1999 Obstetrics & Gynaecology

By Duy Thai

LOWER GENITAL TRACT INFECTION

• Lower genital tract is colonised by commensal organisms

• Upper genital tract is meant to be sterile
• Lower genital tract infection comprises mainly of:
1. Vaginitis
• Presenting symptom is vaginal discharge
2. Cervicitis
• May be asymptomatic
• Will have pain on PV examination of the cervix

Factors protecting the vagina

1. Normal flora
• Colonised by lactobacillus acidophilus
• Metabolises glycogen present in vaginal epithelium to lactic acid
2. Acidic environment
• Maintained by the action of lactobacillus producing lactic acid
• pH = 3.8 – 4.5
• Acidic environment prevents superadded infection and colonisation
3. Healthy epithelium
• Oestrogen keeps vaginal epithelium healthy by causing proliferation of a multilayered epithelium which is glycogen rich
• Oestrogen deficiency (e.g. menopause) results in a thin, atrophic vaginal epithelium which has an increased risk of
superadded infection (because no glycogen = no lactic acid from lactobacillus = no more acid pH), especially if still
sexually active
4. Secretory IgA

Abnormal discharge
• What is abnormal depends on woman’s perception
• Do they normally have any discharge? Is the discharge more than usual? Does the discharge look/smell different?
• Some discharge is normally present
• The endocervical canal has a single layer of columnar epithelium containing crypts which produce mucous
• Oestrogen stimulates the production of a thin, watery mucous
• This mucous production is normally increased during the pre ovulatory oestrogen surge in menstruation
• Staining of the underwear may lead to concern if it does not normally occur
• There is an incidence of 17% of women complaining of abnormal discharge in a family planning center

Causes of abnormal discharge

1. Physiological
• Increased normal production of cervical mucous
2. Infective
• See later
3. Neoplastic
4. Atrophic vaginitis
• Loss of multilayered squamous epithelium
• Only a single basal layer is left, which exudes fluid
• Occurs in post menopausal women due to falling oestrogen levels
• Less glycogen à less lactobacilli à loss of acidity
• Tend to get a mixed superfinfection (especially if sexually active)
• Symptoms:
• Dyspareunia
• Sparse, non offensive discharge
• Signs
• Thin, atrophic vaginal epithelium
• May have petechial haemorrhages
• Treatment
• Topic oestrogens or systemic HRT
5. Foreign body
• Foul smelling discharge
• Commonly seen in children
6. Chemical
• Repeated douching leads to chronic vulvitis
• Also, douch fluid is alkaline, so increases propensity for bacterial colonisation
7. Fistulae
• Recto-vaginal fistulae seen in diverticulitis
• Chron’s

Clinical assessment of vaginal discharge

1. History
• Nature – colour, amount, smell
• Duration
• Periodicity
• Pain
• Dyspareunia
• Relationship to menses

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 1999 Obstetrics & Gynaecology
By Duy Thai

• Sexual history
• Number of partners
• Contraception
• Previous history and treatment of any abnormal discharge
• Medical history
2. Examination
• Vulva
• Vagina
• Cervix
• Discharge
• Bimanual
3. Investigation
• Sniff test
• Wet prep
• KOH prep
• Swabs for M/C/S
• Cytology

Candida vaginitis
A. Organism
• Candida albicans (monila)
• Pseudobranching yeast
• Proliferates in pH 5 – 6.5
• Normal flora
B. Risk factors/associations
• High oestrogen levels – high glycogen content which the yeast thrives on
• Diabetes – high sugar
• Antibiotics – disrupt normal balance of commensals
• Pregnancy
C. Clinical features
• Thick, white discharge – cottage cheese appearance
D. Investigations
• KOH prep shows branching hyphae or budding yeasts
E. Treatment
• Topical imidazoles – Clotrimazole is best

Trichomonas vaginitis
A. Organism
• Flagellated protozoan
• Very motile
• Likes pH 5 – 7
B. Associations
• Implicated in PROM and pre term labour
C. Clinical features
• Reddened cervix/vagina – strawberry appearance
• Green, foul smelling discharge
D. Investigations
• Wet prep may show motile protozoa
E. Treatment
• Oral imidazole – metronidazole 2g STAT
• 7 day course
• Treat partner as well, since protozoa can move up male urethra, into seminal vescicles and prostate, becoming a carrier

Bacterial vaginosus
A. Organism
• Polymicrobial colonisation of vagina by anaerobic organisms
• Commonsest is Gardnerella
B. Clinical features
• Thin, grey offensive discharge
• Pruritis and pain is prominent
• Fishy, amine odour – partner usually complains of odour after intercourse due to deposits of semen which is alkaline,
which allows organism to break down substances
• Not much inflammation (hence not a “vaginitis”)
C. Investigations
• Superficial swab of epithelial cells showing clue cells on Gram stain – epithelial cells covered with organism

D. Treatment
• Only treat if patient complains of discharge/odour
• Metronidazole for 7 days, including partner

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 1999 Obstetrics & Gynaecology
By Duy Thai

Gonorrhoea
A. Organism
• Neisseria gonorrhoea
• Gram –ve intracellular diplococcus
• Entirely sexually transmitted
• Incubation period 3 – 7 days, highly infectious
• Infects columnar epithelium, not squamous. Hence it only infects surfaces like: Skeines ducts, urethra, Bartholin glands,
cervix (endocervical part)
B. Clinical features
• Depends on where the organism infects
• Urethritis
• Bartholinitis
• Proctitis (anal sex)
• Pharyngitis (oral sex)
• Opthalmia neonatorium
• If disseminated – arthritis
• Long standing infection can spread and cause infection of the upper genital tract
• Cervicitis
• Usually chronic since it is asymptomatic in early stages
• Since patient is asymptomatic, won’t know they have it and so can infect other partners – contact tracing is
important
• When do present with a discharge, it is usually late (months or years)
C. Investigations
• Endocervical swabs and urethral swabs in Stuarts medium
• Also do tests for chlamydia and syphillis since often have other STD’s present (50% of those with gonorrhoea have
coexisting Chlamydia infection)
• Contact tracing is very important
D. Treatment
• Ceftriaxone 250 mg IM STAT (30% of gonococcus are PPNG)
• Treat all contacts

Chlamydia trachomatis
A. Organism
• An obligate intracellular pathogen
• Can only live in columnar epithelium (like gonorrhoea)
• Exclusively sexually transmitted
B. Clinical features
• Infects the columnar epithelium of the endocervix
• Slow growing pathogen and so produces a chronic cervicitis which is asymptomatic
• When symptoms do appear, usually of a vaginal discharge. However, when symptoms have appeared, there has already
been long standing damage
• Since asymptomatic, the woman is a carrier
• Long term infection can lead to infection of the upper genital tract
C. Investigations
• Endocervical swab
• Contact tracing
D. Treatment
• Minimum of 4 weeks doxycycline

Viruses
1. Herpes simpex 2
• Symptoms occur when infection is acquired
• Virus is expressed on the vulva as fluid filled vescicles
• These vescicles ulcerate à pain
• The areas of ulceration eventually heal
• However, the virus migrates to the posterior ganglia and remain dormant there, and can cause recurrence
• Number of recurrences vary
• Primary infection presents with symptoms of intense vulval pain
• Secondary infection (recurrence) usually has less severe symptoms
• Major problem during pregnancy
• If have active lesions during delivery, the baby can become infected and get a viremia à herpetic encephalitis
• Hence, elective CS is done
2. Human papilloma virus (HPV)
• Majority is sexually transmitted
• Can infect any part of the lower genital tract
• Infection of the vulva or vagina produces condylomata
• Infection of the cervix may produce warts which are exophytic or flat
• The only way to detect cervical infection is via a pap smear, showing HPV virions inside cells on
cytology
• HPV (types 16 and 18) is implicated in cervical dysplasia, a pre neoplastic change detectable on pap
smear (hence the need for regular pap smears)

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