1. Lower Genital Tract Infections Nazila Karamy-MD Obstetrics and Gynecology Specialist wwww.doctorkaramy.ir

3. Case 1 A 25 y married woman come with little non –malodor, white discharge without burning @pruritis,LMP:2 weeks ago ? Suggestive DX@ T??

4. “Normal” Vaginal Discharge? Normal increase in cervical mucous production mid-cycle (ovulation)tht helpful for fertility, White or clear(not yellow or green), non- malodorous and not accompanied by irritative symptoms

5. Case 2 35 y female with 2 sexual partners complains of smelly discharge. The pelvic exam reveals no vulvar or vaginal inflammation,no burning; a foamy, thin discharge with pH of 5.0; and some bleeding at the cervix. Wet prep reveals 2 clue cells and no motile organisms. Your diagnosis?

6. Case 3 Healthy 33 y Bad –smelling,Grey colour vaginal discharge. She is sexually active with 1 male partner. This is the first time she has had these symptoms and is worried it may represent a serious health problem. What is ur suggestive DX??? Do u suggest tratment of her partner??

7. Bacterial Vaginosis Most common cause of vaginitis in premenopausal women Represents in change vaginal flora –Decrease in lactobacilli –Increase in gardnerella vaginalis, mycoplasma hominis, anaerobic G- rods, and peptostreptococci

8. Bacterial Vaginosis

9. Clinical Features 50% are asymptomatic Unpleasant, “fishy smelling” discharge No Itching and inflammation

10. Amstel Criteria grayish-whitish discharge Vaginal pH > 4.5 Positive Whiff test Clue cells on wet mount

11. Clue Cells

12. Complications Increases risk for: –Preterm labor in pregnant women –Endometritis and postpartum fever –Post-hysterectomy vaginal-cuff cellulitis –Postabortal infection

13. Therapy May resolve spontaneously Treat if: –Symptomatic –Asymptomatic prior hysterectomy, IUD placement,Pregnant and have history of PTL No need to treat sexual partners

14. Therapy Metronidazole –500mg PO BID x 7 days or metro-gel 1 applicator full qd x 5d –Single dose therapy (2gm) but has higher relapse rate

15. Therapy Clindamycin –Topical vaginal cream –As effective as metronidazole –Can use oral but less effective Side effect::Pseudomembranous colitis in oral taking

16. case4 A 19 Y not married woman come with cheesy discharge.she has HX of travel,she took antibiotic for the sinusitis. Suggestive DX????

17. Case 5 A 23 y woman come with watery discharge,pruritis,burning tht exacerbate after cuitus tht had 2 days ago. Suggestive DX???

18. Candida Vulvovaginitis Up to 75% of premenopausal women have at least one episode Rare before menarche@ postmenopausal women( unless taking estrogen)

19. Predisposing factors (Candida albicans) –Antibiotics –Diabetes mellitus –OCPs –Contraceptive devices (IUD, tampon) –Pregnancy

20. Clinical Features Vulvar/vaginal pruritis “Burning”,Irritation, soreness, dyspareunia White, clumpy discharge,but sth watery like

21. CANDIDIA pH 4- 4.5 (normal)

22. Therapy Mostly improve with therapy within 2 days Severe infections may require up to 14 days to improve

23. Therapy – “Azole” Antifungals Imidazoles – effective against C. albicans:Miconazole, clotrimazol, all OTC Triazoles – effective against C. albicans, and C. glabrata and tropicalis – fluconazole, ketoconazole

24. PREVENTION THERAPY Taking @sitting yogurt full of lactobacillus Taking alkalotic agent NaHco3 (not acidic agent as venegar ) Forbid of humid,warm condition(as tight underwear),dryness after washing forward to backward

25. CASE 6 A 37 Y married woman come with malodor green colour discharge, external dysuria,dysparonia since yesterday. Suggestive DX@T?? Do u suggest tratment of partner???

26. Trichomoniasis 3 rd most common vaginitis Nonaerobic,active Flagellated protozoan – trichomonas vaginalis Elevated PH Infects vagina, urethra and paraurethral glands always sexually transmitted

27. Clinical Features Ranges from asymptomatic to severe, acute inflammatory disease Purulent, malodorous, thin, frothy discharge Dysuria (external), dyspareunia and pruritis are common “strawberry cervix”

28. Trichomoniasis

29. Therapy Metronidazole 500 mg Bd till 7 days,2gm single dose If refractory to treatment –treat with partner

30. CASE 7 A 57 Y menopause woman come with a little wattery discharge,external dysuria,dysparonia. Suggestive DX@T??

31. Other Causes of Vaginitis Atrophic vaginitis –High vaginal pH, thin epithelium –Topical estrogen cream

32. CASE 8 A 26 y married woman come with aphtus itchy ulcer,external dysuria bilateral inguinal lymphadenopathy tht had low grade fever,headache,LBP, from 3 days ago. Suggestive DX???

33. Herpes Simplex Virus HSV – 1 –Mostly oro-labial, but increasing cause of genital herpes HSV – 2 –Almost entirely genital –> 95% of recurrent genital lesions Primary infections Recurrent infections

34. Case 9 A pregnant woman G2L1 (NVD) term,HX:HSV 2 one month ago but no ulcers exists now. Wht is the root of delivery?

35. Transmission Horizontal Transmission –Intimate sexual contact (oral/genital) Vertical Transmission –Maternal-infant via infected cervico-vaginal secretions, blood or amniotic fluid

36. Primary Herpes – Classic Symptoms Systemic – fever, myalgia, malaise –Can have meningitis, encephalitis, or hepatitis Local – clusters of small, painful blisters that ulcerate and crust outside of mucous membranes –Itching, dysuria, vaginal discharge,bilateral inguinal adenopathy, bleeding from cervicitis

38. Diagnosis Viral isolation (culture) –High specificity, low sensitivity Direct detection of virus ( PCR) Serology –Newer tests that are specific for type of virus ( IgG detect, ELISA)

39. Management Goals Relieve symptoms Heal lesions Reduce frequency of recurrency@ viral transmission Patient support and counseling

40. Oral Antiviral Therapy Acyclovir (Zovirax) Famciclovir (Famvir)(in resistant cases)

41. SUGGESTION Because of transmission of virus even in remmission period Barrier(condom) suggested for the partner cos of stop transmission

42. CASE 10 A 24 y Married woman come with a plaque,multiple gray nodules with non smooth surface on external genitalia. DX,T???

43. HPV Can convert SCC,esp in CX DUE TO Hpv type 16,18 T:cryo,cauter,laser,5 FUO,medical (TCC,…),Podophylin ONLY In codyloma acuminata =>do C/S(Due to risk of larynx papiloma)

44. CASE 11 A 22 Y Woman,multipartner,sexually active,BC:IUD,In mense period,come with severe lower abdominal pain,a lot of malodor discharge,severe tenderness in exam DX,TREATMENT???

45. Pelvic Inflammatory Disease A Condition Requiring Closer Attention

46. What is PID ? Inflammation of pelvic structures Ascending spread of infection from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, &/ or adjoining structures =>>> salpingitis endometritis, parametritis, tubo-ovarian abscess & pelvic peritonitis

47. Presentation: Acute PID Severe pain & tenderness lower abdomen Fever, Malaise, vomiting, tachycardia Offensive vaginal discharge Irregular vaginal bleeding Bilat adnexal tenderness Tubo-ovarian mass

48. Presentation: Chronic PID Chronic lower abdominal pain, Backache General malaise & fatigue Deep dyspareunia, Dysmennorhea Intermittent offensive vaginal discharge Lower abdominal/ pelvic tenderness Bulky, tender uterus Infertility due to adhesion

49. Predisposing Factors Frequent sexual encounters, many partners Young age, early age at first intercourse Relative ill-health & poor nutritional status. Previously infection (STD/ PID) Frequent vaginal douching

50. PID: Differential Diagnosis Ectopic Pregnancy Torsion/ Rupture adnexal mass Appendicitis Endometriosis Cystitis/ pyelonephritis

51. Pathogenesis

52. Infective Organisms Sexually transmitted - Chlamydia trachomatis Neisseria gonorrhoeae Endogenous Aerobic - Streptococci Haemophilus E. coli Anaerobes - Bacteroides, Peptostrptococcus - Bacterial Vaginosis - Actinomyces israelii Mycoplasma hominis, Ureaplasma Mycobacterium tuberculosis & bovis

53. Antibiotic Therapy Gonorrhea : Cephalosporins,quinolone(ciprofloxacin) Chlamydia: Doxycycline, Erythromycin,Azitromycin Anaerobic organisms: Flagyl (metronidazole), Clindamycin

54. Antibiotic Regimens (CDC 2002) Parenteral regimen A Cefoxitin 2 g IV q 6h / cefotetan 2 g IV q 12h + Doxycycline 100 mg PO/IV q12h + Metronidazole or Clindamycin (TO abscess)