1. Genital Tract Infections
A. Alobaid, MBBS, FRCS(C), FACOG
Consultant, Gynecologic Oncology
Assistant professor, KSU
Medical Director, Women’s Specialized Hospital
King Fahad Medical City

2. 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

3. 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

4. Bacterial Vaginosis (BV)
Diagnosis:
Fishy odor (especially after intercourse)
Gray secretions
Presence of clue cells
PH >4.5
+ve whiff test (adding KOH to the vaginal secretions will give a fishy odor)

5. Bacterial Vaginosis (BV)
Treatment:
Flagyl 500mg Po Bid for one week (95% cure)
Flagyl 2g PO x1 (84% cure)
Flagyl gel PV
Clindamycin cream PV
Clindamycin PO
Treatment of the partner is not recommended

6. 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)

7. Trichomonas Vaginalis
Diagnosis:
Profuse, purulent malodorous discharge
It may be accompanied by vulvar pruritis
Secretions may exudate from the vagina
If severe → patchy vaginal edema and strawberry cervix
PH >5
Microscopy: motile trichomands and ↑ leukocytes
Clue cells may if BV is present
Whiff test may be +ve

8. Trichomonas Vaginalis
Treatment:
Falgyl PO (single or multi dose)
Flagyl gel is not effective
The partner should be treated

9. 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

10. Candidiasis Predisposing factors:
Antibiotics: disrupting the normal flora by ↓ lactobacilli
Pregnancy (↓ cell-mediated immunity)
Diabetes

11. Candidiasis Diagnosis: Vulvar pruritis and burning
The discharge vary from watery to thick cottage cheese discharge
Vaginal soreness and dysparunea
Splash dysuria
O/E: erythema and edema of the labia and vulva
The vagina may be erythematous with adherent whitish discharge
Cervix is normal
PH< 4.5budding yeast or mycelia on microscopy
The culture will confirm the diagnosis

12. Candidiasis Treatment: Topical Azole drugs (80-90% effective)
Fluconazole is equally effective (Diflucan 150mg PO x1), but symptoms will not disappear for 2-3 days
1% hydrocortisone cream may be used as an adjuvant treatment for vulvar irritation
Chronic infections may need long-term treatment (6 months) with weekly Fluconazole

13. 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

14. Atrophic Vaginitis In post-menopausal women
May be accompanied by purulent discharge, dysparunea and post-coital bleeding
It is treated with topical Estrogen cream

15. 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

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

18. 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

19. 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

20. PID

21. PID

22. 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

23. 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

24. Genital ulcer disease
Have to R/O syphilis by serology, dark field examination or direct IF for Treponema pallidum
Culture for HSV

25. Genital ulcer disease

26. Genital ulcer disease
Still ¼ of the diagnosis is made by clinical examination only:
Syphilis: non-painful, min. tender ulcer, not accompanied by LAP
HSV: grouped vesicles mixed with ulcers with a history of similar lesions
Chancroid: 1-3 extremely painful ulcers with tender inguinal LAP
LGV: inguinal bubo without ulcers

27. Genital ulcer disease Treatment:
Chancroid: Azithromycin 1gm PO x1, ceftazidime 250mg IM x1, or Erythromycin
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)
Syphilis: Benzathine Pen G 2.4 million units IM x1 dose

28. 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

29. Genital Warts

30. HIV 20-25% of patients are women
36% is secondary to heterosexual transmission
Median age between HIV infection and AIDS is 10 years

31. 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

32. Thank you