Clinical Assessment of the Vagina Dr Helen Wemyss Obstetrician and Gynaecologist

Wikipedia "vagina" Latin word meaning "a sheath or scabbard“ a scabbard into which one might slide and sheath a sword ( "sword" was the penis)

Definitions of Vagina Medical Definition Muscular canal from the hymen (or remnants) to the cervix Legal Definition Begins at the vulva – between the labia

Clitoral Hood and Clitoris Labia minora Urethral opening Vaginal Opening

Vaginal Functions Pathway for menstruation Sexual and reproductive function Old fashioned way to have a baby Microbiota/ commensals

Microbiota Dynamic ecosystem of mutually symbiotic flora of microorganisms Undergoes change over life time -neonate-puberty-menarche-menopause -pH 7- 4-7 -influenced by glycogen, oestrogen and lactobacilli -acidic environment helps keep pathogenic bacteria at bay And cyclical change- fluctuating hormones

Vaginal Microbiome Maybe important for gut colonisation of the baby and prevention of childhood disease eg asthma Seeding from vaginal swab for babies born by elective LUSCS

Normal Vaginal Secretions White, non-irritant, mucoid Affected by -life cycle – prepubertal, reproductive, post- menopausal -monthly cycle -pre or post ovulatory - exogenous hormones – contraception - pregnancy -disruption of normal microbiome

Physiological Reproductive Secretions

Abnormal Vaginal Discharge “Normal” is highly variable in volume Discharge is a poor predictor of STI

Abnormal Vaginal Discharge 1 Creamy discharge Vulvitis/vaginitis

Candidiasis Creamy discharge Vulvitis/vaginitis

Abnormal Vaginal Discharge 2 Offensive frothy discharge +/- vulvitis/vaginitis

Trichomonas Offensive frothy discharge +/- vulvitis/vaginitis Skin irritation May well be asymptomatic STI – co-exists with chlamydia Strawberry cervix

Trichomonas Protozoa Treat with Metronidazole (Flagyl) Treat sexual partner (s)

Abnormal Vaginal Discharge 3 Malodorous, grey, frothy discharge No vulvitis or vaginitis

Bacterial vaginosis Malodorous, grey, frothy discharge No vulvitis or vaginitis Increase in anaerobic bacteria, loss of lactobacilli (increase in pH) Gardnerella vaginalis Treat with metronidazole

Normal Cervix

Cervicitis (Inflammation of Cervix) Infective/STIs, Chlamydia, Gonorrhoea, HSV Douching/irritants HPV, warts Retained tampon

Nabothian Follicle

Blood Stained Discharge Benign conditions -vaginal atrophy, uterine polyp, cervical polyp -infection or inflammation

Vaginal Intraepithelial Neoplasia (VAIN) Can be picked up on a cervical smear If colposcopy of cervix is normal need to look elsewhere!

Vulval Warts

Vaginal Cancer

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