosuppressed, antibiotic therapy, corticosteroids)
of increased glycogen (diabetics, pregnant, OCPs)
Keeping the vagina moist and warm with tightfitting clothing like a bathing suit also is a risk
factor Severe inflammation leads to bright red erythema,
vulvar pruritus (severe itching), burning, dysuria (painful urination) & dyspareunia
(painful intercourse) Lumpy/Thick adherent white cottage cheese
like discharge Odorless
Normal pH You can see here an example of the Budding
yeast & psuedohyphae seen on the KOH portion of a wet prep
Treatment = OTC topical miconazole (monostat), oral fluconazole (diflucan) & or topical terconazole
(Terazol)
Trichomoniasis (AKA Trichomonas Vaginalis) is a very contagious STD, therefore the question
stem will almost always mention unprotected sexual activity.
Inflammation leads to burning, itching, erythema, dysuria and dyspareunia.
Many leukocytes are seen on microscopic examination Patchy Erythema on cervix is referred to as
Strawberry Petechiae.
Note that this finding can be easily confused with Cervicitis (Gon/Chlyamdia).
Thin/watery frothy (bubbly) yellow-green discharge On Saline prep you see motile or moving flagellated
protozoa.
Can have malodorous/fishy smell/foul smell Alkalotic pH (>4.5 in reproductive age)
Treatment is oral metronidazole for both partners to prevent reinfection.
So it is the same treatment as BV which makes things a bit easier to remember.
To review here are some buzzwords that should stand out to you in question stems.
If you just know the info on this slide you can probably get most of these questions right.
Trich is the only 1 of the 3 that is an STD and motile under a microscope.
A strawberry cervix is also only present in Trich when talking about these 3 different
diseases although other diseases can cause cervical inflammation.
Candida has budding yeast & psuedohyphae as well as a normal pH.
BV has clue cells and minimal itching.
Thank you to CLARK JOHNSEN from New York who generous donation helped bring this video
to you all.
If you would like to help out you can donate on our website or help spread the word via
telling your classmates or even posting on social media sites like facebook.
That would really help us out.
If you would like to be taken to our next video in the microbio section you can click
on this black box here.
That video will be about Viruses.