1. LOWER FEMALE GENITAL TRACT INFECTIONS

2. Defence Mechanism Against Ascent of Infection (Natural Barrier)
Vulva:
Apocrine glands: modified sweat glands → fungicidal acid
Apposition of labia closes introitus
Vagina:
Apposition of anterior and posterior walls
Stratified squamous epithelium resistant to infection
Vaginal acidity
Flora: the G+ve Doderlein’s bacilli splits glycogen into lactic acid
Cervix: closed by bacteriolytic cervical mucus
Uterus: Periodic endometrial shedding during menstruation eliminates any infection

3. Variations in The Efficacy of Defence Mechanism
With Age:
During childhood and after the menopause
Estrogen deficiency →  glycogen and Doderlein bacilli → absent vaginal acidity.
Endometrium poorly developed or atrophic and does not undergo cyclic shedding.
With menstruation:
Absent cervical mucus plug
Lowered vaginal acidity by alkaline menstruation.

4. Variations in The Efficacy of Defence Mechanism
During the puerperium:
Uterus, cervix & vagina widely opened
Vaginal acidity neutralized by alkaline lochia
Raw placental site
Lacerations
Low general resistance

5. VAGINITIS PRIMARY VAGINITIS
During childhood: Vulvovaginitis of children
During the reproductive period:
Trichomonas infection
Monilia infection
Bacterial vaginosis
Puerperal infection
Others; Gonococcal, T.B. syphilis, bilharziasis
Post menopausal: Senile vaginitis

6. VAGINITIS SECONDARY VAGINITIS Spread from
Urinary conditions: Vesico-vaginal fistula
Rectal conditions: Recto-vaginal fistula and complete perineal tear
Mechanical irritation (pessary or tampon)
Chemical irritation (drugs and douches)

7. BACTERIAL VAGINOSIS (Non-specific Vaginitis, Gardnerella Vaginitis)
Incidence:
The most common cause of vaginitis
12-25%
32-64% of women in clinics for STDs.
Organism:
Alternation of normal flora; decrease lactobacilli and increase Gardnerella and anaerobes.
Mode of infection:
Sexual transmission

8. Clinical Picture: Symptoms: 50% may be asymptomatic
Discharge: thin excessive greyish frothy malodorous
Pruritis
Signs:
Characteristic discharge and vulvovaginitis

9. Investigations: Fresh drop: Culture: Gram stain: Whiff test:
Clue cells; vaginal epithelium with obscured borders due to attachment of the organism
Culture:
Casman’s agar
Blood agar at 10% CO2
Gram stain:
gram -ve rods, absent lactobacilli
Whiff test:
Discharge + 10% KOH → fishy odour

10. Diagnosis: Amsel’s criteria: (3 of the following criteria)
Thin homogeneous discharge on examination.
pH of discharge > 4.5.
Whiff test: vaginal discharge + 10% KOH → "amine-like" or "fishy" odor.
Clue cells on microscopy,
Gram-stained vaginal smear
Culture of vaginal secretions has no place in the diagnosis of BV.

11. Treatment: A) Intravaginal preparations;
Clindamycin cream 2% at bed time for 7 days
Metronidazole once daily for 5 days
B) Oral regimens:
Metronidazole as a single 2 gm dose
Clindamycin 300 mg twice daily for 7 days
C) Sexual partner should be treated if infection is recurrent
D) During pregnancy;
Clindamycin may be used throughout pregnancy
Metronidazole may be used after the first trimester

12. Trichomonas Vaginitis
the 3rd most common cause for vaginitis
Organism: Trichomonas vaginalis,
ovoid, motile, flagellated protozoon,
4 anterior flagellae and an axostyle,
20mm in length and 10mm in width
flourishes in weak acid medium pH

13. Trichomonas Vaginitis
Sites of infection:
Vagina, urethra, Skene’s tubules, bladder and cervix
Mode of infection:
Sexual intercourse
Contaminated towels and instruments

14. Trichomonas Vaginitis
Clinical picture: Incubation period 3-28 days
Symptoms:
Often manifests after menstruation; vaginal pH is raised
Profuse yellowish, frothy malodorous vaginal discharge
Pruritis vulvae
Vaginal soreness
Dysparunia and dysuria
Signs:
Vulvitis (redness, hotness, oedema)
Vagina: red, oedematous, tender with punctate haemorrhage (strawberry vagina)
Cervix: Strawberry like, sometimes eccentric erosion
The characteristic discharge (forthy, yellowish, maloderous…….. etc)

15. Trichomonas Vaginitis
Investigations:
Fresh smear: Shows the organism and leucocytes
Stained film: Giemsa stain
Culture on Finberg-Whittington media

16. Trichomonas Vaginitis
Treatment:
Metronidazole tablets (Flagyl):
500 mg/12 h for 10 days OR
2 gm single dose
Protozole and Tinedazole:
Clotrimazole, vaginal pessaries used during pregnancy and lactation in stead of metronidazole.
The husband should be treated at the same time

17. Monilia Vaginitis (Candidiasis)
Organism:
Candida albicans causes 90% of cases.
C. tropicalis and C. glabrata cause 10% of cases.
Flourishes in acidic media.
Incidence:
The second most common cause of vaginitis.
Mode of infections:
May be present in the vagina and flourish
with predisposing factors  vaginal acidity
or suppression of other vaginal flora.
Sexual intercourse.

18. Predisposing factors:
Antibiotics →  the lactobacilli that  Candida growth
Oral contraceptives → glycogen
Pregnancy high oestrogen level → glycogen
Steroids and immunosuppressives lower immunity
Male partner infection
Diabetes → glycogen deposition and low immunity
Lack of proper hygiene

19. Clinical Picture: Symptoms: Signs:
Discharge: thick, scanty, white, curd-like, adherent
Burning sensation in the vaginal
Itching and scratching sensation on the vulva.
Dyspareunia and dysuria
Signs:
Vulvitis: redness, oedema, itching marks
Vaginitis: red, tender vaginal, with adherent plaques
Characteristic discharge

20. Investigations: Fresh drop with added 10% KOH
G+ve spores and long pseudohyphae on wet preparation microscopic examination.
Stained film with methylene blue
Culture of Feinberg-Whittington media

21. Treatment: Vaginal Antifungal preparations
Vaginal suppositories or intravaginal creams with special applicator available as either a single dose, a 3-day course, or a 7-day course
Agents include clotrimazole, miconazole, and tioconazole preparations
Oral antifungal treatment
Fluconazole; Single oral dose 150 mg, for treatment of uncomplicated cases
Ketoconazole; 200 mg twice a day for 5 days, for recurrent cases. Treatment can be repeated on special schedules along a period of 3 -6 months, for chronic cases.

23. Vulvovaginitis of Children
Microorganism:
E. coli, Strept, Staph, gonococci, Candida, Trichomonas
Predisposing factors:
Foreign body (oxyuris)
Decreased vaginal acidity
Poor hygiene
Mode of infection: Infected towels
Clinical picture:
Symptoms:
Purulent, sometimes bloody, vaginal discharge,
Itching, pain, sometimes dysuria
Signs:
Foul discharge, vulvitis, vaginitis

24. Vulvovaginitis of Children
Investigations:
U.S. ± X-ray to detect foreign body
Investigations to detect oxyuris, culture and sensitivity of discharge
Treatment:
Treatment of oxyuris,
Removal of foreign body
Systemic antibiotics
Local cleanliness with diluted antiseptics
Estrogen: Ethinyl estradiol 10 g/12 hours for 2 weeks, followed by 10 g/day for another 2 weeks

25. Senile Vaginitis Organisms: Clinical Picture: Investigations:
Various cocci and gram-negative bacilli
Clinical Picture:
Symptoms:
Purulent vaginal discharge sometimes spotting
Pruritis: Dyspareunia
Signs:
Atrophy of vulva and vagina with areas of vaginal ulcerations
Purulent (sometimes bloody) discharge
Investigations:
Exclude genital malignancy by Pap smear and fractional current
Culture and sensitivity of the discharge
Treatment:
Antibiotics; ampicillin, cephalosporines,…… etc
Topical estrogen cream and hormone replacement therapy
Lactic acid 1% vaginal douches 

26. Acute Cervicitis
Acute inflammation of the endocervical glands and underlying tissues.
Cause:
Gonococcal
Chlamydial
Puerperal
Post-abortive
Post-operative infection, after instrumentation or cervical dilatations, cauterization or trachelorraphy (i.e. repair of a lacerated cervix)

27. Clinical Picture: Symptoms: Signs: Investigations:
Mucopurulent discharge
Mild fever
Dyspareunia and backache
Signs:
The cervix is red swollen with mucopurulent discharge
Marked tenderness on moving the cervix
Investigations:
Culture and sensitivity of the discharge

28. Acute Cervicitis Treatment:
Antibiotics , according to organism (broad spectrum)
Complications:
Commonly turns chronic infection due to the racemose nature of the cervical glands
Secondary vaginitis
Spread to:
upper genital tract
parametrium
urinary tract

29. Chronic Cervicitis CLINICAL PICTURE: Symptoms Mucopurulent discharge
Congestive dysmenorrhea and menorrhagia (pelvic congestion)
Backache (spread of infection along the uterosacral ligament)
Contact bleeding (cervical erosion)
Dyspareunia (parametritis)
Infertility (hostile cervical discharge)
Frequency of micturition (cystitis)
Manifestations of septic focus

30. Chronic Cervicitis CLINICAL PICTURE: Signs by Speculum examination →
Mucopurulent discharge coming out from the cervix (Endocervicitis)
Cervical erosion
Mucous polypi: reddish pedunculated small (hyperplasia of endocervical epithelium)
Nabothian follicles: small blue or yellowish cysts projecting on the portiovaginalis (distended blocked cervical glands)
Swollen, hyperaemic cervix (Chronic hypertrophic cervicitis)
Ectropion: the anterior and posterior lips of the cervix are everted due to bilateral cervical tears. 

31. Signs by Speculum examination →
Mucopurulent discharge
Mucous polypi:
Nabothian follicles:
Swollen, hyperaemic cervix
Ectropion:

32. Chronic Cervicitis Investigations: Treatment: Exclusion of malignancy
Culture and sensitivity of the discharge.
Treatment:
Oral or vaginal Antibiotics
Cervical Cauterization
Trachelorraphy: to treat cervical tears
Conization in suspicious lesions

33. Cervical Erosion (Ectopy)
A bright red area around the external os due to replacement of the stratified squamous epithelium of the ectocervix with endocervical columnar epithelium, which is thin and shows the underlying blood vessels.
Etiology
Chronic Cervicitis:
Infected discharge produces denuded area around external os.
Columnar epithelium grows from the cervical canal to cover the denuded area
Congenital erosion:
Persistence of the intra-uterine condition where the columnar epithelium covers an area on the ectocervix.
Hormonal erosion:
Excess estrogen causes the columnar epithelium to grow and replace the stratified squamous epithelium

34. Clinical Picture: Symptoms: Signs:
Mucous discharge
Contact bleeding
Symptoms of chronic cervicitis if present
Signs:
Vaginal examination: Velvety sensation and occasional contact bleeding
Speculum examination:
Flat erosion: red area.
Papillary erosion; raised folds.
Follicular erosion; glandular distension
Investigations: Vaginal and cervical smears exclude malignancy

35. Treatment:
Hormonal erosion: NO ttt except if the case persists for more than three months.
Antibiotics to treat associated infection.
Cauterisation:
The main line of treatment
It opens and drains the infected glands and coagulates the superficial epithelium over the erosion

36. Methods Of Cauterisation
Electrocautery
Cryocautery (freezing)
Laser Cauterisation
Endcoagulation: Semm’s coagulator
Chemical Cautery

37. Electrocautery No anaesthesia
Cervix is exposed and cleaned by sodium carbonate
Using a red-hot electrode, 3 linear burns are made on the anterior and posterior lips of the cervix extending from the internal as to the edge of the erosion.
The depth of cauterisation is 2 mm.
Vaginal discharge will increase for 10 days
Squamous epithelium takes 4-6 weeks to cover the cauterised area.

38. Electrocautery Complications: Secondary haemorrhage:
Due to sloughing
About the 10th day
Treated by packing, antibiotics
Ascending infection and parametritis
Cervical stenosis

39. Cryocautery (freezing):
Using CO2 or nitrogen cylinder; a cone shaped probe is applied on the external os extending in the lower part of the cervical canal.
Application of the probe for 2 minutes to -60˚C freezes the tissues to a depth of 2 mm leading to necrosis and separation of these tissues.
The healing after cryocautery is much better than electrocautery; and the complications are less.

40. Laser Cauterization
Controlled destruction of the superficial thin layer of tissues by vaporization of cells.
It gives excellent results but the instrument is expensive and requires training.

41. Endcoagulation: Semm’s coagulator
The probe is heated to 100°C causing coagulation without excessive necrosis the results are excellent but the instrument is expensive.

42. Chemical Cautery:
Using silver nitrate 20% (after protecting the vagina with Ferguson speculum).
It is an old method but can be used for mild residual lesions