DISORDERS OF THE VULVA AND VAGINA pps

20

DISORDERS OF THE VULVA

AND VAGINA

CHAPTER

571

COMMON VULVOVAGINAL

INFECTIONS ASSOCIATED

WITH LEUKORRHEA

Leukorrhea is a usually whitish vaginal discharge that may occur

at any age and affects virtually all women at some time. Although

some vaginal discharge (mucus) is physiologic and nearly always

present, when it becomes greater or abnormal (bloody or soils cloth￾ing), is irritating, or has an offensive odor, it is considered patho￾logic. Pathologic discharge is often coupled with vulvar irritation.

Commonly, the pathologic conditions are due to infection of the

vagina or cervix. Other causes may include uterine tumors, estro￾genic or psychic stimulation, trauma, foreign bodies (retained tam￾pon), excessive douching (especially with irritating medications),

and vulvovaginal atrophy (hypoestrogenism).

Vulvovaginal disorders constitute the major reason for office gy￾necology visits. These disorders are heavily influenced by the phys￾iologic alterations summarized in Table 20-1. Estrogen and pro￾gesterone influence the nonkeratinized squamous epithelium of the

vagina and vulva. Without hormonal influence, the epithelium is

thin and atrophic and contains little glycogen, and the vaginal fluid

has a high pH. By contrast, with adequate estrogen and proges￾terone, cellular glycogen content increases and the pH decreases

(partially due to breakdown of glycogen to lactic acid). During their

reproductive lives, most women harbor three to eight major types

of pathogenic bacteria at any given time (Table 20-1).

Physiologic vaginal secretions consist mainly of cervical mu￾cus (a transudate from the vaginal squamous epithelium) and exfo￾liated squamous cells. Lesser amounts are contributed by the meta￾bolic products of the microflora, exudates from sebaceous sweat

glands, Bartholin glands, and Skene glands, and small amounts of

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TABLE 20-1

SUMMARY OF THE HORMONAL INFLUENCE, VAGINAL pH, AND USUAL (PREDOMINANT)

VAGINAL ORGANISMS AT DIFFERENT TIMES OF A FEMALE’S LIFE

Time of Life Hormonal Influence Vaginal pH Usual Predominant Vaginal Organisms

Birth Estrogen Progesterone 3.7–6.3 Anaerobic and aerobic

Infant None 6.0–8.0 Gram-positive cocci and bacilli

Puberty–Reproductive Estrogen Progesterone 3.5–4.5 Aerobes (%)

Lactobacillus (70–90)

Staphylococcus epidermidis (30–60)

Diphtheroids (30–60)

Alpha-hemolytic Streptococcus (15–50)

Group D Streptococcus (10–40)

Nonhemolytic Streptococcus (5–30)

Escherichia coli (20–25)

Beta-hemolytic Streptococcus (10–20)

Anaerobes (%)

Bacteroides fragilis (5–40)

Bacteroides species (1–40)

Peptococcus (5–60)

Peptostreptococcus (5–40)

Clostridium (5–15)

Veillonella (10–15)

Menopause Little or none 6.0–8.0 Gram-positive cocci and bacilli

572