1. Inflammation of the Female
Reproductive Tract

3. 1. Vulvitis
Bartholinitis/Bartholin’s cyst
2. Vaginitis
Cervicitis
Pelvic inflammatory disease (PID)
Genital tuberculosis
Sexually transmitted diseases (STD)

5. Vulvitis

6. Clinical Manifestation
Vulvar pruritus
Pain
Burning sensation
Congestion
Swelling
Eczema

9. Etiology Specific organisms or non-infective dermatitis
Irritation from vaginal discharge or menses
Lack of vulvar hygiene
Glycouria

10. Treatment Keep the vulva clean and dry Remove the cause
1/5000 kMnO4 (potassium permanganate, PP)
solution bath
Antibiotics ointment

11. Bartholinitis Bartholin’s Cyst Infection of the major vestibular
glands
(Bartholin’s glands)
Bartholin’s Cyst

12. Major vestibular glands (Bartholin’s glands)

13. Bartholinitis Etiology
Staphylococcus, E.coli, streptococcus, enterococcus, gonococcus, and polymicrobial infection is common.
Clinical manifestation
Symptoms of a local infection
Abscess of Bartholin gland: a painful red swelling
Treatment
Antibiotics (Ampicillin) in the early stage
Drain the abscess (excision of an elliptical piece of skin)

14. Bartholin’s Cyst Marsupialization for preservation of the
gland function
Excision for recurrent
cases

15. Vaginitis Trichomonal vaginitis Candidal Vulvovaginitis
Bacterial Vaginosis (BV)
Senile vaginitis
Infantile vulvovaginitis

16. Trichomonal Vaginitis
(Trichomoniasis)

17. Etiology Trichomonad A flagellate protozoan
Best living environment : Moist, anaerobic,
pH:

18. Transmission Pathogenesis
1. Sexual contact (70% male infection, asymptomatic carrier)
2. Nonsexual transmission (iatrogenic)
Pathogenesis
The trichomonad lives on glycogen and iron of the host cell
Direct contact and damage of the target cell
Induction of immune reaction resulting in inflammation

19. Clinical Picture Latent period: 4-28 days Asymptomatic: 25-50%
Symptoms：
Main: Profuse vaginal discharge and pruritus
Occasional: odor, pain, dyspareunia , dysuria,
infertility

21. Characteristics of the vaginal discharge
Copious,
Purulent
Gray to yellow color,
Malodorous
Frothy
Strawberry cervix:
Tiny, punctate hemorrhages
grossly visible on the mucosa

22. Diagnosis 1. Microscopic (wet mount) identification of the
trichomonad (60%-70%)
2. Precautions for the examination
Avoid : intercourse 1-2 days before examination
washing and medication
lubricant
heat preservation
3. Culture for suspected cases
4. PCR (Polymerase chain reaction)

24. Treatment (1) 1. Systemic therapy (First choice) Oral metronidazole
a) 2g single dose
b) 400mg, twice or 3 times a day, for 7 days.
2. Topical application (≤50%)
a) Effervescent tablets of metronidazole
200mg/day, 7-10 days
b) Metronidazole gel
c) Acidification of vagina with 1% lactic acid or
0.5% acetic acid

25. Treatment (2) Criterion for cure:
Negative finding in postmenstrual examination
of the vaginal discharge for three times
Failure rate: 5%-10%
Poor compliance
Repeated infection
To avoid repeated infection:
Sterilization of underwear, towels, etc
Treatment of the sexual partner
Metronidazole is still effective in recurrent cases.

26. Candidal Vulvovaginitis
(Vulvovaginal Candidiasis)

27. a) About 1/3 of vaginitis cases are caused by fungal infection.
Etiology
1. Very common
a) About 1/3 of vaginitis cases are caused by
fungal infection.
b) About 75% of women develop candidiasis at
least once in life.
2. The etiologic agent is Candida
Candida albicans is responsible
for 80-90% of vulvovaginal candidiasis.

28. Treatment is not indicated unless symptoms are present.
3. Candida albicans is an opportunistic pathogen.
1) Suitable environment: acidic (＜4.5), warm, and moist
2) Candida albicans can be isolated from 10-20%
nonpregnant and 30% pregnant asymptomatic women.
Treatment is not indicated unless symptoms are present.

29. Predisposing factors 1. Pregnancy 2. Diabetes mellitus
3. Immunosuppressants
4. Broad-spectrum antibiotics
suppressing the vaginal normal flora
(esp. lactobacillus)
5. Others: restrictive synthetic underwear, obesity,
contraceptive medication

30. Transmission 1) Endogenous infection (most often)
Vagina, oral cavity, intestinal tract
2) Sexual contact
3) Contacting fomites

31. Pathogenesis Two phases of candida albicans 1) Yeast spores
Asymptomatic parasitism
2) Pseudohyphae
Pathogenic
3) Mechanism:
a) Candida at the pseudohypha phse penetrate vaginal
epithelium for nutrients
b) Growing candida albicans release proteolytic enzymes
and toxins etc. resulting in inflammation reaction

32. Clinical Picture 1. Vulvovaginal pruritus (main)
usually intense, coincident with menses or intercourse
2. Increased vaginal discharge
The classic finding is white, thick,curd-like discharge
forming patches adherent to the vaginal walls.

33. Diagnosis candida albicans in the discharge Saline: 30-50%
1. Wet mount microscopic identification of
candida albicans in the discharge
Saline: 30-50%
10% KOH: 70-80%
2. Gram’s stain: 80%
3. Culture: higher sensitivity and drug test
4. Measurement of pH value may be useful for
discovering cases of complicated infection
( ).
a pH<4.5 simple infection
a pH>4.5 combined infection

35. Treatment Vaginal suppositories：
1. Elimination of predisposing factors
2. Topical application of antifungal agents
Vaginal suppositories：
1) Miconazole
a) 200mg/day for 7days
b) 400mg/day for 3 days
2) Clotrimazole
a) 150mg/day for 7 days
b) 150mg, twice a day for 3 days
c) 500mg single dose

36. 3. Systemic medication 3) Nystatin 100,000units/day for 10-14 days
4) Methyl violet
0.5-1% , 3-4 times/week for 2 weeks.
3. Systemic medication
Oral agents are used only for cases that can not be
treated with topical application of antifungal drugs.
Fluconazole
150mg, single use.
2) Itraconazole
a) 200mg/day for 3-5 days
b) 400mg for 1 day divided in two doses

37. 3) Ketoconazole
200mg, once or twice/day until culture result is negative
Hepatotoxicity may occur.
Points of note for treating VVC
Treatment should be followed-up with a premenstrual
examination of the vaginal discharge.
Approximately 10% of cases will not respond to
initial therapy.
Prolongation of treatment up to 14 days may cure
some patients.
Identification and elimination of predisposing
factors is important.
Recurrent VVC should be treated with oral therapy
followed by prophylactic doses.

38. Treatment of sexual partner?
No treatment for asymptomatics.
15% should be treated

39. Bacterial Vaginosis

40. Etiology 1. Imbalance of normal vaginal flora
Diminution of Doderlein lactobacillus and
increase in other bacteria, in particular,
anaerobic bacteria.
2. Causative factors of the imbalance are unknown
Gardnerella vaginalis

41. Clinical Picture Symptoms: Signs: 1. 10-40% asymptomatic
2. Mild pruritus or burning
sensation
3. Increased vaginal discharge
and fishy odor
Signs:
Discharge: thin, greyish-white,
homogenous, but not sticky
No inflammation reaction
(No epithelial edema or erythema)

42. Diagnosis
Identification of clue cells *(wet mount in saline) together with 2 of the following 3 items
1. Vaginal discharge: homogenous, thin and white
2. pH>4.5: in virtually all cases, usu
3. Positive Whiff test (with 10% KOH)
* Clue cells are desquamated epithelial cells covered with clumps of coccobacili esp. Gardnerella vaginalis which gives the cells a speckled appearance.

43. Whiff test

45. 1. Systemic therapy (oral) (80%) 1) Metronidazole
Treatment (1)
1. Systemic therapy (oral) (80%)
1) Metronidazole
400mg, 2-3 times a day for 7 days
2) Clindamycin
300mg, twice a day for 7 days
2. Topical therapy (80%)
1) Effervescent tablets of metronidazole
200mg/day, for 7-10 days
2) 2% Clindamycin cream, once a day for 7 days
3. Vaginal washing
1-3% H2O2 , 1% lactic acid, 0.5% acetic acid

46. Treatment (2)
1. Systemic or topical treatment has the same cure rate (80%).
2. Patients who are asymptomatic, but scheduled to
have a gynecologic surgical procedure should be treated.
3. Patients who are pregnant can be treated with oral
metronidazole.
4. Follow-up examination should be given 1-2 and 3-4
weeks (postmenstrual) after the treatment.
Criteria for cure:
Absence of clue cells with at least 1 of the following items:
a) Normal vaginal discharge
b) pH≤4.5
c) Whiff test negative

47. Other forms of vulvovaginitis
Senile vaginitis
Atrophic vaginitis
2. Infantile vulvovaginitis

49. Differential Diagnosis of vaginitis
Bacterial Vaginosis Candidiasis Trichomoniasis
Complaints
Vaginal
discharge
epithelium
Vaginal pH
Whiff test
Microscopic
examination
discharge↑mild pruritus
severe pruritus burning
discharge↑ mild pruritus
white homogenous fishy
white curd-like
thin purulent frothy
normal
edema erythema
punctate hemorrhage
＞4.5 ( ) ＜ ＞5 ( )
＋ － －
Clue cells WBC rare
Candida WBC some
Trichomonad WBC many

50. Inflammation of the Cervix
1. Common: 50% women of reproductive age
2. May lead to pelvic infection
3. Need to identify a venereal disease and
differentiate from malignancies
Cervicitis: Vaginal portion of the cervix (Ectocervix)
Mucosa of the cervical canal (Endocervix)

51. Acute Cervicitis

52. Etiology Neisseria gonorrhoeae Chlamydia trachomatis
causing superficial infection of the cervical
columnar mucosa
Staphylococcus
streptococcus
enterococcus
causing infection after an abortion, puerperium,
cervical injury, foreign bodies

53. 2. Mucopurulent vaginal discharge
Clinical Picture
Symptoms
1. Asymptomatic
2. Mucopurulent vaginal discharge
Vaginal irritation symptoms:pruritus, burning sensation
Lumbosacral pain,
Intermenstrual bleeding, postcoital bleeding
Symptoms of the lower urinary tract
Signs
Inflammation of the cervix with mucopurulent
discharge (MPC for mucopurulent cervicitis)

55. Diagnosis 1. Gram’s stain of the cervical discharge for leukocyte
≥30/HP or ≥10/×1,000
2. Tests for gonococcus and chlamydia
3. Wet mount microscopy for trichomonads

57. Management Systemic medication
Choice of drugs depends on the pathogens.
Examples:
Gonorrhea infection：Third generation Cephalosporins
Ceftriaxone Sodium
Spectinomycin
Chlamydia trachomatis
Doxycycline
Azithromycin
Erythromycin
Ofloxacin

58. Chronic Inflammation of
the Cervix

60. Etiology When the stratified epithelium which
Cervical Erosion
Etiology
When the stratified epithelium which
normally covers the vaginal portion of the cervix is replaced by columnar epithelium which is continuous with that of the cervical canal.
2. Most erosion are not infected, nor they are the result of inflammation.
3. Occurs in the newborns, pregnancy, oral contracepives

61. Clinical Features Symptoms Signs Classification
The only symptom is a mucoid discharge.
A slight postcoital bleeding (but malignancy should be excluded)
Signs
A red area is seen around the external os.
Classification
Depends on the depth and area of the lesion
Types: simple, granular, papillary
Grades: I (＜1/3), II (1/3-2/3), III (＞2/3)

62. Treatment Erosion found on routine examination should
not be treated unless it is causing troublesome
discharge.
A cervical smear is needed before the treatment,
and if necessary, colposcopy and biopsy.
Cervical ectropion
Physical therapy
Thermal cauterization,
Cryotherapy,
Laser therapy

64. Cervical Polyps Small pedunculated neoplasms of the cervix
Endocervical polyp:
Originating from the endocervix
Ectocervical polyp:
Originating from the vaginal portion

65. Pathology Gross appearance:
Endocervical polyp: Red or pink, rounded or tongue-like
Ectoervical polyp: Pale, flesh-colored, smooth, rounded
with a broad pedicle
Microscopic:
Vascular connective tissue stroma covered with columnar
or squamous epithelium or both. Congestion, edema or
leukocytein filtration may be present.

66. Clinical Features Treatment Some are asymptomatic.
Slight postcoital bleeding
Treatment
Cervical polyp should be treated.
Malignant change (<1%)
Polypoid cervical cancer
Twisting off a polyp without an anesthetic
and cauterizing the base. Recurrent cases
are treated with canal dilation and cauterization
of the stalk.

67. Chronic Endocervicitis (Infection) Etiology
Pathogens:
Normal cervical and vaginal flora
Pathology
Thickened endocervix that produces a whitish pus
A cervical os surrounded by a reddish area
Hypertrophy of the lacerated cervix

68. Clinical Features 1. Persistent leukohrrea usu. mucopurulent
2. Slight postcoital staining
3. Pains
lower abdominal discomfort, lumbosacral
backache, dysmenorrhea, dyspareunia
4. Infertility
5. Urinary symptoms
frequency, urgency, dysuria due to
subvesical lymphangitis not to cystitis

69. Diagnosis The characteristic discharge from external os of the cervix.
Cytologic and colposcopic studies are helpful, but
only biopsy is definitive.
Cultures are not so helpful.

70. Treatment Even if chronic endocervicitis is asymptomatic,
it should be treated.
1. Medical treatment
Systemic rather than topical
Based on culture and sensitivity test
2. Surgical treatment
A note of caution: postoperative bleeding, infection,
stricture formation, infertility.
Methods: thermal therapy, cryotherapy, laser therapy
conization, hysterectomy.

72. Nabothian Cysts Cervical Hypertrophy
Retention cysts of the cervical glands caused by
obstruction of the gland orifices by the growth
of squamous epithelium. The cysts may be infected
and contain pus.
Cervical Hypertrophy

74. Cervical Hypertrophy

76. Pelvic Inflammatory Disease (PID)
Infection of the upper genital tract
Terms:
Endometritis (子宫内膜炎)
Salpingitis (输卵管炎)
Oophoritis (卵巢炎)
Myometritis (子宫肌炎)
Pyosalpinx (输卵管积脓)
Hydrosalpinx (输卵管积水)
Peritonitis (腹膜炎)
Tubal ovarian abscess (TOA) (输卵管卵巢脓肿)

77. Epidemiology Sexual activity
A disease of sexually active, menstruating women.
Acute PID occurs in 1-2% of young sexually
active women annually.
Age
The peak incidence occurs in their late teens
and early twenties.
The most common serious infection in women
of years of age

78. Contraceptive practices
Contraceptive methods No.of PID/woman-years
Sexually active, using no contraception: 3.42
Oral contraceptives:
Barrier methods
Intrauterine devices (IUD)

79. Financial cost
In USA, $3.5 billion annually in 1990s
Medical sequelae
Ectopic pregnancy: 6-10 fold increase
PID accounts for 50%
Chronic pain: fold increase
Infertility: acute PID account for 5-60% of cases
Tubal obstruction: %, 23.1%,54.3% from 1, 2, 3
episodes of infection
Mortality: septic shock and death

80. Etiology Pathogens that are sexually transmitted
1) Neisseria gonorrhoeae: in USA, 40-50% cases of PID
2) Chlamydia trachomatis: in USA, 10-40% cases of PID
The two pathogens may account for 2/3 of the PID
3) Mycoplasma (支原体)
Recovered from the pus in 2-20% cases of salpingitis
Endogenous bacteria
1) Aerobic: streptococci, staphylococci, Escherichia coli
2) Anaerobic: Bacteroides fragilis (脆弱类杆菌),
peptococcus (消化球菌) ，
peptostreptococcus (消化链球菌)

81. Spreading Route of Infection
1. Ascending along the reproductive tract
For non-pregnant and non-puerperal women
Gonococcus, C. trachomatis, staphylococcus
2. Lymphatic vessels
In puerperal infection, post-abortion infection
and IUD associated infection
Streptococcus, E.coli, anaerobic bacteria
3. Blood vessels
Tuberculosis
4. Direct spreading
Infection from other visceral organs.

82. Acute PID

83. Predisposing Factors 1. Intrauterine manipulation
e.g. artificial abortion , IUD, etc.
2. Infection in the lower reproductive tract, esp. STD
3. Sexual activity
4. Bad hygiene
4. Direct spreading from adjacent viscera
6. Acute onset of a chronic PID

84. Pathology 1. Acute endometritis and myometritis
2. Acute salpingitis, pyosalpinx and
tubo-ovarian abscess (TOA)
3. Acute pelvic peritonitis
4. Acute inflammation of the peritoneal
connective tissue (parametritis)(宫旁结缔组织炎)
5. Septicemia (败血症) and pyemia (脓毒血症)
6. Fitz-Hugh-Curtis syndrome

87. Fitz-Hugh-Curtis syndrome
Perihepatitis: inflammation of Glisson’s capsule
without involvement of the liver parenchyma.
Suppurative (脓性) and fibrous exudation of the
capsule occurs causing adhesion between the capsule
and the anterior peritoneum.
It happens in 5-10% cases of salpingitis.
It is caused by gonococcus or Chlamydia trachomatis.
Edema and adhesion of the capsule may lead to pain
in the upper abdominal region.

89. Clinical Features Symptoms
Vary depending on severity and extent of the infection
and types of pathogens
Most common: lower abdominal pain, fever, increase
in vaginal discharge.
Gonorrhea/Chlamydia Trichomatis
Signs
Variable
Typical:
Bimanual examination:

90. Diagnosis Criteria for the diagnosis of PID Minimum:
Pain on compression of uterine body
or the adnexal region
2) Tenderness of the cervix
Specific:
1) Biopsy of the endometrium showing endometritis
2) Ultrasound/MRI identification of liquid-filled
enlarged oviducts or TOA
3) Laparoscopic examination
Additional:

91. Differential Diagnosis
Appendicitis
Rupture or abortion of tubal pregnancy
Torsion or rupture of an ovarian tumor

92. Treatment (1) 1. Systemic medication
(Ideal) Based on drug sensitivity test
(Empirical) Combination use of drugs
Patient’s condition and possible pathogens
1) Oral: Ofloxacin (氧氟沙星) Metronidazole for 14 days
2) Intravenous: Penicillin or Erythromycin (红霉素)
Gentamycin (庆大霉素) or Amikacin (阿米卡星/丁胺卡那霉素)
Metronidazole for endogenous bacteria
3) Cefuroxime sodium (头孢呋辛钠/西力欣) for gonococcus
4) Doxycycline (多西环素/强力霉素) or Azithromycin (阿奇霉素)
for chlamydia or mycoplasma
5) Clindamycin (克林/氯林/氯洁霉素) for anaerobic bacteria

93. Treatment (2)
2. Surgical treatment
for TOA or peritoneal abscesses that can not be
controlled by drugs (2-3 days)
Indications:
1) Failure of drug therapy
2) Persistent existence of abscesses (2-3 weeks)
3) Rupture of the abscess
3. Traditional Chinese medicine

95. Chronic PID

96. Etiology 1. Incomplete treatment of the acute PID
2. Infection from certain pathogens such
as Chlamydia trachomatis
3. Residual lesions from previous acute PID
Characteristics of chronic PID:
1. Persistence of the condition
2. Difficult to identify the pathogens

97. Pathology 1. Chronic endometritis
2. Chronic salpingitis and hydrosalpinx
3. Salpingo-oophoritis and tubo-ovarian cyst
4. Chronic inflammation of pelvic connective tissue

99. Clinical Features 1. Chronic pelvic pain
2. Infertility (20-30%) and ectopic pregnancy
3. Abnormal menstrual cycle
4. Systemic symptoms
5. Signs

100. Diagnosis Based on history of acute PID, symptoms and signs
Differential diagnosis
Pelvic congestion or varicosity (静脉曲张)
Endometriosis
Tumors
Ultrasound and laparoscopic examination is helpful

101. Treatment According to place of the lesion and the patient’s complaint
Usu. comprehensive treatment is required.
1. Physical
2. Traditional Chinese medicine (赤丹丸)
3. Antibiotics (抗炎II号栓)
4. Drugs that dissolve and absorb
inflammatory lesions
5. Surgical treatment