Genital

tract infection
Objectives
To list possible causes of GTI
Describe character of the different
discharges
List the possible diagnostic tools and
treatment modalities
GENITAL TRACT INFECTION
Lower GTI
At birth the vagina is lined by stratified
sq.epith.under the influnce of maternal oestrogen.
This lining is changed to simple cuboidal in young
female with neutral PH.
This lining become stratified sq. epith.with low PH at
puberty under the influence of oestrogen.
Atrophic changes occur at menopause with rise in
PH.
Vaginal discharge can arise from LGT or UGT.
LGT discharge could be:
1-physiological
2- bacterial vaginosis(BV)
3-candidiasis
4-tichomonas vaginalis
Normal flora:
Normal flora includes multiple aerobic,facultative
And anaerobic species.they exist in a symbiotic
relationship.the function and reason of its
existanc is not known.
Aerobic----GM+VE---lactobacilli,stph auerus,----
GM-VE----E-coli.,proteus,------
Anaerobic GM+VE---clostridium sp,peptostreptoco.
GM-VE---bacteroids,bacteroid fragills
Yeast candida albicans,other spp.

festrogen A Glycogen A lactobacill T lactic

Vaginal PH: acid

Vaginal ph is acidic (4-4.5) .this acidity arise from

the production of lactic acid ,fatty acid and other
organic acid by lactobacilli from the glycogen in the
mucosa .this glycogen content decrease in
menopause---decrease acid----rise PH.
Altered flora:
1-young girls and postmenopauseal female have
lower prevalance of lactobacilli compared with
reproductive age female.
2-M.C may alter the flora especially during first
half
3-broad spectrum AB may result in symptoms due
to candida spp.

4-after hysterectomy and removal of the CX result

in increase in anaerobic spp. Post tryst Vaultdischarge
Vaginal discharge :
1—physiological:
Normal discharge is white ,become yellowish on
cntact with air due to oxidation.it consist of :
--desequmated cells from vagina and cx
--mucus from cx glands
--bacteria (95% lactobacilli)
--fluid transudate from the vaginal wall.
Its PH IS acidic.this discharge increase normally at
midcycle,pregnancy and female using COCP.
 discharge
I
ask whether bad or not bad ad mistly Suggest
b act in feet
I
Ash whether itchy or not itchy musty suggested
Candida

NII i Trichomones Share Some f both charact

 2- BACTERIAL VAGINOSIS:
BV is the COMMONEST cause of abnormal
discharge in female of child bearing
age.prevalance(12%).it is not considered to be
STD.when BV develops the anaerobic bacteria
become more predominant and increase up to
thousand fold accompanied by inrease in PH (4.5-
7) and disappearance of lactobaciili.
e Commomest organismwith BV are –gardenella

vaginalis,bacteroids,mobiluncus spp.,mycoplasma
hominis.
N B it is not an STD but bact Vaginosis has an increased Prevalan
in 9 ni STD
We don’t know what tiggers these changes but
certain risk factors are contributable to BV e.g
vaginal douching,black
race,smocking,IUCD,multiple sex partners.
The main symptoms fo BV is an offensive fishy characterist
smell discharge ,thin homogenus,adherent
non
to where
vaginal wall.white or yellow .the smell mainly excessive
secret1
noticed around MC and following intercourse. mostly t
Trichur
The dx commonly made in clinical practice using
AMSEL CRITERIA.
AMSEL CRITERIA: I'd b a
1--Vaginal ph alkaline more than 4.5
2—release of fishy smell on addition of alkaline
(10%)KOH .(whiff test)
Yellow white
3—special discharge on examination Adherent
4—presence of CLUE CELLS on microscopy.
w
epith.cat surrounding microbes

Samle of vaginal discharge is taken with a cotton

swab and mixed with few drops of normal saline
on a slide .on microscope we see the vaginal epith.
Cells are covered with bacteria to the extent that
the cell borders are blurred and nnuclei are not
visible.
 Tretment of BV :
3 regimens of treatment are proposed for BV in
non pregnant female ,cure rate (80-90%) at one
week but 30% recur within 3 months.
af Metronidazole 500mg oral *2 daily for 7 days.

of Metronidazole(0.75%) gel --- 5gm intravaginally

once daily for 5 days.
09 Clindamycin cream2%---5gm vaginally for 5 days.
S

concent is not required but Period is required If

3 months

N B n There is increased risk of recurrence Period at which flora to be restored

Implication of BV in gynae.and obs.: Most common of
Increase risk of second trimester miscarriage .
Increase risk of PTLB Preterm Term Delivery
= = of endometritis following termination
of pregnancy.
Increase risk of pelvic infection after hysterectomy.

Treatment of recurrent BV
Pt. kept on once or twice a month on oral or
topical metronidazol.
Candidiasis
More than 75% of female had at least one episod
of candida ,few had recurrent(more than 4 /year).
-organism carried under nail,gut ,vx and skin.
--80% caused by c.albicans,
-classical presentation: Signs of scratching
Itching ,soreness of vagina and vulva with cheesy
like white discharge which may smell yeasty.vulvar
erthyema ,oedema and excoriation are common
findings.
--PH of vagina normal Candida like acidity
Microscopic exam. Reveal the presence of
pseudohyphae and mycelia. not important

Culture is not routinly recommended except in

those with failed empric treatment.
RISK FACTORS:
--immune suppression
--HIV-- ---underlying dermatosis
--DM ----broadspectrum AB Pencillin Containing
brad seat
--vaginal douching
--pregnancy
--cocp and increase oestrogen
 How to distinguish Complicatedfrom non comp
CLASSIFICATION :
gsp
Uncomplicated --complicated
-sporadic -recurrent
-mild to moderate - severe
-caused by albicans spp. -- non albicans spp.
-non immune suppressed --immne suppressed

Treatment:
Local treatment is better than systemic to decrease
side effect.differrent doses and duration
Systemic antifungal Hepatotoxic
Intra vaginal agents: Doses are not required
--clotrimozole:1% cream ,5 gm
of vaginally 7-14 days
1st line in Pregnancy
:100mg tablet vaginally for 7 days
--miconazole
of :2% cream,5gm vaginally for 7 days
:100mg supp.for 7 days
:200mg supp.for 3 days
Singledose ifmensenearby
J a :1200 mg once only Poor compliant

nystatin :100 000 unit tablet vaginally for 14

days
Oral agent 150mg oral. Treatment of recurrent is
with once or twice per month for 6 months.
 rules
ClotrimaZule miconaZule 9 Category 13 in Pregh
fluconazole Category C orally

fluconazole given orally in Virgin Pt

Suspected GET
i feet
Trichomoniasis:
It is a STD
-can be asym.for several months
In men it is often asym.but may present as non
gonococcal urethritis.(70% of male are asym.)
C/F extensiveitching

In female present with severe vulvovaginitis

,purulent and s.t offensive vx discharge and in
many case BV develop as well.the parasite is a
marker of high risk sexual behaviour and co
infection with other STD is common esp.N.G.
doesnot Ascend
The parasite has prediction for sq.epith. to uters or Else
Exam;
Yellow-green vx discharge with inflammation s.t
extend out to the vulva and adjacent
skin.punctate haemorrhage occur on the cx
giving the appearance of STRAWBERRY CX (due
I
to subepith.haemorrhage.) to Suspect
mored
g Trichmoners
Dx:
Incubation of T.vaginlis require 3days -4
wks(vx,urethra,cx,UB)can be infected.no
symp.may be present for up to 50% of
female.and such colonization may persist for
months or years .
In those with compliant:
1-c/f(discharge+signs of vulvovaginitis)
2-strawberry cx on exam.
3-microscopic identification of the parasite in saline
prepration .parasite is ant. Flagellated ,motile,an
aerobic protozoa.they are oval in shape slightly
larger than WBC and become less mobile with
cooling ,so the slide should be read within 20
min.sensitivity is 60% lowSens dryness Micro
resemble
he
neutrophil

Vx PH RISE. L
dSensit
NAAT ----sensitive and specific nucleic acid amplificationtest
Screen for other STD AND THE PARTNER.
 TREATMENT:
af Metronidazole single 1 gm oral
= 500 mg *2 for 7 days
ofTinidazol 2g oral single dose

09
Rx partner
BARTHOLIN ABSCESS:bartholin glands situated on
either side of vaginal opening .if the opening of the
gland closed –cyst----if infected---abscess
Treatment AB +marsupilisation. Marsupialization is the surgical technique of
cutting a slit into an abscess or cyst and
suturing the edges of the slit to form a
continuous surface from the exterior surface to
bartholin cyst Mucus plug the interior surface of the cyst or abscess.

3 Abscess infected
UPPER GENITAL TRACT INFECTION(PID):
Term used to describe upper GT
infection(endometritis,parametritis,salpingitis,o
ophoritis).these infection usually spread from
the cx and vx , through lymphatics,bowel,blood
born.80% of microorganisms are STD either GC
or chlamydia+secondary invadors such as
bacteroids and mycoplasma.
PID is an important condition because it result
oin tubal damage and infertility and ectopic preg
and chronic pelvic pain .
 important to screen among
Chlamydia trachomatis: Secondy infertile couple

It is the commonest bacterial STD in the

developed country esp. in female less than 25
years.many infection are asym.(50% in male,80%
in female).in male it is the most common cause of
non gonococcurethritis.in female it cause
cervivisitis and PID.genital strains can colonize the
throat and can cause conjuctivitis.
Chlamydia T. :
Small bacterium ,obligate intracellular pathogen
.serotypes (A—C) cause trachoma,D—K cause
genital ,L1—L3 lymphogranuloma venereum.
The infectious particles are the elementary bodies
that infect the columner epith. They gain entry to the
cells by binding to specific surface receptors .once
they enter the cell ----inclusion bodies which contain
metabolically active reticulate bodies .these divide by
binary fission .after 48 hours reticulate bodies
condens into elementary bodies which are released
from the cells.heavily infected cells die but it is the
inflammatory response to infection that cause most
of the damage.cell mediated immunity is the
important type of immunity in controlling infections
,antibodies are serovar specific.
 Dx: samples from endocx (columnar epith.)
ELISA—limited sensitivity
ligasechainreaction
PCR AND LCR ---more sensitive(APPLIED TO
URINE AND VAGINAL SAMPLES)
TREATMENT:
roofDoxycycline 100mg*2 for 7 days

of Azithromycin 1 gm single dose given f r partnerCindy

of Ofloxacin 400mg daily for 7 days

In pregnancy most critical
feat f chlaneia
off Azithromycin 1 gm single dose is that it is
asymptomatic
Erthryromycin 500mg *2 for 14 days
if destruction occurs in one Tube There is alway

damage to opposite Tube Too to bilateral Tube