Table II-2-3. Inhibit/Promote Voiding



Inhibit Voiding Promote Voiding
   
Bladder relaxants Bladder contraction
Antispasmodics Cholinergics
Oxybutynin (Ditropan) Bethanechol (Urecholine)
Flavoxate (Urispas) Neostigmine (Prostigmin)
Anticholinergics  
Pro-Banthine  
Tricyclics  
Imipramine (Tofranil)  
Vesical neck contraction Vesical neck relaxants
Alpha adrenergics Alpha antagonists
Ephedrine Methyldopa
Imipramine Phenothiazines
Estrogen stimulates alpha receptors  
Progesterone stimulates beta receptors  
   

 

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GI

 

 

Disorders of

3

   
the Vagina and Vulva    
       

 

 

VAGINAL DISCHARGE

A 25-year-old woman complains of a whitish vaginal discharge. The patient states that this is the first time that she has this complaint, and it is associated with vaginal and vulvar pruritus. There is no significant medical history, and she is not on oral contraception.

 

 

Diagnostic Tests

 

Visual inspection. The vulva and vagina should be examined for evidence of aninflammatory response as well as the gross characteristics of the vaginal discharge seen on speculum examination.

 

Vaginal pH. Normal vaginal pH is an acidic <4.5. Identification of the pH is easilyperformed using pH-dependent Nitrazine paper. Normal vaginal discharge leaves the paper yellow, whereas an elevated pH turns the paper dark.

 

Microscopic examination. Two drops of the vaginal discharge are placed on a glassslide with a drop of normal saline placed on one, and a drop of KOH placed on the other. The 2 sites are covered with cover slips and examined under the microscope for WBC, pseudohyphae, trichomonads, and clue cells.

 

Bacterial Vaginosis

 

Background. This is the most common (50%) cause of vaginal complaints in the United States.It is not a true infection but rather an alteration in concentrations of normal vaginal bacteria. The normal predominant lactobacilli are replaced by massive increases in concentrations of anaerobic species and facultative aerobes. It is frequently seen postmenopausally because of low levels of estrogen. It is not sexually transmitted, but it is associated with sexual activity.

 

Symptoms. The most common patient complaint is a fishy odor. Itching and burning are notpresent.

 

Speculum Examination. The vaginal discharge is typically thin, grayish-white. No vaginalinflammation is noted. The vaginal pH is elevated above 4.5. A positive “whiff” test is elicited when KOH is placed on the discharge, releasing a fishy odor.

 

Wet Mount. Microscopic examination reveals “clue cells” on a saline preparation. These arenormal vaginal epithelial cells with the normally sharp cell borders obscured by increased num-bers of anaerobic bacteria. WBCs are rarely seen.


 

GYN Triad

Bacterial Vaginosis

 

• Vaginal discharge pH >4.5

 

• Fishy odor

 

• “Clue” cells


 

 

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USMLE Step 2 l Gynecology


 

 

GYN Triad

Trichomonas Vaginitis

 

• Vaginal discharge >4.5

 

• Itching and burning

 

• “Strawberry” cervix

 

 

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phil.cdc.gov

 

Figure II-3-1. Clue Cells on Wet Mount

 

 

100

                 
     

Non-Lactobacillus

 

Non-Lactobacillus

     

80

             

 

   

30%

 

Mostly

     
           
                 

60

          anaerobes      
         

85%

     
               

40

      Lactobacillus   Bacteriodes spp.      
      70%   Peptostreptococcus      
            Haemophilus      

20

          Gardenerella      
                 
            Lactobacillus      

0

          15%      
     

Normal

 

BV

 
           

 

Figure II-3-2. Change in Vaginal Flora with Bacterial Vaginosis (BV)

 

 

Management. The treatment of choice is metronidazole or clindamycin administered eitherorally or vaginally. Metronidazole is safe to use during pregnancy, including the first trimester.

 

 

Trichomonas Vaginitis

 

Background. This is the most common cause of vaginal complaints worldwide and is thesecond most common sexually transmitted disease (STD) in the United States. It is caused by a flagellated pear-shaped protozoan that can reside asymptomatically in male seminal fluid.

 

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GI

Chapter 3 l Disorders of the Vagina and Vulva


 

 

Symptoms. The most common patient complaint is vaginal discharge associated with itching,burning, and pain with intercourse.

Speculum Examination. Vaginal discharge is typically frothy and green. The vaginal epitheliumis frequently edematous and inflamed. The erythematous cervix may demonstrate the charac-teristic “strawberry” appearance. Vaginal pH is elevated >4.5.

 

Wet Mount. Microscopic examination reveals actively motile “trichomonads” on a saline prepa-ration. WBCs are seen.

 

Management. The treatment of choice is oral metronidazole for both the patient and her sexualpartner. Vaginal metronidazole gel has a 50% failure rate. Metronidazole is safe to use during pregnancy, including the first trimester.

 

 

Candida (Yeast) Vaginitis

 

Background. This is the second most common vaginal complaint in the United States. The most common organism isCandida albicans. It is not transmitted sexually.

 

Risk Factors. These include diabetes mellitus, systemic antibiotics, pregnancy, obesity, anddecreased immunity.

 

Symptoms. The most common patient complaint is itching, burning, and pain with inter-course. Candida vaginitis is seen in non-sexually active patients as well.

 

Speculum Examination. Vaginal discharge is typically curdy and white. The vaginal epitheliumis frequently edematous and inflamed. Vaginal pH is normal <4.5.

Wet Mount. Microscopic examination reveals pseudohyphae on a KOH prep. WBCs are fre-quently seen.

 

Management. The treatment of choice is either a single oral dose of fluconazole or vaginal“azole” creams. An asymptomatic sexual partner does not need to be treated.

 

 

Physiologic Discharge

 

Background. This condition is the result of the thin, watery cervical mucus discharge seen withestrogen dominance. It is a normal phenomenon and becomes a complaint with prolonged anovulation, particularly in patients with wide eversion of columnar epithelium.

 

Risk factors. These include chronic anovulatory conditions such as polycystic ovarian (PCOS)syndrome.

 

Symptoms. The most common patient complaint is increased watery vaginal discharge. Thereis no burning or itching.

 

Speculum Exam. The columnar epithelium of the endocervical canal extends over a wide areaof the ectocervix, producing abundant mucus discharge. Vaginal discharge is typically thin and watery. The vaginal epithelium is normal appearing with no inflammation. Vaginal pH is normal (<4.5).

 

Wet Mount. Microscopic examination reveals an absence of WBCs, “clue cells,” trichomonads,or pseudohyphae.

 

Management. The treatment of choice is steroid contraception with progestins, which willconvert the thin, watery, estrogen-dominant cervical discharge to a thick, sticky progestin-dominant mucus.

 

S2 OB-GYN.indb 163


 

 

GYN Triad

Yeast Vaginitis

 

• Vaginal discharge pH <4.5

 

• Itching and burning

 

• Pseudohyphae

 

 

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Note

Vulvar dystrophies must also be considered in patients presenting with vulvar itching.


 

VULVAR DISEASES


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