The vagina, (from Latin, literally "sheath" or "scabbard" ) is the tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct. The Latinate plural (rarely used in English) is vaginae.

In common speech, the term "vagina" is often used inaccurately to refer to the vulva or female genitals generally; strictly speaking, the vagina is a specific internal structure and the vulva is the exterior genitalia only.

The human vagina is an elastic muscular canal that extends from the cervix to the vulva. Although there is wide anatomical variation the average vagina is 6 to 7 inches (15 to 18 cm) in length; its elasticity allows it to stretch during sexual intercourse and during birth to offspring. The vagina connects the superficial vulva to the cervix of the deep uterus.

If the woman stands upright, the vaginal tube points in an upward-backward direction and forms an angle of slightly more than 45 degrees with the uterus. The vaginal opening is at the caudal end of the vulva, behind the opening of the urethra. Above the vagina is Mons Veneris. The vagina, along with the inside of the vulva, is reddish pink in color, as with most healthy internal mucous membranes in mammals.

Vaginal lubrication is provided by the Bartholin's glands near the vaginal opening and the cervix. The membrane of the vaginal wall also produces moisture, although it does not contain any glands. Before and during ovulation, the cervix produces cervical mucus, which provides a favorable environment for sperm to survive.

The hymen is a membrane which is situated at the opening of the vagina. As with many female animals, the hymen covers the opening of the vagina from birth until it is ruptured during activity. The hymen may rupture during sexual or non-sexual activity. Vaginal penetration with the fingers, a dildo or penis, may rupture the hymen. A pelvic examination, injury, or certain types of exercises, such as horseback riding or gymnastics may also rupture the hymen. Sexual intercourse does not always rupture the hymen. Therefore, the presence or absence of a hymen does not indicate virginity or prior sexual activity.

Biological functions of the vagina:

Menstruation

The vagina provides a path for menstrual blood and tissue to leave the body. In modern societies, tampons, menstrual cups and sanitary towels may be used to absorb or capture these fluids.

Sexual activity

The concentration of the nerve endings that lie close to the entrance of a woman's vagina can provide pleasurable sensation during sexual activity, when stimulated in a way that the particular woman enjoys. During sexual arousal and particularly stimulation of the clitoris, the walls of the vagina self-lubricate, reducing friction during sexual activity.

An erogenous zone referred to commonly as the G-spot is located at the anterior wall of the vagina, about five centimeters in from the entrance. Some women experience intense pleasure if the G-spot is stimulated appropriately during sexual activity. A G-Spot orgasm may be responsible for female ejaculation, leading some doctors and researchers to believe that G-spot pleasure comes from the Skene's glands, a female homologue of the prostate, rather than any particular spot on the vaginal wall. Some researchers deny the existence of the G-spot.

Childbirth

During childbirth, the vagina provides the route to deliver the baby from the uterus to its independent life outside the body of the mother. During birth, the vagina is often referred to as the birth canal. The vagina is remarkably elastic and stretches to many times its normal diameter during vaginal birth.

Sexual health and hygiene

The vagina is a self-cleaning organ and needs no special treatment. Doctors discourage douching, which upsets the balance of vaginal flora, and may cause infection, including PID, or other problems. Betty Dodson addresses the self-consciousness that many women feel about the scent or flavor of their vaginal fluids in her writings, and encourages women to accept their bodies as normal and natural.

The vagina is examined during gynecological exams, often using a speculum, which holds the vagina open for visual inspection of the cervix or taking of samples (see pap smear).

Vulvovaginal disorders can affect the vagina, including vaginal cancer and yeast infections, as well as sexually transmitted infections.  [More info below ads]

1. Bacterial vaginosis (BV) is the most common cause of vaginal infection (vaginitis). For grammatical reasons, some people prefer to call it vaginal bacteriosis. It is NOT generally considered to be a sexually transmitted infection (see causes below). BV is caused by an imbalance of naturally occurring bacterial flora, and should not be confused with yeast infection (candidiasis), or infection with Trichomonas vaginalis (trichomoniasis) which are not caused by bacteria.

Symptoms and signs

The most common symptom of BV is an abnormal vaginal discharge (especially after sex) with an unpleasant fishy smell. There is rarely itching.Nearly half of all women with BV don't notice any symptoms. By contrast, a 'normal' discharge will be odourless and will vary in consistency and amount with your menstrual cycle - a normal discharge is at its clearest about 2 weeks before your period starts.

Diagnosis: for patients

When you go to your healthcare provider with questions about vaginal discharge, he or she will have several diagnoses in mind to account for it. These may include:

* The discharge is normal for you
* Candidiasis (thrush, or a yeast infection)
* Trichomonas vaginalis (trichomoniasis)
* Bacterial vaginosis

To find out which of these is the case, a few simple tests are done. The provider will carry out a speculum examination and take some swabs from high in the vagina. These swabs will be tested for:

* A characteristic smell—this is called the whiff test. A small amount of an alkali is added to a microscope slide that has been swabbed with the discharge—a 'fishy' odour is a positive result for bacterial vaginosis.
* Loss of acidity—the vagina is normally slightly acidic (with a pH of 3.8–4.2), which helps to control bacteria. A swab of the discharge is put onto litmus paper to check the acidity. A positive result for bacterial vaginosis would be a pH of over 4.5.
* 'Clue cells'—so called because they give a clue to the reason behind the discharge. These are epithelial cells (like skin) that are coated with bacteria. They can be seen under microscopic examination of your discharge.

2. A douche is a device used to introduce a stream of water into the body for medical or hygienic reasons, or the stream of water itself. The word comes from the French language, in which its principal meaning is a shower (it is thus a notorious false friend encountered by non-native speakers of English; the phrase for vaginal douching is douche vaginale, meaning vaginal shower).

The word can refer to the rinsing of any body cavity but usually applies to vaginal irrigation, rinsing of the vagina. A douche bag is a piece of equipment for douching: a bag for holding the water or fluid used in douching (the term douche bag can also be used as an insult; see below for slang uses). To avoid transferring intestinal bacteria into the vagina, the same bag must not be used for a vaginal douche and an enema.

Overview

Vaginal douches may consist of water, water mixed with vinegar, or even antiseptic chemicals. Douching has been touted as having a number of supposed but unproven benefits. In addition to promising to clean the vagina of unwanted odors, it can also be used by women who wish to avoid smearing a sexual partner's penis with menstrual blood while having intercourse during menstruation. In the past, douching was also used after intercourse as a method of birth control, though it is not very effective (see below).

Many health care professionals state that douching is dangerous, as it interferes with both the vagina's normal self-cleaning and with the natural bacterial culture of the vagina, and it might spread or introduce infections. For example, the U.S. Department of Health and Human Services strongly discourages douching, warning that it can lead to irritation, bacterial vaginosis, and pelvic inflammatory disease. Frequent douching with water may result in an imbalance of the pH of the vagina, and thus may put women at risk for possible vaginal infections, especially yeast infections.

Antiseptics may also result in an imbalance of the natural bacteria in the vagina, also resulting in an increased likelihood of infection. Furthermore, unclean douching equipment may also introduce undesirable foreign bodies into the vagina. For these reasons, the practice of douching is now strongly discouraged except when ordered by a physician for specific medical reasons. Douching may also wash bacteria into the uterus and Fallopian tubes, causing fertility problems.

Douching after intercourse is estimated to reduce the chances of conception by only 15-25%. In comparison, proper condom use reduces the chance of conception by as much as 97%. In some cases douching may force the ejaculate further into the vagina, increasing the chance of pregnancy. A review of studies by researchers at the University of Rochester (N.Y.) School of Medicine showed that women who douched regularly and later became pregnant had higher rates of ectopic pregnancy, infections, and low birth weight infants than women who only douched occasionally or who never douched.

The practice of douching is now largely restricted to the United States, where douching equipment is often available in pharmacies. A 1995 survey quoted in the University of Rochester study found that 27 percent of U.S. women age 15 to 44 douched regularly, but that douching was more common among African-American women (over 50%) than among white women (21%).

The irrigation of the anus is also known as an enema.

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3. Pelvic inflammatory disease (or disorder) (PID) is a generic term for infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to tissue necrosis with/or without abscess formation. Pus can be released into the peritoneum. Two thirds of patients with laparoscopic evidence of previous PID were not aware they had had PID (Cecil's 5th ed). PID is often associated with sexually transmitted diseases, as it is a common result of such infections. PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. PID should be classified by affected organs, the stage of the infection, and the organism(s) causing it. Although a std is often the cause, other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or Intrauterine device (IUD) related, and hematogenous spread.

Epidemiology

In the United States, more than one million women are affected by PID each year, and the rate is highest with teenagers. Approximately 50,000 women become infertile in the US each year from PID. N. gonorrhoea is isolated in only 40-60% of women with acute salpingitis (Current OBGYN 9th ed 2003). C. trachomatis was estimated by current obgyn 9th ed to be the cause in about 60% of cases of salpingitis, which may lead to PID. It is unsure how much is due to a single organism and how much is due to multiple organisms; many other pathogens that are in normal vaginal flora become involved in PID. 10% of women in one study had asymptomatic Chlamydia trachomatis infection and 65% had asymptomatic infection with Neisseria gonorrhoeae (Current OBGYN 9th ed.) It was noted in one study that 10-40% of untreated women with N. gonorrhoea develop PID and 20-40% of women infected with C. trachomitis developed PID. (Cecil's essentials of medicine 5th ed.). PID is the leading cause of infertility. "A single episode of PID results in infertility in 13% of women." (Cecil's 5th ed.) This rate of infertility increases with each infection.

Diagnosis

There may be no actual symptoms of PID. If there are symptoms then fever, cervical motion tenderness, lower abdominal pain, new or different discharge, painful intercourse, or irregular menstrual bleeding may be noted. It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms. Laparoscopic identification is helpful in diagnosing tubal disease, 65-90% positive predictive value in patients with presumed PID (current obgyn 9th ed 2003). Regular Sexually transmitted disease (STD) testing is important for prevention. Treatment is usually started empirically because of the terrible complications. Definitive criteria include: histopathologic evidence of endometritis, thickened filled fallopian tubes, or laparoscopic findings. Gram-stain/smear becomes important in identification of rare and possibly more serious organisms (Cecil's 5th ed.).

Differential Diagnosis

Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually transmitted disease.

Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).

Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours.

No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. A large mulitsite U.S. study found that cervical motion tenderness as a minimum clinical criterion increases the sensitivity of the CDC diagnostic criteria from 83% to 95%. However, even the modified 2002 CDC criteria does not identify women with subclinical disease.

Prognosis

Although the PID infection itself may be cured, effects of the infection may be permanent. This makes early identification by someone who can prescribe appropriate curative treatment so important in the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, postpartum, miscarriage or abortion). Prevention is also very important in maintaining viable reproduction capabilities.

If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur.

Complications

PID can cause scarring inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, infertility (difficulty becoming pregnant), ectopic pregnancy (the leading cause of pregnancy-related deaths in adult females), and other dangerous complications of pregnancy. Multiple infections and infections that are treated later are more likely to result in complications.

Persons with infertility may wish to see a specialist, because there may be a possibility in restoring fertility after scarring. Traditionally tuboplastic surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. In vitro fertilization (IVF) was developed to bypass tubal problems and has become the main treatment for patients who want to become pregnant.

Treatment

Treatment depends on the cause and generally involves use of antibiotic therapy. If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment. Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment. Hospitalization may be necessary if Tubo-ovarian abscess, very ill, immunodeficient, pregnancy, incompetence, or because this or something else life threatening can not be ruled out. Treating partners for STD's is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.

A systematic review of the literature related to PID treatment was performed prior to the 2006 CDC sexually transmitted diseases treatment guidelines. Strong evidence suggests that neither site nor route of antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease. Data on women with severe disease was inadequate to influence the results of the study.

Prevention

* Risk reduction against sexually transmitted diseases through abstinence or barrier methods such as condoms, see human sexual behavior for other listings.
* Going to the doctor immediately if symptoms of PID, sexually transmitted diseases appear, or after learning that a current or former sex partner has, or might have had a sexually transmitted disease.
* Getting regular gynecological (pelvic) exams with STD testing to screen for symptomless PID.
* Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases.
* Regularly scheduling STD testing with a physician and discussing which tests will be performed that session.
* Getting a STD history from your current partner and insisting they be tested and treated before intercourse.
* Understanding when a partner says that they have been STD tested they usually mean chlamydia and gonorrhea in the US, but that those are not all of the sexually transmissible diseases.
* Treating partners so you don't become reinfected or they do not infect another.

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3. In gynecology, the Papanikolaou test or Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a medical screening method, invented by Georgios Papanikolaou, primarily designed to detect premalignant and malignant processes in the ectocervix. It may also detect infections and abnormalities in the endocervix and endometrium.

The endocervix may be partially sampled with the device used to obtain the ectocervical sample, but due to the anatomy of this area, consistent and reliable sampling cannot be guaranteed. As abnormal endocervical cells may be sampled, those examining them are taught to recognize them.

The endometrium is not directly sampled with the device used to sample the ectocervix. Cells may exfoliate onto the cervix and be collected from there, so as with endocervical cells, abnormal cells can be recognised if present but the Pap Test should not be used as a screening tool for endometrial malignancy.

The pre-cancerous changes (called dysplasias or cervical or endocervical intraepithelial neoplasia) are usually caused by sexually transmitted human papillomaviruses (HPVs). The test aims to detect and prevent the progression of HPV-induced cervical cancer and other abnormalities in the female genital tract by sampling cells from the outer opening of the cervix (Latin for "neck") of the uterus and the endocervix. The sampling technique changed very little since its invention by Georgios Papanikolaou (1883–1962) to detect cyclic hormonal changes in vaginal cells in the early 20th century until the development of liquid based cell thinlayer technology. The test remains an effective, widely used method for early detection of cervical cancer and pre-cancer. The UK's call and recall system is among the best; estimates of its effectiveness vary widely but it may prevent about 700 deaths per year in the UK. It is not a perfect test. "A nurse performing 200 tests each year would prevent a death once in 38 years. During this time she or he would care for over 152 women with abnormal results, over 79 women would be referred for investigation, over 53 would have abnormal biopsy results, and over 17 would have persisting abnormalities for more than two years. At least one woman during the 38 years would die from cervical cancer despite being screened."[1] HPV vaccine may offer better prospects in the long term.

It is generally recommended that sexually active females seek Pap smear testing annually, although guidelines may vary from country to country. If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in three to twelve months. If the abnormality requires closer scrutiny, the patient may be referred for detailed inspection of the cervix by colposcopy. The patient may also be referred for HPV DNA testing, which can serve as an adjunct (or even as an alternative) to Pap testing.

About 5% to 7% of pap smears produce abnormal results, such as dysplasia, possibly indicating a pre-cancerous condition. Although many low grade cervical dysplasias spontaneously regress without ever leading to cervical cancer, dysplasia can serve as an indication that increased vigilance is needed. Endocervical and endometrial abnormalities can also be detected, as can a number of infectious processes, including yeast and Trichomonas vaginalis. A small proportion of abnormalities are reported as of "uncertain significance".

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