New GP GU

Question 1

What is bacterial vaginosis (BV)?

Answer 1

Overgrowth of bacteria in the vagina
(Specifically anaerobic bacteria)

Question 2

What is BV caused by?

Answer 2

Loss of the lactobacilli (‘friendly bacteria’) in the vagina

Question 3

What can BV increase the risk of?

Answer 3

Women developing STIs

Question 4

What bacteria is the main component of healthy vaginal bacterial flora?

Answer 4

Lactobacilli

Question 5

What is the pathophysiology of BV?

Answer 5

• Lactobacilli = main component of healthy vaginal bacterial flora
• Lactobacilli = prodiuce lactic acid → keeps pH low (below 4.5)
• The acidic environment = prevents other bacteria from overgrowing
• Reduced numbers of lactobacilli → pH rise
• Alkaline environment → enables anaerobic bacteria to multiply

Question 6

What is the most common anaerobic bacteria associated with BV?

Answer 6

Gardnerella vaginalis

Question 7

Can BV occur along other infections?

Answer 7

Yes!
(E.g. candidiasis, chlamydia, gonorrhoea)

Question 8

Name 2 risk factors for developing BV

Answer 8

• Multiple sexual partners (although it is not sexually transmitted)
• Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
• Recent antibiotics
• Smoking
• Copper coil

Question 9

In which women is BV less common in?

Answer 9

• Taking the combined pill
• Using condoms effectiviely

Question 10

What is the main sign of bacterial vaginosis?

Answer 10

Fishy-smelling discharge

Question 11

When taking a history from someone with BV, what do you ask about when thinking about a cause?

Answer 11

• Use of soaps to clean the vagina
• Vaginal douching

Question 12

What is the standard presenting feature of bacterial vaginosis?

Answer 12

Fishy-smelling watery grey or white vaginal discharge
(Half of women with BV = asymptomatic)

Question 13

A young women who is sexually active and tells you that she might have BV (change in discharge), however she also mentions itching, irritation and pain. What are you thinking the diagnosis is?

Answer 13

• Alternative cause
• Co-occurring infection

Question 14

What examination can be performed in a patient with suspected BV?

Answer 14

Speculum examination
(To confirm the typical discharge, complete a high vaginal swab + exclude other causes of symptoms)

Question 15

What investigations can you perform in a patient with BV?

Answer 15

• Vaginal pH → swab + pH paper (BV = occurs with a pH above 4.5)
• Charcoal vaginal swab → taken for microscopy (high vaginal swab during speculum Ex OR self-taken low vaginal swab)

Question 16

What cells are shown on microscopy for bacterial vaginosis?

Answer 16

CLUE CELLS
(Clue cells = epithelial cells from the cervix that have bacteria stuck inside of them - usually Gardnerella vaginalis)

Question 17

After taking a charcoal vaginal swab and took for microscopy, it shows clue cells. What does the women have?

Answer 17

Bacterial vaginosis

Question 18

What is the management for BV?

Answer 18

• Asymptomatic → usually no management, may resolve by itself
• Metronidazole = specifically targets anaerobic bacteria (PO or vaginal gel)
• Clindamycin = alternative (less optimal antibiotic choice)

Question 19

What important point should you inform a patient of when prescribing metronidazole? What happens as a result of this interaction?

Answer 19

AVOID ALCOHOL
Can cause a ‘disulfiram-like reaction’
(with nausea + vomiting + flushing)
Sometimes severe symptoms of shock + angioedema

Question 20

What are the complications of BV?

Answer 20

Increased risk of catching STIs (chlamydia, gonorrhoea, HIV)

Complications in pregnant women:
* Miscarriage
* Preterm delivery
* Premature rupture of membranes
* Chorioamnionitis
* Low birth weight
* Postpartum endometritis

Question 21

What is atrophic vaginitis?

Answer 21

Dryness + atrophy of the vaginal mucosa - related to lack of oetrogen
(Atrophic vaginitis = referrred to as genitourinary syndrome of menopause → it occurs in women entering the menopause)

Question 22

When does atrophic vaginitis occur?

Answer 22

In women entering the menopause

Question 23

Explain the pathophysiology of atrophic vaginitis

Answer 23

• Epithelial lining of the vagina + urinary tract = responds to oestrogen → becoming thicker + more elastic + produce secretions
• **Enter menopause → oestrogen levels fall → mucosa = becomes thinner + less elastic + more dry **
• → tissue = more prone to inflammation
• • changes in vaginal pH + microbial flora → contributes to localised infections

Question 24

Give two examples of why oestrogen is so important in female physiology?

Answer 24

• Oestrogen = helps maintain healthy connective tissue around pelvic organs
• Epithelial lining of the vagina + urinary tract = responds to oestrogen → becoming thicker + more elastic + produce secretions

Question 25

What are the consequences of falling oestrogen levels?

Answer 25

* **Vaginal epithial lining** becomes **thinner + less elastic + more dry** * Less healthy **connective tissue around pelvic organs** contribute to **pelvic organ prolapse + stress incontinence**

Question 26

What are the symptoms of atrophic vaginitis?

Answer 26

Atrophic vaginitis presents in postmenopausal women with symptoms of: * **Itching** * **Dryness** * **Dyspareunia** (discomfort or pain during sex) * **Bleeding** due to localised infection

Question 27

When should you consider atrophic vaginitis?

Answer 27

In postmenopausal (older) women that present with: * Recurrent urinary tract infections * Stress incontinence * Pelvic organ prolapse And obvs the symptoms: * Itching * Dryness * Bleeding due to localised inflammation * Dyspareunia (discomfort or pain during sex)

Question 28

What are the signs of atrophic vaginitis?

Answer 28

* Pale mucosa * Thin skin * Reduced skin folds * Erythema and inflammation * Dryness * Sparse pubic hair

Question 29

What are the management options for atrophic vaginitis?

Answer 29

Vaginal lubricants (e.g. YES) Topical oestrogen * **Estriol cream**, applied using an applicator (syringe) at bedtime * **Estriol pessaries**, inserted at bedtime * **Estradiol tablets** (Vagifem), once daily * **Estradiol ring** (Estring), replaced every three months

Question 30

What treatment is contraindicated with topical oestrogen?

Answer 30

Systemic HRT

Question 31

What are the contraindications of topical oestrogen with systemic HRT?

Answer 31

* Breast cancer * Angina * Venous thromboembolism

Question 32

What is trichomonas vaginalis?

Answer 32

A type of **parasite (protozoan)** spread via sexual intercourse Trichomonas = protozoan, single-celled organism with **flagella**

Question 33

Where does trichomonas live?

Answer 33

* Urethra of men * Vagina of women

Question 34

What can trichomonas vaginalis increase the risk of?

Answer 34

* **Contracting HIV** (by damaging the vaginal mucosa) * **Bacterial vaginosis** * **Cervical cancer** * **Pelvic inflammatory disease** * **Pregnancy-related complications** (such as preterm delivery)

Question 35

What are the symptoms of trichomoniasis?

Answer 35

50% cases = asymptomatic Symptoms (= non-specific): * **Vaginal discharge** (**green-yellow, frothy, maybe fishy**) * **Itching** * **Dysuria** (painful urination) * **Dyspareunia** (painful sex) * **Balanitis** (inflammation of the glans penis)

Question 36

What examination finding will you see of the cervix of someone with trichomonas vaginalis?

Answer 36

**Strawberry cervix** (AKA colpitis macularis) A strawberry cervix = caused by** inflammation (cervicitis)** relating to the trichomonas infection. There are **tiny haemorrhages across the surface** of the cervix, giving strawberry appearance

Question 37

Investigations for trichomoniasis

Answer 37

* Vaginal pH → raised pH (above 4.5) * Charcoal swab + microscopy (Swabs should be taken from the **posterior fornix of the vagina** (behind the cervix) in women. A **self-taken low vaginal swab** = alternative) * Men: **Urethral swab** or **first-catch urine**

Question 38

What is the treatment for trichomoniasis?

Answer 38

**Metronidazole** (+ contact tracing)