1. Reproductive tract infections
2016

2. Normal physiology and microecology of the vagina:
The vagina is lined by nonkeratinized squamous epithelium which is powerfully influenced by oestrogen and progesterone.
The vagina of the new born is colonized by aerobic and anaerobic bacteria acquired while passing through the birth canal. The newborn’s vaginal epithelium is strongly estrogenized and rich in glycogen,which supports the growth lactic acid producing lactobacilli,this result in low PH<4.5,further support the growth of acidophilic protective microflora. Within days of delivery,oestrogen decreases ,the epithelium become thin ,atrophic and devoid of glycogen.the vaginal PH rises,and the predominant vaginal flora becomes diverse gram positive cocci and bacilli .

3. With the onset of puberty and steroidogenesis, the vagina become estroginized,and the glycogen content increases,lactobacilli become predominant with self sustained vaginal PH( ) providing some protection from STIs including HIV ,even though a wide variety of aerobic and anaerobic bacteria can be cultured from the normal vagina and at any time a women can harbor at least 3 -8 type of bacteria.

4. Multiple factors alter this protective microflora, as:
1.antibiotics suppress the growth of commonsal organisms allowing pathogenic strains to be predominant(yeast).
2.douching with water or non buffered solutions may transiently alter the PH or selectively suppress the endogenous bacteria.

5. 3. Sexual intercoarse with introduction of semen raises PH to 7
3.Sexual intercoarse with introduction of semen raises PH to 7.2 to 6-8 hours ,also the vaginal transudate during coitus as a lubricant increase vaginal PH (7.4)which also favor abnormal flora. 4. The presence of foreign body in the vagina in children and the presence of forgotten tampon and diaphragm in adult disturbs normal vaginal cleansing mechanisms and may lead to secondary infection.

6. Physiologic vaginal fluid: is mainly composed of proteins ,polysaccharides, aminoacids, enzymes, and immunoglobulines.
Vaginal fluid is a mixture of(source):
Cervical fluid secretion(major component).
Endometrial fluid.
Oviductal fluid.
Excudate from the bartholine’s gland and skene’s.
Transudate from vaginal squamous epithelium, squamous cell it self,and metabolic product of the microflora.

7. Physiologically the vaginal and endocervical fluid increases during:
Pregnancy.
Mid cycle
Intercoarse.
The vaginal fluid become markedly reduced
in post menopausal women.

8. Etiology of vaginal discharge:
Up to 90% of cases are caused by 3 conditions:
-bacterial vaginosis(40%-50%)
-vulvovaginal candidiasis(20%-25%)
-trichomoniasis(15%)
Others :
mucopurulant cervicitis caused by chlamydia,neisseria gonorrhoea,mycoplasma or BV associated bacteria
Atrophic vaginitis(over growth with aerobic anaerobic bacteria)less common.
Foreign body vaginitis.
Genital ulcer disease as herpes and syphilis.
Desquamative vaginitis.
Lichen planus.
Irritation from sexual activity.
Irritation from allergen containing substanses.
Fistula(urinary or faecal )

9. Bacterial vaginosis:
Is the most common cause of vaginal discharge and in many case is the only symptoms.
It’s mainly caused by disruption of normal healthy vaginal lactobacillus (hydrogen peroxide producing)flora(lactobacillus jensenii and lactobacillus crispatus) and an overgrowth of predominantly anaerobic bacteria. Anaerobic bacteria can be found in less than 1% of the flora of normal women. In women with BV, the concentration of anaerobes, and G. vaginalis and Mycoplasma hominis, is 100 to 1000 times higher than in normal women ..
most common organisms involved in BV:
Garderella vaginalis,
genital mycoplasmas(mycoplasma hominis,mycoplasma urealyticum)
Vaginal anaerobic bacteria as:prevotella, bacteroids, mobiluncus species

10. a clue cell, which is an epithelial cell with “serrated” edges caused by bacteria (arrows).

11. Risk factors of bacterial vaginosis:
New sexual partner.
Smoking.
Intrauterine device use.
Frequent douching

12. Clinical features of bacterial vaginosis:
A profuse , milky, non adherent discharge that demonstrate an amine or fishy odour after alkalization with a drop of KOH(positive whiff test).
Risk from having bacterial vaginosis:
- pelvic inflammatory disease (PID),
-postabortal PID,
-postoperative cuff infections after hysterectomy,
-abnormal cervical cytology.
-Pregnant women with BV are at risk for premature rupture of
the membranes, preterm labor and delivery, chorioamnionitis,
and post cesarean endometritis.
Partner treatment is generally not Recommended.

13. Office-based testing is required to diagnose BV.
a microscopy of a clue cell.
The addition of potassium hydroxide to the vaginal secretions (the “whiff” test) releases a fishy, amine-like odor.
Clinicians who are unable to perform microscopy can use alternative diagnostic tests such as a pH and amines test card,
detection of G. vaginalis ribosomal RNA,
Gram stain. Culture of G. vaginalis is not recommended as a diagnostic tool because of its lack of specificity.

14. Treatment of bacterial vaginosis
Metronidazole 500 mg orally twice a day for 7 days.
OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally , once a day for 5 days
OR Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days†

15. Vulvovaginal candidiasis:
It’s the second most common cause of vulvovaginal related symptoms.
Candida albicans cause more than 90% of cases formerly ,
Now less azole susceptible species such as candid glabrata recognized as causative agent in 15% of cases..those less susceptible yeast require prolonged or alternative treatments.

16. Candida’s require oestrogenated tissues so VVC becomes more common after menarche and less common after menopause. An estimated 75% of women acquire Vulvo- vaginal candidiasis sometimes in their life . 5% suffer frequent symptomatic recurrence (more than 5 attacks/year)

17. Risk factors for recurrent VVC include :
High oral contraceptive pills.
Diaphragm use with spermicide.
Diabetes mellitus.
Antibiotic use .
Pregnancy.
Immunosuppression from any cause (HIV,Aids,/ transplantation ,steroid use)
Tight occlusive clothing.

18. Clinical presentations
Vaginal itching.
Burning sensation.
Irritation.
Post voiding dysuria.
The discharge is odorless ,PH less than 4.7,thick or crudy with the appearance of cottage cheese.
Examination shows vulvovaginal erythema with evidence of acute or chronic excoriation.

19. Microscopic examination of a wet –mount preperation is positive for budding yeast cells,pseudohyphae or myceleal tangles in 50%-70% of cases..women with clinical suggestion with absent wet preparation evidence may benefit from ,,fungal culture.

20. Treatment of vulvovaginal candidiasis Treatment of the underlying cause Over the counter antifungal treatment: Clotrimazole 1% cream 5 g intravaginally for 7-14 days OR Clotrimazole 2% cream 5 g intravaginally for 3 days OR Miconazole 2% cream 5 g intravaginally for 7 days OR Miconazole 4% cream 5 g intravaginally for 3 days OR Miconazole 100 mg vaginal suppository, one suppository for 7 days OR Miconazole 200 mg vaginal suppository, one suppository for 3 days OR Miconazole 1200 mg vaginal suppository, one suppository for 1 day OR Tioconazole 6.5% ointment 5 g intravaginally in a single application

21. Prescription Intravaginal Agents Butoconazole 2% cream (single dose bioadhesive product), 5 g intravaginally for 1 day
OR Terconazole 0.4% cream 5 g intravaginally for 7 days
OR Terconazole 0.8% cream 5 g intravaginally for 3 days
OR Terconazole 80 mg vaginal suppository, one suppository for 3 days
Oral Agent:
Fluconazole 150 mg oral tablet, one tablet in single dose .

22. Treatment of recurrent V VC
First line treatment is or oral antifungal regimen consists of inducing a remission of chronic symptoms with fluconazole (150 mg every 3 days for three doses), then maintaining a suppressive dose of this agent (fluconazole, 150 mg weekly) for 6 months. On this regimen, 90% of women with RVVC will remain in remission
In recurrent cases may be treated after confirming the diagnosis with weekly suppressive doses of topical imidazoles.
Boric acid (600mg vaginal gelatin capsules)3 times daily for 1 week is an effective treatment for imidazole resistant species.
VVC is not sexually transmitted in most cases male partners sometimes reinfect their partners and may be required to be treated.

23. Trichomoniasis : It’s caused by protozoan trichomonas vaginalis.
Trichomoniasis is a cause of cervicitis vaginitis ,and urethritis.and upper reproductive tract symptoms,
increased risk of adverse pregnancy outcome (prematurity,low birth weight)
increased transmission of HIV infection.
About 50% of cases in women and men are asymptomatic.
Symptomatic infection is classically manifested
by a green-yellow ,frothy vaginal discharge with a musty odor.
dyspareunia ,vulvovaginal irritation and occasionally dysuria may be present.

24. In patients with high concentrations of organisms, a patchy vaginal erythema and colpitis macularis (“strawberry” cervix) may be observed. Microscopy of the secretions may reveal motile trichomonads and increased numbers of leukocytes.

25. Male partners are often asymptomatic even though they demonstrate non gonococcal urethritisp on direct examination.
Couples with trichomoniasis should be screened for other STIs and empiric treatment of partners.

26. Diagnosis :clinical features
Saline wet mount to see the characteristic motility of the trichomonas.
Culture is more sensitive.
Polymerase chain reaction .
Antigen testing.

27. Treatment:
Metronidazole 2 gm single oral treatment is a recommended.(not take alcohol 2 days sfter treatment)
Multidose treatment 500mg twice daily for 7 days,,,bothe single and multiple therapy is effective in 95% of cases.
Metronidazole resistance should be treated by tinidazole,or higher doses of metronidazole 2 gm daily for 7 days.

28. Causes of vulvovaginitis
treatment
diagnosis
symptoms
infection
Butoconazole2% cream, 5 gm for 3 days vaginally..oral fluconazole 150 mg orally single.
Wet prep/KOH/ microscopic ex. (pseudohyphae or budding yeast.
Vaginal burning/itching/ irritation/crudy white discharge
yeast
Metronidazole 500mg orally twice a day for 7 days,clindamycin cream 2%,one applicator 5 gm intravaginally at bed time.
Wet prep(clue cells).release of amine odor ,positive whiff test with koh vaginal fluid
ph>4.5
Asymptomatic, or vaginal
odour, odour after intercoarse or increased disharge
Bacterial
vaginosis
Metronidazole 2 gm orally as single dose or tinidazole 2 gm orally in single dose for resistant cases.
Motile trichomcnads on microscopic examination or wet preparation
Asymptomatic increased thin or thick green yellow foul amelling discharge afrothy in 2%-3% of cases,strawberry cx.in 2-3% of cases.
Trichomon-iasis

29. Atrophic vaginitis:
Atrophic vaginitis : is the most common cause of vaginal irritation among may be climacteric patients. there is vaginal atrophy followed by secondary infection and the condition is exacerbated by the presence of foreign body (pessary).

30. Patient complain of vulvar irritation and discharge, which may be clear or purulent , yellow and occasionally will be blood stained, may be associated with symptoms of frequency ,urgency ,and stress incontinence may occurs.
Examination of the external genitalia may reveals a watery discharge with generalized vulvar erythema often with excoriation.

31. Speculum examination may reveals a pale epithelium with patches of erythema . superficial blood vessels may be seen and bleed easily on contact(we should consider coexistent neoplasm.
The discharge has a PH of 4.7 or higher.
Saline wet mount preparation .
Pap smear .
Confirm the diagnosis with immature basal
cells and parabasal cells replacing superficial
vaginal epithelial cells.

32. Management:
Treatment of choice is topical estrogen available as vaginal creams,suppositories or rings.
Systemic estrogen if desirable , oral tablets, transdermal patches, sprays and gel are available
Aerobic culture for predominant microorganisms should be obtained in refractory cases and when the infection is suspected.

33. Foreign body vaginitis:
when child has vulvar itching ,infection , or a bloody vaginal discharge, Foreign body should be suspected , in addition to sexual abuse.
In adults a forgotten or lost tampons diaphragm or condoms may be the cause of vaginitis , removal of the foreign body and vaginal application of estrogen cream, result into a rapid improvement.

34. Other sexually transmitted infection :
Genital herpes: is the most prevalent STI in the united state , with 50 million adult infected with the virus (active or latent ).
Only 10-20%of infected persons knows they are infected.
70% of transmissions are from asymptomatic viral shedding from infected partners with no visible lesion.
Individuals who are infected with HSV are at risk of acquiring and transmittting HIV.

35. There are two serotypes,HSV-1and HSV-2.
HSV1 is most commonly associated with oral lesions(cold sores), 30% of primary genital herpes is due to HSV1,
HSV 2 is the cause of 70% cases of primary genital herpes and 95% of recurrent genital herpes.
The frequency of recurrence is much higher after a primary infection with HSV2 than HSV1.
The virus enters the body through the mucosa or microabrasions in the skin and follows the sensory nerves to the dorsal spinal ganglion, where it remains dormant until reactivated.

36. Transmission occurs through intimate genital,oral or anal contact.
infected mother can transmit the virus to her infant during delivery resulting in significant fetal mortality and morbidity.
Regular condom use decreases transmission by about 50% especially from men to women.

37. Primary genital herpes infection occurs when the infected person has bilateral, no HSV2 or HSV1 antibodies.
The usual clinical presentation is multiple, bilateral and painful anogenital vesicles or ulcers with an erythematous base,
Systemic symptoms may also present such as fever ,headache malaise and lymphoadenopathy may be present.
Acute cervicitis may be present ,the lesions heals heal without scarring in days.

38. Recurrent genital herpes infection occurs when the infected person has HSV antibodies to the same serotype .the lesion are fewer ,unilateral and less painful.
Systemic symptoms and lymphadenopathey are rare.the lesions heals without scarring in 5-7 days in immuno-competent individuals.

39. Laboratory tests that are used to confirm the diagnosis include :
1. Viral culture that requires live cells from the lesion, which is expensive time consuming has a relatively low sensitivity (50% to 80%).
2.PCR which is expensive and very accurate.
3.type specific serologic test for HSV1,and HSV2 antibodies.
These are highly sensitive and specific test that can identify individuals who are asymptomatic .

40. Treatment
The goals of treatment for genital herpes are symptom relief , acceleration of lesion healing and a decrease in frequency recurrences.
Education and supportive counseling are also important.
Antiviral agents( acyclovir,vamciclovir and valacyclovir) are safe and effective for treating primary and episodic outbreaks and for providing suppressive therapy for patients with chronic disease.
No treatment can eradicate the latent virus from the dorsal ganglia of the spinal cord
A vaccine for HSV is underway to develop.

41. Human papillomavirus (HPV)
Genital HPV is a common viral STI with 20million infected in united state and 5 million new cases every year.
75% of sexually active adult will be infected sometimes in their life.
MOST HPV cases are latent infections with no visible lesions and are only diagnosed by DNA hybridization testing performed in the evaluation of an abnormal pap smear.
Subclinical infections have lesions seen only during colposcopy.
Clinical infections are characterized by readily visible warty growths called condylomata acuminata on the vulva, vagina,cervix ,urethra and perianal area.

42. HPV infection clears spontaneously within 2 years ,but recurrence are common.
There are 200 HPV subtypes . some have been strongly associated with genital neoplasia and cancer especially cervical.
Biopsies of atypical or persistent lesion is
required to rule out neoplastic disease, syphilis,
also must be excluded in atypical lesion mimic
condylomata lata.

43. Transmission :
HPV can be transmitted even when no visible lesion is seen .regular condom use may provide some degree of protection.
During pregnancy condylomata may increase in number and size but transmissiom from the mother to the fetus is rare.

44. Vaccination: vaccination is available and 95% effective in women not exposed to the virus before.
(Gardasil) is now available that protect against four HPV serotypes(6,8,16,18), which together are responsible for 70% of cervical cancer and 90% of genital wart. (Licensed in in females aged 9-26 years).
(Ceravix) against 16-18(Lincensed from 2008)

45. Treatment : Aim of treatment of genital warts are to :
-relieve symptoms of pain and bleeding.
-improve psychological and cosmotic concerns of the patient.
Multiple treatment modalities are available:
Podophylin resin 10% to 25%in tinicture benzoin.
Trichloroacetic acid(80-90)%.
Both are not used in pregnancy.
Surgical treatment:
-crytherapy , laser vaporization
-surgical excision , intralesional interferone.
-electrocautery,

46. Genital wart (HPV) External genital warts are a manifestation of (HPV)
infection. The non-oncogenic
HPV types 6 and 11are
usually responsible.
The warts tend to occur in areas most directly affected by coitus, namely the posterior fourchette and lateral areas of the vulva. Less frequently, warts can be found throughout the vulva, in the vagina, and on the cervix.
Minor trauma associated with coitus can cause breaks in the vulvar skin, allowing direct contact between the viral particles from an infected man and the basal layer of the epidermis of his susceptible sexual partner

47. Infection may be latent or may cause viral particles to replicate and produce a wart.
External genital warts are highly contagious; more than 75% of sexual partners develop this manifestation of HPV infection when exposed.
The goal of treatment is removal of the warts; it is not possible to eradicate the viral infection. Treatment is most successful in patients with small warts that have been present for less than 1 year. It has not been determined whether treatment of genital warts reduces transmission of HPV.

48. Selection of a specific treatment regimen depends on the anatomic site, size, and number of warts, and the expense, efficacy, convenience, and potential adverse effects.

49. Preferred treatment:
Excision of warts using either:
Trichloroacetic acid
Electrodessication
Cautery
Laser
Alternative treatment:
Cryotherapy OR
Imiquimod 5% cream OR
Sinecatechins 15% ointment OR
Popofilox 0.5%

50. Recurrences more often result from reactivation of subclinical infection than reinfection by a sexual partner; therefore, examination of sexual partners is not absolutely necessary. However, many partners may have external genital warts and may benefit from therapy and counseling concerning transmission of warts. HPV infection with types 6, 11, 16, 18, 31, 33, 45, 52, and 58 can be prevented with the nonavalent HPV vaccine.

51. Thank you .. to be continued …