陰道感染及陰道炎

謝醫(yī)師簡(jiǎn)介Americanboard-certifiedfamilyphysicianpracticingmedicineinBeijingforthelast7yearsatBJU.Ihad7yearsexperiencebeforethatintheU.S.andNewZealandinprivatepractice.Iammarriedwith2sons.

IhavewantedtobeafamilyphysiciansinceIwas4yearsold.美國(guó)家庭科執(zhí)照醫(yī)師，近7年在BJU工作曾在美國(guó)和新西蘭從事私人醫(yī)生職業(yè)7年我已經(jīng)結(jié)婚并有2個(gè)兒子，我從4歲起就想成為一名家庭醫(yī)生了1編輯版pptVaginalInfectionsandVaginitis

陰道感染及陰道炎

Dr.MarieShieh謝美虹醫(yī)師FamilyPhysician全科醫(yī)師2編輯版pptVaginalandGenitalInfections

andIrritationsBacterialvaginosis細(xì)菌性陰道病CandidaVaginitis念珠菌性陰道炎Trichomonasvaginitis滴蟲陰道炎AtrophicVaginitis萎縮性/老年性陰道炎StreptococcalVaginitis鏈球菌陰道炎DesquamativeInflammatoryVaginitis炎性脫屑性陰道炎NoninfectiousVaginitis非感染性陰道炎Cervicitis宮頸炎3編輯版pptGeneralApproach

一般接診步驟Symptoms癥狀Pruritis,irritation,burning,odor,dysuria

搔癢

刺激感

燒灼感臭味排尿困難Sexualhistory性交史–newpartner

新性伴侶？Abdominalpain(PID)

腹痛(盆腔炎)Hygeine:pantyliners

衛(wèi)生:護(hù)墊Medications藥物:antibiotics/contraceptives/antifungals抗生素避孕藥

抗真菌藥Timingwithmenses

與月經(jīng)時(shí)間的關(guān)系Candidaisoftenpremenstrual

念珠菌感染通常在經(jīng)期前發(fā)生Trichomonasisoftenduringorrightaftermenses滴蟲感染通常在經(jīng)期當(dāng)中或之后4編輯版pptVaginalsymptoms癥狀Vaginaldischarge白帶增多Pruritisoritching瘙癢Soreness疼痛Burning燒灼感Odor臭味Dyspareunia–painwithintercourse性交痛Bleeding出血Dysuria–painwithurination尿痛5編輯版pptPhysicalExam

查體Vulva外陰–erythema,edema,fissureformationsuggestcadida,trichomoniasisordermatitis紅腫龜裂，提示：念珠菌，滴蟲，皮炎Vulvardischarge陰門分泌物–unreliable并不可靠Greenishyellow黃綠色–trichomonas滴蟲Cottage-cheese豆腐渣樣–candida念珠菌Fishysmelling/grey魚腥味/灰色–bacterialvaginosis細(xì)菌性陰道病Cervicalinflammationvsectropion宮頸炎癥vs宮頸外翻Abdominalorcervicalmotiontenderness宮頸舉痛GeneralApproach

一般接診步驟6編輯版pptCervicalectropionvscervicitis

宮頸外翻vs宮頸炎7編輯版pptDiagnosticstudiesVaginalpH陰道酸堿度–applytovaginalsidewall置于陰道側(cè)壁pH>5bacterialvaginosisortrichomonaspH值大于5細(xì)菌性陰道病或滴蟲感染pH4-5candidapH值在4-5念珠菌感染Microscopywithin10-20minutesofcollection10~20分鐘內(nèi)鏡檢分泌物標(biāo)本Saline:

candidalbudsorhyphae在生理鹽水中看到念珠菌芽孢或菌絲Motiletrichomads游動(dòng)的滴蟲Cluecells線索細(xì)胞VaginalcultureandCervicalculture陰道/宮頸分泌物培養(yǎng)8編輯版pptpHVaginalpH陰道酸堿度–applytovaginalsidewall置于陰道側(cè)壁pH>5bacterialvaginosisortrichomonaspH>5細(xì)菌性陰道病或滴蟲感染pH4-5candidapH4-5念珠菌感染9編輯版pptWetMount,ProbeandCulture

濕涂片，探針，培養(yǎng)Swabinsidecervicalosforchlamydia拭子伸入宮頸口，檢測(cè)衣原體Wetmount濕涂片10編輯版pptPatient1病人140yearoldwoman40歲女患者“Fishy-smelling”vaginaldischarge帶魚腥味白帶Worseaftersexualintercourse性交后更嚴(yán)重Cigarettesmoker吸煙Intrauterinedevice(IUD)宮內(nèi)節(jié)育器Nopainoritching不痛不癢11編輯版pptBacterialVaginosis

細(xì)菌性陰道病Mostcommoncauseofvaginitisinwomenofchildbearingage生育年齡女性最常見的陰道炎10-35%incidencedependingongroup發(fā)病率隨不同人群而不同，10-35%Highprevalenceinwomen-womensexualrelations女同性戀人群發(fā)病率高Riskfactors危險(xiǎn)因素:earlyageofcoitus性交年齡早,multiplepartners多性伴,smoking吸煙,douching陰道沖洗,IUD宮內(nèi)節(jié)育器12編輯版pptBacterialVaginosis–Microbiology

細(xì)菌性陰道病—微生物學(xué)Notasingleorganism非單一致病菌Complexchangesinflora復(fù)雜的菌群改變Reductioninlactobacilli乳酸桿菌屬減少IncreaseinGardnerella加德諾菌屬,Moiluncus,Mycoplasma支原體,AnaerobicGram(-)rodslike革蘭陰性厭氧菌，如：Prevotella,Porphyromonas,Atopobium,Bacteroides類桿菌屬,andPeptostreptococcus消化鏈球菌屬13編輯版pptBacterialVaginosis–Diagnosis

細(xì)菌性陰道病—診斷AMSTELCRITERIA診斷標(biāo)準(zhǔn)3outof4以下4條滿足3條Homogenous,thingrayish-whitedischargethatsmoothlycoatsthevaginalwalls均質(zhì)，淡灰白色分泌物均勻覆蓋陰道壁VaginalpH陰道pH值>4.5Whiff-aminetest–10%KOHfishyodor析氨試驗(yàn)－分泌物加入10％KOH后散發(fā)出魚腥臭味Cluecellsonsalinewetmount鹽水濕涂片找到線索細(xì)胞14編輯版pptBacterialVaginosis

細(xì)菌性陰道病Grey,whiteliquidwithfishyodor帶魚腥味的灰白色液體15編輯版pptCLUECELLS線索細(xì)胞Vaginalepithelialcellsstuddedwithcoccobacilli.Atleast20%ofcells.滿布球桿菌的陰道上皮細(xì)胞。占至少20%的細(xì)胞Sensitivity敏感性>90%Specificity特異性77%16編輯版pptBacterialVaginosis–Diagnosis

細(xì)菌性陰道病—診斷Gramstain革蘭氏染色

–cumbersome麻煩Sensitivity敏感性90-100%PAPsmearisNOTreliable宮頸涂片檢查不可靠Sensitivity敏感性is49%,Specificity特異性93%DNAprobesandpH>4.5DNA探針和pH>4.5Sensitivity敏感性95%Specificity特異性99%Vaginalculture陰道分泌物培養(yǎng)–“norole”沒用G.vaginalispositiveinalmostallcase陰道革蘭氏菌幾乎在所有BV患者中陽(yáng)性（即敏感性100％）Butpositivein50-60%asymptomaticwomen但在50～60％無(wú)癥狀女性中也為陽(yáng)性（特異性不夠）17編輯版pptGramstain

革蘭氏染色Normalvaginalsecretionsgramstain正常陰道分泌物Bacterialvaginosisgramstain細(xì)菌性陰道病18編輯版pptBacterialVaginosis–Treatment

細(xì)菌性陰道病—治療BVresolvesspontaneouslyinupto1/31/3的細(xì)菌性陰道病可自愈Treatmentonlyforsymptomaticwomenor有癥狀的病人才需要治療或者Asymptomaticwomenwhohavehadinfectionpriortoabortion,hysterectomyor在流產(chǎn)或子宮切除前有陰道感染史的無(wú)癥狀者Asymptomaticpregnantwithpreviouspretermlabor–screeningcontroversial有早產(chǎn)史的無(wú)癥狀者–是否篩檢，尚有爭(zhēng)議19編輯版pptBacterialVaginosis–Treatment

細(xì)菌性陰道病—治療Metronidazoleisthemostsuccessfultherapy甲硝唑是最有效的藥Metronidazoleoral500mgbidfor7daysor750mgdailyfor7days口服甲硝唑500mg每天兩次或750mg每天一次，連服7天90%earlycure90%初期即治愈,80%after4weeks80%4周后治愈Sideeffects副作用:metallictaste,cannotdrinkalcohol(disulfuramreaction)金屬味,不能喝酒（戒酒硫反應(yīng)）Metronidazolevaginal陰道用甲硝唑0.75%gel,5gramsoncedailyfor5days0.75%凝膠5g，每日1次連用5日200mgvaginaltablets1bidfor5days200mg陰道栓劑，每日2次連用5日20編輯版pptBacterialVaginosis–AlternativeTreatments

細(xì)菌性陰道?。渌委?%Clindamycincreamdailyfor7days2％克林霉素軟膏，每日涂抹連用7日Ledtoclindamycinresistance54%vs17%after90days

導(dǎo)致克林霉素耐藥用藥90天以后54％比17％Noresistancewithmetronidazole

甲硝唑不發(fā)生耐藥OralClindamycin300mgbidfor7days

口服克林霉素300mg每日2次連用7日Ampicillinoramoxicillin–66%cure氨芐青霉素或阿莫西林－治愈率66％Triple-sulfacreams,erythromycin,tetracylcine,aceticacidgeliodinedouchessignificantlylesseffectivethanmetronidazoleandclindamycin三磺軟膏，紅霉素，四環(huán)素，醋酸凝膠碘陰道灌洗等方法療效顯著低于甲硝唑和克林霉素Noevidenceforlactobacillussuppositories乳酸桿菌栓劑療效，尚缺證據(jù)Noevidencetotreatpartners性伴侶治療，尚缺證據(jù)21編輯版ppt細(xì)菌性陰道病—其它治療2%克林霉素軟膏每天涂一次涂7天-用藥90天后，54%耐藥-對(duì)甲硝唑沒有抗藥性口服克林霉素300毫克一天兩次，連用7天氨芐西林或阿莫西林-66%治愈陰道溶三硫膏,紅霉素,四環(huán)索,乙酸膠及碘沖洗的療效都沒有甲硝唑或克林霉素來(lái)的好.乳酸桿菌栓劑—無(wú)有效證明治療性伴侶--無(wú)有效證明

22編輯版pptBacterialVaginosis–Treatment

細(xì)菌性陰道病—治療Relapse復(fù)發(fā)30%initialresponsewillrelapsein3months30％初愈3個(gè)月內(nèi)會(huì)復(fù)發(fā)50%willrelapsein12months50%12個(gè)月內(nèi)會(huì)復(fù)發(fā)Treatmentofsymptomaticrecurrenceisprolongedtherapy10-14dayswithadifferentregimenthaninitiallygiven如癥狀復(fù)發(fā)，需換用與初治不同的藥來(lái)治療，而且療程要長(zhǎng)至10-14天Suppressivetherapycanbegivenwithvaginalmetronidazoledailyfor10daysandthentwiceweeklyfor3-6months–canleadtocandida

抑制性療法---陰道給甲硝唑，每天1次給10天，然后1周兩次給3到6個(gè)月–可能會(huì)導(dǎo)致念珠菌感染23編輯版pptBacterialVaginosisinPregnancy

妊娠期間細(xì)菌性陰道病Cochranereviewof10trialsof4249pregnantwomen–nodifferenceinpretermbirthwithorwithouttreatmentforBVCochrane循證醫(yī)學(xué)數(shù)據(jù)庫(kù)綜述：10個(gè)針對(duì)共4249個(gè)孕婦的臨床試驗(yàn)—妊娠時(shí)是否治療細(xì)菌性陰道病并不降低早產(chǎn)幾率

However–Subgroupofwomenwithhistoryofpretermbirth–treatmentofBVreducedpretermprelaborruptureofmembranes但是,在有早產(chǎn)史的孕婦人群中—治療可減低胎膜早破的幾率24編輯版pptTreatmentofHighRiskPregnantPatients

高危妊娠患者的治療MetronidazoleORAL400mgbidfor2daysandrepeatifstillpositiveafter4weeks【Br.ObstetGyn1997;107:1391】

口服甲硝唑400mg每天2次連服2天,如4周后仍為陽(yáng)性，重復(fù)治療MetronidazoleORAL250mgtidfor7days–nosecondtreatment【NEJM1995;333:1732】

口服甲硝唑250mg每天3次連服7天－無(wú)需重復(fù)治療MetronidazoleORAL250mgtidfor7daysplusErythromycin333mgtiefor14days.Repeattestat28weeksgestationandrepeattreatmentifstillpositive【AmJObGyn1994;171:345】

口服甲硝唑250mg每天3次連服7天，紅霉素333mg每天3次連服14天；孕28周時(shí)復(fù)查BV，如陽(yáng)性重復(fù)治療25編輯版pptPatient235yearoldwomanonoralcontraceptiveswhohashaditchinessinhervulvaforthepast4days.Shehashadsomeburningwithurinationaroundhervulva.Shetookantibioticsfora“cold”1weekago.Shehashadasmallamountofwhite,cottagecheese-likedischarge.Sheismonogamouswithherhusband.26編輯版ppt病人235歲使用避孕藥的女性外陰瘙癢4天小便時(shí)外陰輕微灼熱感少量豆腐渣樣白帶一周前因感冒服用抗生素丈夫是她唯一的性伴侶27編輯版pptCandidaVaginitis

念珠菌陰道炎1/3ofallvaginitiscases占所有陰道炎的1/3Candidaisinthelowergenitaltractof20-50%ofhealthyasymptomaticwomen

念珠菌存在于20-50%健康五癥狀女性的下生殖道Candidaalbicans80-92%ofallcases

所有陰道炎中，白色念珠菌占80-92%Predispositionwiththefollowing易感因素Diabetes糖尿病Antibiotics抗生素Incestrogen–oralcontraceptives含雌激素的口服避孕藥,pregnancy懷孕,estrogenuse使用雌激素

Immunosuppression/Steroids免疫抑制/激素28編輯版pptCandialvaginitis念珠菌陰道炎

–SignsandSymptoms

癥狀和體征Vulvarpuritus/Itching外陰瘙癢Dysuria排尿困難

–externalorvulvar外陰Soreness酸痛,irritation不舒服,dyspareunia性交痛Nodischargeorlittledischargethatisclumpywhitedischarge無(wú)白帶或少許塊狀白色分泌物Examshowserythemaofthevulvaandvaginalmucosawiththewhiteclumpydischarge婦檢可見外陰和陰道粘膜發(fā)紅，且有白色塊狀分泌物29編輯版pptCandidalvaginitis

念珠菌陰道炎

Clumpy,whitedischarge白色塊狀分泌物30編輯版pptCandidalVaginitis–Diagnosis

念珠性陰道炎–診斷VaginalpH4-4.5–normal陰道pH值4-4.5--正常Wetmount+KOHshowsbuddingyeastandhyphae濕涂片+KOH可見芽孢和菌絲Microscopyisnegative50%鏡檢50%陰性CultureisrecommendedifmicroscopyisnegativeandpHisnormal如鏡檢(-)且pH正常，推薦做陰道分泌物培養(yǎng)Selfdiagnosiscanleadtoalargenumberofmisdiagnosis患者的自我診斷可能造成大量的誤診－Sobel.AmJObGyn1985152:92431編輯版pptWetmount/KOHincandidiasis

念珠菌陰道炎的KOH濕涂片32編輯版pptMoremicroscopiccandida

顯微鏡下的念珠菌Hyphaeandbuddingyeast

菌絲和芽孢33編輯版pptDifferentialDiagnosis鑒別診斷Hypersensitivityreactions超敏反應(yīng)AllergicorChemicalreactions過敏或化學(xué)反應(yīng)ContactDermatitis接觸性皮炎Insufficientlubricationwithcoitus性交時(shí)不夠潤(rùn)滑34編輯版pptRecurrentcandidalvaginitis

反復(fù)性念珠菌陰道炎4ormoreepisodesperyear一年4次以上5-8%ofhealthywomen5～8％的健康女性Usuallyfromendogenousstrainsofcandidaalbicans通常由自身菌群的白色念珠菌引起Predisposingfactors易感因素Diabetes糖尿病Abnormalvaginalmucosaimmunity/bloodgroupAgs陰道粘膜免疫功能異常/血型抗原Panty-liners,panty-hose,sexuallubricants衛(wèi)生護(hù)墊，連褲襪，陰道潤(rùn)滑劑35編輯版pptCandidaVaginitis-Treatment

念珠菌陰道炎－治療Umcomplicatedinfections無(wú)并發(fā)癥的感染Sporadic,infrequent散發(fā)，偶發(fā)Mildtomoderatesymptomsandsigns癥狀體征輕至中度Healthyandnonpregnant健康非孕婦Oralmedicineispreferredbymostwomenbutcantake1-2dayslongertobeeffective.SideeffectsoffluconazoleareGIupset,headache

大多數(shù)患者愿意使用口服藥物，但（比陰道用藥）需多用1～2天才能見效。氟康唑的副作用有消化道不適和頭痛。72hoursinvaginalsecretions陰道分泌物72小時(shí)內(nèi)減少Topicalmedicinecanburn陰道局部用藥會(huì)有燒灼感36編輯版pptCandidalVaginitis–Treatment

念珠菌陰道炎－治療Complicatedinfections有并發(fā)癥的感染Poorlycontrolleddiabetes糖尿病控制不佳Severesignsandsymptoms癥狀體征較重Candidaglabrata平滑念珠菌Pregnancy孕婦Recurrent–morethan4peryear復(fù)發(fā)性-每年超過4次7-14daysoftopicaltherapyor2sequentialfluconazole150gm72hoursapart

陰道局部用藥7～14日,或口服氟康唑，序貫2次相隔3天，每次150mg37編輯版pptRoleofCleansingAgents

陰部清潔劑的使用Chlorhexadine:1articlesupportinguse

洗必泰：1篇文獻(xiàn)主張使用BoricAcid-TreatmentofTorulopsisglabratavaginitis:retrospectivereviewofboricacidtherapy–ClinInfDis1997

硼酸治療光滑球擬酵母陰道炎：硼酸治療綜述，臨床感染病學(xué)1997Povodineiodine

絡(luò)合碘38編輯版pptTreatmentofCandidalVaginitis

念珠菌陰道炎－治療Fluconazole150mgx1orrepeat72hoursforcomplicatedinfections氟康唑150mg頓服，若有并發(fā)癥則3天后重復(fù)1次NOTrecommendedinpregnancy孕婦不推薦使用167RMB￥167Topicalazoles陰道局部使用的唑類Butoconazole2%cream5g/day–1daySR,3daysregularpreparation硝酸布康唑2%軟膏,5g/天,用3天Clotrimazole1%cream5g/day7-14daysor100mgvaginaltabletdailyfor7days[500mgtabletatBJU147RMB]

克霉唑1%軟膏,5g/天,用7-14天或者每天用100毫克陰道片劑,用7天Miconazole2%creamfor7daysorsuppositoriesfor1,3and7days咪康唑2％軟膏連用7日，或陰道栓劑1，3，7天

[200mgvaginaltabletsx7=85RMB]200mg陰道栓×7＝￥85[400mgvaginaltabletsx3=102RMB]400mg陰道栓×3＝￥10239編輯版pptTrichomonasvaginitis

滴蟲性陰道炎4-35%ofvaginitis占陰道炎的4-35%Flagellatedprotozoan有鞭毛的原生動(dòng)物Incubation4-28days潛伏期4-28天Alwayssexuallytransmitted大部分由性行為傳染Inmen,limitedandtransientcarriage在男性為自限和暫時(shí)的攜帶狀態(tài)10days–spontaneousresolution

通常10天內(nèi)會(huì)自愈40編輯版pptTrichomonasvaginitis–signsandsymptoms滴蟲性陰道炎－癥狀體征Asymptomatic無(wú)癥狀Purulent,malodorous,thindischarge70%膿性惡臭稀薄分泌物（70％）Burning,pruritis,dysuria,urinaryfrequencyanddyspareunia燒灼感，瘙癢，尿痛，尿急，性交痛Postcoitalbleeding性交后出血Erythemaofvulvaandyellowfrothydischarge10-30%.“Strawberry”cervix=punctatehemorrhagesonvaginaandcervix外陰發(fā)紅，黃色多泡分泌物，草莓樣宮頸－陰道粘膜或?qū)m頸的點(diǎn)狀出血（10～30％）41編輯版pptFrothy,foulsmellingdischarge

多泡，臭味的分泌物42編輯版pptTrichomonasVaginitis–Diagnosis

滴蟲性陰道炎－診斷CultureonDiamond’smediaDiamond培養(yǎng)基陰道分泌物培養(yǎng)

sensitivityand>95%specificity

敏感性95％特異性>95％RapidTests:DNAprobesnotavailableintheU.S.快速檢測(cè)：DNA探針，美國(guó)目前無(wú)此檢查項(xiàng)目Cervicalcytology:60-70%Sensitivitythoughliquidbasedpapsare99%specific

宮頸細(xì)胞學(xué)檢查：敏感性低60～70％，但“液基PAP”特異性高99％MicroscopyandpH鏡檢和pHpH5-6稍高于正常陰道pHMotiletrichomonads鏡下找到游動(dòng)的滴蟲43編輯版pptTrichomonasvaginalis

滴蟲性陰道炎Seeflagella可見鞭毛44編輯版pptTrichomonasVaginitis–Treatment

滴蟲性陰道炎－治療MetronidazoleORAL2grams

甲硝唑，口服，2gTinidazole-?BetterORAL2grams

替硝唑，最好口服，2gCurerates治愈比率達(dá)85-90%Treatmalepartners同時(shí)也要經(jīng)驗(yàn)性地治療性伴侶simultaneously/empircallyIfsymptomaticpregnantwoman,treatwithmetronidazoleorally500mgbidfor5-7days

懷孕患者如有癥狀，口服甲硝唑500mg每日2次連服5-7天45編輯版pptOtherinfectionscausingvaginitis

其它導(dǎo)致陰道炎的感染Staphylococcusaureus金黃色葡萄球菌Ulcerativevaginitiswithtoxicshocksyndrome潰瘍性陰道炎，中毒性休克綜合癥TSSStreptococcalvaginitis鏈球菌陰道炎GroupAstrep–uncommoncause甲型鏈球菌，少見陰道感染Mothersofinfectedchildren感染的兒童的母親Symptomsarepurulentdischargeandirritationanderythema膿性分泌物，外陰刺激感和發(fā)紅GroupBstrep乙型鏈球菌Colonizesvaginaandcancauseneonatalsepsisandmaternalendometritis定植于陰道，可致新生兒敗血癥和母體子宮內(nèi)膜炎Controversialifitisapathogeninthevagina對(duì)于乙鏈?zhǔn)欠袼阋环N陰道病原體，尚存爭(zhēng)議46編輯版pptAtrophicvaginitis萎縮性陰道炎PerimenopausalandMenopausalWomen圍絕經(jīng)期和絕經(jīng)后婦女Canbeinlactatingwomen也可在哺乳婦女Upto40%ofMenopausalwomen>40%絕經(jīng)后婦女SideEffectofMedications=Tamoxifen,Lupron藥物副作用－它莫西芬，柳菩林Cigarettesmokingmakesitworse吸煙加重47編輯版pptTreatmentofAtrophicVaginitis

萎縮性陰道炎治療Estrogen雌激素Topical外用Oral口服Combinedwithprogesteroneifchronictreatmenttoprotectagainstendometrialcancer若長(zhǎng)期治療應(yīng)與孕酮聯(lián)合避免內(nèi)膜癌Lubricants陰道潤(rùn)滑劑48編輯版pptIrritantorContactVaginitis

刺激性或接觸性陰道炎Irritant/Contactvaginitisandvulvitis非感染性陰道炎/外陰炎Irritants–minipads,spermicides,iodine,soaps,perfumes,tampons,condoms,laundrydetergent刺激物－衛(wèi)生護(hù)墊，殺精劑，碘，皂，香水，衛(wèi)生棉球，安全套，洗滌劑Mildtosevereitching輕重不等的搔癢Burningsensation燒灼感Looksredandirritatedandcanhaveexcoriations局部發(fā)紅，可有抓痕49編輯版pptTreatmentofirritantvaginitis

刺激性陰道炎的治療Removalofoffendingagent去除刺激物Sodiumbicarbonatesitzbaths小蘇打坐浴Topicalvegetableoils局部外敷植物油Notjustcorticosteroidsbecausethesecausemuchburning不要只給激素，因?yàn)檫@會(huì)造成較重的燒灼感50編輯版pptOthercausesofvaginaldischargeandvaginitis

其它導(dǎo)致陰道炎和陰道分泌物增多的情況Desquamativeinflammatoryvaginitis–perimenopausal

脫屑性炎性陰道炎－圍絕經(jīng)期Physiologicleukorrhea生理性白帶–1-4mls/24hours每日1～4mlpH4.4~4.5有一定pH與陰道酸堿度一致Cervicitis;chlamydiaandgonorrhea/PID

宮頸炎；衣原體和淋球菌性盆腔感染Fistula:pospartum,post-hysterectomy,IBD

陰道直腸瘺：產(chǎn)后，子宮切除術(shù)后，炎性腸病Cervicallesions:ectropion,endocervicalpolyps,granulationtissueandneoplasia

宮頸病變：外翻，宮頸內(nèi)息肉，肉芽組織和新生物Noninfectiousvaginitisandvulvitis非感染性陰道炎/外陰炎Irritants–minipads,spermicides,iodine,soaps,perfumes

刺激物－衛(wèi)生護(hù)墊，殺精劑，碘，皂，香水Allergens－latexcondoms,creams,seminalfluid

變應(yīng)原－橡膠避孕套，軟膏，精液lichenplanus

扁平苔蘚51編輯版pptVulvovaginalcomplaintsintheprepubertalchild

青春期前女性的外陰陰道疾病Specificinfections:特異性感染Pinworms蟯蟲Respiratoryflora–s.pyogenes呼吸道菌群，如化膿性鏈球菌Candida–overdiagnosed(3%)念珠菌，被過度診斷Bacterialvaginosis細(xì)菌性陰道病STD’s性傳播疾病Condylomaacuminata尖銳濕疣Nonspecificvulvovaginitis–25-75%非特異性感染Lackoflabialdevelopment陰唇發(fā)育不良Unestrogenizedthinmucosa未雌激素化的菲薄粘膜MorealkalinepH陰道pH（較成熟女性）偏堿性Poorhygiene個(gè)人衛(wèi)生差Bubblebaths盆浴Clothing衣物52編輯版pptGeneralApproach

一般接診步驟Symptoms癥狀Pruritis,irritation,burning,odor,dysuria

瘙癢

刺激感

燒灼感臭味排尿困難Sexualhistory性交史–newpartner

新性伴侶？Abdominalpain(PID)

腹痛(盆腔感染)Hygeine:pantyliners

衛(wèi)生:護(hù)墊Medications藥物:antibiotics/contraceptives/antifungals抗生素避孕藥

抗真菌藥Timingwithmenses

與月經(jīng)時(shí)間的關(guān)系Candidaisoftenpremenstrual

念珠菌感染通常在經(jīng)期前發(fā)生Trichomonasisoftenduringorrightaftermenses滴蟲感染通常在經(jīng)期當(dāng)中或之后53編輯版pptPhysicalExam

查體Vulva外陰–erythema,edema,fissureformationsuggestcadida,trichomoniasisordermatitis紅斑,水腫,龜裂，提示：念珠菌，滴蟲，皮炎Vulvardischarge外陰分泌物–unreliable并不可靠Greenishyellow黃綠色–trichomonas滴蟲Cottage-cheese豆腐渣樣–candida念珠菌Fishysmelling/grey魚腥味/灰色–bacterialvaginosis細(xì)菌性陰道病Cervicalinflammationvsectropion

宮頸炎癥vs宮頸外翻Abdominalorcervicalmotiontenderness盆腔痛或?qū)m頸舉痛GeneralApproach

一般接診步驟54編輯版pptVaginalpH陰道酸堿度–applytovaginalsidewall置于陰道側(cè)壁pH>5bacterialvaginosisortrichomonas細(xì)菌性陰道病或滴蟲感染pH4-5candida念珠菌感染Microscopywithin10-20minutesofcollection10~20分鐘內(nèi)鏡檢分泌物標(biāo)本Saline:

candidalbudsorhyphae在鹽水中見到念珠菌芽孢或菌絲Motiletrichomads游動(dòng)的滴蟲Cluecells線索細(xì)胞VaginalcultureandCervicalculture陰道/宮頸分泌物培養(yǎng)Diagnosticstudies

診斷檢查55編輯版pptScreeningforSexuallyTransmittedDiseases性病的篩檢HIV艾滋病病毒Gonorrhea淋球菌Chlamydia衣原體Trichomoniasis滴蟲Syphillis梅毒Herpessimplex1and2單純皰疹病毒HepatitisA,BandC甲乙丙型肝炎Humanpapillomavirus人乳頭瘤病毒HPV

56編輯版pptNormal正常BacterialVaginosis細(xì)菌陰道病Tricho-monas滴蟲Candida念珠菌VaginalpH陰道pH3.8-4.2>4.5>4.5<=4.5Discharge分泌物White白Thin,grey-whiteincreased增多，稀薄灰白Yellow,greenincreased增多，黃綠Whitecurdy白色豆腐渣Whifftest氨氣試驗(yàn)Absent無(wú)Presentfishy臭魚味Maybepresent可能有Absent無(wú)Maincomplaints主訴None無(wú)Discharge,odor,mayitch分泌物，氣味，可搔癢Excessdischarge,odor,itchy,dysuria分泌物大量，氣味，搔癢，尿痛Itchy,burning,discharge搔癢，燒灼，分泌物Microscopic鏡檢Lactobacilli,epithelialcells乳桿菌，上皮細(xì)胞Cluecellsw/adherentbacteria,0WBC’s線索細(xì)胞黏附著細(xì)菌，無(wú)WBCTrichomonadsWBC>10滴蟲，WBC>10Buddingyeast,hyapheandpseudohyphae–KOH出芽酵母，菌絲和假菌絲－KOH57編輯版pptQUESTION1Inapatientwithsuspectedbacterialvaginosisinfection,thepHisusually當(dāng)你懷疑病人有病菌性陰道炎時(shí)，她的陰道pH通常是多少？

a.)lessthan4小於4

b.)4-4.5

c.)5-6

d.)above66以上58編輯版pptQUESTION1Inapatientwithsuspectedbacterialvaginosisinfection,thepHisusually當(dāng)你懷疑病人有病菌性陰道炎時(shí)，她的陰道pH通常是多少？

a.)lessthan4小於4

b.)4-4.5

c.)5-6

d.)above66以上59編輯版pptQUESTION2Inapatientwithvaginaldischarge,whichofthefollowingcombinationscorrectlydiagnosesthesourceofinfection病人有白帶時(shí)，下列那種組合能正確的診斷出病因？

a.)historyandphysical,vaginalpH,wetmountmicroscopy,whifftest病史和理學(xué)檢查，陰道PH,溼凃片，析氨試驗(yàn)

b.)historyandphysicaland

wetmountmicroscopy病史和理學(xué)檢查和溼凃片

c.)