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Case # 11
A 22-year old single nulligravid factory worker in Taiwan con-
sulted because of vulvar pruritus for 4 days. On PE, there were
multiple warty growths, 0.7 – 1.5 cm diameter, on the fourchet and
medial aspect of the labia majora and minora. On speculum
examination, the vaginal mucosa was hyperemic. The cervix was
smooth with yellowish green foul discharge. IE: Cervix – firm, long,
closed; Uterus – normal in size; Adnexae - (-)mass/tenderness.
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information, possible questions such as the following would be of much
help.
Are you having or have you ever had sex with men or women?
How many partners have you had in the past six months? past five years?
Does your partner have sex with someone other than yourself?
Have you had sexual contact with someone who uses injection drugs or a
man who has sex with other men?
Do you use barrier protection like condoms or gloves during sexual contact?
What kind?
Has she had any other symptoms such as vaginal ulcers, excoriations,
discharge, dryness, itchiness, abnormal odor emanating from her genitalia?
Does her partner also have or had genital warts or some other form of STD?
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symptom of vaginitis. It is usually external and is defined as pain and burning when
urine touches the vulva. In contrast, internal dysuria, defined as pain inside the
urethra, is usually a sign of cystitis.
Because the diagnostic tests and treatments for cervicitis are different from
those for vaginitis, it is important to differentiate these conditions. Several clues can
help to rule out cervical infection as the cause of a vaginal discharge. Almost 90
percent of symptomatic or asymptomatic women with chlamydial cervicitis meet at
least two of the following criteria: (1) younger than 24 years, (2) sexual intercourse
with a new partner in the previous two months, (3) presence of mucopurulent
cervicitis, (4) cervical bleeding induced by swabbing the endocervical mucosa and
(5) no form of contraception. If cervicitis is suspected, cultures for Chlamydia
species and Neisseria gonorrhoeae should be obtained.
If the findings of the history and/or physical examination suggest that the
patient has vaginitis, a sample of the vaginal discharge should be obtained for gross
and microscopic examination. Standard office examinations include a wet-mount
preparation using saline, a slide prepared with 10 percent potassium hydroxide
(KOH), a "whiff" test to detect amines and a litmus test of the pH level of vaginal
fluid.
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Diagnosis of Vaginitis
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On speculum exam, the vaginal mucosa of our patient was
hyperemic. The cervix was smooth with yellowish green foul discharge
which is suggestive of Trichomonas Vaginitis.
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proximal extremities. Red papular lesions also may appear on the palms,
soles, face, and scalp and may become necrotic. Patchy and nonpatchy
alopecia may occur. In intertriginous areas, papules may coalesce to form
highly infectious lesions called condylomata lata. Lesions usually progress
from red, painful, and vesicular to "gun metal grey" as the rash resolves.
Mucous patches are superficial mucosal erosions, usually painless, that may
develop on the tongue, oral mucosa, lips, vulva, vagina, and penis.
The most common causes of vaginitis in symptomatic women are bacterial vaginosis
(BV) (22-50%), vulvovaginal candidiasis (17-39%), and trichomoniasis (4-35%); yet,
7-72% of women with vaginitis may remain undiagnosed. Accurate diagnosis may be
elusive and must be distinguished from other infectious and noninfectious causes.
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adherent thick, cottage cheese–like vaginal discharge (the cervix usually
appears normal)
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large keratinocytes with an eccentric, pyknotic nucleus surrounded by a perinuclear
halo. Immunohistochemical staining with the peroxidase-antiperoxidase technique
stains cells infected by viral particles. Certain screening tests are available with a
relatively high sensitivity and specificity; they include the following: ViraPap,
ThinPrep Pap and Hybrid capture II.
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Conservatively, follow-up is not required for patients using self-administered therapy.
However, it might be useful several weeks into therapy to determine the
appropriateness of medication use and the response to treatment.
Physician-Administered:
Cryotherapy with liquid nitrogen or cryoprobe causes thermal-induced cytolysis.
Physicians must be trained on its proper use because over- and undertreatment
might result in complications or low efficacy. Pain after application of the liquid
nitrogen, followed by necrosis and sometimes blistering, is common. Local
anesthesia (topical or injected) might facilitate therapy if warts are present in many
areas or if the area of warts is large. Repeat applications every 1–2 weeks.
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intraurethral warts, particularly for those patients who have not responded to other
treatments.
Alternative Regimens
Interferons, both natural or recombinant, have been used for the treatment of
genital warts. They have been administered systemically (i.e., subcutaneously at a
distant site or IM) and intralesionally (i.e., injected into the warts). Systemic
interferon is not effective. The efficacy and recurrence rates of intralesional
interferon are comparable to other treatment modalities. Administration of
intralesional interferon is associated with stinging, burning, and pain at the injection
site. Interferon is probably effective because of its antiviral and/or immunostimulating
effects. Interferon therapy is not recommended as a primary modality because of
inconvenient routes of administration, frequent office visits, and the association
between its use and a high frequency of systemic adverse effects.
References:
Harrison’s Principles of Internal Medicine 16th edition
Berek et al., eds. Novak’s Gynecology. 14th ed. USA: Lippincott Williams & Wilkins.
2007.
http://www.aafp.org/afp/20060715/279.html
http://www.aafp.org/afp/20000901/1095.html
http://www.cdc.gov/std/treatment/2006/genital-warts.htm
http://www.cdc.gov/std/treatment/2006/vaginal-discharge.htm#vagdis3
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