1. Genital Tract Infections
King Khalid University Hospital
Department of Obstetrics & Gynecology
Course 481
Genital Tract Infections

2. Normal vaginal discharge
The normal vaginal flora is predominately aerobic organisms
The most common is the H+ peroxide producing lactobacilli
The normal PH is <4.5

3. Normal vaginal discharge
Normal vaginal secretions
In reproductive aged women it consists of
1-4 mL fluid (per 24 hours), white or transparent, thick or thin, and mostly odorless.
formed by mucoid endocervical, sloughing epithelial cells, normal vaginal flora, and vaginal transudate.
↑ in the middle of the cycle because of (physiologic leukorrhea)↑ in the amount of cervical mucus:
during ovulation, pregnancy and in patient using OCP.

4. Abnormal vaginal discharge(vaginitis)
Extremely common
signs and symptoms are generally similar
Women with vaginitis present with one or more of the following vulvovaginal signs and symptoms:
-Change in the volume, color, or odor of vaginal discharge
-Pruritus, burning, Irritation, erythema
-Dyspareunia, dysuria
-Spotting
The most common causes of vaginitis symptoms: bacterial vaginosis, candida vulvovaginitis and trichomoniasis (>90% of cases).

5. 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
May present with Fishy odor (especially after intercourse) no dyspareunia
Increases risk for:
-in pregnant women (PTL, endometritis and postpartum fever)
-Post-hysterectomy vaginal-cuff cellulites
-Postabortal infection
-Acquiring other STDs, especially HIV

7. Bacterial Vaginosis (BV)
Diagnosis: Amstel Criteria
Homogenous, grayish-whitish discharge
Presence of clue cells
PH >4.5
+ve whiff test(amine test) (adding KOH to the vaginal secretions will give a fishy odor) in 70-80% of cases
“Clue cells are the most reliable predictor of BV”

8. Clue Cells

9. 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

10. 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)

11. Trichomonas Vaginalis
Diagnosis:
Profuse, frothy ,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

12. Wet Mount Trichomonads seen only in 50 – 70% Elevated pH
Can increase leukocytes
Paps

13. Trichomoniasis

14. Trichomoniasis

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

16. 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

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

18. Candidiasis Diagnosis:
Symptoms: Vulvar pruritis and burning Vaginal soreness an dysparunea and splash dysuria
The discharge vary from watery to thick cottage cheese discharge
O/E: erythema and edema of the labia and vulva &the vagina may be erythematous with adherent whitish discharge
PH< 4.5budding yeast or mycelia on microscopy
Microscopic saline wet mount :
Pseudohyphae (in about 70 percent of patients)
Culture if microscopy nondiagnostic

19. Candidiasis

20. 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

21. Other Causes of Vaginitis
Atrophic vaginitis (in post mepausal women)
High vaginal pH, thin epithelium, d/c
Parabasal cells on wet mount
Topical estrogen cream
Atypical manifestations: HSV, HPV
Noninfectious vulvovaginitis
Irritants/allergens
Lichens syndromes (sclerosus, simplex chronicus, planus)
Cytolytic vaginitis

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

23. Transmission Horizontal Transmission Vertical Transmission
Intimate sexual contact (oral/genital)
Aerosol and fomite transmission is rare
Vertical Transmission
Maternal-infant via infected cervico-vaginal secretions, blood or amniotic fluid at birth
Autoinoculation
From one site to another

25. Diagnosis Viral isolation (culture)
High specificity, low sensitivity
50% for primary infxn
20% for recurrent infxn
Direct detection of virus (Tzcank smears, PCR)
Serology
Newer tests that are specific for type of virus (HerpesSelect 2, herpes glycoprotein for IgG, ELISA)

26. Oral Antiviral Therapy
Valacyclovir (Valtrex)
Famciclovir (Famvir)
Acyclovir (Zovirax)

27. Genital Warts
Condyloma accuminata secondary to HPV infection (usually 6&11), these are non-oncogenic types
HPV Types 16 and 18 (oncogenic type) are the most commonly isolated HPV types in cervical cancer
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

28. Genital Warts

29. Genital Warts

30. 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

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

32. 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

33. Fitz-Hugh-Curtis

34. 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

35. Sequelae Infertility -In 20% of patients Ectopic pregnancy
-infertility rate increase direct with number of episodes of acute pelvic infection
Ectopic pregnancy
-increase 6-10 fold
Chronic pelvic infection
-4 fold increase
TOA
-10% risk
-if rupture high mortality rate

36. CDC Recommended treatment regimens for OPD of acute PID

37. 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
Surgical treatment

38. Tubo-ovarian Abscess (TOA)

39. Thank you