notes by dr Claudio Italiano
In women, infections of the lower urinary tract, of the cervix, of the vulva
and of the vagina determine various combinations of dysuria, vulvar irritation,
dyspareunia and qualitative modifications or increased vaginal secretion. Two
aspects are essential in the assessment of symptoms of the lower genitourinary
pathways in women:
1) the differential diagnosis between cystitis, urethritis, vulvovaginitis,
cervicitis;
2) exclusion of associated diseases of the upper tract (eg, pyelonephritis,
salpingitis).
C. trachomatis, N. gonorrhoeae and sometimes HSV are a cause of symptomatic
urethritis in women, with or without cervicitis. Sexually acquired uretritis
often occurs in women as urethral syndrome, characterized by "internal" dysuria
(usually without urgent urination or pollakiuria) and pyuria, with absence of
E. coli or other uropathogens in numbers greater than or equal to 103 per ml of
urine. The dysuria associated with vulvar herpes or with vulvovaginal
candidiasis (and perhaps with trichomoniasis) is often described as "external",
being determined by the painful contact of urine with the vulvar lips or the
inflamed vaginal ostium. In women with acute dysuria and pollakiuria the
presence of costovertebral pain or pain and fever suggests an acute
pyelonephritis. The treatment of bacterial infections of the urinary tract has
been discussed at the page on the diagnosis and treatment of urinary infections.
Signs of vulvovaginitis, associated with symptoms of external dysuria, suggest
vulvar or vaginal infection. Among women without signs of vulvovaginitis,
bacterial urinary infection should be differentiated from urethral syndrome by
means of risk assessment, symptomatic picture and objective signs, as well as
by specific microbiological tests. An etiology that sets for an MTS is
suggested by the young age, by the presence of multiple sexual partners or a
new partner in the month before the onset of symptoms, or by the coexistence of
a purulent mucous cervicitis. Bacterial cystitis is suggested by an acute onset,
haematuria or suprapubic bladder pain. The finding of a single conventional
urinary pathogen, such as Escherichia coli or Staphylococcus saprophyticus,
with a bacterial count equal to or greater than 102 per ml in a urine sample
collected aseptically from the intermediate mesio urine, in a symptomatic woman
with pyuria, indicates a probable infection of the bacterial urinary tract; in
contrast, a pyuria with a bacterial load of urinary pathogens below 102 per ml
of urine ("sterile" pyuria) is compatible with acute urethral syndrome due to
C. trachomatis or N. gonorrhoeae. Infection with gonococcus and chlamydia can
be ascertained by cervical cultures and other specific methods. Therapy with
tetracyclines (eg, doxycycline, 100 mg x 2 times a day for 7 days) improves
disordered symptoms in women with sterile pyuria, but not in women without
pyuria or in whom no pathogen has been isolated.
- not vaginitis if: Absence of infections; No symptoms; normal secretion,
usually white and stringy, linked to the ovulatory cycle; no sign of epithelial
inflammation at the PAP test, acid pH ie <4.5; no bad smell; so no care is
needed.
- Candida vaginitis if: Vulvar pruritus and irritation with vaginal ostium; Poor
secretion of ricotta flakes, with white-greyish adhering plates, infusion of the
evident epithelium with redness, dryness of the vagina, vulvar dermatitis and
burning of the ostium; the always acid pH, <4.5; there is no foul smell in the
secretions; leucocytes, pseudo micelles up to 80% candida appear in the
microscopic investigation. The treatment, always under the supervision of your
doctor, never by chance, with products such as Miconazole or clotrimazole for
local use (vaginal creams, eg canesten) or fluconazole 150 mg a single dose,
excellent use of preparations with vaginal ovules of Meclon. The cure is also
for the partners.
-Vaginitis from Trichomonas if Trichomonas vaginalis is present; secretions
become abundant and frothy, yellow and very abundant, appears an annoying
redness of the vulva and vagina (Erythema of vaginal mucosa and vaginal ostium,
common vulval dermatitis -Magular dermatitis), the pH tends more towards
alkalinity, pH> 5; A nauseating putrid smell may be present; the protozoa, T.
vaginalis, can be shown fresh. The treatment, always under strict and careful
control of the gynecologist (attention in pregnant women!) Is implemented with
Metronidazole 2 grams per os in single dose or metronidazole 500 mg x two x 7
days of care
- Bacterial vaginosis, can be associated with Gardnerella and Vari anaerobi. The
secretions are malodorous, but not abundant, there is no inflammation of the
vulva or vagina, the pH is> 4.5; in the smear presence of reduced lactobacilli
and G. vaginalis and some species of anaerobes. The cure is with Metronidazole
500 mg cpr x 7 days
Clindamycin 2% vaginal cream for 7 applications at night, Metronidazole vaginal
gel, good Meclon's eggs, e.g. but always under control of your gynecologist.
This type of infections can be associated with intense sexual activity, with the
passage of faecal bacteria into the vagina.
The color of vaginal secretions is assessed by examining them against the white
background of a sample. The determination of pH does not appear useful if blood
is present. To highlight the fungal elements, the vaginal secretions are
macerated in 10% KOH solution before the microscopic examination; for the other
characters and secretions are mixed with physiological solution. Gram stain is
excellent for yeasts and pseudomycels and to distinguish normal flora with the
mixed flora that is observed in bacterial vaginosis, but it is less sensitive
than the physiological solution to look for T vaginalis.