SUPERFICIAL VAGINAL INFECTIONS

While we are talking about Dyspareunia, let us complete the subject by talking about Superficial Vaginal Infections(SVI) and inflammatory conditions called Vulvar Dermatoses, they also cause Dyspareunia, Vulvo Vaginal Pruritus and Vaginal Discharge.

All women have vaginal discharge during their reproductive life, in varying amounts during their menstrual cycle. I wonder if any of you have ever thought what a great house keeping function this discharge does by keeping the vagina clean, by washing away the dead cells and infections.
This normal vaginal discharge comes from the glands located in cervix and the vagina.
There is increased discharge at appropriate times such as ovulation and sexual arousal.
It is very important to keep the personal vaginal hygiene up to date.

The question is where do these infections come from, some of the organisms are locally present and under conditions favourable to them , they start playing around and cause disease, the commonest of these is a fungus called Candida.
On other occasions the infections come after child birth, pelvic operations, sexual intercourse, unscientific use of antiseptics, scented soaps, bubble baths and washes and the list can go on.
The main discharge problems along with pain and pruritus are as follows;
1-Candidiasis,2-Bacterial Vaginosis,3-Trichomonas,4- Nabothian Follicles,5-Cytolitic Vaginosis,6-Streptococcal Vaginosis,7-Erosive Vaginitis,8-Atrophic Vaginitis,9-Chlamydia,10-Gonococcus,11-Foreign Body, 12-Malignancy.

We have already discussed Chlamydia and Gonococcus in our previous post on PID, its difficult to discuss all the above conditions, but we will discuss the commonest of these being Candidiasis, Bacterial Vaginosis, and Trichomonas.

VULVO VAGINAL CANDIDIASIS(VVC)
It is estimated that 50 to 70 percent of women of all ages during their reproductive life suffer from at least one episode of VVC.
They generally do not suffer prepuberty and postmenopausal, because Candida loves oestrogen and oestrogen milieu and during this period of life is absent or low.
The infection is caused by a variety of Candida Albicans, the other variety of Candida often found is called Candida Glabrata and this requires special and stronger treatment.

Vulva and Vagina are both involved but often not together. In diabetic women VVC is often very severe the area looks very inflamed and swollen and the infection spreads to the groin and perianal area.

The symptoms of VVC can be mild or severe and they include severe itching, and maybe pain on passing urine. The risk factors are pregnancy when the oestrogen level is high, use of antibiotics, diabetes, and HRT.

The diagnosis is easy considering the history, and examination which shows redness and white curdy discharge in the area.
There is a simple office microscopic test using saline and sodium hydroxide which shows fine filaments which is called pseudohyphae, this test also shows Trichomonas vaginalis -this organism will be readily recognisable by its characteristic movement.
Bacterial vaginosis -have a special cell, called a clue-cells.
We can also see the hormone status of the individual by looking at the vaginal cells. So this test gives a lot of information. Still it is best to send a vaginal swab, cervical cytology and STD test in high risk patients.
The treatment of VVC is to remove the risk factors, control diabetes and for the very first episode, local vaginal nystatin cream for one week, this can be used during pregnancy as well. It is important to clear candidiasis in pregnant women because it can be passed on to the baby at birth as an oral infection, subsequently the baby can pass it on to the mother during breast feeding.
If candidiasis persists we have to look for the reasons for persistence, I often do a glucose tolerance test to exclude diabetes, if they are on high dosage oestrogen pill, change the pill or use a different type of contraception. Depoprovera and Mirena are good alternatives. Mirena is a progesterone releasing intrauterine device. DPMA is an injectable progestron which is given by a IM injection of 150mg every three months.
Both these are good long term contraceptives and help in getting rid of chronic candidiasis.
Long term recurrence requires long term treatment, which is given over a period of six months.
1- Vaginal nystatin pessaries every night or alternate night for six months.
2-Oral flucanazole of 100mg twice weekly for six months.
3-Oral ketoconazole 200mg a day for six months. This is hepatoxic, so the liver needs to be tested every two to three months.
The vagina can be painted with gentian violet weekly for several weeks.

Once again the subject that we have just discussed needs more time and information and this will be followed up in our next post.