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MODULE 2 , scenario 1.
A woman, 30 year old, GIIIPIIA0 gravid 34 weeks, came to policlinic with chief complaint
flour albus greenish-yellowish with bad odors, itching, disuria and dispareunia.
Difficult word
Dyspareunia : pain during intercourse. There are 2 kinds :
Superficial: felt on the external genitalia.
Deep : felt internally.
Fluor albus : The whites; leucorrhea: secretion of the vagina.
Woman, 30 y.o
UK 34 weeks
Fluor Albus
Bad Odor
1. Explain anatomy, physiology, biochemistry of female genital organs
2. Explain patomechanism of formatiom fluor albus
3. Types of Fluor Albus
4. Patomechanism itching and bad odor
5. Relationship between fluor albus with pregnancy
6. Patomechanism of dispareunia
7. Patomechanism of dyuria related to case
8. Additional anamnesis + supporting examination
9. DD
1. Explain anatomy, physiology, biochemistry of female genital organs.
Before discussing vaginal discharge, it is important to have a basic understanding of
the female reproductive anatomy. Vaginal discharge is not usually noticeable until it exits
the vagina, which is the passage from the uterus to the outside of the body. At the top
end (inside) of the vagina is the cervix, while the lower end (outside) leads to the vulva
and labia. The vulva is the name for the skin around the vaginal opening.

Vaginal discharge is made by the skin cells of the vagina and cervix under the
influence of the female hormone, estrogen. Women who are menopausal normally have
minimal vaginal discharge as a result of lower levels of estrogen.
In women who are premenopausal, it is normal to have about one-half to one
teaspoon of white or clear, thick, mucus-like, and mostly odorless vaginal discharge
every day. However, the amount and consistency of the discharge varies from one
woman to another. The amount can also vary at different times during the menstrual
cycle. It may become more noticeable at certain times, such as during pregnancy, with
use of birth control pills/patch/vaginal ring, near ovulation, and in the week before the
menstrual period.
Normally, discharge contains vaginal skin cells, bacteria, and mucus and fluid
produced by the vagina and cervix. A normal discharge often has a slight odor and may
cause mild irritation of the vulva. This discharge helps to protect the vaginal and urinary
tract against infections and provides lubrication to the vaginal tissues.
External genitalia (vulva)

Mons pubis fatty rounded area

labia majora elongated fatty skin folds

labia minora fat free folds ofskin. Contain someerectile tissue

Vestibule area between the labiaminora. Urethra & vagina open here. Vaginal
orificein virgins is covered with a incomplete membrane (hymen)
Clitoris composed of erectile tissue. Very sensitive hooded by the prepuce of the
Greater vestibular glands situated at the vaginal orifice in the superficial perineal
space. Ducts open to vestibule. Secretions lubricate the vulva.
Uterine cervix
Less smooth muscles
More dense connective tissue (85%)
Supra vaginal part lined by columnar epitheliums with mucous glands

Mucus acts as a barrier for bacteria and lubricate the vagina

Vaginal part is lined by a stratified squamous epithelium

The wall has three layers
1. Outer fibroelastic adventia usually vagina is collapsed But can expand
enormously during child birth and intercourse
2. Muscular layer mainly longitudinal smooth muscles
3. Mucosa Stratified squamous epithelium no glands ( lubricated by cervical glands)
Glycogen is metabolized to lactic acid by normal vaginal bacteria
Vaginal acidity prevents infections
Vaginal discharges composition:
Water,pyridine,squelene,urea,acetic acid,lactic acid,complex
alcohol & glycol,aldehydes
Consistency, texture, taste, colour, odor depend on :
Inection,genetic,diet,menstrual cycle,sexual arousal
pH: 3.8-4.5 (contrast to male semen, 7.2-8.0)

2. Explain patomechanism of formatiom fluor albus.

Ecosystem of the vagina controlled by main factor which is estrogen and
Lactobacillus bacteria or bacteria that does not affect vagina. Estrogen function as the
precursor of the glucose a energy resources in the body (glycogen). Glycogen nourish
the Lactobacillus bacteria which will be metabolized for the growth. The products
produced are lactic acid which maintain the acidity of the vagina (3.8-4.2). At the same
time, there is no place for the pathogen to growth. When there is disruption of the
ecosystem of the vagina, which causes the acidity to decreased, protection from the
bacteria will also decrease and high susceptibility for the infection. The infection will
causes the number of pathogen to overcome the Lactobacillus bacterias number that
will lead to the fluor albus.

Disturbance of
the ecosystem
of the vagina

susceptibility to
the infection

Fungal & other

bacteria starts
to grow

Causes flour

Changes of the
acidity of the

Stress in
number of the
flora normal

Causes of fluor albus

Oral contraception.
Diabetes mellitus.
Mestrual blood.
Hormonal imbalance.

3. Types of Fluor Albus.

occurs in the fertile, well before and after
menstruation, can be found on newborn until
the age of about ten days, when menarche,
adult woman when she is stimulated before
and during coitus (coitus), the time of
ovulation in women with chronic diseased
ektropion porsionis uteri
color is clear or slightly whitish(milky)

because the infection in the vagina, the
presence of foreign objects into the vagina or
hormonal disturbances due to menopause,
inherited disorders of the female genitals, the
malignancy / cancer. Infection can be as a
result of bacteria, fungi or protozoa

the color of cream, or yellowish green, or

even mixed with blood, when Fluor Albus
had become a disease.
does not itch and odorless
itchy in the vaginal area, and smelling
mucus, causing an uncomfortable feeling
sometimes a mucous epithelium containing more leukocytes
many rare with leukocytes


Itching :
Nociceptive sensory neurons with small diameter nerve fibers are responsive to noxious
stimuli. A subset of nociceptive nerve fibers that terminate in the skin, respond to one or
more chemicals that make us itch. These neurons are termed pruriceptive (from the latin
word, prurere, to itch) whereas nociceptive neurons that do not respond to itchy chemicals
are called nociceptive specific. Both types of neurons project to pathways in the central
nervous system.

Itch can be prompted by diverse stimuli, including light touch, vibration, and wool fibers.
There are a number of chemical mediators as well as different mechanisms by which the
sensation of itch occurs. Mediators: Histamine is one of the most significant mediators. It is
synthesized and stored in mast cells in the skin and is released in response to various
stimuli. Other mediators (eg, neuropeptides) can either cause the release of histamine or act
as pruritogens themselves, thus explaining why antihistamines ameliorate some cases of
itching and not others. Opioids have a central pruritic action as well as stimulating the
peripherally mediated histamine itch.
Mechanisms: There are 4 mechanisms of itch:
Dermatologictypically caused by inflammatory or pathologic processes (eg, urticaria,

Systemicrelated to diseases of organs other than skin (eg, cholestasis)

Neuropathicrelated to disorders of the CNS or peripheral nervous system (eg, multiple


Psychogenicrelated to psychiatric conditions


The bad bacteria convert nitrogen into ammonia compounds, thereby causing the
foul ammonia odor
The overgrowth of anaerob microorganism produce proteolytic enzymes that act on
vaginal peptides to release several biologic products, including polyamines, which
volatize in the accompanying alkaline environment to elaborate foul-smelling
5. Relationship between fluor albus with pregnancy.


on body

Estrogen ,
n cairan
berlebih di
vagina ->
Fluor albus

6. Patomechanism of dispareunia .
The medical term for painful intercourse is dyspareunia); which is defined as persistent or
recurrent genital pain that occurs just before, during or after intercourse.
Physical causes of painful intercourse tend to differ, depending on whether the pain occurs
at entry or with deep thrusting. Emotional factors can be associated with many types of
painful intercourse.
Entry pain
Pain during penetration may be associated with a range of factors, including:

Insufficient lubrication. This is often the result of not enough foreplay. Insufficient
lubrication is also commonly caused by a drop in estrogen levels after menopause,
after childbirth or during breast-feeding. In addition, certain medications are known to
inhibit desire or arousal, which can decrease lubrication and make sex painful. These
include antidepressants, high blood pressure medications, sedatives, antihistamines
and certain birth control pills.
Injury, trauma or irritation. This includes injury or irritation from an accident, pelvic
surgery, female circumcision, episiotomy or a congenital abnormality.
Inflammation, infection or skin disorder. An infection in your genital area or
urinary tract can cause painful intercourse. Eczema or other skin problems in your
genital area also can be the problem.
Vaginismus. Involuntary spasms of the muscles of the vaginal wall (vaginismus) can
make attempts at penetration very painful.

Deep pain
Deep pain usually occurs with deep penetration and may be more pronounced with certain
positions. Causes include:

Certain illnesses and conditions. The list includes endometriosis, pelvic

inflammatory disease, uterine prolapse, retroverted uterus, uterine fibroids, cystitis,
irritable bowel syndrome, hemorrhoids and ovarian cysts.
Surgeries or medical treatments. Scarring from surgeries that involve your pelvic
area, including hysterectomy, can sometimes cause painful intercourse. In addition,
medical treatments for cancer, such as radiation and chemotherapy, can cause
changes that make sex painful.

Emotional factors
Emotions are deeply intertwined with sexual activity and may play a role in any type of
sexual pain. Emotional factors include:

Psychological problems. Anxiety, depression, concerns about your physical

appearance, fear of intimacy or relationship problems can contribute to a low level of
arousal and a resulting discomfort or pain.
Stress. Your pelvic floor muscles tend to tighten in response to stress in your life.
This can contribute to pain during intercourse.
History of sexual abuse. Most women with dyspareunia don't have a history of
sexual abuse, but if you have been abused, it may play a role.

7. Pathophysiology dysuria.

Dysuria is painful or uncomfortable urination, typically a sharp, burning sensation. Some
disorders cause a painful ache over the bladder or perineum. Dysuria is an extremely
common symptom in women, but it can affect men and can occur at any age.
Dysuria results from irritation of the bladder trigone or urethra. Inflammation or stricture of
the urethra causes difficulty in starting urination and burning on urination. Irritation of the
trigone causes bladder contraction, leading to frequent and painful urination. Dysuria most
frequently results from an infection in the lower urinary tract, but it could also be associated
with an upper UTI. Impaired renal concentrating ability is the main reason for frequent
urination in upper UTIs.
Symptoms of dysuria
Dysuria have various symptoms such as:
Hematuria, or blood in the urine
Urinary frequency
Urinary hesitation
Urinary slowness
Vaginal discharge
Dyspareunia, or pain during sexual intercourse
Abnormal vaginal bleeding.
Urinary urgency
Urethral discharge
Vaginal infection may be suspected if the pain occurs as urine passes over the labia. Pain
inside the body suggests urethritis or cystitis. If the pain occurs at the onset of urination, then

it's usually caused by inflammation of the urethra but if it occurs after urination, then bladder
infection may be the cause. Other signs and symptoms that may accompany dysuria also
help the clinician determine the underlying cause.

8. Additional anamnesis?
In order to confirm the diagnosis of the patient, we have to ask some additional question.
This will exclude all the possibilities of other diagnosis. For example, What is her
occupation? Is she still having sexual relationship with her partner while in pregnant?
History of the other disease? Such as diabetes mellitus. Is she have ever use
contraception pill? Is she have ever consumed antibiotics?

Differential diagnosis:




Woman, 30 y.o

UK 34 weeks

Fluor Albus : greenishyellowish

Bad Odor




*our most suitable diagnosis is TRICHOMONIASIS VAGINALIS


An infection caused by Trichomonas


Generally caused by sexual intercourse.

Frequently attacks the lower urogenital

tract of women and men.

Clinical Findings
In Women :
Complain of a malodorous, yellow-green vaginal discharge, foamy and smell
Vulvar pruritus and erythema,
Bleeding post coitus, cervicitis.
Erythematous and edema of the vagina and cervix strawberry cervix
Dysuria, dyspareunia.
Lower abdominal pain
Infection tends to occur in sexually active women

In Men:
Trichomonas vaginalis was found in the urethra.
Itching and irritation in the urethra
Pain after coitus
Pain in the abdomen

Laboratory Test
Vaginal pH> 4.5
Direct preparations vaginal dischage with physiological solution and in check
with microscopic
Gram staining
Acridine orange staining
Serology: ELISA, Imunofluorecent antibody, latex aglutination, PCR

On Women:
Premature birth
Postpartum endometritis
Abscess bartholini
In Men
Urethral stricture
Affect fertility
Phimosis, namely in patients who are not in circumcision
Recommended :
Metronidazole 2 g single oral dose.
Metronidazole 500 mg twice a day for 7 days.
Metronidazole 2 g single dose for 3-5 days.
Local treatment:
Clotrimazole cream 1% for 7 days.
Vaginal tablet 100 mg 1 tablet once a day for 7 days.
Examination and treatment along with the couple.
Do not coitus during treatment
It is advisable to use condoms
Trichomoniasis vaginalis is an infection caused by T.vaginalis, and generally
caused by sexual intercourse.
In women usually complain of a malodorous, yellow-green vaginal discharge,
foamy, smell, vulvar pruritus and erythema
Laboratory test : vaginal pH> 4.5, direct preparations vaginal dischage, gram
staining, culture and serology
Examination and treatment along with the couple