CERVICITIS,

VULVOVAGINITIS,
EPI
Dr. Cristian Rodrguez C.
GINECOOBSTETRA
HRC-UNC

CERVICITIS
Inflamacin

del cuello uterino.

Aguda, crnica, infecciosa y no
infecciosa.
Importante: infeccin ascendente,
embarazo, secuelas.

CERVICITIS AGUDA
ETIOLOGA

INFECCIOSA:

Chlamydia trachomatis y Neisseria

gonorrhoeae. Afectan epitelio columnar
del endocrvix.
Herpes simple, Trichomona vaginalis.
Afectan epitelio escamoso del ectocrvix.
Tuberculosis, Mycoplasma genitalium.
Vaginosis bacteriana, estreptococo del
grupo A.

CERVICITIS AGUDA
ETIOLOGA

NO INFECCIOSA:

Irritacin mecnica o qumica.

Sndrome de Behet.

CERVICITIS AGUDA
SIGNOS

Y SNTOMAS:

Mayora son asintomticas

Inespecficos: descarga vaginal purulenta o
mucopurulenta, sangrado intermenstrual o
poscoital.
Disuria, polaquiuria, dispareunia, irritacin
vulvovaginal.

CERVICITIS AGUDA
EXAMEN

FSICO:

Hallazgo cardinal:

secrecin mucopurulenta,
friabilidad al roce.
Edema y eritema.
Cuello sensible al
movimiento.
Lesiones vesiculares y
ulceraciones (HSV).
Hemorragias puntiformes
(cuello en fresa): T. vaginalis

Mucopurulent discharge is visible coming from the os in a patient with Chlamydia cervicitis. The cervix is erythematous and friable.

CERVICITIS AGUDA

T. vaginalis

HSV

CERVICITIS AGUDA
DIAGNSTICO:

Clnico.
DETERMINAR LA CAUSA:

Pruebas para detectar Clamidia y

gonorrea, Vaginosis bacteriana y
tricomoniasis. (Ampliacin de cidos
nucleicos)
Excluir EPI mediante el examen bimanual.

CERVICITIS AGUDA
TRATAMIENTO:

Emprico: cubrir clamidiagonorrea

(especialmente 25 aos)

GONORREA: Ceftriaxona 250 mg dosis nica,

Espectinomicina 2g dosis nica. Fluoroquinolonas altas
tasas de resistencia.
CLAMIDIA: Azitromicina 1g dosis nica, doxiciclina 100
mg bid x 1 semana.
Parejas sexuales deben recibir tratamiento para ambos
patgenos.

CERIVICITIS AGUDA
TRATAMIENTO:

TRICHOMONA VAGINALIS:

Metronidazol o
tinidazol 2 g dosis nica. Metronidazol
500mg bid x 7 das. Pareja sexual debe
recibir tratamiento.
HERPES SIMPLE: Aciclovir 400mg tid,
fanciclovir 250mg tid o valaciclovir 1g bid.

CERVICITIS AGUDA
SEGUIMIENTO:

Ofrecer pruebas de HIV y sfilis en caso de

clamidia, gonorrea o trichomonas.
Repetir pruebas de diagnstico al mes de
inicio de tratamiento si persisten sntomas.

VULVOVAGINITIS

Vaginitis es el trmino general para describir

los trastornos de la vagina causados por
infeccin, inflamacin o cambios de la flora
vaginal.
CAUSAS: 90% son producidos por:

Vaginosis bacteriana
Vulvovaginitis candidisica
Tricomoniasis.

10%: atrofia vaginal, cervicitis, cuerpos extraos,

irritantes, alergenos, causas sistmicas.

VULVOVAGINITIS
SIGNOS

Y SNTOMAS:

Cambio en el volumen, color, u olor de la

secrecin vaginal, prurito, ardor, irritacin,
eritema, dispareunia, disuria.

DIAGNSTICO:
Historial detallado, examen fsico, ayuda diagnstica .

Likelihood of common vaginal infections

Infection
Candidiasis

Bacterial vaginosis

Trichomoniasis

Sign/symptom

Likelihood ratio*

Pruritus absent

0.18 to 0.79

Pruritus as chief complaint

3.3

Inflammatory signs present

1.4 to 8.4

Curdlike discharge with pruritus

150

Yeast not seen on KOH wet prep

0.51 to 0.66

No complaint of odor

0.07

Complaint of malodorous
discharge

1.6 to 3.2

Inflammatory signs present

6.4

Trichomonads on saline wet

mount

51 to 310

Trichomonads absent on saline

wet mount

0.34 to 0.51

VULVOVAGINITIS

DIAGNSTICO:

HISTORIAL DETALLADO

Estado de estrgenos: atrofia.

Agudeza y momentos de sntomas: agudo, crnico,
intermitente.
Sntomas asociados: EPI
Prcticas sexuales.
Ingesta de medicamentos: antibiticos.
Prcticas de higiene: irritantes, alergenos.
Historial mdico: herpes simple, sndrome de Behet,
diabetes, trasplantes
Antecedentes quirrgicos: Episiorrafa, HAT, cuerpos
extraos.

Los hallazgos clnicos en mujeres con vaginitis

Parameter

Normal findings

Vulovaginal
candidiasis

Bacterial vaginosis
Malodorous
discharge, no
dyspareunia

Trichomoniasis

Symptoms

None or mild,
transient

Pruritus, soreness,
dyspareunia

Malodorous
discharge, burning,
postcoital bleeding,
dyspareunia, dysuria

Signs

Normal vaginal
discharge consists of
1 to 4 mL fluid (per
24 hours), which is
white or transparent,
thin or thick, and
mostly odorless

Vulvar erythema
Off-white/gray thin
Thin green-yellow
and/or edema.
discharge that coats discharge,
Discharge may be
the vagina
vulvovaginal
white and clumpy
erythema
and may or may not
adhere to vagina.

Vaginal pH

4.0 to 4.5

4.0 to 4.5

>4.5

5.0 to 6.0

Amine test

Negative

Negative

Positive (in 70-80

percent of patients)

Often positive

Saline microscopy

PMN:EC ratio <1;

rods dominate;
squames +++

PMN:EC ratio <1;

rods dominate;
squames +++;
pseudohyphae
(present in about 40
percent of patients);
budding yeast for
nonalbicans
Candida

PMN:EC <1; loss of

rods; increased
coccobacilli; clue
cells comprise at
least 20 percent of
epithelial cells
(present in >90
percent of patients)

PMN ++++; mixed

flora; motile
trichomonads
(present in about 60
percent of patients)

Los hallazgos clnicos en mujeres con vaginitis

Los hallazgos
normales
10 percent potassium Negative
hydroxide
microscopy

Candidiasis
Vulovaginal
Pseudohyphae (in
about 70 percent of
patients)

La vaginosis
bacteriana
Negative

Other tests

If microscopy
nondiagnostic:
Culture
DNA hybridization
probe (eg, Affirm VP
III)

Quantitative Gram
stain (eg, Nugent
criteria, Hay/Ison
criteria)
DNA Hybridization
probe (eg, Affirm VP
III)

Parmetro

Culture of no value

Differential diagnosis Physiologic

leukorrhea

Contact irritant or
allergic vulvar
dermatitis, chemical
irritation, focal vulvitis
(vulvodynia)

Elevated pH in
trichomoniasis,
atrophic vaginitis,
and desquamative
inflammatory
vaginitis

PMN: polymorphonuclear leukocytes; EC: vaginal epithelial cells.

Tricomoniasis
Negative

If microscopy
nondiagnostic:
Culture (eg, InPouch
TV culture system)
Rapid antigen test
(eg, OSOM
Trichomonas Rapid
Test)
Nucleic acid
amplification test
(eg, APTIMA
Trichomonas
vaginalis test)
DNA Hybridization
probe (eg, Affirm VP
III)

Purulent vaginitis,
desquamative
inflammatory
vaginitis, atrophic
vaginitis, erosive
lichen planus

Condyloma acuminatum involving vulva, vagina, and perianal region

VULVOVAGINITIS
EXAMEN EN FRESCO:

Levaduras

Hifas

VULVOVAGINITIS

Trichomonas vaginalis

VULVOVAGINITIS
(A) Wet mount showing
characteristic clue cells. Note that
the epithelial cells are so heavily
covered by bacteria as to obscure
the margins.
(B) A clue cell. The vaginal
epithelial cell on the right has
shaggy borders obscured by
coccobacilli (1003 magnification).
The more normal appearing
epithelial cell on the left has
sharper borders.

Clulas clave

VULVOVAGINITIS

High power view of clue cells observed in a patient with bacterial

vaginosis. Note the obliteration of each epithelial cell margin by
adherent G. vaginalis.

VULVOVAGINITIS

Flujo por Cndida

VULVOVAGINITIS

CASOS ESPECIALES:

Prurito con cultivo negativo para Cndida:

Vaginosis citoltica: exceso de lactobacilos.

Neoplasia intraepitelial vaginal/vulvar
Dermatitis vulvar.

Inicio agudo de secrecin purulenta y dolor:

prepberes (E. grupo A: E. pygenes)
Descarga serosanguinolenta y dolor plvico:
NM de trompas de Falopio (Triada de Latzko).
Dolor crnico en introito: vulvodinia.
Prurito postcoital y dolor.
Vaginitis inflamatoria descamativa:
Perimenopausia.

VULVOVAGINITIS
CASOS

ESPECIALES:

S. grupo B no son patgenos.

Vaginitis bacteriana inespecfica no existe
ms (Vaginosis bacteriana).

Treatment of uncomplicated vaginal candidiasis

Drug and trade name(s)
Clotrimazole

Gyne-Lotrimin
Gyne-Lotrimin 3
Gyne-Lotrimin

Miconazole

Monistat 7

Requires a prescription in US
No

1 percent cream

No

2 percent cream

Not applicable (not available in

US)

100 mg vaginal tablet

No

2 percent cream
(combination kit may include 2
percent miconazole cream for
external use)
4 percent cream

No

Monistat 7

Monistat 3 , Vagistat-3

No
No (combination kit)
Yes (generic suppository)

Monistat 1

No

Monistat 3

Preparation

Nystatin

Nystatin vaginal (former US trade Not applicable (not available in

name Mycostatin)
US)
Terconazole

Terazole 7, Zazole
Yes

100 mg vaginal suppository

200 mg vaginal suppository
(combination kit may include 2
percent miconazole cream for
external use)
1200 mg vaginal suppository
(combination kit may include 2
percent miconazole cream for
external use)

Intravaginal* dose for adult

1 applicatorful (~5 g) daily for 7
days
1 applicatorful (~5 g) daily for 3
days
Insert 1 vaginal tablet daily for 7
days or 2 tablets daily for 3 days
1 applicatorful (~5 g) daily for 7
days

1 applicatorful (~5 g) daily for 3

days
1 suppository daily for 7 days
1 suppository daily for 3 days

1 suppository for 1 day

100,000 unit vaginal tablet

Insert 1 vaginal tablet daily for 14

days

0.4 percent cream

1 applicatorful (~5 g) daily at

bedtime for 7 days
1 applicatorful (~5 g) daily at
bedtime for 3 days
1 suppository daily at bedtime for
3 days

Terazole 3, Zazole

Yes

0.8 percent cream

Terazole 3, Zazole

Yes

80 mg vaginal suppository

Tioconazole

Vagistat-1, 1-Day (from Monistat) No

6.5 percent ointment

1 applicatorful (~5 g) at bedtime

as a single dose

Butoconazole
Gynazole-1

2 percent cream

1 applicatorful (~5 g) as a single

dose

150 mg oral tablet

Single dose by mouth

Yes

Fluconazole ORAL ADMINISTRATION

Diflucan
Yes

Treatment of complicated vaginal candidiasis

Severe vaginitis symptoms

Oral fluconazole 150 mg every 72 hours for 2 or 3 doses (depending on severity)
OR
Topical azole antifungal therapy daily for 7 to 14 days. A low potency topical corticosteroid can be applied to the vulva for
48 hours to relieve symptoms until the antifungal drug exerts its effect.
Recurrent vulvovaginal candidiasis
Induction with fluconazole 150 mg every 72 hours for 3 doses, followed by maintenance fluconazole 150 mg once per week
for 6 months.
If fluconazole is not feasible, options include 10 to 14 days of a topical azole or alternate oral azole (eg, itraconazole)
followed by topical maintenance therapy for 6 months (eg, clotrimazole 200 mg [eg, 10 grams of 2 percent] vaginal cream
twice weekly or 500 mg vaginal suppository once weekly).

Non-albicans Candida vaginitis

Therapy depends upon species identified:
C. glabrata: Intravaginal boric acid* 600 mg daily for 14 days
If failure occurs: 17 percent topical flucytosine cream, 5 grams nightly for 14 days
C. krusei: Intravaginal clotrimazole, miconazole, or terconazole for 7 to 14 days
All other species: Conventional dose fluconazole
Compromised host (eg, poorly controlled diabetes, immunosuppression, debilitation) and Candida isolate susceptible to
azoles
Oral or topical therapy for 7 to 14 days
Pregnancy
Topical clotrimazole or miconazole for 7 days

Treatment options for bacterial vaginosis (nonpregnant women)

Drugs of choice
Metronidazole 500 mg oral twice daily for seven days OR
Metronidazole gel 0.75 percent 5 g* (one full applicator) intravaginally once daily for five days OR

Clindamycin 2 percent cream 5 g (one full applicator) intravaginally at bedtime for seven days
Alternatives
Clindamycin 300 mg orally twice daily for seven days OR
Clindamycin ovule (vaginal suppository) 100 mg intravaginally once daily for three days OR

Tinidazole 2 g orally for two days OR

Tinidazole 1 g orally once daily for five days
Although data are limited, metronidazole 750 mg extended release tablets once daily for seven days OR a single
vaginal dose of clindamycin 2 percent bioadhesive cream (US trade name: Clindesse) 5 g, one full applicator, also
appear to be effective.
* 5 grams of metronidazole 0.75 percent vaginal gel contains 37.5 mg of metronidazole.
5 grams of clindamycin 2 percent vaginal cream contains 100 mg of clindamycin.
Adapted from: Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR Recomm Rep 2010 (RR-12); 59.

NO requiere tratamiento a la pareja sexual.

EPI
Infeccin

del tracto superior genital

femenino (endometritis, salpingitis,
ooforitis, perihepatitis, peritonitis, absceso
tuboovrico.
El tamizaje precoz de C. trachomatis y N.
gonorreae disminuye la prevalencia de
EPI.

EPI
CARACTERSTICAS

CLNICA:

Dolor abdominal bajo es el sntoma

cardinal aunque con carcter sutil
HUA se produce en ms de 1/3 de
pacientes.
El dx. de EPI es menos probable si
predominan los sntomas urinarios y/o
intestinales.

EPI
CARACTERSTICAS

CLNICAS:

Factores de riesgo para ETS:

Menor

de 25 aos.
Primera relacin sexual muy joven.
No uso de anticonceptivos de barrera.
Nuevo, mltiples, o sintomticas parejas
sexuales.
Anticonceptivos orales.
Ectopia cervical.

EPI
CARACTERSTICAS

CLNICAS:

Factores de riesgo para EPI:

Episodio

anterior de EPI
Sexo durante la menstruacin
Sexo contranatura
Duchas vaginales
Vaginosis bacteriana
Dispositivo intrauterino

EPI
CARACTERSTICAS

CLNICA:

Fiebre: de pacientes
Dolor con rebote en cuadrantes inferiores y
disminucin de ruidos intestinales.
Dolor en CSD: 10%, sndrome de Fitz-Hugh
Curtis (perihepatitis)
Secrecin cervical y dolor cervical y anexos
al examen bimanual.

EPI
EPI

SUBCLNICA:

Factor de riesgo: Infeccin del tracto

genital inferior por gonorrea, clamidia y
Vaginosis bacteriana.
Dx: Presencia de neutrfilos y clulas
plasmticas en tejido endometrial.
1/3 de mujeres con dx. de infertilidad
tienen Clamidia en tracto superior.

EPI
DIAGNSTICO:

Criterios mnimos CDC: dolor anexial, dolor

al movimiento del cuello uterino en un
contexto de dolor abdominal bajo.
Temperatura

oral > 38.3 C

Descarga mucopurulenta por crvix.
Leucocitos abundantes en secrecin vaginal.
PCR y VSG aumentados.

EPI

DIAGNSTICO (casos confirmados):

Dolor plvico y sensibilidad en anexos ms uno de

los siguientes datos:

Endometritis aguda o crnica (clulas plasmticas) o

salpingitis aguda en biopsia.
Demostracin de C. trachomatis o N. gonorrhoeae
en tracto genital.
Salpingitis visualizado en laparoscopa o laparotoma.
Aislamiento de bacterias patgenas en tracto
superior.
Lquido inflamatorio, purulento plvico sin otra fuente.

EPI
DIAGNSTICO

DIFERENCIAL:

Gastrointestinal: apendicitis, colecistitis,

estreimiento, gastroenteritis, enfermedad
inflamatoria del intestino.
Renal: cistitis, pielonefritis, litiasis renal,
uretritis.
Obsttrico / Ginecolgico: dismenorrea,
embarazo ectpico, complicacin del
embarazo intrauterino, quiste de ovario,
torsin ovrica, tumor de ovario.

EPI
AYUDA

DIAGNSTICA:

bHCG, hemograma (< son positivos)

Tincin Gram de secrecin vaginal o
cervical (diplococos Gram negativos
intracelulares)
Leucocitos en fluido vaginal ( 3/campo)
S: 78% E: 38%

EPI
AYUDA

DIAGNSTICA:

ECOGRAFA:
Tiene

un valor limitado.
La presencia de trompas dilatadas y llenas de
liquido ayuda al diagnstico pero la ausencia
no descarta el Dx.

EPI
TRATAMIENTO:
Recommended

Parenteral Regimen A

Cefotetan 2 g IV every 12 hours

OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12
hours x 14 days

EPI
Recommended

Parenteral Regimen B

Clindamycin 900 mg IV every 8 hours

PLUS
Gentamicin loading dose IV or IM (2 mg/kg
of body weight), followed by a
maintenance dose (1.5 mg/kg) every 8
hours. Single daily dosing (35 mg/kg) can
be substituted.

EPI
Alternative

Parenteral Regimens

Ampicillin/Sulbactam 3 g IV every 6 hours

PLUS
Doxycycline 100 mg orally or IV every 12
hours X 14 Days

EPI
Oral Recommended Regimen
Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally
administered concurrently in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Other parenteral third-generation cephalosporin (e.g.,
ceftizoxime or cefotaxime)
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days

EPI
INDICACIONES DE HOSPITALIZACIN

Embarazo
La falta de respuesta o tolerancia a los
medicamentos orales
La no adherencia a la terapia
La incapacidad de tomar medicamentos por va
oral debido a las nuseas y vmitos
Enfermedad clnica grave (fiebre alta, nuseas,
vmitos, dolor abdominal severo)
PID complicada con absceso plvico (incluyendo
absceso tuboovrico)
Posible necesidad de intervencin quirrgica o
exploracin de diagnstico de etiologa alternativa
(por ejemplo, apendicitis)