阴道感染及阴道炎

谢医师简介Americanboard-certifiedfamilyphysicianpracticingmedicineinBeijingforthelast7yearsatBJU.Ihad7yearsexperiencebeforethatintheU.S.andNewZealandinprivatepractice.Iammarriedwith2sons.

IhavewantedtobeafamilyphysiciansinceIwas4yearsold.美国家庭科执照医师，近7年在BJU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1编辑版pptVaginalInfectionsandVaginitis

阴道感染及阴道炎

Dr.MarieShieh谢美虹医师FamilyPhysician全科医师2编辑版pptVaginalandGenitalInfections

andIrritationsBacterialvaginosis细菌性阴道病CandidaVaginitis念珠菌性阴道炎Trichomonasvaginitis滴虫阴道炎AtrophicVaginitis萎缩性/老年性阴道炎StreptococcalVaginitis链球菌阴道炎DesquamativeInflammatoryVaginitis炎性脱屑性阴道炎NoninfectiousVaginitis非感染性阴道炎Cervicitis宫颈炎3编辑版pptGeneralApproach

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Sexualhistory性交史–newpartner

新性伴侶？Abdominalpain(PID)

腹痛(盆腔炎)Hygeine:pantyliners

卫生:护垫Medications药物:antibiotics/contraceptives/antifungals抗生素避孕药

抗真菌药Timingwithmenses

与月经时间的关系Candidaisoftenpremenstrual

念珠菌感染通常在经期前发生Trichomonasisoftenduringorrightaftermenses滴虫感染通常在经期当中或之后4编辑版pptVaginalsymptoms症状Vaginaldischarge白带增多Pruritisoritching瘙痒Soreness疼痛Burning烧灼感Odor臭味Dyspareunia–painwithintercourse性交痛Bleeding出血Dysuria–painwithurination尿痛5编辑版pptPhysicalExam

查体Vulva外阴–erythema,edema,fissureformationsuggestcadida,trichomoniasisordermatitis红肿龟裂，提示：念珠菌，滴虫，皮炎Vulvardischarge阴门分泌物–unreliable并不可靠Greenishyellow黄绿色–trichomonas滴虫Cottage-cheese豆腐渣样–candida念珠菌Fishysmelling/grey鱼腥味/灰色–bacterialvaginosis细菌性阴道病Cervicalinflammationvsectropion宫颈炎症vs宫颈外翻Abdominalorcervicalmotiontenderness宫颈举痛GeneralApproach

一般接诊步骤6编辑版pptCervicalectropionvscervicitis

宫颈外翻vs宫颈炎7编辑版pptDiagnosticstudiesVaginalpH阴道酸碱度–applytovaginalsidewall置于阴道侧壁pH>5bacterialvaginosisortrichomonaspH值大于5细菌性阴道病或滴虫感染pH4-5candidapH值在4-5念珠菌感染Microscopywithin10-20minutesofcollection10~20分钟内镜检分泌物标本Saline:

candidalbudsorhyphae在生理盐水中看到念珠菌芽孢或菌丝Motiletrichomads游动的滴虫Cluecells线索细胞VaginalcultureandCervicalculture阴道/宫颈分泌物培养8编辑版pptpHVaginalpH阴道酸碱度–applytovaginalsidewall置于阴道侧壁pH>5bacterialvaginosisortrichomonaspH>5细菌性阴道病或滴虫感染pH4-5candidapH4-5念珠菌感染9编辑版pptWetMount,ProbeandCulture

湿涂片，探针，培养Swabinsidecervicalosforchlamydia拭子伸入宫颈口，检测衣原体Wetmount湿涂片10编辑版pptPatient1病人140yearoldwoman40岁女患者“Fishy-smelling”vaginaldischarge带鱼腥味白带Worseaftersexualintercourse性交后更严重Cigarettesmoker吸烟Intrauterinedevice(IUD)宫内节育器Nopainoritching不痛不痒11编辑版pptBacterialVaginosis

细菌性阴道病Mostcommoncauseofvaginitisinwomenofchildbearingage生育年龄女性最常见的阴道炎10-35%incidencedependingongroup发病率随不同人群而不同，10-35%Highprevalenceinwomen-womensexualrelations女同性恋人群发病率高Riskfactors危险因素:earlyageofcoitus性交年龄早,multiplepartners多性伴,smoking吸烟,douching阴道冲洗,IUD宫内节育器12编辑版pptBacterialVaginosis–Microbiology

细菌性阴道病—微生物学Notasingleorganism非单一致病菌Complexchangesinflora复杂的菌群改变Reductioninlactobacilli乳酸杆菌属减少IncreaseinGardnerella加德诺菌属,Moiluncus,Mycoplasma支原体,AnaerobicGram(-)rodslike革兰阴性厌氧菌，如：Prevotella,Porphyromonas,Atopobium,Bacteroides类杆菌属,andPeptostreptococcus消化链球菌属13编辑版pptBacterialVaginosis–Diagnosis

细菌性阴道病—诊断AMSTELCRITERIA诊断标准3outof4以下4条满足3条Homogenous,thingrayish-whitedischargethatsmoothlycoatsthevaginalwalls均质，淡灰白色分泌物均匀覆盖阴道壁VaginalpH阴道pH值>4.5Whiff-aminetest–10%KOHfishyodor析氨试验－分泌物加入10％KOH后散发出鱼腥臭味Cluecellsonsalinewetmount盐水湿涂片找到线索细胞14编辑版pptBacterialVaginosis

细菌性阴道病Grey,whiteliquidwithfishyodor带鱼腥味的灰白色液体15编辑版pptCLUECELLS线索细胞Vaginalepithelialcellsstuddedwithcoccobacilli.Atleast20%ofcells.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%16编辑版pptBacterialVaginosis–Diagnosis

细菌性阴道病—诊断Gramstain革兰氏染色

–cumbersome麻烦Sensitivity敏感性90-100%PAPsmearisNOTreliable宫颈涂片检查不可靠Sensitivity敏感性is49%,Specificity特异性93%DNAprobesandpH>4.5DNA探针和pH>4.5Sensitivity敏感性95%Specificity特异性99%Vaginalculture阴道分泌物培养–“norole”没用G.vaginalispositiveinalmostallcase阴道革兰氏菌几乎在所有BV患者中阳性（即敏感性100％）Butpositivein50-60%asymptomaticwomen但在50～60％无症状女性中也为阳性（特异性不够）17编辑版pptGramstain

革兰氏染色Normalvaginalsecretionsgramstain正常阴道分泌物Bacterialvaginosisgramstain细菌性阴道病18编辑版pptBacterialVaginosis–Treatment

细菌性阴道病—治疗BVresolvesspontaneouslyinupto1/31/3的细菌性阴道病可自愈Treatmentonlyforsymptomaticwomenor有症状的病人才需要治疗或者Asymptomaticwomenwhohavehadinfectionpriortoabortion,hysterectomyor在流产或子宫切除前有阴道感染史的无症状者Asymptomaticpregnantwithpreviouspretermlabor–screeningcontroversial有早产史的无症状者–是否筛检，尚有争议19编辑版pptBacterialVaginosis–Treatment

细菌性阴道病—治疗Metronidazoleisthemostsuccessfultherapy甲硝唑是最有效的药Metronidazoleoral500mgbidfor7daysor750mgdailyfor7days口服甲硝唑500mg每天两次或750mg每天一次，连服7天90%earlycure90%初期即治愈,80%after4weeks80%4周后治愈Sideeffects副作用:metallictaste,cannotdrinkalcohol(disulfuramreaction)金属味,不能喝酒（戒酒硫反应）Metronidazolevaginal阴道用甲硝唑0.75%gel,5gramsoncedailyfor5days0.75%凝胶5g，每日1次连用5日200mgvaginaltablets1bidfor5days200mg阴道栓剂，每日2次连用5日20编辑版pptBacterialVaginosis–AlternativeTreatments

细菌性阴道病－其它治疗2%Clindamycincreamdailyfor7days2％克林霉素软膏，每日涂抹连用7日Ledtoclindamycinresistance54%vs17%after90days

导致克林霉素耐药用药90天以后54％比17％Noresistancewithmetronidazole

甲硝唑不发生耐药OralClindamycin300mgbidfor7days

口服克林霉素300mg每日2次连用7日Ampicillinoramoxicillin–66%cure氨苄青霉素或阿莫西林－治愈率66％Triple-sulfacreams,erythromycin,tetracylcine,aceticacidgeliodinedouchessignificantlylesseffectivethanmetronidazoleandclindamycin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Noevidenceforlactobacillussuppositories乳酸杆菌栓剂疗效，尚缺证据Noevidencetotreatpartners性伴侣治疗，尚缺证据21编辑版ppt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

22编辑版pptBacterialVaginosis–Treatment

细菌性阴道病—治疗Relapse复发30%initialresponsewillrelapsein3months30％初愈3个月内会复发50%willrelapsein12months50%12个月内会复发Treatmentofsymptomaticrecurrenceisprolongedtherapy10-14dayswithadifferentregimenthaninitiallygiven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Suppressivetherapycanbegivenwithvaginalmetronidazoledailyfor10daysandthentwiceweeklyfor3-6months–canleadtocandida

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23编辑版pptBacterialVaginosisinPregnancy

妊娠期间细菌性阴道病Cochranereviewof10trialsof4249pregnantwomen–nodifferenceinpretermbirthwithorwithouttreatmentforBVCochrane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–Subgroupofwomenwithhistoryofpretermbirth–treatmentofBVreducedpretermprelaborruptureofmembranes但是,在有早产史的孕妇人群中—治疗可减低胎膜早破的几率24编辑版pptTreatmentofHighRiskPregnantPatients

高危妊娠患者的治疗MetronidazoleORAL400mgbidfor2daysandrepeatifstillpositiveafter4weeks【Br.ObstetGyn1997;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MetronidazoleORAL250mgtidfor7days–nosecondtreatment【NEJM1995;333:1732】

口服甲硝唑250mg每天3次连服7天－无需重复治疗MetronidazoleORAL250mgtidfor7daysplusErythromycin333mgtiefor14days.Repeattestat28weeksgestationandrepeattreatmentifstillpositive【AmJObGyn1994;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25编辑版pptPatient235yearoldwomanonoralcontraceptiveswhohashaditchinessinhervulvaforthepast4days.Shehashadsomeburningwithurinationaroundhervulva.Shetookantibioticsfora“cold”1weekago.Shehashadasmallamountofwhite,cottagecheese-likedischarge.Sheismonogamouswithherhusband.26编辑版ppt病人235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27编辑版pptCandidaVaginitis

念珠菌阴道炎1/3ofallvaginitiscases占所有阴道炎的1/3Candidaisinthelowergenitaltractof20-50%ofhealthyasymptomaticwomen

念珠菌存在于20-50%健康五症状女性的下生殖道Candidaalbicans80-92%ofallcases

所有阴道炎中，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药,pregnancy怀孕,estrogenuse使用雌激素

Immunosuppression/Steroids免疫抑制/激素28编辑版pptCandialvaginitis念珠菌阴道炎

–SignsandSymptoms

症狀和体征Vulvarpuritus/Itching外阴瘙痒Dysuria排尿困难

–externalorvulvar外阴Soreness酸痛,irritation不舒服,dyspareunia性交痛Nodischargeorlittledischargethatisclumpywhitedischarge无白带或少许块状白色分泌物Examshowserythemaofthevulvaandvaginalmucosawiththewhiteclumpydischarge妇检可见外阴和阴道粘膜发红，且有白色块状分泌物29编辑版pptCandidalvaginitis

念珠菌阴道炎

Clumpy,whitedischarge白色块状分泌物30编辑版pptCandidalVaginitis–Diagnosis

念珠性阴道炎–诊断VaginalpH4-4.5–normal阴道pH值4-4.5--正常Wetmount+KOHshowsbuddingyeastandhyphae湿涂片+KOH可见芽孢和菌丝Microscopyisnegative50%镜检50%阴性CultureisrecommendedifmicroscopyisnegativeandpHisnormal如镜检(-)且pH正常，推荐做阴道分泌物培养Selfdiagnosiscanleadtoalargenumberofmisdiagnosis患者的自我诊断可能造成大量的误诊－Sobel.AmJObGyn1985152:92431编辑版pptWetmount/KOHincandidiasis

念珠菌阴道炎的KOH湿涂片32编辑版pptMoremicroscopiccandida

显微镜下的念珠菌Hyphaeandbuddingyeast

菌丝和芽孢33编辑版pptDifferentialDiagnosis鉴别诊断Hypersensitivityreactions超敏反应AllergicorChemicalreactions过敏或化学反应ContactDermatitis接触性皮炎Insufficientlubricationwithcoitus性交时不够润滑34编辑版pptRecurrentcandidalvaginitis

反复性念珠菌阴道炎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阴道粘膜免疫功能异常/血型抗原Panty-liners,panty-hose,sexuallubricants卫生护垫，连裤袜，阴道润滑剂35编辑版pptCandidaVaginitis-Treatment

念珠菌阴道炎－治疗Umcomplicatedinfections无并发症的感染Sporadic,infrequent散发，偶发Mildtomoderatesymptomsandsigns症状体征轻至中度Healthyandnonpregnant健康非孕妇Oralmedicineispreferredbymostwomenbutcantake1-2dayslongertobeeffective.SideeffectsoffluconazoleareGIupset,headache

大多数患者愿意使用口服药物，但（比阴道用药）需多用1～2天才能见效。氟康唑的副作用有消化道不适和头痛。72hoursinvaginalsecretions阴道分泌物72小时内减少Topicalmedicinecanburn阴道局部用药会有烧灼感36编辑版pptCandidalVaginitis–Treatment

念珠菌阴道炎－治疗Complicatedinfections有并发症的感染Poorlycontrolleddiabetes糖尿病控制不佳Severesignsandsymptoms症状体征较重Candidaglabrata平滑念珠菌Pregnancy孕妇Recurrent–morethan4peryear复发性-每年超过4次7-14daysoftopicaltherapyor2sequentialfluconazole150gm72hoursapart

阴道局部用药7～14日,或口服氟康唑，序贯2次相隔3天，每次150mg37编辑版pptRoleofCleansingAgents

阴部清洁剂的使用Chlorhexadine:1articlesupportinguse

洗必泰：1篇文献主张使用BoricAcid-TreatmentofTorulopsisglabratavaginitis:retrospectivereviewofboricacidtherapy–ClinInfDis1997

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1997Povodineiodine

络合碘38编辑版pptTreatmentofCandidalVaginitis

念珠菌阴道炎－治疗Fluconazole150mgx1orrepeat72hoursforcomplicatedinfections氟康唑150mg顿服，若有并发症则3天后重复1次NOTrecommendedinpregnancy孕妇不推荐使用167RMB￥167Topicalazoles阴道局部使用的唑类Butoconazole2%cream5g/day–1daySR,3daysregularpreparation硝酸布康唑2%软膏,5g/天,用3天Clotrimazole1%cream5g/day7-14daysor100mgvaginaltabletdailyfor7days[500mgtabletatBJU147RMB]

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Miconazole2%creamfor7daysorsuppositoriesfor1,3and7days咪康唑2％软膏连用7日，或阴道栓剂1，3，7天

[200mgvaginaltabletsx7=85RMB]200mg阴道栓×7＝￥85[400mgvaginaltabletsx3=102RMB]400mg阴道栓×3＝￥10239编辑版pptTrichomonasvaginitis

滴虫性阴道炎4-35%ofvaginitis占阴道炎的4-35%Flagellatedprotozoan有鞭毛的原生动物Incubation4-28days潜伏期4-28天Alwayssexuallytransmitted大部分由性行为传染Inmen,limitedandtransientcarriage在男性为自限和暂时的携带状态10days–spontaneousresolution

通常10天内会自愈40编辑版pptTrichomonasvaginitis–signsandsymptoms滴虫性阴道炎－症状体征Asymptomatic无症状Purulent,malodorous,thindischarge70%脓性恶臭稀薄分泌物（70％）Burning,pruritis,dysuria,urinaryfrequencyanddyspareunia烧灼感，瘙痒，尿痛，尿急，性交痛Postcoitalbleeding性交后出血Erythemaofvulvaandyellowfrothydischarge10-30%.“Strawberry”cervix=punctatehemorrhagesonvaginaandcervix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（10～30％）41编辑版pptFrothy,foulsmellingdischarge

多泡，臭味的分泌物42编辑版pptTrichomonasVaginitis–Diagnosis

滴虫性阴道炎－诊断CultureonDiamond’smediaDiamond培养基阴道分泌物培养

sensitivityand>95%specificity

敏感性95％特异性>95％RapidTests:DNAprobesnotavailableintheU.S.快速检测：DNA探针，美国目前无此检查项目Cervicalcytology:60-70%Sensitivitythoughliquidbasedpapsare99%specific

宫颈细胞学检查：敏感性低60～70％，但“液基PAP”特异性高99％MicroscopyandpH镜检和pHpH5-6稍高于正常阴道pHMotiletrichomonads镜下找到游动的滴虫43编辑版pptTrichomonasvaginalis

滴虫性阴道炎Seeflagella可见鞭毛44编辑版pptTrichomonasVaginitis–Treatment

滴虫性阴道炎－治疗MetronidazoleORAL2grams

甲硝唑，口服，2gTinidazole-?BetterORAL2grams

替硝唑，最好口服，2gCurerates治愈比率达85-90%Treatmalepartners同时也要经验性地治疗性伴侣simultaneously/empircallyIfsymptomaticpregnantwoman,treatwithmetronidazoleorally500mgbidfor5-7days

怀孕患者如有症状，口服甲硝唑500mg每日2次连服5-7天45编辑版pptOtherinfectionscausingvaginitis

其它导致阴道炎的感染Staphylococcusaureus金黄色葡萄球菌Ulcerativevaginitiswithtoxicshocksyndrome溃疡性阴道炎，中毒性休克综合症TSSStreptococcalvaginitis链球菌阴道炎GroupAstrep–uncommoncause甲型链球菌，少见阴道感染Mothersofinfectedchildren感染的儿童的母亲Symptomsarepurulentdischargeandirritationanderythema脓性分泌物，外阴刺激感和发红GroupBstrep乙型链球菌Colonizesvaginaandcancauseneonatalsepsisandmaternalendometritis定植于阴道，可致新生儿败血症和母体子宫内膜炎Controversialifitisapathogeninthevagina对于乙链是否算一种阴道病原体，尚存争议46编辑版pptAtrophicvaginitis萎缩性阴道炎PerimenopausalandMenopausalWomen围绝经期和绝经后妇女Canbeinlactatingwomen也可在哺乳妇女Upto40%ofMenopausalwomen>40%绝经后妇女SideEffectofMedications=Tamoxifen,Lupron药物副作用－它莫西芬，柳菩林Cigarettesmokingmakesitworse吸烟加重47编辑版pptTreatmentofAtrophicVaginitis

萎缩性阴道炎治疗Estrogen雌激素Topical外用Oral口服Combinedwithprogesteroneifchronictreatmenttoprotectagainstendometrialcancer若长期治疗应与孕酮联合避免内膜癌Lubricants阴道润滑剂48编辑版pptIrritantorContactVaginitis

刺激性或接触性阴道炎Irritant/Contactvaginitisandvulvitis非感染性阴道炎/外阴炎Irritants–minipads,spermicides,iodine,soaps,perfumes,tampons,condoms,laundrydetergent刺激物－卫生护垫，杀精剂，碘，皂，香水，卫生棉球，安全套，洗涤剂Mildtosevereitching轻重不等的搔痒Burningsensation烧灼感Looksredandirritatedandcanhaveexcoriations局部发红，可有抓痕49编辑版pptTreatmentofirritantvaginitis

刺激性阴道炎的治疗Removalofoffendingagent去除刺激物Sodiumbicarbonatesitzbaths小苏打坐浴Topicalvegetableoils局部外敷植物油Notjustcorticosteroidsbecausethesecausemuchburning不要只给激素，因为这会造成较重的烧灼感50编辑版pptOthercausesofvaginaldischargeandvaginitis

其它导致阴道炎和阴道分泌物增多的情况Desquamativeinflammatoryvaginitis–perimenopausal

脱屑性炎性阴道炎－围绝经期Physiologicleukorrhea生理性白带–1-4mls/24hours每日1～4mlpH4.4~4.5有一定pH与阴道酸碱度一致Cervicitis;chlamydiaandgonorrhea/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Cervicallesions:ectropion,endocervicalpolyps,granulationtissueandneoplasia

宫颈病变：外翻，宫颈内息肉，肉芽组织和新生物Noninfectiousvaginitisandvulvitis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Allergens－latexcondoms,creams,seminalfluid

变应原－橡胶避孕套，软膏，精液lichenplanus

扁平苔藓51编辑版pptVulvovaginalcomplaintsintheprepubertalchild

青春期前女性的外阴阴道疾病Specificinfections:特异性感染Pinworms蛲虫Respiratoryflora–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Bacterialvaginosis细菌性阴道病STD’s性传播疾病Condylomaacuminata尖锐湿疣Nonspecificvulvovaginitis–25-75%非特异性感染Lackoflabialdevelopment阴唇发育不良Unestrogenizedthinmucosa未雌激素化的菲薄粘膜MorealkalinepH阴道pH（较成熟女性）偏碱性Poorhygiene个人卫生差Bubblebaths盆浴Clothing衣物52编辑版pptGeneralApproach

一般接诊步骤Symptoms症狀Pruritis,irritation,burning,odor,dysuria

瘙痒

刺激感

烧灼感臭味排尿困難Sexualhistory性交史–newpartner

新性伴侶？Abdominalpain(PID)

腹痛(盆腔感染)Hygeine:pantyliners

卫生:护垫Medications药物:antibiotics/contraceptives/antifungals抗生素避孕药

抗真菌药Timingwithmenses

与月经时间的关系Candidaisoftenpremenstrual

念珠菌感染通常在经期前发生Trichomonasisoftenduringorrightaftermenses滴虫感染通常在经期当中或之后53编辑版pptPhysicalExam

查体Vulva外阴–erythema,edema,fissureformationsuggestcadida,trichomoniasisordermatitis红斑,水肿,龟裂，提示：念珠菌，滴虫，皮炎Vulvardischarge外阴分泌物–unreliable并不可靠Greenishyellow黄绿色–trichomonas滴虫Cottage-cheese豆腐渣样–candida念珠菌Fishysmelling/grey鱼腥味/灰色–bacterialvaginosis细菌性阴道病Cervicalinflammationvsectropion

宫颈炎症vs宫颈外翻Abdominalorcervicalmotiontenderness盆腔痛或宫颈举痛GeneralApproach

一般接诊步骤54编辑版pptVaginalpH阴道酸碱度–applytovaginalsidewall置于阴道侧壁pH>5bacterialvaginosisortrichomonas细菌性阴道病或滴虫感染pH4-5candida念珠菌感染Microscopywithin10-20minutesofcollection10~20分钟内镜检分泌物标本Saline:

candidalbudsorhyphae在盐水中见到念珠菌芽孢或菌丝Motiletrichomads游动的滴虫Cluecells线索细胞VaginalcultureandCervicalculture阴道/宫颈分泌物培养Diagnosticstudies

诊断检查55编辑版pptScreeningforSexuallyTransmittedDiseases性病的筛检HIV艾滋病病毒Gonorrhea淋球菌Chlamydia衣原体Trichomoniasis滴虫Syphillis梅毒Herpessimplex1and2单纯疱疹病毒HepatitisA,BandC甲乙丙型肝炎Humanpapillomavirus人乳头瘤病毒HPV

56编辑版pptNormal正常BacterialVaginosis细菌阴道病Tricho-monas滴虫Candida念珠菌VaginalpH阴道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，黄绿Whitecurdy白色豆腐渣Whifftest氨气试验Absent无Presentfishy臭鱼味Maybepresent可能有Absent无Maincomplaints主诉None无Discharge,odor,mayitch分泌物，气味，可搔痒Excessdischarge,odor,itchy,dysuria分泌物大量，气味，搔痒，尿痛Itchy,burning,discharge搔痒，烧灼，分泌物Microscopic镜检Lactobacilli,epithelialcells乳杆菌，上皮细胞Cluecellsw/adherentbacteria,0WBC’s线索细胞黏附着细菌，无WBCTrichomonadsWBC>10滴虫，WBC>10Buddingyeast,hyapheandpseudohyphae–KOH出芽酵母，菌丝和假菌丝－KOH57编辑版pptQUESTION1Inapatientwithsuspectedbacterialvaginosisinfection,thepHisusually當你懷疑病人有病菌性陰道炎時，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编辑版pptQUESTION1Inapatientwithsuspectedbacterialvaginosisinfection,thepHisusually當你懷疑病人有病菌性陰道炎時，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编辑版pptQUESTION2Inapatientwithvaginaldischarge,whichofthefollowingcombinationscorrectlydiagnosesthesourceofinfection病人有白帶時，下列那種組合能正確的診斷出病因？

a.)historyandphysical,vaginalpH,wetmountmicroscopy,whifftest病史和理學檢查，陰道PH,溼凃片，析氨试验

b.)historyandphysicaland

wetmountmicroscopy病史和理學檢查和溼凃片

c.)