1. Genital Tract Infections
XU JIAN

2. The Normal Vagina
The normal vaginal flora is mostly aerobic, with an average of six different species of bacteria
the most common of which is hydrogen peroxide (H2O2) producing lactobacilli.
The pH level of the normal vagina is lower than 4.5, which is maintained by the production of lactic acid.
Aerobic需氧的；lactobacilli乳酸杆菌；pH小于4.5

3. The Normal Vagina Vaginal self-purification
Estrogen-stimulated vaginal epithelial cells are rich in glycogen.
Vaginal epithelial cells break down glycogen to monosaccharides, which can then be converted by the cells themselves, and lactobacilli to lactic acid.
Maintaining the pH level lower than 4.5.
Glycogen糖原（多糖）；Monosaccharides单糖（3-7碳，主要如葡萄糖，果糖，半乳糖）

4. The Normal Vagina Against infection: Vaginal self-purification
Immunity
Vulva
Uterine cervix
Endometrium)
Aerobic需氧的；lactobacilli乳酸杆菌；pH小于4.5

5. Trichomonas Vaginitis

6. Trichomonas Vaginitis
is caused by the sexually transmitted,
flagellated parasite, Trichomonas vaginalis.
The transmission rate is high; 70% of men contract the disease after a single exposure to an infected woman,
The parasite, which exists only in trophozoite form, is an anaerobe that has the ability to generate hydrogen to combine with oxygen to create an anaerobic environment.
It often(60%) accompanies BV.
性转播，厌氧、Flagellated有鞭毛的；parasite寄生虫；trophozoite（滋养体）

7. Trichomonas Vaginitis-Diagnosis
Vaginal discharge: thin, purulent, malodorous (when accompany BV).
Strawberry cervix may be observed.
The pH usually higher than 5.0
Motile trichomonads.
Clue cells may be present (when accompany BV)
The whiff test may be positive (when accompany BV)
Purulent脓性的； malodorous（恶）臭的

8. Trichomonas Vaginitis-Diagnosis
Women with this infection should be tested for other sexually transmitted diseases (STDs), particularly Neisseria gonorrhoeae
Chlamydia trachomatis.
Syphilis
Human immunodeficiency virus (HIV)
Because of the sexually transmitted nature of trichomonas vaginitis, 淋病、衣原体、梅毒

9. Trichomonas Vaginitis-Treatment
Metronidazole :first choice for treatment (cure rates 95%)
single-dose (2 g orally) OR
multidose (500 mg twice daily for 7 days)
The sexual partner should also be treated.
Metronidazole gel (effective for the treatment of BV) should not be used for the treatment of TV.
Treatment of pregnancy women…

10. Trichomonas Vaginitis-Treatment
Not respond to initial therapy?
Treated again with metronidazole, 500 mg, Bib X 7 ds.
Repeated treatment not effective?
Treated with a single 2-g dose of metronidazole Qd X5 ds or tinidazole, 2 g, Qd X5 ds .
Still not effective?
Exclude the possibility of reinfection
Expert consultation.
Culture of the parasite to determine its susceptibility to metronidazole and tinidazole.

11. Vulvovaginal Candidiasis(VVC)

12. Vulvovaginal Candidiasis(VVC)
Very common ：An estimated 75% of women experience at least one episode of VVC.
Is usually endogenous
Candida albicans is responsible for 85% to 90% of vaginal yeast infections.
Other species of Candida, such as C. glabrata and C. tropicalis, can cause vulvovaginal symptoms and tend to be resistant to therapy.
白色念珠菌（Candida albicans） 或亦称“白色假丝酵母”。一种呈椭圆形、行出芽繁殖的假丝酵母。通常存在于正常人的口腔、肠道、上呼吸道等处，能引起鹅口疮等口腔疾病或其他疾病
Candida glabrata （光滑假丝酵母）， C. tropicalis（热带假丝霉菌）,

13. Vulvovaginal Candidiasis(VVC)
Candida are dimorphic
blastospores, responsible for transmission and asymptomatic colonization
mycelia, result from blastospore germination and enhance colonization and facilitate tissue invasion.
Dimorphic二态性的；mycelia菌丝体

14. Vulvovaginal Candidiasis(VVC)
Factors that predispose women to the development of symptomatic VVC include:
Long-term antibiotic use：Disequilibrium of of normal vaginal flora.
Pregnancy: decrease in cell-mediated immunity
Diabetes : decrease in cell-mediated immunity

15. Vulvovaginal Candidiasis(VVC)
Classification of VVC
Uncomplicated
Complicated
Sporadic or infrequent in occurrence
Recurrent symptoms
Mild to moderate symptoms
Severe symptoms
Likely to be Candida albicans
Non-albicans Candida
Immunocompetent women
Immunocompromised, e.g., diabetic women
Immunocompetent免疫正常的

16. VVC-Diagnosis Symptoms:
Vulvar pruritus associated with a vaginal discharge that typically resembles cottage cheese.
Others:Vaginal soreness, dyspareunia, vulvar burning, and irritation.
Examination:
Erythema and edema of the labia and vulvar skin.
The vagina may be erythematous with an adherent, whitish discharge.
The cervix appears normal.

17. VVC-Diagnosis The pH is usually normal (<4.5).
Fungal elements, either budding yeast forms or mycelia, appear in as many as 80% of cases.
The results of saline preparation of the vaginal secretions usually are normal.
The whiff test is negative.
A fungal culture is recommended to confirm the diagnosis.

18. VVC-Treatment
Topically applied azole (吡咯) drugs are the most commonly available treatment and are more effective than nystatin (制霉菌素)
fluconazole (氟康唑), used in a single 150-mg dose (orally), has been approved for the treatment of VVC.
Miconazole（咪康唑）200mg qd X 7ds

19. VVC-Treatment Patients with complicated VVC :
an additional 150-mg dose of fluconazole given 72 hours after the first dose.
or with a more prolonged topical regimen lasting 10 to 14 days.
Adjunctive treatment with a weak topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irritative symptoms.

20. Recurrent VVC Definition: four or more episodes in a year.
Symptoms :persistent irritative of the vestibule and vulva.
Burning replaces itching
Diagnosis: should be confirmed by direct microscopy of the vaginal secretions and by fungal culture.
Many women with RVVC presume incorrectly they have a chronic yeast infection. Many of these patients have chronic atopic dermatitis or atrophic vulvovaginitis.
Vestibule前庭；itching痒；atrophic萎缩性的

21. Recurrent VVC-treatment
A remission of chronic symptoms with fluconazole (150 mg every 3 days for 3 doses).
Then be maintained on 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. After suppressive therapy, approximately one half will remain asymptomatic. Recurrence will occur in the other half and should prompt reinstitution of suppressive therapy

22. Bacterial Vaginosis (BV)

23. Bacterial Vaginosis (BV)
BV has previously been referred to as nonspecific vaginitis or Gardnella vaginitis.
The loss of hydrogen peroxide producing lactobacilli
Overgrowth of predominantly anaerobic bacteria, as well as G. vaginalis and Mycoplasma hominis.
Mycoplasma hominis (人型支原体)

24. Bacterial Vaginosis (BV)
It is not known what triggers the disturbance of normal vaginal flora.
Alkalinization of the vagina, which occurs with frequent sexual intercourse or use of douches, plays a role.
After normal hydrogen peroxide producing lactobacilli disappear, it is difficult to reestablish normal vaginal flora, and recurrence of BV is common.
重在预防！Alkalinization碱性化；Douches冲洗、灌洗

25. Bacterial Vaginosis (BV)
Sequelae:
Pelvic inflammatory disease (PID)
Postabortal PID
Postoperative cuff infections after hysterectomy ;
Abnormal cervical cytology ;
Premature rupture of the membranes ;
Preterm labor and delivery;
Chorioamnionitis;
Postcesarean endometritis

26. Bacterial Vaginosis-Diagnosis
A fishy vaginal odor
Vaginal discharge are present.
The pH is higher than 4.5 (usually 4.7 to 5.7).
Increased number of clue cells
Leukocytes are conspicuously absent.
The whiff test releases a fishy, aminelike odor.

27. Bacterial Vaginosis-Treatment
Ideally, treatment of BV should inhibit anaerobes but not vaginal lactobacilli.
Metronidazole: is the drug of choice for the treatment of BV. 500 mg, orally twice daily for 7 days
Clindamycin, 300 mg, orally twice daily for 7 days
Treatment of the male sexual partner has not been shown to improve therapeutic response
Metronidazole: an antibiotic with excellent activity against anaerobes but poor activity against lactobacilli,
孕妇的治疗 由于BV可能与一系列妊娠并发症有关，如胎膜早破、早产、绒毛膜羊膜炎、羊水感染等，故应密切随访。一般认为患BV的孕妇可局部使用甲硝唑、氯林可霉素治疗，也可口服氯林可霉素及氨苄青霉素，用法同前，但妊娠头3个月内禁服甲硝唑。

28. Bacterial Vaginosis-Differential DiagnosisBV
VVC TV
Symptoms
asymptomatic
vulvar pruritus & burning
pruritus
Vaginal discharge
gray , fishy odor
white, cottage cheese
Yellow,purulent , malodorous
Vaginal wall
normal
Erythema, edema
erythema pH
>4.5(4.7 to 5.7)
<4.5
>5
whiff test
positive
negative
microscopy
clue cells
budding yeast forms or mycelia
trichomonads,
leukocytes
Pruritus（瘙痒）

29. Acute Cervicitis

30. Acute Cervicitis
The cause of cervical inflammation depends on the epithelium affected.
The ectocervical epithelium can become inflamed by the same micro-organisms that are responsible for vaginitis.
Trichomonas, candida, and HSV can cause inflammation of the ectocervix.
Conversely, N. gonorrhoeae and C. trachomatis infect only the glandular epithelium

31. Acute Cervicitis-Diagnosis
The diagnosis of cervicitis is based on the finding of a purulent endocervical discharge, generally yellow or green in color and referred to as mucopus

32. Acute Cervicitis-Diagnosis
Endocervical canal green or yellow color of the mucopus.
Cervix is friable or easily induced to bleed.
An increased number of neutrophils (30 per high-power field).
Intracellular gram-negative diplococci:gonococcal endocervicitis?
negative for gonococci, chlamydial cervicitis?
Tests for both gonorrhea and chlamydia, preferably using PCR, should be performed.
Neutrophils中性的

33. Acute Cervicitis -Treatment
Treatment Regimens for Gonococcal Infections
Neisseria gonorrhoeae endocervicitis:
Cefixime头孢克肟, 400 mg orally (single dose)
or    Ceftriaxone头孢曲松, 125 mg im (single dose),
or    Ciprofloxacin环丙沙星, 500 mg orally (single dose)
or    Ofloxacin, 400 mg orally (single dose)
or    Levofloxacin 250 mg orally (single dose)

34. Acute Cervicitis -Treatment
Treatment Regimens for Chlamydial Infections
Chlamydia trachomatis endocervicitis
Azithromycin, 1 g orally (single dose),
or    Doxycycline, 100 mg orally twice daily for 7 days,
or    Ofloxacin, 300 mg orally twice daily for 7 days,
or    Levofloxacin, 500 mg orally for 7 days 

35. Acute Cervicitis -Treatment
It is imperative that all sexual partners be treated with a similar antibiotic regimen.
Cervicitis is commonly associated with BV, which, if not treated concurrently, leads to significant persistence of the symptoms and signs of cervicitis.
Imperative强制的

36. Chronic Cervicitis

37. Chronic Cervicitis Pathology:
Cervical erosion: three types and three degrees
Cervical polyp
Naboth cyst
Endocervicitis
Cervical hypertrophy

38. Chronic Cervicitis-Diagnosis
Symptoms
Discharge
Lower abdominal pain
Sourness
Infertility
Bleeding
Others
Signs

39. 上图；正常；下图：生理性柱状上皮移位；右图：慢性宫颈炎（病理性移位、宫颈糜烂样改变）

40. Chronic Cervicitis-Treatment
Physical treatment: the main way.
Electrocautery
Laser
Freezing
HIFU
Medicine
Operation?

41. HIFU治疗后

42. Pelvic Inflammatory

43. Pelvic Inflammatory
PID is a clinical diagnosis implying that the patient has upper genital tract infection and inflammation.
The inflammation may be present at any point along a continuum that includes endometritis, salpingitis, and peritonitis

44. Pelvic Inflammatory
PID commonly is caused by the sexually transmitted micro-organisms N. gonorrhoeae and C. trachomatis
Endogenous micro-organisms found in the vagina, particularly the BV micro-organisms, also often are isolated from the upper genital tract of women with PID, which include anaerobic bacteria such as Prevotella and peptostreptococci as well as G. vaginalis.

45. Pelvic Inflammatory
BV often occurs in women with PID, and the resultant complex alteration of vaginal flora may facilitate the ascending spread of pathogenic bacteria by enzymatically altering the cervical mucus barrier.
Less frequently, respiratory pathogens such as Haemophilus influenzae, group A streptococci, and pneumococci can colonize the lower genital tract and cause PID.

46. Pelvic Inflammatory -Diagnosis
In the diagnosis of PID, the goal is to establish guidelines that are sufficiently sensitive to avoid missing mild cases but sufficiently specific to avoid giving antibiotic therapy to women who are not infected.

47. Pelvic Inflammatory -Diagnosis
Traditionally, the diagnosis of PID has been based on a triad of symptoms and signs.
It is now recognized that there is wide variation in many symptoms and signs.
Some women may develop PID without having any symptoms .

48. Pelvic Inflammatory -Diagnosis
PID should be considered in women with any genitourinary symptoms, including, but not limited to, lower abdominal pain,
excessive vaginal discharge,
menorrhagia, metrorrhagia,
fever, chills,
urinary symptoms.
Pelvic organ tenderness, (uterine alone or uterine with adnexal )
Cervical motion tenderness
Direct or rebound abdominal tenderness
Menorrhagia月经过多； metrorrhagia子宫出血

49. Pelvic Inflammatory -Diagnosis
Evaluation of both vaginal and endocervical secretions is a crucial part of the workup of a patient with PID .
An increased number of polymorphonuclear leukocytes may be detected in a wet mount of the vaginal secretions or in the mucopurulent discharge.

50. Pelvic Inflammatory -Diagnosis
More elaborate tests may be used,including
Endometrial biopsy to confirm the presence of endometritis,
Ultrasound or radiologic tests to characterize a tubo-ovarian abscess,
Laparoscopy to confirm salpingitis visually.

53. Pelvic Inflammatory -Diagnosis
Clinical Criteria for the Diagnosis of PID
Symptoms    
None necessary
Signs    
Pelvic organ tenderness    
Leukorrhea and/or mucopurulent endocervicitis
Additional criteria to increase the specificity
Endometrial biopsy showing endometritis    
Elevated C-reactive protein
Elevated erythrocyte sedimentation rate    
Temperature higher than 38°C    
Leukocytosis    
Positive test for gonorrhea or chlamydia
Elaborate criteria    
Ultrasound documenting tubo-ovarian abscess    
Laparoscopy visually confirming salpingitis

54. Pelvic Inflammatory -Treatment
Therapy regimens for PID must provide empirical, broad-spectrum coverage of likely pathogens,including
N. gonorrhoeae,
C. trachomatis,
gram-negative facultative bacteria,
anaerobes, and
streptococci.

55. Pelvic Inflammatory -Treatment
Hospitalization is recommended only
when the diagnosis is uncertain,
pelvic abscess is suspected,
clinical disease is severe,
or compliance with an outpatient regimen is in question.

56. Pelvic Inflammatory -Treatment
Hospitalized patients can be considered for discharge when their fever has lysed (37.5°C for more than 24 hs),
the white blood cell count has become normal,
rebound tenderness is absent,
and repeat examination shows marked amelioration of pelvic organ tenderness.
Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea (Table 16.3). One of these STDs usually is found in the male sexual partners of women with PID not associated with chlamydia or gonorrhea (42,43).

57. Pelvic Inflammatory -Treatment
Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea.
One of these STDs usually is found in the male sexual partners of women with PID not associated with chlamydia or gonorrhea.

58. Pelvic Inflammatory – Tubo-ovarian Abscess
Tubo-ovarian abscess, an end-stage process of acute PID, is diagnosed when a patient with PID has a pelvic mass that is palpable during bimanual examination.
The condition usually reflects an agglutination of pelvic organs (tube, ovary, bowel) forming a palpable complex.
Occasionally, an ovarian abscess can result from the entrance of micro-organisms through an ovulatory site.

59. Pelvic Inflammatory – Tubo-ovarian Abscess
Tubo-ovarian abscess is treated with an antibiotic regimen administered in a hospital.
About 75% of women with tubo-ovarian abscess respond to antimicrobial therapy alone.
Failure of medical therapy suggests the need for drainage of the abscess

60. Pelvic Inflammatory -Treatment USA-CDC Guidelines
Outpatient Treatment
Regimen A    
Cefoxitin, 2 g im, + probenecid, 1 g orally concurrently,
Or  Ceftriaxone, 250 mg im,
Or  Equivalent cephalosporin +  Doxycycline, 100 mg bid x 14 ds
With or without: Metronidazole, 500 mg orally bid x 14 ds a
Regimen B    
Ofloxacin, 400 mg orally bid x 14 ds
Or  Levofloxacin, 500 mg orally once daily for 14 days    
With or without:  Metronidazole, 500 mg orally bid x 14 ds a

61. Pelvic Inflammatory -Treatment USA-CDC Guidelines
Inpatient Treatment
Regimen A    
Cefoxitin, 2 g iv q6h,
Or  Cefotetan, 2 g iv q12h, + Doxycycline, 100 mg orally or iv q12h
Regimen B    
Clindamycin, 900 mg iv q8h + Gentamicin,
loading dose iv or im (2 mg/kg of body weight)
followed by a maintenance dose (1.5 mg/kg) q8h
Use of metronidazole recommended in those cases in which BV is diagnosed concurrently with PID.

62. Sequelae of PID Diagnosis Medical history Chronic Infertility
Recurrent acute PID
Ectopic pregnancy
Signs

64. Genital tuberculosis

65. Genital tuberculosis Way of infection Blood flow: main way
Direct spread: some times
lymph vesse： less
sexually transmitted：very rarely

66. Genital tuberculosis Pathology
Tuberculosis of fallopian tube: 90%-100%,bilateral usually
Endometrial tuberculosis: 50%-80%
Ovarian tuberculosis: 20%-30%
Tuberculosis of cervix: rarely
Pelvic peritoneal tuberculosis: common

67. Genital tuberculosis-Diagnosis
Symptoms
Infertility
Abnormal menstruation
Lower abdominal pain
Symptoms of tuberculosis
Signs

68. Genital tuberculosis-Diagnosis
Auxiliary diagnosis
Dilatation & curettage：frequent giant cells, caseous necrosis, and granuloma formation (time, site, streptomycin)
X-ray
Laproscopy
Tubercle bacillus: microscopy, culturing, PCR
Tuberculin test：（-），(+) and (+++）

69. Genital tuberculosis-Treatment
Antitubercular agent
Isoniazid （H,异烟肼）
Rifampicin (R,利福平)
Streptomycin (S,链霉素)
Ethambutol (E,乙胺丁醇)
Pyrazinamide (Z,吡嗪酰胺)
Regimen A: 2SHRZ/4HR or 2SHRZ/4H3R3
Regimen B: 2SHRZ/6HRE or 2SHRZ/6H3R3E3

70. 谢
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