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Female genital tract infection

Lecture objectives

2-describe effects of endogenous steroid hormones on the vagina in prepubertal, active reproductive age , and post
menopausal women

3-recognize microbiological criteria, clinical features and treatment of vulvovaginal candidiasis

4- recognize microbiological criteria, clinical features and treatment of trichomonas vaginalis

5-- recognize microbiological criteria, clinical features and treatment of bacterial vaginosis

6-describe clinical presentation and management of atrophic vaginitis, Toxic shock syndrome, Bartholin's abscess, common
Infestations like Pubic lice and scabies.

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• At birth, the neonate has been exposed to high levels of estrogen and
progesterone from the mother and the vagina is lined with stratified squamous
epithelium. Sometimes a baby girl has a withdrawal bleed analogous to a period,
as the effect of maternal estrogen wanes. It's possible for trichomonas vaginalis
to be transmitted at birth, but the infection usually clears spontaneously.

• In young prepubertal females the vagina is lined with a simple cuboidal

epithelium. The PH is neutral and it's colonized by organisms similar to skin
commensals.

Under the influence of estrogen at puberty, stratified squamous epithelium

develops and lactobacilli become the predominant organisms. A drop in the PH
accompanies this change to a level of approximately 3.5-4.5.

Following the menopause, atrophic changes occur, with a return to bacterial flora
similar to that of the skin. The PH rises again to 7.

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Vaginal discharge can be :

• Physiological

• infective

• malignant or due to other

• miscellaneous causes like foreign body

1. Physiological vaginal discharge:

Physiological vaginal discharge is white becomes yellowish on contact with air, due to
oxidation. It consist of desquamated epithelial cells, mucus originate from cervical
glands, bacteria and fluid which's formed as transudate from the vaginal wall.

More than 95% of bacteria present are lactobacilli which metabolize epithelial
glycogen into lactic acid thus maintain acidic PH. Physiological discharge increase
due to increased mucus production from the cervix in midcycle, pregnancy, and
women using combined oral contraceptive pills.

So it is important to differentiate normal physiological discharge from pathological

discharge

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Vulvoaginal candidiasis (VVC)

One of the most common genital infections, 80-92% of cases caused by Candida
albicans ( a common commensal in the gut flora)
Non albicans species, can cause similar symptoms but sometimes be more severe and
recurrent, these include
c. tropicalis, c.glabrata, c.krusei
Predisposing factors:
• Pregnancy
• High dose oral contraceptive pills(OCP)
• Immunosuppression
• Broad spectrum antibiotics
• Diabetes mellitus
• Hormone replacement therapy
• HIV-infected women

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Signs and symptoms Vulval itching and soreness, thick curdy vaginal discharge,
dyspareunia and dysuria.Vulval edema, excoriation, redness and erythema,
symptoms may be more frequent and persistent when the woman is
diabetic,immuno -compromised and in pregnancy. Normal vaginal PH

Differential diagnosis : Contact dermatitis, Allergy, Non specific vaginal infection.

Diagnosis

• Perineal and /or vaginal swab, Gram stain or wet film examination

• Typing the species may be required in recurrent and in severe VVC

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Treatment

• Asymptomatic women require no treatment

General measures

• Avoid using soaps, perfumes

• Avoid tight fitting synthetic underwear

• Change high dose estrogen OCP to low estrogen dose preparations or to

progesterone only contraception

• Blood sugar control of diabetic patient

• Avoid recurrent courses of broad spectrum antibiotic

For uncomplicated VVC : azoles/imidazoles (clotrimazole, econazole and

miconazole) are the mainstay of treatment used either as local (pessaries) or oral
preparation depending on physician preference, cost and availability. Cure rate
>80%

treatment course :

topical→ single dose 500mg, single dose fluconazole 150 mg for 1 day

multiple dose → 100 mg for 6 days oral itraconazole 200mg twice /day for 1 day

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complicated infection (severe infection predisposed by diabetes, immunosuppression, or

pregnancy)

• topical preparation for 2 weeks

Recurrent infection: is defined as at least 4 episodes of infection/year/ or positive

microscopy of moderate to heavy growth of c. albicans.

• Treatment is by induction+maintenance e.g. fluconazole 150 mg is given in 3 doses 72

hr apart, then 150 mg orally/week for 6 months

in pregnancy topical treatment for 2 wks then 500mg /wk for 6-8 wks

• no evidence support the use of oral , vaginal lactobacillus, oral carbohydrates, or

yeasts to treat VVC.

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Trichomonas vaginalis
Sexually transmitted flagellated protozoan can causes
1-severe vulvovaginitis
2-urinary tract infection
• Both partners need to be treated
Signs and symptoms
• Can be asymptomatic
• Vulval soreness and itching
• Foul smelling vaginal discharge, 20% characteristic yellowish green frothy in nature
• Dysuria abdominal pain
• Swollen edematous cervix with punctuate haemorrhages giving characteristic
strawberry appearance

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Diagnosis
• Wet mount vaginal discharge is mixed with saline and examined under microscopy
sensitive 60-70%
• Culture in Finnberg or Diamond medium.
Treatment principles
• Both partners should be treated
• Both partners should be screened for other STD
Metronidazole single oral dose of 2 g, (cheaper, more patient compliance)
400mg twice daily for 5-7 days both give cure 95% of cases
Tinidazole 2g single oral dose equally effective, more cost.

Treatment failure can be caused by:

• Non compliance because of side effects

• Partner not treated

• Resistant to antibiotic

Those are treated by

I. Review history

II. Increase dose

III. Rectal rather than oral route

IV. Treat with broad spectrum antibiotic

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Bacterial vaginosis(BV)

Common condition characterized by the presence of foul smelling vaginal discharge

with no obvious inflammation due to the overgrowth of anerobic microorganisms
on expense of vaginal lactobacilli with increase in vaginal pH making it more
alkaline,

Anerobes include Gardenella vaginalis, mycoplasma hominis, bacteroides and

mobilinicus spp.

Signs and symptoms

• asymptomatic
• Fishy malodorous discharge
More prominent during and following menstruation
• Creamy or yellowish-white vaginal discharge adherent to vaginal wall.
Complication of (BV)
• In obstetric patient, 1st TMS BV infection can cause late 2nd TMS abortion or preterm
labour, so patient with such history should have early pregnancy vaginal swab and
treated if infection detected.
• In gyn. Patient BV can predispose to upper genital tract infection

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Diagnosis : 3 of 4 Amsel's criteria are diagnostic

1. clue cells on microscopic exam(epithelial cells covered by bacteria )giving

stippled appearance.

2. creamy grayish white discharge seen by naked eye.

3. vaginal p H >4.5 .

4. release of characteristic fishy odour on addition of alkali 10% potassium

hydroxide.

Other criteria based on Gram stain

Hay/Ison criteria: Grade1: normal lactobacillus predominance
Grade2: intermediate:lactobacillus seen with
presence of Gardenerella or mobilinicus
Grade 3:lactobacilli absent or markedly reduced
with predominance of Gardenerella or mobilinicus
Nuget criteria : Proportion of anerobes given 0-10 scores
<4:normal ,, 4-6:intermediate ,, >6 BV

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Treatment

Oral single dose 2g, or 400mg twice/d for 5-7 d or vaginal metronidazole 0.75% at
night for 5-7 days

it is safe in pregnancy but large doses and long courses need to be avoided .

oral 300mg 2/d for 5 d or local clindamycin 2% also effective but more expensive.

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Bartholin's abscess: Bartholin 's gland are situated on either side of the vagina,
with their ducts opening in to the vestibule. Cyst can develop if the opening
becomes blocked; these present as painless swellings. If they become infected
Bartholin abscess develop culture may yield Niesseria gonorrhea, streptococci,
staphylococci, mixed anerobes, E coli Clinically they are hot , tender, swellings
adjacent to the lower part of the vagina, treatment 1) marsupialization ,, 2)gland
excision is indicated

repeated recurrences with damaged gland duct in women >40 years lesion
suspicious of Bartholin's adenocarcinoma.

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Toxic shock syndrome:

Is a rare condition associated with the retention of
tampons or foreign body in the vagina, an over growth of
staphylococci producing toxin cause systemic shock with
fever, diarrhea, vomiting and an erythematous rash.
There's 10% mortality rate, more commonly a FB or
retained tampon merely cause an offensive discharge.

Atrophic vaginitis

It's common in post menopausal women. Over the 5 years following the
cessation of menstruation, the vaginal epithelium atrophies and the lactobacilli
are once again replaced by typical skin commensals organisms. this can lead to
superficial dyspareunia and vaginal soreness, the treatment of choice is estrogen
replacement with either local or systemic estrogen therapy. occasionally a true
bacterial vaginitis is encountered with either streptococci or other organism. It
respond to appropriate antibiotic therapy.

Infestations

Pubic lice and scabies?

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