阴道感染及阴道炎PPT课件.ppt

1、谢医师简介 American board-certified family physician practicing medicine in Beijing for the last 7 years at BJU. I had 7 years experience before that in the U.S. and New Zealand in private practice. I am married with 2 sons. I have wanted to be a family physician since I was 4 years old. 美国家庭科执照医师，近7年在BJ

2、U工作 曾在美国和新西兰从事私人医生职业7年 我已经结婚并有2个儿子，我从4岁起就想成为一名家庭医生了Vaginal Infections and Vaginitis阴道感染及阴道炎Dr. Marie Shieh谢美虹 医师Family Physician全科医师.Vaginal and Genital Infectionsand Irritations Bacterial vaginosis 细菌性阴道病 Candida Vaginitis 念珠菌性阴道炎 Trichomonas vaginitis 滴虫阴道炎 Atrophic Vaginitis 萎缩性/老年性阴道炎 Streptococ

3、cal Vaginitis 链球菌阴道炎 Desquamative Inflammatory Vaginitis 炎性脱屑性阴道炎 Noninfectious Vaginitis 非感染性阴道炎 Cervicitis 宫颈炎General Approach一般接诊步骤 Symptoms 症狀 Pruritis, irritation, burning, odor, dysuria 搔痒 刺激感 烧灼感 臭味 排尿困難 Sexual history 性交史 new partner 新性伴侶？ Abdominal pain (PID) 腹痛 (盆腔炎) Hygeine: pantyliners 卫

4、生: 护垫 Medications药物: antibiotics/contraceptives/antifungals 抗生素 避孕药 抗真菌药 Timing with menses 与月经时间的关系 Candida is often premenstrual 念珠菌感染通常在经期前发生 Trichomonas is often during or right after menses 滴虫感染通常在经期当中或之后Vaginal symptoms 症状 Vaginal discharge 白带增多 Pruritis or itching 瘙痒 Soreness 疼痛 Burning 烧灼感 O

5、dor 臭味 Dyspareunia pain with intercourse 性交痛 Bleeding 出血 Dysuria pain with urination 尿痛 Physical Exam 查体 Vulva 外阴 erythema, edema, fissure formation suggest cadida, trichomoniasis or dermatitis 红肿龟裂，提示：念珠菌，滴虫，皮炎 Vulvar discharge 阴门分泌物 unreliable 并不可靠 Greenish yellow 黄绿色 trichomonas 滴虫 Cottage-cheese

6、 豆腐渣样 candida 念珠菌 Fishy smelling/grey 鱼腥味/灰色 bacterial vaginosis 细菌性阴道病 Cervical inflammation vs ectropion 宫颈炎症 vs 宫颈外翻 Abdominal or cervical motion tenderness 宫颈举痛General Approach一般接诊步骤Cervical ectropion vs cervicitis宫颈外翻 vs 宫颈炎Diagnostic studies Vaginal pH 阴道酸碱度 apply to vaginal sidewall 置于阴道侧壁 pH

7、5 bacterial vaginosis or trichomonas pH值大于5细菌性阴道病或滴虫感染 pH4-5 candida pH值在4-5念珠菌感染 Microscopy within 10-20 minutes of collection 1020分钟内镜检分泌物标本 Saline: candidal buds or hyphae 在生理盐水中看到念珠菌芽孢或菌丝 Motile trichomads 游动的滴虫 Clue cells 线索细胞 Vaginal culture and Cervical culture 阴道/宫颈分泌物培养pH Vaginal pH 阴道酸碱度 a

8、pply to vaginal sidewall 置于阴道侧壁 pH5 bacterial vaginosis or trichomonas pH5细菌性阴道病或滴虫感染 pH4-5 candida pH4-5念珠菌感染Wet Mount, Probe and Culture湿涂片，探针，培养 Swab inside cervical os for chlamydia 拭子伸入宫颈口，检测衣原体 Wet mount 湿涂片Patient 1 病人 1 40 year old woman 40 岁女患者 “Fishy-smelling” vaginal discharge 带鱼腥味白带 Wors

9、e after sexual intercourse 性交后更严重 Cigarette smoker 吸烟 Intrauterine device (IUD) 宫内节育器 No pain or itching 不痛不痒Bacterial Vaginosis 细菌性阴道病 Most common cause of vaginitis in women of childbearing age 生育年龄女性最常见的阴道炎 10-35% incidence depending on group 发病率随不同人群而不同， 10-35% High prevalence in women-women sex

10、ual relations 女同性恋人群发病率高 Risk factors 危险因素: early age of coitus 性交年龄早, multiple partners 多性伴, smoking 吸烟, douching 阴道冲洗, IUD 宫内节育器Bacterial Vaginosis Microbiology细菌性阴道病 微生物学 Not a single organism 非单一致病菌 Complex changes in flora 复杂的菌群改变 Reduction in lactobacilli 乳酸杆菌属减少 Increase in Gardnerella加德诺菌属,

11、Moiluncus, Mycoplasma支原体, Anaerobic Gram (-) rods like革兰阴性厌氧菌，如：Prevotella, Porphyromonas, Atopobium, Bacteroides类杆菌属, and Peptostreptococcus消化链球菌属Bacterial Vaginosis Diagnosis细菌性阴道病诊断 AMSTEL CRITERIA 诊断标准 3 out of 4 以下4条满足3条 Homogenous, thin grayish-white discharge that smoothly coats the vaginal w

12、alls 均质，淡灰白色分泌物均匀覆盖阴道壁 Vaginal pH 阴道pH 值 4.5 Whiff-amine test 10% KOH fishy odor 析氨试验分泌物加入10KOH后散发出鱼腥臭味 Clue cells on saline wet mount 盐水湿涂片找到线索细胞Bacterial Vaginosis细菌性阴道病 Grey, white liquid with fishy odor 带鱼腥味的灰白色液体CLUE CELLS线索细胞 Vaginal epithelial cells studded with coccobacilli. At least 20% of

13、cells.满布球杆菌的阴道上皮细胞。占至少20%的细胞 Sensitivity 敏感性 90% Specificity 特异性77%Bacterial Vaginosis Diagnosis细菌性阴道病诊断 Gram stain 革兰氏染色 cumbersome 麻烦 Sensitivity敏感性90-100% PAP smear is NOT reliable 宫颈涂片检查不可靠 Sensitivity敏感性is 49%, Specificity特异性93% DNA probes and pH 4.5 DNA探针和pH 4.5 Sensitivity敏感性95% Specificity特异

14、性99% Vaginal culture 阴道分泌物培养 “no role” 没用 G.vaginalis positive in almost all case 阴道革兰氏菌几乎在所有BV患者中阳性（即敏感性100） But positive in 50-60% asymptomatic women 但在5060无症状女性中也为阳性（特异性不够）Gram stain 革兰氏染色 Normal vaginal secretions gram stain正常阴道分泌物 Bacterial vaginosis gram stain 细菌性阴道病Bacterial Vaginosis Treatme

15、nt细菌性阴道病治疗 BV resolves spontaneously in up to 1/3 1/3的细菌性阴道病可自愈 Treatment only for symptomatic women or 有症状的病人才需要治疗 或者 Asymptomatic women who have had infection prior to abortion, hysterectomy or 在流产或子宫切除前有阴道感染史的无症状者 Asymptomatic pregnant with previous preterm labor screening controversial 有早产史的无症状者

16、 是否筛检，尚有争议Bacterial Vaginosis Treatment细菌性阴道病治疗 Metronidazole is the most successful therapy 甲硝唑是最有效的药 Metronidazole oral 500 mg bid for 7 days or 750 mg daily for 7 days口服甲硝唑500mg每天两次或750mg每天一次，连服7天 90% early cure 90%初期即治愈, 80% after 4 weeks 80% 4周后治愈 Side effects 副作用: metallic taste, cannot drink

17、alcohol (disulfuram reaction) 金属味, 不能喝酒（戒酒硫反应） Metronidazole vaginal 阴道用甲硝唑 0.75% gel, 5 grams once daily for 5 days 0.75%凝胶5g，每日1次连用5日 200 mg vaginal tablets 1 bid for 5 days 200mg阴道栓剂，每日2次连用5日Bacterial Vaginosis Alternative Treatments细菌性阴道病 其它治疗2 % Clindamycin cream daily for 7 days 2克林霉素软膏，每日涂抹连用

18、7日Led to clindamycin resistance 54% vs 17% after 90 days 导致克林霉素耐药 用药90天以后 54 比 17No resistance with metronidazole 甲硝唑不发生耐药Oral Clindamycin 300 mg bid for 7 days 口服克林霉素300mg每日2次连用7日Ampicillin or amoxicillin 66% cure 氨苄青霉素或阿莫西林治愈率66Triple-sulfa creams, erythromycin, tetracylcine, acetic acid gel iodin

19、e douches significantly less effective than metronidazole and clindamycin 三磺软膏，红霉素，四环素，醋酸凝胶碘阴道灌洗等方法疗效显著低于甲硝唑和克林霉素No evidence for lactobacillus suppositories 乳酸杆菌栓剂疗效，尚缺证据No evidence to treat partners 性伴侣治疗，尚缺证据细菌性阴道病其它治疗 2%克林霉素软膏每天涂一次涂7天 -用药90天后，54%耐药 -对甲硝唑没有抗药性 口服克林霉素300毫克一天两次，连用7天 氨苄西林或阿莫西林-66%治愈

20、阴道溶三硫膏, 红霉素, 四环索, 乙酸胶及碘冲洗的疗效都没有甲硝唑或克林霉素来的好. 乳酸杆菌栓剂无有效证明 治疗性伴侣-无有效证明 Bacterial Vaginosis Treatment细菌性阴道病治疗 Relapse 复发 30% initial response will relapse in 3 months 30初愈3个月内会复发 50% will relapse in 12 months 50%12个月内会复发 Treatment of symptomatic recurrence is prolonged therapy 10-14 days with a differen

21、t regimen than initially given 如症状复发，需换用与初治不同的药来治疗，而且疗程要长至10-14天 Suppressive therapy can be given with vaginal metronidazole daily for 10 days and then twice weekly for 3-6 months can lead to candida 抑制性疗法-阴道给甲硝唑，每天1次给10天，然后1周两次给3到6个月可能会导致念珠菌感染Bacterial Vaginosis in Pregnancy妊娠期间细菌性阴道病 Cochrane revi

22、ew of 10 trials of 4249 pregnant women no difference in preterm birth with or without treatment for BV Cochrane循证医学数据库综述：10个针对共4249个孕妇的临床试验妊娠时是否治疗细菌性阴道病并不降低早产几率 However Subgroup of women with history of preterm birth treatment of BV reduced preterm prelabor rupture of membranes 但是 , 在有早产史的孕妇人群中治疗可减低

23、胎膜早破的几率Treatment of High Risk Pregnant Patients高危妊娠患者的治疗 Metronidazole ORAL 400 mg bid for 2 days and repeat if still positive after 4 weeks 【Br. Obstet Gyn 1997;107:1391】 口服甲硝唑400mg每天2次连服2天,如4周后仍为阳性，重复治疗 Metronidazole ORAL 250 mg tid for 7 days no second treatment 【NEJM 1995; 333:1732】 口服甲硝唑250mg每天

24、3次连服7天无需重复治疗 Metronidazole ORAL 250 mg tid for 7 days plus Erythromycin 333 mg tie for 14 days. Repeat test at 28 weeks gestation and repeat treatment if still positive 【Am J ObGyn 1994; 171:345】 口服甲硝唑250mg每天3次连服7天，红霉素333mg每天3次连服14天；孕28周时复查BV，如阳性重复治疗Patient 2 35 year old woman on oral contraceptives

25、 who has had itchiness in her vulva for the past 4 days. She has had some burning with urination around her vulva. She took antibiotics for a “cold” 1 week ago. She has had a small amount of white, cottage cheese- like discharge. She is monogamous with her husband.病人 2 35 岁使用避孕药的女性 外阴瘙痒4天 小便时外阴轻微灼热感

26、 少量豆腐渣样白带 一周前因感冒服用抗生素 丈夫是她唯一的性伴侣Candida Vaginitis念珠菌阴道炎 1/3 of all vaginitis cases 占所有阴道炎的1/3 Candida is in the lower genital tract of 20-50% of healthy asymptomatic women 念珠菌存在于20-50%健康五症状女性的下生殖道 Candida albicans 80-92% of all cases 所有阴道炎中，白色念珠菌占80-92% Predisposition with the following 易感因素 Diabete

27、s 糖尿病 Antibiotics 抗生素 Inc estrogen oral contraceptives 含雌激素的口服避孕药, pregnancy 怀孕, estrogen use 使用雌激素 Immunosuppression / Steroids 免疫抑制/激素Candial vaginitis念珠菌阴道炎 Signs and Symptoms 症狀和体征 Vulvar puritus / Itching 外阴瘙痒 Dysuria排尿困难 external or vulvar 外阴 Soreness 酸痛, irritation 不舒服, dyspareunia 性交痛 No dis

28、charge or little discharge that is clumpy white discharge 无白带或少许块状白色分泌物 Exam shows erythema of the vulva and vaginal mucosa with the white clumpy discharge 妇检可见外阴和阴道粘膜发红，且有白色块状分泌物Candidal vaginitis念珠菌阴道炎 Clumpy, white discharge 白色块状分泌物Candidal Vaginitis Diagnosis念珠性阴道炎 诊断 Vaginal pH 4-4.5 normal 阴道p

29、H值4-4.5-正常 Wet mount + KOH shows budding yeast and hyphae 湿涂片+KOH可见芽孢和菌丝 Microscopy is negative 50% 镜检50%阴性 Culture is recommended if microscopy is negative and pH is normal 如镜检(-)且pH正常，推荐做阴道分泌物培养 Self diagnosis can lead to a large number of misdiagnosis 患者的自我诊断可能造成大量的误诊 Sobel. AmJ ObGyn 1985 152:92

30、4Wet mount/KOH in candidiasis念珠菌阴道炎的KOH湿涂片More microscopic candida显微镜下的念珠菌 Hyphae and budding yeast 菌丝和芽孢Differential Diagnosis鉴别诊断 Hypersensitivity reactions 超敏反应 Allergic or Chemical reactions 过敏或化学反应 Contact Dermatitis 接触性皮炎 Insufficient lubrication with coitus 性交时不够润滑Recurrent candidal vaginitis

31、反复性念珠菌阴道炎 4 or more episodes per year一年4次以上 5-8% of healthy women 58的健康女性 Usually from endogenous strains of candida albicans 通常由自身菌群的白色念珠菌引起 Predisposing factors 易感因素 Diabetes 糖尿病 Abnormal vaginal mucosa immunity/blood group Ags 阴道粘膜免疫功能异常/血型抗原 Panty-liners, panty-hose, sexual lubricants 卫生护垫，连裤袜，阴

32、道润滑剂Candida Vaginitis- Treatment念珠菌阴道炎治疗 Umcomplicated infections 无并发症的感染 Sporadic, infrequent 散发，偶发 Mild to moderate symptoms and signs 症状体征轻至中度 Healthy and non pregnant 健康非孕妇 Oral medicine is preferred by most women but can take 1-2 days longer to be effective. Side effects of fluconazole are GI u

33、pset, headache 大多数患者愿意使用口服药物，但（比阴道用药）需多用12天才能见效。氟康唑的副作用有消化道不适和头痛。 72 hours in vaginal secretions 阴道分泌物72小时内减少 Topical medicine can burn 阴道局部用药会有烧灼感Candidal Vaginitis Treatment念珠菌阴道炎治疗 Complicated infections 有并发症的感染 Poorly controlled diabetes 糖尿病控制不佳 Severe signs and symptoms 症状体征较重 Candida glabrata

34、平滑念珠菌 Pregnancy 孕妇 Recurrent more than 4 per year 复发性-每年超过4次 7-14 days of topical therapy or 2 sequential fluconazole 150 gm 72 hours apart 阴道局部用药714日 ,或口服氟康唑，序贯2次相隔3天，每次150mgRole of Cleansing Agents阴部清洁剂的使用 Chlorhexadine: 1 article supporting use 洗必泰：1篇文献主张使用 Boric Acid - Treatment of Torulopsis gl

35、abrata vaginitis: retrospective review of boric acid therapy Clin Inf Dis 1997 硼酸治疗光滑球拟酵母阴道炎：硼酸治疗综述，临床感染病学1997 Povodine iodine 络合碘Treatment of Candidal Vaginitis念珠菌阴道炎治疗 Fluconazole 150 mg x 1 or repeat 72 hours for complicated infections 氟康唑150mg顿服，若有并发症则3天后重复1次 NOT recommended in pregnancy 孕妇不推荐使用

36、 167 RMB ￥167 Topical azoles 阴道局部使用的唑类 Butoconazole 2% cream 5g/day 1 day SR, 3 days regular preparation 硝酸布康唑 2%软膏,5g/天,用3天 Clotrimazole 1% cream 5g/day 7-14 days or 100 mg vaginal tablet daily for 7 days 500 mg tablet at BJU 147 RMB 克霉唑1%软膏, 5g/天,用7-14天或者每天用100毫克阴道片剂,用7天 Miconazole 2% cream for 7

37、days or suppositories for 1, 3 and 7 days 咪康唑2软膏连用7日，或阴道栓剂1，3，7天 200 mg vaginal tablets x 7 = 85 RMB 200mg阴道栓7￥85 400 mg vaginal tablets x 3 = 102 RMB 400mg阴道栓3 ￥102Trichomonas vaginitis 滴虫性阴道炎 4-35% of vaginitis 占阴道炎的4-35% Flagellated protozoan 有鞭毛的原生动物 Incubation 4-28 days 潜伏期4-28天 Always sexually

38、 transmitted 大部分由性行为传染 In men, limited and transient carriage 在男性为自限和暂时的携带状态 10 days spontaneous resolution 通常10天内会自愈Trichomonas vaginitis signs and symptoms 滴虫性阴道炎症状体征 Asymptomatic 无症状 Purulent, malodorous, thin discharge 70% 脓性恶臭稀薄分泌物（70） Burning, pruritis, dysuria, urinary frequency and dyspareun

39、ia 烧灼感，瘙痒，尿痛，尿急，性交痛 Post coital bleeding 性交后出血 Erythema of vulva and yellow frothy discharge 10-30%. “Strawberry” cervix = punctate hemorrhages on vagina and cervix 外阴发红，黄色多泡分泌物，草莓样宫颈阴道粘膜或宫颈的点状出血（1030） Frothy, foul smelling discharge 多泡，臭味的分泌物Trichomonas Vaginitis Diagnosis滴虫性阴道炎诊断 Culture on Diamon

40、ds media Diamond培养基阴道分泌物培养 sensitivity and 95% specificity 敏感性95 特异性95 Rapid Tests: DNA probes not available in the U.S. 快速检测：DNA探针，美国目前无此检查项目 Cervical cytology: 60-70% Sensitivity though liquid based paps are 99% specific 宫颈细胞学检查：敏感性低6070，但“液基PAP”特异性高99 Microscopy and pH 镜检和pH pH 5-6 稍高于正常阴道pH Moti

41、le trichomonads 镜下找到游动的滴虫Trichomonas vaginalis滴虫性阴道炎 See flagella 可见鞭毛Trichomonas Vaginitis Treatment滴虫性阴道炎治疗 Metronidazole ORAL 2 grams 甲硝唑，口服，2g Tinidazole - ? Better ORAL 2 grams 替硝唑，最好口服，2g Cure rates 治愈比率达 85-90% Treat male partners 同时也要经验性地治疗性伴侣simultaneously/empircally If symptomatic pregnant

42、 woman, treat with metronidazole orally 500 mg bid for 5-7 days 怀孕患者如有症状，口服甲硝唑500mg每日2次连服5-7天Other infections causing vaginitis其它导致阴道炎的感染 Staphylococcus aureus 金黄色葡萄球菌 Ulcerative vaginitis with toxic shock syndrome 溃疡性阴道炎，中毒性休克综合症TSS Streptococcal vaginitis 链球菌阴道炎 Group A strep uncommon cause 甲型链球菌，

43、少见阴道感染 Mothers of infected children 感染的儿童的母亲 Symptoms are purulent discharge and irritation and erythema 脓性分泌物，外阴刺激感和发红 Group B strep 乙型链球菌乙型链球菌 Colonizes vagina and can cause neonatal sepsis and maternal endometritis 定植于阴道，可致新生儿败血症和母体子宫内膜炎 Controversial if it is a pathogen in the vagina 对于乙链是否算一种阴道

44、病原体，尚存争议Atrophic vaginitis 萎缩性阴道炎 Perimenopausal and Menopausal Women 围绝经期和绝经后妇女 Can be in lactating women 也可在哺乳妇女 Up to 40% of Menopausal women 40%绝经后妇女 Side Effect of Medications = Tamoxifen, Lupron 药物副作用它莫西芬，柳菩林 Cigarette smoking makes it worse 吸烟加重QuickTime and aTIFF (Uncompressed) decompressora

45、re needed to see this picture.Treatment of Atrophic Vaginitis萎缩性阴道炎治疗 Estrogen 雌激素 Topical 外用 Oral 口服 Combined with progesterone if chronic treatment to protect against endometrial cancer若长期治疗应与孕酮联合避免内膜癌 Lubricants 阴道润滑剂Irritant or Contact Vaginitis刺激性或接触性阴道炎 Irritant/Contact vaginitis and vulvitis

46、非感染性阴道炎/外阴炎Irritants minipads, spermicides, iodine, soaps, perfumes, tampons, condoms, laundry detergent刺激物卫生护垫，杀精剂，碘，皂，香水，卫生棉球，安全套，洗涤剂Mild to severe itching 轻重不等的搔痒Burning sensation 烧灼感Looks red and irritated and can have excoriations 局部发红，可有抓痕Treatment of irritant vaginitis刺激性阴道炎的治疗 Removal of off

47、ending agent 去除刺激物 Sodium bicarbonate sitz baths 小苏打坐浴 Topical vegetable oils 局部外敷植物油 Not just corticosteroids because these cause much burning 不要只给激素，因为这会造成较重的烧灼感Other causes of vaginal discharge and vaginitis其它导致阴道炎和阴道分泌物增多的情况Desquamative inflammatory vaginitis perimenopausal 脱屑性炎性阴道炎围绝经期Physiolog

48、ic leukorrhea 生理性白带 1-4 mls/24 hours 每日14mlpH4.44.5 有一定pH与阴道酸碱度一致Cervicitis; chlamydia and gonorrhea/PID 宫颈炎；衣原体和淋球菌性盆腔感染Fistula: pospartum, post-hysterectomy, IBD 阴道直肠瘘：产后，子宫切除术后，炎性肠病Cervical lesions: ectropion, endocervical polyps, granulation tissue and neoplasia 宫颈病变：外翻，宫颈内息肉，肉芽组织和新生物Noninfectio

49、us vaginitis and vulvitis 非感染性阴道炎/外阴炎Irritants minipads, spermicides, iodine, soaps, perfumes 刺激物卫生护垫，杀精剂，碘，皂，香水Allergenslatex condoms, creams, seminal fluid 变应原橡胶避孕套，软膏，精液lichen planus 扁平苔藓 Vulvovaginal complaints in the prepubertal child青春期前女性的外阴阴道疾病 Specific infections: 特异性感染 Pinworms 蛲虫 Respirat

50、ory flora s. pyogenes 呼吸道菌群，如化脓性链球菌 Candida overdiagnosed (3%) 念珠菌，被过度诊断 Bacterial vaginosis 细菌性阴道病 STDs 性传播疾病 Condyloma acuminata 尖锐湿疣 Nonspecific vulvovaginitis 25-75% 非特异性感染 Lack of labial development 阴唇发育不良 Unestrogenized thin mucosa 未雌激素化的菲薄粘膜 More alkaline pH 阴道pH（较成熟女性）偏碱性 Poor hygiene 个人卫生差