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The Vagina.Pptx 9/5/14 The “V” The word the you cannot say on TV SHELAGH LARSON, WHNP, NCMP UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER 1 9/5/14 Celebrity Vaginas???????? Parts Vulva Vestibule Vagina vagina is a specific internal Secretions of fluid from the The inside parts structure, whereas the vulva is vestibule glands lubricate the The hallway to the Uterus the whole external genitalia vaginal orifice during sexual excitement. Gateway to the vagina is the space between the labia is the seat for female sexual minora and vagina pleasure helps by flushing out the vulvovaginal fluids and usually maintains normal vaginal health Means: “covering” 2 9/5/14 The Vulva u Mons Pubis: “mountain of Venus” a pad of fat and hair that cushions during lovemaking. You cannot ‘diet’ to make it as less fat u Labia Majora: outer, larger lips covered in pubic hair. Derived from same tissue as scrotum. Produce sebum (Earwax)to waterproof from urine, menstrual blood and bacteria. u Intralabial sulcus (folds) Trench between labia majora and minora u Labia Minora: inner lips without hair. Top called “frenulum” the split at the clitoris. The base of the vaginal opening it comes back to together at the fourchette. u Clitoris: top of the labia minora. Fully formed by 27 week gestation. 8K nerve endings sensitive to touch (2x that of the penis). Covered with a hood” “prepuce”. Sole purpose: sexual enjoyment The Vestibule u Area inside the labia minora; u The hallway to the vagina approached by going through 2 doors u Upper part: Urethra, lower part: vagina separated at the ‘Hart Line” u Bulbs of the vestibule: bundle of blood vessels that line the floor/walls of the hallway. “G spot” Maybe tender to touch u Skene’s Ducts/para-urethral glands: either side of urethral opening. Provide lubrication. u Bartholin Glands: base of the labia majora. provides lubrication u The Hymen: no biological function. Changes in size and shape he 3 years of life. Ring-like as a toddler. After sex or other penetration it widens and becomes petal-like The vagina u women of reproductive age, Lactobacillus is the predominant constituent of normal vaginal flora. u Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to 4.2), u high estrogen levels maintain vaginal thickness, bolstering local defenses. u Postmenopause a marked decrease in estrogen causes vaginal thinning, increasing vulnerability to infection and inflammation. u Some treatments (eg, oophorectomy, pelvic radiation, certain chemotherapy drugs) also result in loss of estrogen. 3 9/5/14 Vaginal Myths • Vagina Dentata. • Period Is Punishment • Hysteria • You Can’t Get Pregnant If It’s Legitimate Rape § Sex With A Virgin Can Cure HIV/AIDS § You can see someone's vagina if they go commando § Douching after sex prevents pregnancy § You can't get STDs from oral sex. § You can lose something if inserted into the vagina § You can't get pregnant if you have your period Hormone Fluctuations During Menstrual Cycle The Bi Manual Exam 4 9/5/14 Anteflex Uterus Retroverted Uterus Retroflexed Uterus 5 9/5/14 Degrees of Uterine Version The Pelvic Exam u 1. Select appropriate sized speculum, warm speculum and test speculum on the patient’s leg for comfortable temperature u 2. Inform patient prior to speculum insertion u 3. Insert speculum at 45 degree angle then rotate and open when completely inserted u 4. Visualize the cervix by adjusting the speculum anteriorly or posteriorly u 5. Use the appropriate collection vial with the correct attached swab for each culture u 6. For Chlamydia and Gonorrhea cervical cultures, insert the swab into the endocervix for approximately 10 seconds (insert only superficially in pregnancy) u 7. For vaginal cultures, obtain a specimen from the posterior fornix u 8. Insert the swab into the vial, break off the excess swab and cap off the collection vial/tube securely and label the specimen Speculums 6 9/5/14 Vaginitis Abdominal pain definition u inflammation of the vagina that often occurs in combination with inflammation of the vulva, a condition known as vulvovaginitis. u often the result of an infection with bacteria, yeast or Trichomonas, but it may also arise due to physical or chemical irritation of the area. u In pregnancy, Trichomonas infection and bacterial vaginosis are associated with an increased risk of adverse pregnancy outcomes, including preterm labor, PROM, preterm delivery, low birth weight, and postpartum endometritis 7 9/5/14 Causes Hypersensitivity Physical Other causes hygiene sprays or perfumes, Fistulas between the cervicitis menstrual pads, intestine and genital skin disorders (eg, laundry soaps/bleaches, tract, which allow psoriasis, tinea vesicular fabric softeners, intestinal flora to seed Lichen Schlerosis fabric dyes, the genital tract, synthetic fibers, bathwater pelvic radiation or additives, toilet tissue, tumors, spermicides, vaginal lubricants/creams, Poor hygiene latex condoms, vaginal contraceptive rings, or diaphragms. 3 main culprits Bacterial Fungal Trichomonisis accounts for 15-20% cases; accounts for 40-50% of accounts for 20-25% vaginitis cases vaginitis cases 3 million cases occur each year The most common vaginal In 85-90% of cases is caused infection in US women of by C albicans, 5-10%, is C childbearing age, glabrata or C parapsilosis incidence ; in blacks (23%), Hispanics(16%), whites(9%) and Asians (6%) 85% are asymptomatic caused by an overgrowth of Gardnerella vaginalis , Mobiluncus species, Mycoplasma hominis,or Peptostreptococcus species. Disorder Signs & Symptoms Criteria for Diagnosis Microscopic Findings Differential Dx Bacterial Gray, thin, fishy-odor 3 of the following: Clue cells, decreased Trichomonal vaginosis discharge, often with Gray discharge, lactobacilli, increased vaginitis “BV” pruritus and irritation; no pH> 4.5, fishy odor, coccobacilli (40-45%) dyspareunia and clue cells Candidal Thick, white discharge; Typical discharge, Budding yeast, Contact vaginitis vaginal and sometimes pH< 4.5, and pseudohyphae, or irritant or “Yeast” vulvar pruritus with or microscopic findings* mycelia; best examined allergic (20-25%) without burning, with 10% K hydroxide vulvitis irritation, or dyspareunia diluent Chemical irritation Vulvodynia Trichomonal Profuse, malodorous, Identification of vaginitis yellow-green discharge; causative organism “Tric” dysuria; dyspareunia; by microscopy* (15-20%) erythema (occasionally by culture) 8 9/5/14 BV Bacterial Vaginosis Treatments for BV Oral Vaginal u Tinidazole 2 g orally QD for 2 days u Clindamycin ovules 100 mg intravaginally HS for 3 days u Tinidazole 1 g orally QD for 5 days u Metronidazole gel 0.75%, one full u Metronidazole 500 mg orally BID for 7 applicator (5 g) intravaginally, HS for 5 days* days u Clindamycin 300 mg orally BID for 7 u Clindamycin cream 2%, one full days applicator (5 g) intravaginally HS for 7 days† 9 9/5/14 Pregnancy & BV u BV is associated with adverse pregnancy outcomes, including premature rupture of membranes, preterm labor, preterm birth, intra- amniotic infection, and postpartum endometritis, u Multiple studies and meta-analyses have not demonstrated an association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns u Regardless of the antimicrobial agent in pregnant women, oral therapy is preferred because of the possibility of subclinical upper- genital–tract infection. BV: Recommended Regimens for Pregnant Women u Metronidazole 500 mg orally twice a day for 7 days u Metronidazole 250 mg orally three times a day for 7 days u Clindamycin 300 mg orally twice a day for 7 days Vulvovaginal Candidiasis (VVC) 10 9/5/14 Vulvovaginal Candidiasis (VVC) u usually is caused by C. albicans, but occasionally is caused by other Candida sp. or yeasts. u Typical symptoms of VVC include pruritus, vaginal soreness, dyspareunia, external dysuria, and abnormal vaginal discharge. u An estimated 75% of women will have at least one episode of VVC, and 40%–45% will have two or more episodes within their lifetime. u VVC can be classified as either uncomplicated or complicated u Approximately 10%–20% of women will have complicated VVC that necessitates diagnostic and therapeutic considerations. Classification of vulvovaginal candidiasis (VVC) Uncomplicated Complicated u Sporadic or infrequent vulvovaginal u Recurrent vulvovaginal candidiasis candidiasis u Severe vulvovaginal candidiasis u Mild-to-moderate vulvovaginal candidiasis u Non-albicans candidiasis u Likely to be C. albicans u Women with uncontrolled diabetes, debilitation, or immunosuppression u Non-immunocompromised women Uncomplicated VVC u presence of external dysuria and vulvar pruritus, pain, swelling, and redness. u Signs include vulvar edema, fissures, excoriations, or thick, curdy vaginal discharge. u associated with a normal vaginal pH (<4.5), and therefore, pH testing is not a useful diagnostic tool. Diagnosis u Use of 10% KOH in wet preparations improves the visualization of yeast and mycelia by disrupting cellular material that might obscure the yeast or pseudohyphae. Treatment u Short-course topical formulations (i.e., single dose and regimens of 1–3 days) u The topically applied azole drugs are more effective than nystatin. u Treatment with azoles results in relief of symptoms and negative cultures in 80%–90% of patients who complete therapy. 11 9/5/14 Candidiasis (VVC) Over-the-Counter Intravaginal Agents: Prescription (Rx) u Butoconazole 2% cream 5 g intravaginally for 3 days u Butoconazole 2% cream (single dose), 5 g intravaginally for 1 day u Clotrimazole 1% cream 5
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