Genital Tract Infections

A. Alobaid, MBBS, FRCS(C), FACOGConsultant, Gynecologic OncologyAssistant professor, KSUMedical Director, Women’s Specialized HospitalKing Fahad Medical City

The normal vaginal flora is predominately aerobic organisms

The most common is the H+ peroxide producing lactobacilli

The normal PH is <4.5 Normal vaginal secretions ↑ in the

middle of the cycle because of ↑ in the amount of cervical mucus

Bacterial Vaginosis (BV)

It is caused by alteration of the normal flora, with over-growth of anaerobic bacteria

It is triggered by ↑ PH of the vagina (intercourse, douches)

Recurrences are common

Bacterial Vaginosis (BV)

Diagnosis:

1. Fishy odor (especially after intercourse)

2. Gray secretions

3. Presence of clue cells

4. PH >4.5

5. +ve whiff test (adding KOH to the vaginal secretions will give a fishy odor)

Bacterial Vaginosis (BV)

Treatment: 1. Flagyl 500mg Po Bid for one week (95%

cure)2. Flagyl 2g PO x1 (84% cure)3. Flagyl gel PV4. Clindamycin cream PV 5. Clindamycin PO Treatment of the partner is not

recommended

Trichomonas Vaginalis

It is an anaerobic parasite, that exists only in trophozite form

60% of patients also have BV 70% of males will contract the disease

with single exposure Patients should be tested for other

STDs (HIV, Syphilis)

Trichomonas Vaginalis

Diagnosis: 1. Profuse, purulent malodorous discharge2. It may be accompanied by vulvar pruritis3. Secretions may exudate from the vagina 4. If severe → patchy vaginal edema and

strawberry cervix5. PH >56. Microscopy: motile trichomands and ↑

leukocytes 7. Clue cells may if BV is present8. Whiff test may be +ve

Trichomonas Vaginalis

Treatment:

1. Falgyl PO (single or multi dose)

2. Flagyl gel is not effective

3. The partner should be treated

Candidiasis

75% of women will have at least once during their life

45% of women will have two or more episodes/year

90% of yeast infections are secondary to Candida Albican

Other species (glabrata, tropicalis) tend to be resistant to treatment

Candidiasis

Predisposing factors:

1. Antibiotics: disrupting the normal flora by ↓ lactobacilli

2. Pregnancy (↓ cell-mediated immunity)

3. Diabetes

Candidiasis

Diagnosis:1. Vulvar pruritis and burning2. The discharge vary from watery to thick cottage

cheese discharge3. Vaginal soreness and dysparunea4. Splash dysuria5. O/E: erythema and edema of the labia and vulva6. The vagina may be erythematous with adherent

whitish discharge7. Cervix is normal8. PH< 4.5budding yeast or mycelia on microscopy 9. The culture will confirm the diagnosis

Candidiasis

Treatment: 1. Topical Azole drugs (80-90% effective) 2. Fluconazole is equally effective (Diflucan

150mg PO x1), but symptoms will not disappear for 2-3 days

3. 1% hydrocortisone cream may be used as an adjuvant treatment for vulvar irritation

4. Chronic infections may need long-term treatment (6 months) with weekly Fluconazole

Inflammatory Vaginitis

Diffuse exudative discharge with epithelial cells exfoliation

The cause is uncertain but could be Strept

The treatment is with clindamycin cream

30% of patients will have relapse

Atrophic Vaginitis

In post-menopausal women May be accompanied by purulent

discharge, dysparunea and post-coital bleeding

It is treated with topical Estrogen cream

Cervicitis

Neisseria Gonorrhea and Chlamydia Trachomatis infect only the glandular epithelium and are responsible for mucopurulent endocervisitis (MPC)

Ectocx epithelium is continuous with the vaginal epithelium, so Trichomonas, HSV and Candida may cause ectocx inflammation

Cervicitis

Tests for Gonorrhea (culture on Thayer- martin media) and Chlamydia (ELISA, direct IFA) should be performed

Pelvic Inflammatory Disease (PID)

Ascending infection, ? Up to the peritoneal cavity

Organisms: Chlamydia, N Gonorrhea Less often: H Influenza, group A

Strept, Pneumococci, E-coli

PID

Diagnosis: difficult because of wide variation of signs and symptoms

Clinical triad: fever, pelvic pain and cervical motion and adnexal tenderness

Cervical motion tenderness indicate peritoneal inflammation

Patients may or may not have mucopurulent discharge

PID

PID

Tubo-ovarian Abscess (TOA)

End-stage PID Causes agglutination of pelvic organs

(tubes, ovaries and bowel) 75% of patients respond to IV

antibiotics Drainage may be necessary

Genital ulcer disease

Mostly caused by HSV or Syphilis, then chancroid, LGV, and granuloma inguinale (donovanosis)

Other causes: abrasions, drug eruptions, cancer and behcet’s disease

Genital ulcer disease

Have to R/O syphilis by serology, dark field examination or direct IF for Treponema pallidum

Culture for HSV

Genital ulcer disease

Genital ulcer disease

Still ¼ of the diagnosis is made by clinical examination only:

1. Syphilis: non-painful, min. tender ulcer, not accompanied by LAP

2. HSV: grouped vesicles mixed with ulcers with a history of similar lesions

3. Chancroid: 1-3 extremely painful ulcers with tender inguinal LAP

4. LGV: inguinal bubo without ulcers

Genital ulcer disease

Treatment:1. Chancroid: Azithromycin 1gm PO x1,

ceftazidime 250mg IM x1, or Erythromycin

2. Herpes: 1st episode is treated with acyclovir, this will not eradicate the infection, recurrences are common, for patients with > 6 recurrences/year → daily suppressive treatment is indicated (will not eliminate viral shedding and transmission)

3. Syphilis: Benzathine Pen G 2.4 million units IM x1 dose

Genital Warts

Condyloma accuminata secondary to HPV infection (usually 6&11), these are non-oncogenic types

Usually at areas affected by coitus (posterior fourchette)

75% of partners are infected when exposed Recurrences after treatment are secondary

to reactivation of subclinical infection

Genital Warts

HIV

20-25% of patients are women 36% is secondary to heterosexual

transmission Median age between HIV infection

and AIDS is 10 years

HIV

Diagnosis: by HIV1 antibody test,

screening by ELISA, if +ve → confirm by western blot

95% of the antibody is detected within 6 months of the infection

Patients are referred to a an infectious disease specialist for treatment

CD4 is the best indicator of disease progression

Thank you