INFECTIONS OF

THE LOWER
GENITAL TRACT

Dr. Renna Cristina de Leon

 Scope:

• Clinical presentation and differential

diagnosis of vulvitis, vaginitis, and
cervicitis
• Toxic shock syndrome (TSS)
• Syphilis
 INFECTIONS OF THE VULVA

• 3 most prevalent primary viral

infections

• herpes genitalis
• condyloma acuminatum
• molluscum contagiosum
 Infections of the Bartholins Gland
• Bartholin’s glands
– located at the entrance of the
vagina at 5 and 7 o’clock
• open in a groove between the
hymen and labia minora, in
the posterior lateral wall of
the vagina
– Mucinous secretions  provide
moisture for the epithelium of
Bartholin’s duct cyst
the vestibule but are not
important for vaginal
lubrication
– ducts  ~ 2 cm in length
 Infections of the Bartholins Gland
• 2% of adult women
• most common cause  cystic dilation of Bartholin’s
duct
• Bartholins duct cyst - obstruction of the duct
secondary to
non-specific inflammation or trauma
• > 80% cultures - sterile
• Differential Diagnosis:
– mesonephric cyst of the vagina
– epithelial inclusion cyst
– lipoma
Bartholin’s duct cyst
• Asymptomatic
• 1-8 cms in diameter
• Unilateral, tense and non-painful
• Unilocular
• Abscess tend to develop rapidly
over 2-4 days
– Symptoms include:
• acute vulvar pain
• dyspareunia
Bartholin’s abscess
• pain in walking
 TREATMENT
• Asymptomatic cyst in <40 yo:
– No treatment
• Acute adenitis without abscess formation:
– broad spectrum antibiotic and hot sitz bath

• Bartholins abscess:
– Marsupialization - develop a fistulous tract
• elliptical wedge of tissue removed
• remaining edges of the duct or abscess are
everted and sutured to the surrounding skin
with interrupted sutures
– forms an epithelialized pouch that
provides drainage for the gland
• Insertion of a Word catheter –
– alternative to marsupialization
– (a short catheter with an
inflatable Foley balloon)
through a stab incision into
the abscess
– leave it in place for 4 to 6
weeks
• Excision of a Bartholin duct and gland:
– Indications:
• persistent deep infection
• multiple recurrences of abscesses
• recurrent enlargement of the gland in women
older than 40 years
 Pediculosis Pubis & Scabies
• Pediculosis pubis
– infestation by the crab louse
“pthirus pubis”
– Transmitted by close contact
– over 90% of sexual partners are
infected following a single
exposure
– Major nourishment – human blood
– louse's life cycle has three stages:
• Egg (nit)
• Nymph
• Adult
– Symptom : constant pubic pruritus sec.
to allergic sensitization
– Incubation period: 30 days
– Dx: Examination of the vulvar area
without magnification  eggs and
adult lice
and “pepper grain” feces adjacent to
the hair shafts
– Definitive dx: microscopic slide by
scratching the skin papule with a
needle and placing the crust under a
drop of mineral oil
• louse's body – miniature crab with
six legs w/ claws
• Scabies
– parasitic infection of the itch mite
“Sarcoptes scabies”
– transmitted by close contact
– Widespread
– adult female itch mite digs a burrow just
beneath the skin
• lays eggs in this home during her life span
of approximately 1 month
• adult itch mite is usually less than 0.5 mm
long
• travels rapidly over skin and may move up
to 2.5 cm in 1 minute
– Symptom: severe but intermittent itching
• intense pruritus  at night (skin is warmer and
the mites are more active)
• Initial symptoms 3 weeks after primary
infestation
– papules, vesicles, or burrows
– pathognomonic sign : burrow in the skin
– Dx: Microscopic slides w/ mineral oil and a scratch
technique
• Mites lack lateral claw legs but have two
anterior triangular hairy buds
– great dermatologic imitator
 Treatment

Pediculosis Pubis Scabies Avoid Reinfection

• Permethrin 1% • Permethrin 5% • Treat sexual
cream cream contacts within
• Pyrethrins with • Ivermectin, 200 the previous 6
piperonyl butoxide mg/kg orally weeks and other
(repeated in 2 close household
weeks) contacts
• Alternative:
• Treat close
• Malathion 0.5%
• Alternative: physical contact
lotion (8 -12hrs
at the same time
and washed off) • lindane, 1%, 1 oz
as the infected
• Ivermectin 250 of lotion or 30 g
woman
mg/kg (repeated of cream
• Bedding and
in 2 weeks)
clothing should be
decontaminated
or removed from
body contact for
 Molluscom Contagiosum

• pox virus
• chronic localized infection
• flesh-colored, dome-shaped papules with an umbilicated
center
• direct skin to skin contact
• incubation time is 2 to 7 weeks
• closely related to underlying cellular immunodeficiency
– HIV infection
– chemotherapy
– corticosteroid administration
• Diagnosis : characteristic appearance
of the lesions
– 1-5mm diameter ; small nodules or
domed papules
– more mature nodules -umbilicated
center
– Confirmatory Dx: white, waxy
material from inside the nodule
• intracytoplasmic molluscum
bodies(Wright or Giemsa stain)
• major complication: bacterial
superinfection
• Treatment:

– Injection of a local anesthetic with a small

subdermal wheal of 1% lidocaine (Xylocaine)
• caseous material  evacuated
• Nodule excised with a sharp dermal curette
• base of the papule  chemically treated with
either ferric subsulfate (Monsel solution) or
85% trichloroacetic acid

– alternative method: canthardin, a chemical

blistering agent
 Condyloma acuminatum

• Sexually transmitted
• HPV Type 6 & 11
• Diagnosis: direct inspection
• Biopsy:
– lesions do not respond to standard therapy
– condition accelerates during therapy
– Immunocompromised
– growths are pigmented, indurated, fixed, or
ulceratedk
– Initial lesions  pedunculated, soft papules ~
2 -3 mm in diameter and 10 -20mm long
• pinhead-sized papules to large cauliflower-
like masses
– Asymptomatic
– depending on size and location some are
symptomatic, producing pain, itching,
tendency to bleed when friable, and an odor
when secondarily infected
– differential diagnosis:
• micropapillomatosis labialis
• seborrheic keratosis
• Nevi
• condyloma lata
• molluscum contagiosum
• giant condyloma or bowenoid papulosis or
squamous cell carcinoma
Genital Ulcers
 GENITAL ULCERS

• GENITAL HERPES
– recurrent and incurable
– frequently transmitted by asymptomatic
shedding
– highly contagious, ( 75% of sexual partners of
infected individuals contracting the disease)
– two distinct types: (HSV-1) and (HSV-2)
 Genital Herpes:
• incubation period is between 3 and 7 days
• symptoms:
– Paresthesia of the vulvar skin
– multiple vesicles that become shallow, superficial
ulcers
– Severe vulvar pain
– Tenderness
– inguinal adenopathy
• Systemic symptoms
– general malaise and fever
– CNS infection- herpes encephalitis
• Recurrence:
– prodromal phase
• Sacroneuralgia
• vulvar burning
• Tenderness
• pruritus for a few hours to 5 days before vesicle
formation

– herpesvirus resides in a latent phase in the dorsal

root ganglia of S2, S3, and S4
• clinical diagnosis: simple clinical inspection
– Herpetic ulcers  painful when touched with a
cotton-tipped applicator
– ulcers of syphilis  painless

• Viral cultures  useful in confirming the diagnosis in

primary episodes when culture sensitivity is 80%
• less useful in recurrent episodes
• PCR  most accurate and sensitive technique

• Serologic tests  helpful in determining whether a

woman has been infected in the past with herpesvirus

• Western blot assay for antibodies to herpes most

specific method for diagnosing recurrent herpes, as well
as unrecognized or subclinical infection
• Type-specific HSV serology:
(1) recurrent genital symptoms or atypical symptoms,
with negative HSV cultures;
(2) clinical diagnosis of genital herpes without
laboratory confirmation;
(3) partner with genital herpes

– considered for persons

• presenting for an STI evaluation
• especially for those with multiple sex partners
• HIV infection
• increased risk for HIV acquisition
 Treatment
1. Primary episode
– duration and severity of symptoms are lessened and
shedding is shortened with antiviral therapy
– Antiviral therapy is recommended

2. Recurrent episode
– shorten the duration of the outbreak if started
within 24 hours of prodromal symptoms or lesion
appearance

3. Daily suppression
– six or more episodes annually or for psychological
distress
TREATMENT
 Granuloma inguinale (Donovanosis)
• Chronic, ulcerative, bacterial infection
• intracellular gram negative, non-motile encapsulated
rods: “klebsiella granulomatis”
• spread both by STD and close non-sexual contact
• Incubation period 1-12 weeks
• initial growth  asymptomatic nodule  skin over the
nodule ulcerates  “beefy-red ulcer”with fresh
granulation tissues
– Ulcer easily bleeds on touch, painless unless
secondarily infected
• Vulvar edema is a common feature
• Adenopathy is not a prominent feature
• Diagnosis :
– Donovan bodies in smears (clusters
of dark staining bacteria with a
bipolar appearance found in the
cytoplasm of large mononuclear
cells)

• Differential diagnosis:
– lymphogranuloma venereum
– vulvar carcinoma
– syphilis
– chancroid
– genital herpes
– amebiasis
• Treatment:
 Lyphogranuloma Venereum

• chronic infection of the lymphatic tissue

• “Chlamydia trachomatis” serotypes L1,L2,L3
• Male to female ratio is 5:1
• Vulva - most frequent site of infection
• Incubation period = 3 to 30 days
• Primary infection:
– shallow, painless ulcer of the vestibule or labia
– heals rapidly without therapy

• Secondary phase:
– 1-4 weeks after the Primary infection
– Painful adenopathy in the inguinal and perirectal areas
– If not treated, the infected nodes become BUBO
– Groove sign or the double genitocrural fold
• classical clinical sign
• depression between groups of inflamed nodes
• Develops in 20% of women

• 3rd phases:
– Ruptured BUBO and form multiple draining sinuses and
fistulas
– Extensive tissue destruction sec to extensive scarring
and fibrosis
• Diagnosis:
– Culture
– Direct immunofluorescence
– Nucleic acid detection
– Chlamydia serology (complement fixation titers >1:64)

• Differential diagnosis:
– Syphilis
– Chancroid
– Granuloma inguinale
– Bacterial lymphadenitis
– Vulvar carcinoma
– Genital herpes
– Hodgkin's disease
 Treatment
– Preferred:
• Doxyxycline 100 mg BID x 21 days
– Alternative:
• Erythromycin base 500 mg QID for 21 days
– Tertiary phase:
• surgical reconstruction
 CHANCROID
• Sexually transmitted, acute, ulcerative disease of the
vulva
• soft chancre of chancroid  painful and tender
• “Haemophilus ducreyi”
– highly contagious, small, gram negative rod
– Non-motile, facultative anaerobe
– GS: classic appearance of streptobacillary chains or
school of fish
• Incubation period is 3-6 days
• Tissue infection and excoriation precede initial
infection
• Solitary or multiple ulcers
• Papule-pustule-ulcer
• Ulcers are shallow with ragged edges, have dirty,
gray, necrotic, foul smelling exudate and absence of
induration at the base
• 50% of women develop acute tender inguinal
adenopathy
• Diagnosis:
– GS & culture of purulent discharge

• Treatment:
– Azithromycin 1 gram as single dose
– Ceftriaxone 250mg IM single dose
– Ciprofloxacin 500mg BID for 3 days
– Erythromycin 500 QID for 7 days
– Sexual partners should be treated
 Syphilis
• Chronic, complex systemic disease
• spirochete “Treponema pallidum”
– anaerobic, elongated, tightly wound spirochete
– Diagnosed by dark field microscopy or direct
fluorescent antibody test
• Incubation period: 10-90 days
• Infection initially involves mucous membranes
• Patients are contagious during primary, secondary, and
probably the first year of latent syphilis
• can be spread by kissing or touching a person who has an
active lesion on the lips, oral cavity, breast, or genitals
• Case transmission can occur with oral-genital contact
• Serologic screening test:
– non-specific: VDRL slide test, RPR card test
– Specific:TPI, FTA-ABS, MHA-TP

• False-positive results
– Recent febrile illness
– Pregnancy
– Immunization
– chronic active hepatitis
– Malaria
– Sarcoidosis
– IV drug use
– HIV infection
– Advancing age
– acute herpes simplex
– autoimmune diseases ( lupus erythematosus or rheumatoid
arthritis)
• Stages: Primary, Secondary and Tertiary

• Primary:
– hard chancre, painless ulcer, indurated base, solitary
– Chancre  red, round ulcer with firm, well-formed
raised edges with a non-purulent clean base and
yellow-gray exudate
– Regional adenopathy  non-tender and firm
– Incubation period: 10-100 days
– Ulcer heals within 2-6 wks without antibiotic
treatment
• Secondary syphilis
– Result of hematogenous dessimination and
is a sytemic disease
– Develops between 6 weeks and 6 months
after the primary chancre
– The classic risk:
• red macules and papules over the palms
of the hands and soles of the feet
– Vulvar lesions:
• mucous patches and condyloma latum
associated with painless
lymphadenopathy
– Condyloma latum:
• large, raised flattened, grayish white
areas
• Latent
– Follows the secondary stage
– duration : 2-20 years
– Positve serologic test without symptoms or signs
– Destructive effects is on CNS, CVS and
musculoskeletal systems
– Manifestations: optic atrophy, tabes dorsalis,
generalized paresis, aortic aneurysms, gummas of the
skin and bones
– Gumma  cold abscess with necrotic center and the
obliteration of small vessels by endarteritis
• Treatment:

– Parenteral Penicilin G  drug of choice

• Benzathine penicillin G 2.4 M units IM single dose
• Jarisch-herxheimer reaction- flu-like symptoms
within 24 H after PCN administartion (60% of
women)

– Alternative
• Tetracycline 500 mg every 6H for 14 days
• Doxycycline 100 mg BID for 14 days
• Sexual partners : (evaluated clinically and serologically)
– Primary syphilis : 3 months plus duration of symptoms
– Secondary syphilis: 3 months plus duration of
symptoms
– Early Latent syphilis : 1 year for early latent syphilis

• Those who are exposed within the 90 days preceding

the diagnosis of primary, secondary, or early latent
syphilis in their sexual partners should be treated
presumptively because they may be infected, even if
seronegative.
 Normal Vagina
• vaginal secretions
– vulvar secretions from sebaceous, sweat, Bartholin,
and Skene glands;
– transudate from the vaginal wall;
– exfoliated vaginal and cervical cells;
– cervical mucus;
– endometrial and oviductal fluids;
– micro-organisms and their metabolic products
• Vaginal epithelial cells
– Superficial cells- main cell type in women of
reproductive age
• predominate when estrogen stimulation is present
– Intermediate cells- predominate during the luteal
phase because of stimulation by progesterone
– Parabasal cells - predominate in the absence of
either hormone
• postmenopausal women who are not receiving
hormonal therapy
• normal vaginal floramostly aerobic (ave of 6 diff
species)
– most common : hydrogen peroxide producing
lactobacilli
– Factors: vaginal pH and the availability of glucose for
bacterial metabolism
– pH level of the normal vagina: <4.5
• maintained by the production of lactic acid
• 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
• Normal vaginal secretions:
– floccular in consistency
– white in color
– usually located in the dependent portion of the vagina
(posterior fornix)
– Wet-mount preparationsample of vaginal secretions is
suspended in 0.5 mL of normal saline in a glass tube,
transferred to a slide, covered with a slip, and assessed
by microscopy
• Microscopy of normal vaginal secretions:
– many superficial epithelial cells
– few white blood cells ( <1 per epithelial cell)
– and few, if any, clue cells
 – Clue cells :
» superficial vaginal epithelial cells
with adherent bacteria, usually
Gardnerella vaginalis, which
obliterates the crisp cell border
when visualized microscopically
• Potassium hydroxide 10% (KOH)
– examine the secretions for evidence of fungal elements
– negative in women with normal vaginal microbiology
• Gram stain
– reveals normal superficial epithelial cells and a
predominance of gram-positive rods (lactobacilli)
 VAGINITIS
• Vaginal discharge
– most common symptom in gynecology
• Other symptoms
– Dyspareunia
– Dysuria
– Odor
– vulvar burning &pruritus
• 3 common infections:
– Candidasis (25%) - caused by fungus
– Bacterial vaginosis (50%) - bacteria
– Trichomonas (25%) - protozooan
• Bacterial vaginosis

– Most prevalent cause of vaginitis (12%)

– Caused by Gardnerella vaginalis
– Gram negative, small bacillus
– Condition that results when high concentrations of
anaerobic bacteria replace the normal H2O2 producing
lactobacillus species in the vagina
– Repeated alkalinization of the vagina which occurs
with frequent sexual intercourse or use of douches
• Symptoms:
– unpleasant vaginal odor (musty or fishy),
usually sensed following intercourse
– vaginal discharge: Thin, gray white and
frothy

• Diagnosis:
– Saline wet smear: clumps of bacteria
and clue cells which are vaginal
epithelial cells with clusters of bacteria
adherent to their external surface (2-
50%)
• Four criteria for the diagnosis of BV:
– Fishy vaginal odor
– Vaginal secretions are gray and thinly coat the vaginal
walls
– pH >4.5 (usually 5-6)
– (+) amine-like odor when mixed with KOH (whiffs
test)
– Clue cells
– *3 of the 4 criteria are sufficient for a presumptive
diagnosis
• Gram staining of vaginal discharge –
gold standard for diagnosis
• Treatment:
– Metronidazole 500 mg tab BID for 7 days- 95 % cure rate
– Metronidazole 2 grams as single dose- 75% cure rate
– Clindamycin 30 mg BID for 7 days- for allergic to
Metronidazlole
– Topical: Clindamycin & Metronidazole gel
 Trichomonas vaginal Infection

• Trichomonas vaginalis
– Unicellular protozoon that inhabits the vagina and
LUT especially skenes gland
– Caused by anaerobic, flagellated protozoon
– Definitely a STD
– Highly contagious
– Incubation period: 4-28 days
• Sypmtoms:
– copius discharge , white, gray, yellow or green, frothy
with unpleasant odor
– Erythema and edema of vulva and vagina
– The classic sign of strawberry cervix is rare (10%)
– Vulvar pruritus (25%)
– Dysuria is a symptom
• Diagnosis
– Saline wet preparation
– examination of vaginal fluid mixed with saline
under microscope
• The organism will exhibit forward motion
• Sensitivity is 80-90%
– Vaginal pH: 5.0-7.0
• Treatment: Metronidazole
 Candida Vaginitis
• Produced by ubiquitous, airborne gram-positive fungus
• 75% is caused by C. albicans
• 5-20% is caused by C. glabarata or C. tropicalis
• Candida species are part of the normal flora on the
mucosal surface of the vagina in 25% of women
• Concentration of lactobacilli declines, rapid growth of
Candida species occurskri
• Symptoms:
– Pruritus with vulvar burning
– External dysuria and dyspareunia
– Vaginal discharge: white or whitish gray, highly
viscous, granular or floccular (cottage cheese
type discharge)
– pH is below 4.5
• Diagnosis
– Microscopy- 65% sensitivity
• Wet smear of vaginal secretion + 10-20% KOH
• Active disease: filamentous forms, mycelia or
psedohyphae
– Culture
• Nickerson or Sabouraud medium
– Slide latex agglutination
• 70-75% sensitivity
Classification of vulvovaginal candidiasis
• Treatment
– Topical application of synthetic imidazoles
• Miconazole, cotrimazole, butoconazole, tioconazole, fluconazole
 TOXIC SHOCK SYNDROME
• acute, febrile illness produced by a bacterial exotoxin, with a
fulminating downhill course involving dysfunction of multiple organ
systems
• healthy, young (<30 years), menstruating females
• S. aureus has been isolated from the vagina in > 90% cases
• Nonmenstrual TSS sequela of focal staph infection of the skin and
subcutaneous tissue, often following a surgical procedure
 “streptococcal toxic shocklike syndrome”  severe postoperative
infections by Streptococcus pyogenes produce a similar TSS
related to a surgical wound
• occurs early in the postoperative course

– 3 requirements for the development of classical TSS:

• (1) the woman must be colonized or infected with S. aureus,
• (2) the bacteria must produce TSS toxin-1 (TSST-1) or related
toxins,
• (3) the toxins must have a route of entry into the systemic
circulation
• signs and symptoms - produced by the exotoxin named toxin-1
– toxins act as “superantigens”
• activate up to 20% of T cells
• primary effects of toxin-1 - produce increased vascular
permeability and thus profuse leaking of fluid (capillary leak)
from the intravascular compartment into the interstitial space
and associated profound loss of vasomotor tone, resulting in
decreased peripheral resistance
• high index of suspicion for TSS  unexplained fever and a rash during
or immediately following her menstrual period
– Most women experience a prodromal flulike illness for the first 24
hours
– Between days 2 and 4 of the menstrual period, the patient
experiences an abrupt onset of a high temperature associated
with headache, myalgia, sore throat, vomiting, diarrhea, a
generalized skin rash, and often hypotension
 – Clinically, many women present with a forme fruste of TSS, with
low-grade fever and dizziness rather than hypotension.
• most characteristic manifestations of TSS skin changes
– first 48 hours  skin rash appears similar to an intense sunburn
– next few days erythema will become more macular and look
like a drug-related rash
– days 12 to 15 of the illness  fine, flaky, desquamation of skin
over the face and trunk with sloughing of the entire skin
thickness of the palms and soles
– pelvic examination  patients complain of tenderness of the
external genitalia and vagina
 Treatment
• Clindamycin 600 mg IV every 8 hours plus

• Nafcillin or Oxacillin 2 g IV every 4 hours

 Cervicitis
• inflammatory process in the cervical epithelium and stroma
• associated with trauma, inflammatory systemic disease, neoplasia,
and infection
• Ectocervicitis
– viral (HSV)
– severe vaginitis (e.g., “strawberry cervix” associated with T.
vaginalis infection) or C. albicans
 Endocervicitis
• bacterial infection with either C. trachomatis or N. gonorrhoeae
• Bacterial vaginosis
• M. genitalium
 Mucopurulent Cervicitis
• gross visualization of yellow mucopurulent material on a white
cotton swab
• presence of 10 or more PMN leukocytes per microscopic field
(magnification × 1000) on Gram-stained smears obtained from the
endocervix