TABLE OF LOWER GENITAL TRACT INFECTIONS Prepared by: Paolo Warren (3i)

DISEASE ETIOLOGY PATHOGENESIS SSx DIAGNOSIS TREATMENT

Obstruction of the duct
secondary to nonspec inflamm
Bartholin’s Gland or trauma  continued
Infection secretion of glandular fluid 
cystic dilation of the Bartholin’s
duct
Eggs (nit) deposited at base of
Phthirus pubis (crab or
hair follicle  nymph  adult
pubic louse)
louse (dark gray)
Sites: hairy areas of
Pediculosis Pubis Transmission: direct sexual
vulva, occasionally the
contact (>90% infected after
eyelids
single exposure), may also be
Travels slowly
non-sexually transmitted
Sarcoptes scabiei (itch
mite)
May involve hands, wrists,
Sites: widespread w/o
breasts, vulva and buttocks
Scabies predilection for hairy
Short, “wavy” rashes in the
areas
buttocks and interdigits
Travels rapidly up to
2.5cm/min
Chronic localized infection
Trans: skin-skin contact,
autoinoculation, fomites
Molluscum Widespread infxn closely
Pox virus
contagiosum related to immunodeficiency
(HIV, chemo, corticosteroid
admin)
Cyst: tense, nonpainful
Abscess: develops rapidly (2-4d), fluctuant,
erythema, tenderness, edema, acute vulvar
pain, dyspareunia, pain on walking
Constant itching in the pubic area d/t allergic
sensitization
Pruritus w/in 24h after reinfection
Severe but intermittent itching
Pruritus more intense at night
Papules, vesicles and
Burrows (pathognomonic: twisted line on
skin surface w/ small vesicle at one end)
Flesh-colored small nodule or dome-shaped
papule (1-5mm) w/ umbilicated crater at the
center
Complication – superinfection
ASx cyst + Age<40: No treatment
Acute adenitis w/o abscess formation:
Broad-spectrum antibiotics, hot Sitz bath
Sx cyst or abscess: Marsupialization, word
catheter, antibiotics (only if with cellulitis)
Women age>40: excision biopsy to rule out
malignancy
Examination of vulva w/o
Kill both adult lice and eggs
magnification: eggs and adult lice,
Permethrin 1% cream rinse
“pepper grain” feces adjacent to hair
Pyrethrins w/ piperonyl butoxide
shaft
Alt: Malathione 0.5% lotion
Definitive Dx: Microscopy adult louse
Ivermectin 250 ug/kg
and nit-containing larvae
Kill both adult mites and eggs
Microscopy using scratch technique
Permethrin 5% cream (safe in pregnant)
(mites lack lateral claw legs but have 2
Ivermectin 02mg/kg orally
triangular hairy buds)
Lindane 1% 1 oz lotion or 30g cream
Self-limiting (for solitary lesions)
Microscopy of white waxy material
May inject local anesthetic on individual
from inside the nodule:
papules to evacuate caseous material
intracytoplasmic Molluscum bodies w/
Base of papule treated w/ Ferric subsulfate
Wright or Giemsa stain
(Monsel sol’n) or 85% TCA
Clinical Dx
Cantharidin

Direct cervical inspection: whitish

lesions
Asymptomatic Depends on location, size and extend and
30% clinically overt macroscopic Biopsy: when unresponsive to
HPV 6 and 11 (90% of Pain, itching, tendency to bleed when friable, whether the woman is pregnant
lesions standard Tx, when condition
the causes of genital (+) odor when secondarily infected Chemical, cautery, immunologic Tx, surgery
70% subclinical, no signs of infxn accelerates during Tx, in
Condyloma warts) *RRP – recurrent respiratory papillomatosis Not 100% guarantee of cure
Trans: sexual, autoinoculation immunocompromised, if appears
acuminatum MC viral STD of the Pigmented, indurated, fixed or ulcerated Podofilox 0.5% solution or gel
Predisposing: pigmented, indurated, fixed or
vulva, vagina, rectum cauliflower-like lesions Imiquimod 5% cream
immunosuppressed, diabetic, ulcerated
and cervix Raised warty lesions 2mm-2cm, bigger Cryotherapy, Podophyllin resin,
pregnant, local trauma Microscopy: Koilocytes (perinuclear
pedunculated lesions Trichloroacetic acid
halo), Electron Micrograph: causative
agent
Clinical inspection
Primary Infxn: Viral culture: positive in primary infxn
Paresthesia of the vulvar skin PCR: most accurate and sensitive for
HSV1 – infection
Recurrent, incurable, highly Papule and vesicle formation HSV
above the waist, MC For non-pregnant:
contagious and one of the most Severe vulvar pain, tenderness and inguinal Western blot: most specific for
acquired genital herpes Valacyclovir
frequently encountered STD adenopathy diagnosing recurrent, unrecognized or
in women <25yo, does Acyclovir
Trans: asymptomatic shedding General malaise and fever subclinical herpes
not protect VS HSV2 Famciclovir
Genital Herpes Not a debilitating physical dse, Recurrence: Type-specific HSV serologic assay
HSV2 – infxn below (see table for complete dosing and
but may present an Related to onset of menses or emo stress ELISA and immunoblot test
the waist, offers indications)
overwhelming psych burden ASx but most are half as symptomatic as Lesion: multiple vesicles become
protection VS HSV1,
Resides in a latent phase in the primary shallow then develop as superficial
definite sexual Prevention: regular condom use, vaccine
dorsal root ganglia S2-S4 Prodrome: sacroneuralgia, vulvar burning, ulcers over a large area of the vulva
transmission
tenderness and pruritus Microscopy: Tzanck smear
Cytology: + multinucleated giant cell
Biopsy: + bag of coins
Chronic, slowly progressive,
Microscopy: Donovan bodies –
Klebsiella ulcerative, bacterial infxn of the Initially: ASx ndule w/c ulcerates (beefy red Doxycycline 100mg BID
clusters of dark-staining bacteria w/
granulomatosis – skin and subQ tissue of the ulcer w/ fresh granulation tissue)  coalesce Alternatives:
Granuloma bipolar or safety-pin appearance in
Gram neg, non-motile vulva and if untreated  destroys normal vulvar Ciprofloxacin 750mg BID
inguinale smears and specimen taken from the
encapsulated rod Trans: sexual & non-sexual close architecture Erythromycin base 500mg QID
(Donovanosis) ulcers
Common in tropical contact, not highly contagious, Pseudobubo – subQ involvement Azithromycin 1g PO weekly (for pregnant)
Special silver stain to identify Donovan
climates and chronic exposure is needed Secondary bacterial involvement TMP-SMZ 800mg/160mg BID
bodies
to contract the disease
 DISEASE ETIOLOGY PATHOGENESIS
Primary: shallow painless ulcer
of the vestibule or labia,
resolves spontaneously
Chlamydia trachomatis Secondary: painful adenopathy
– majority of cases in (bubo) in inguinal and perirectal,
Lymphogranuloma men, very disfiguring when untreated becomes
venereum (LGV) Sites: vulva (MC), enlarged, tender and matted
urethra, rectum, “Groove Sign”
cervix Tertiary: formation of multiple
draining sinuses and fistula,
extensive destruction and
secondary extensive scarring
Sexually transmitted, acute,
ulcerative dse of the vulva
Haemophilus ducreyi – Genital ulcers of chancroid
highly contagious small facilitates the transmission of
Chancroid Gram neg rod, non- HIV
motile facultative Tissue trauma or excoriation
anaerobe must precede initial infxn since
H.ducreyi is unable to penetrate
and invade normal skin
Chronic complex systemic dse
Patients are contagious during
Treponema pallidum – the primary, secondary and
anaerobic, elongated, probably the 1st yr of latent
tightly wound syphilis
Syphilis
spirochete, can Trans: sexual contact, kissing or
penetrate skin or touching a person who has an
mucous membrane active lesion on the lips, oral
cavity, breast or genitals
Oral-genital contact
Normal physiologic vaginal
Fungus (candidiasis) discharge: cervical and vaginal
Protozoan epithelial cells, normal bacterial
(trichomoniasis) flora, water, electrolytes, other
Vaginitis
Synergistic bacterial chemicals, pH 4.0
infection (bacterial Normal flora: Lactobacilli,
vaginosis) S.epidermidis, E.coli,
diphtheroids, streptococci
Shift in vaginal flora from
Lactobacilli-dominant to mixed
flora (genital microplasmas,
Bacterial No causative agent has G.vaginalis, anaerobes such as
Vaginosis been identified Peptostreptococci, Prevoterall,
Mobiluncus)
Not classified as an STD (more
of sexually-associated dse only)
SSx
Shallow painless ulcer
Painful adenopathy (bubo)
“Groove Sign”
Multiple draining sinuses, fistula
Elephantiasis, multiple fistulas, stricture
formation of anal canal and rectum
Painful and tender ulcer
Tender suppurative inguinal adenopathy
(buboes)
Primary: solitary painless ulcer (chancre),
heals spontaneously, small ulcerated lesion
on labia majora, on Q-tip probing hard
nontender ulcer base, nontender nodulations
in the inguinal areas
Secondary: d/t hematogenous dissem of
the spirochetes and is a systemic dse, rashes
– red macules and papules over palms and
soles; vulvar lesions – syphilitic lesion,
mucous patches and condyloma latum – pale
brown or pale pinkish gray assoc w/ painless
adenopathy, slightly raised surface, flat, clean,
moist from exudates, highly infectious
Latent: follows secondary, positive serology
w/o SSx of the dse
Tertiary: potentially destructive effects on
the CNS, CVS, and musculoskeletal system
Late: optic atrophy, tabes dorsalis,
generalized paresis, aortic aneurysm,
gummas (areas of tissue necrosis resulting to
ischemia caused by endarteritis and
granulation tissue)) of skin and bones
Nonspecific:
Vaginal discharge
Superficial dyspareunia
Dysuria
Odor
Vulvar burning
Absence of inflammation in biopsies hence
the term vaginosis rather than vaginitis
DIAGNOSIS
Culture
Direct immunofluorescence
NAAT of C. trachomatis of pus or
aspirate from an infected node
Complement fixation antibody titer >
1:64 is indicative of infxn
Gram Stain: “school of fish”
Culture of purulent material by
aspiration of tender lymph nodes
Need to culture bec H.ducreyi is
resistant to multiple antibiotics
Susceptibility of bacterial isolates
should be performed
VDRL (Venereal Dse Research Lab) –
screening test
RPR (Rapid Plasma Reagin) – index for
response to Tx
TIT (Treponema Immobilization Test)
FTA-ABS (Fluorescent-labeled
Treponema antibody absorption)
MHA-TP (microhemagglutination assay
for antibodies to T.pallidum)
Amsel’s Criteria (3 out 4 to Dx):
Homogenous vaginal discharge
pH > or = 4.5
amine-like odor when mixed w/ KOH
(Whiff test)
Wet smear demonstrated clue cells >
20% of the vaginal epithelial cells
Microscopy: Gold Standard
Gram Stain: clue cells – decreased
number of lactobacilli (Nugent criteria
score 7-10)
TREATMENT
Doxycycline 100mg BID for 21 days
Alternatives:
Azithromycin 1g PO once a week for 3wks
Erythromycin base 500mg QID for 21d
Azithromycin 1gm orally
Ceftriaxone 250mg IM single dose
Ciprofloxacin 500mg BID for 3d
Erythromycin base 500mg TID for 7d
Primary, Secondary and Early Latent Phase:
Benzathine Pen G, 2.4M units IM (safe in
pregnant)
If Penicillin-allergic / non-pregnant:
Doxycycline 100mg BID 14d or
Tetracycline 500mg PO QID 2wks
Late Latent Phase: Benzathine Pen G 2.4M
units IM at 1 week intervals x 3 doses
If Penicillin-allergic / non-pregnant:
Doxycycline 100mg BID 4 wks or
Tetracycline 500mg PO QID 4wks
Neurosyphilis: Aqueous crystalline Pen G
18-24M units admin 3-4M units IV q4h for
10-14d
Alternative: Procaine Pen 2.4M units IM OD
+ Probenecid 500mg PO QID for 10-14d
Metronidazole 500mg BID for 7d
Metronidazole gel 0.75%, 5g, intravaginally
OD for 5d
Clindamycin cream 5%, 5g intravaginally
QHS for 7d
Alternative:
Clindamycin 300mg BID for 7d
Tinidazole
Clindamycin ovules 100g intravaginally at
HS for 3d
 DISEASE ETIOLOGY PATHOGENESIS SSx DIAGNOSIS TREATMENT
Trichomonas vaginalis
– unicellular,
Profuse frothy discharge w/ unpleasant odor
intracellular, Metronidazole 2g PO single dose
Erythema and edema of vulva and vagina
Trichomonas anaerobic, flagellated NSS smear / wet smear – visualization Tinidazole 2g PO single dose
Transmission: sexually Strawberry cervix and upper vagina
vaginal infection protozoan of the trichomonas organism Alternative: Metronidazole 500mg BID 7d
Vulvar pruritus
Inhabits vagina and Pregnant: Metronidazole 2g PO single dose
Dysuria
LUT, Skene’s ducts in
the female
Saprophytic organisms on the
mucosal surface of the vagina KOH (10-20%) smear – filamentous
w/c becomes opportunistic Pruritus – intense vaginal pruritus forms, mycelia, hyphae (albicans),
Produced by Intravaginal regimens:
when vaginal ecosystem is exacerbated by menses pseudohyphae (non-albicans)
ubiquitous, airborne, Butoconazole, Clotrimazole, Miconazole,
disturbed Vulvar burning
Gram positive fungus Nystatin, Tioconazole, Terconazole
Candida vaginitis Predisposing: hormonal (mens, External dysuria Culture w/ Nickerson or Saboraud
(Candida albicans /
pregnancy), depressed cell-med Dyspareunia medium – useful when KOH smear is
glabrata / tropicalis) – Oral regimens:
immunity (AIDS), DM, obesity, Shallow erosions on the labia and perineum negative or when a woman has
commensal Fluconazole 150mg in a single dose
debilitating dse, antibiotic use Plaques of white cheesy discharge recently treated herself w/ an
(Penicillin, Tetracycline, antifungal
Cephalosporins)
Ectocervicitis – HSV,
severe vaginitis
(strawberry cervix
assoc w/ T.vaginalis or
C. albicans) Hypertrophic and edematous cervix
Inflammatory process assoc w/
Mucopurulent Vaginal discharge
trauma, inflammatory systemic
cervicitis Endocervicitis – Deep dyspareunia
dse, neoplasia, infection
C.trachomatis or Post-coital bleeding
N.gonorrheae,
Bacterial vaginosis and
M.genitalium have also
been associated
Ceftriaxone 250mg IM or
NAAT (Nucleic Acid Amplification
Cefixime 400mg PO + Chlamydia therapy if
Test) – Gold Standard
N.gonorrheae – Gram not ruled out
Culture
negative diplococci Alternative:
Neisseria Localized acute infxn resulting Gram stain
Sites: epithelium of the Purulent urethral discharge w/ edema of the Spectinomycin 2g IM in a single dose or
gonorrheae to bacteremia / disseminated Enzyme immunoassay
GUT, rectum, pharynx meatus Ceftizoxime 500mg IM or Cefoxitin 2g IM +
infection infxn Nucleic Acid Hybridization Test
or the eye Probenecid 1g orally; or Cefotaxime 500mg
Microscopy – stained smear of the
IM
endocervical swab: gram neg
Azithromycin 2g + Chlamydial therapy if
intracellular diplococci
infxn not ruled out
Empiric therapy – recommended in women
at inc. risk of this common STD (age <25yo,
new or multiple sex partners, unprotected
NAAT – Gold Standard sex)
Chlamydia C.trachomatis – Cell culture Azithromycin 1g single dose
Cervical edema and ectopy with
trachomatis obligatory intracellular Microscopy: Doxycycline 100mg BID 7d
mucopurulent exudation
infection organism Direct immunofluorescence test – Alternative:
elementary bodies Erythromycin base 500mg QID for 7d
Erythromycin base 500mg QID for 7d
Ofloxacin 300mg BID for 7d
Levofloxacin 500mg for 7d

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Prepared by: Paolo Warren (3i)