Dr.

Nilar Win

Gynaecological infection

Quick recall for final professional exam

Common presentations
Pruritus vulvae
Vaginal discharge
Pelvic inflammatory disease
PRURITUS VULVAE
 Causes of Pruritus Vulvae
Infections and Infestation Non-infectious causes

•
Dermatological
Vulvovaginal candidiasis Refer to the International Society for the Study of Vulvar Disease
(ISSVD 2006 classification) along with hidradenitis suppurativa
• Trichomoniasis Neoplastic conditions

• Bacterial Vaginosis Squamous: VIN (Warty, Basaloid, Mixed)

Non-squamous: Paget’s disease, Tumours of melanocytes

• Herpes simplex Hormonal

Atrophic vaginitis, breast feeding

Urinary or faecal incontinence

• Pubic lice (Phthirus pubis) Systemic causes: secondary to renal (chronic renal failure),

• Scabies (Sarcoptes scabiei

Haematologic (Iron deficiency, Polycythaemia rubra vera,
Hypereosinophilic syndrome, essential thrombocythemia,
Myelodysplastic syndrome), Hepatic (Cholestasis), Endocrine
hominis) (Hyperthyroidism, Hypothyroidism, Diabetes mellitus,
Hyperparathyroidism, Hypoparathyroidism), Malignancies (Hodgkin’s

• Thread worm (Enterobius disease, Leukaemia, carcinoid syndrome),Immunosuppression leading

to vulvovaginal candidiasis

vermicularis) Psychosexual disorders

Others: regrowth of pubic hair after shaving

 Common causes of pruritus vulvae
in different age groups
Pre-puberty Poor hygiene
Streptococcal infection
Escherichia coli infection
Pinworms
Scabies
Allergic contact dermatitis
Reproductive age Vaginitis
Allergic contact dermatitis
Hidradenitis suppurativa
Lichen simplex chronicus
Menopause Atrophic vaginitis
Lichen sclerosus
Vulvar cancer
Paget’s disease
Females with diabetes mellitus
Candidiasis
Other dermatophyte infections
Clinical evaluation
• Gynaecological history
❖ duration of presenting symptoms,
❖ severity including impact on quality of life (social, psychological and sexual life)
❖ any past or present treatment
❖ detailed history of treatment with any medication and response
❖ personal or family history of autoimmune conditions
❖ atopic conditions
❖ urinary or faecal incontinence
❖ smoking
❖ cervical smear abnormalities

• Full examination of the vulva, vagina, anogenital region and other skin and mucosal sites should also be carried out.

• Investigations based on underlying causes

General measures

Do’s Don’ts
✔ Use soap substitute • Wash with plain water. Use small amount of
✔ Shower emollient with water, to avoid dry skin.
✔ Gently dab vulval area • Bath - Add bath emollient if bathing.
✔ Dry with soft towel or hair dryer on a cool setting • Avoid sponges or flannels to wash but use
held away from skin emollients and apply with hand.
✔ Wear loose-fitting cotton underwear • Avoid fabric conditioner, biological washing
✔ Sleep without underwear powder, soaps, shower gel, scrubs, bubble bath,
✔ Wear white or light colours of underwear deodorants, baby wipes and douches.
• Avoid coloured toilet paper, panty liners, and
dark coloured under-wear s dark textile dyes may
cause allergies.
 Vulvovaginal Candidiasis

• Causal organism: commonly Candida albicans: affects reproductive age women

*Candida is a normal commensal organism in the vagina. Pathological infection usually

follows a change in the local environment or a decrease in the host’s susceptibility to
infection.

• Symptomatic candidiasis is due to an exaggerated immunological response to the

presence of Candida rather than a failure of immune mechanisms.

• Sore & itchy, thick white discharge. Can cause satellite lesions on inner thighs.

• InVx: Vaginal swab for C&S or spores & hyphae on direct microscopy.
Budding yeasts and Hyphae
Curdy white discharge on vaginal wall
(Clinical diagnosis)
• Diagnosis

• Clinical diagnosis

• Gram stain or a wet preparation (saline, 10% KOH) of vaginal discharge → hyphae, or
pseudohyphae or budding yeasts.

*Candida isolated from culture with no clinical symptoms or signs should not be treated, as about 15% of women harbour
candida in their vagina as a commensal. PCR is not recommended to diagnose candida; culture remains the gold standard for
diagnosis.
• Treatment is usually with
o topical azole (Clotrimazole or Miconazole or nystatin ointment/cream applied to vulva twice a day) OR

o Vaginal clotrimazole pessary 500 mg single dose or 200 mg per night for 3 nights OR

o oral triazole
o Fluconazole 150 mg stat dose or 100 mg daily for 3 days

o Itraconazole 200 mg twice daily for a day

• Treatment of Recurrent candidiasis (at least four episodes per year)

o Induction period of

❑ for 1-2 weeks

❑ either with an oral agent or with a topical antifungal

o Maintenance treatment

❑ lasting for a period of 6 months

❑ either with oral Fluconazole 100 mg weekly or topical Clotrimazole 500 mg weekly

o Treatment can be stopped after 6 months and

o If recurrent infection returns, repeat induction/maintenance should be considered.

o Approximately 90% of women will remain disease-free at 6 months and 40% at 1 year.

o May consider partner treatment.

*Maintenance therapy with triazole is unlicensed.

• Thread worm
o Intense itching around anal opening, which can spread to perianal or vulvovaginal area.

o More noticeable at night.

o Rx: Mebendazole 100 mg oral stat dose. If reinfection, 2nd dose after 2 weeks.

• Pubic lice
o Nits in pubic hair.

o Rx: 0.5% malathion lotion or 1% lindane lotion/cream applied to pubic hair for 12 hours and washed off, repeat
after 7 days.

• Scabies
o Burrows alongside of fingers and front of wrists.

o Rx: Zinc pyrithrone or malathion lotion or cream applied whole body surface except face, scalp on two successive
nights ± oral ivermectin

• Herpes simplex
o Pain predominant + itching, smear shows multinucleated giant cells.

o *Screen and treat other STI.

o Primary - oral acyclovir 200 mg five times for 5 days.

o Recurrent - oral acyclovir 400 mg bd for few months

o Topical acyclovir 5% cream, useful if applied early.

 Genital herpes

Pubic lice
VAGINAL DISCAHRGE
Causes of Vaginal discharge
1. Physiological discharge
2. Bacterial vaginosis
3. Vulvovaginal candidiasis
4. T. Vaginalis
5. Chlamydia, gonorrhoea
6. Herpes simplex virus
7. Foreign body (e.G. Retained tampon and condom)
8. Irritants (e.G. Perfumes or deodorants)
9. Atrophic vaginitis
10. Fistulae
11. Tumours affecting the vulva, vagina and cervix
History
Discharge –quantity, colour, consistency, and odour.
o BV: typically malodorous, thin, grey (never yellow), and is a prominent complaint.
o Candidiasis: scant discharge that is thick, white, odourless, and often curd-like.
o Trichomoniasis: purulent, malodorous discharge, which may be accompanied by burning, pruritus, dysuria, frequency, and/or dyspareunia.

Burning, irritation or other discomfort

o Candida vulvovaginitis often presents with marked inflammatory symptoms (pruritus and soreness).

o In contrast, BV is associated with only minimal inflammation and minimal irritative symptoms. Burning and irritation can also be a
symptom of non-infectious disorders such as vulvodynia.

Pruritus – General pruritus is suggestive of a diffuse process such as infection, allergy, or dermatosis. Persistent or
chronic focal pruritus is suggestive of a localized process such as neoplasia or malignancy.

Vaginal bleeding –not consistent with infectious vaginitis. If present, the patient should be evaluated for erosive
causes of vaginitis (eg, erosive lichen planus) or a uterine source.

Pain – Women with predominant pain symptoms are evaluated for inflammatory causes of vaginitis or non-vaginal
sources, such as pelvic floor myofascial pain or vulvodynia.
Dysuria or dyspareunia –suggestive of inflammatory disorders (infection or
allergy) or vulvovaginal atrophy.

Timing of symptoms
o Candida: often occur in the premenstrual period,
o Trichomoniasis and BV: during or immediately after the menstrual period.
o STIs: Symptoms that develop soon after sexual intercourse
o Vaginal fistula: symptoms that develop after gynaecologic surgery such as
hysterectomy

Hypoestrogenic states – menopausal women, postpartum, lactating, or taking

antiestrogenic drugs, contraceptive use.
• Sexual practices –high risk of BV in homosexual or bisexual; STIs in women with a new sexual partner
(Trichomonas vaginalis or cervicitis related to Neisseria gonorrhoeae or Chlamydia trachomatis)

• Medication history – Antibiotics predispose to candidal vulvovaginitis; estrogen-progestin contraceptives can

increase physiologic discharge; pruritus and burning unresponsive to antifungal agents may be due to vulvovaginal
dermatitis.

• Hygienic practices – Mechanical, chemicals (eg, scented panty liners, spermicides, povidone-iodine, soaps and
perfumes, and some topical drugs) and allergens (eg, latex condoms, topical antifungal agents, seminal fluid,
chemical preservatives)

• Medical history – Does the patient have a history of an oral mucosal, ocular, cutaneous, or systemic disease that
could affect the vulvovaginal area?

• Herpes simplex virus can cause vulvovaginal ulcers.

• Women with diabetes are prone to vulvovaginal candidiasis.

• Women with HIV are prone to vaginal infections.

• Surgical history –recent transvaginal surgery or repair of perineal lacerations from childbirth.
Physical examination
• Assess the degree of vulvovaginal inflammation, characteristics of the vaginal discharge, and
presence of lesions or foreign bodies. Other potentially significant findings include signs of
cervical inflammation and pelvic or cervical motion tenderness.

• Vulva

o BV or leukorrhea: normal vulva

o Candidiasis, trichomoniasis, or dermatitis: erythema, edema, or fissures
o Atrophic vaginitis: Atrophic changes caused by hypoestrogenemia

• *Speculum examination is performed to evaluate the vagina, any vaginal discharge, and the
cervix.
• Vagina
o A foreign body (Eg, retained tampon or condom), Vaginal warts, Granulation tissue or surgical site
infection, Necrotic or inflammatory changes associated with malignancy in the lower or upper
genital tract
o Vaginal discharge
▪ Trichomoniasis: greenish-yellow purulent discharge
▪ Candidiasis: a thick, white, adherent, "cottage cheese-like" discharge
▪ BV: thin, homogeneous, "fishy smelling" grey discharge
▪ Malignancy of the lower or upper genital tract: watery, mucoid, purulent, and/or bloody vaginal discharge.

*However, the appearance of the discharge is unreliable and should never form the basis for diagnosis. A sample of vaginal
discharge is collected with a cotton-swab and tested for pH and with microscopy.

▪ Vesicovaginal and rectovaginal fistulas: source of chronic vaginal discharge especially in

postpartum, post-hysterectomy, post-surgery for prolapse, or have a history of inflammatory bowel
disease or radiation therapy to the pelvis.

• Cervix : Cervicitis - erythematous and friable, with a mucopurulent discharge

• Bimanual examination: pelvic inflammatory disease: adnexal masses

Investigation
• Vaginal pH

o In a premenopausal woman →BV (pH > 4.5) or trichomoniasis (pH 5-6), Candida vulvovaginitis (pH 4-4.5).

o In postmenopausal women , pH of the normal vaginal secretions ≥4.7. The higher pH is due to less glycogen in
epithelial cells, reduced colonization of lactobacilli, and reduced lactic acid production.

• Microscopy

• Saline wet mount: normal → squamous epithelial cells, rare polymorphonuclear leukocytes (PMNs),
and Lactobacillus species morphotype.
• Potassium hydroxide wet mount: candida vaginitis; Amine test – Smelling ("whiffing") the slide
immediately after applying KOH is useful for detecting the fishy (amine) odour of BV.

• Swab taking and culture and sensitivity tests

• High vaginal swab (HVS)

• Endocervical swab (ECS): mainly used for chlamydia and gonorrhoea. The swab is sent for NAAT (nucleic acid
amplification testing).
Bacterial vaginosis

• Prevalence of the anaerobic species (Prevotella species, G. vaginalis, Mobiluncus species,

Peptostreptococcus species and Mycoplasma hominis) in preference to the normal Lactobacillus species.

• Risk: multiple sexual partners, no use of condoms

• Presentation: Mostly asymptomatic carrier (in most cases); conditions such as puerperal endometritis,
preterm labour, premature rupture of membranes, PID/STI and UTI.

*Women with bacterial vaginosis are more likely to acquire other sexually transmitted infections, pregnancy
complications, post-surgery complications and disease recurrence.
Clue cells: epithelial cells studded with adherent coccobacilli or vaginal epithelial cell has shaggy borders
obscured by coccobacilli. The more normal appearing epithelial cell has sharper borders.
Clinical criteria
(Amsel)**clinical use
3 of the following
1. Homogeneous, grey-white
discharge
2. Clue cells on wet microscopy
3. pH of vaginal fluid >4.5
4. Fishy odour with or without
the addition of 10% KOH
(whiff test)
*Gram stain : estimate the concentration
of lactobacilli (Long gram positive rods)
and the gram negative anaerobes
Nuget score (Score 0-10)
Estimate estimates the
relative proportions of bacterial
types on a Gram stained vaginal
smear
Score of <4: normal
Score of 4-6: intermediate
Score of >6: BV.
Hay Ison criteria (Grade 0-4)
based on findings on a Gram stained
smearand gives an idea about flora
types
0: Not related to BV, epithelial cells
only, no lactobacilli.
1 (Normal): Lactobacilli predominate
2 (Intermediate): Mixed flora with
some Lactobacilli, and Gardnerella or
Mobiluncus also present
3 (BV): Few or absent Lactobacilli.
Gardnerella and/or Mobiluncus
morphotypes, clue cells,
predominate.
4: Not related to BV, no lactobacilli,
Gram +ve cocci only.
• Indications for Treatment

o Patients with symptoms.

o Preoperative for vaginal surgery

o Pregnant women, if further investigated with direct microscopy (due to persistent negative gram stain findings
and still symptomatic or failure of treatment) and found positive.

o Treatment individualized in patients with positive direct microscopy without symptom.

• Recommended regimens:

o Oral metronidazole 500 mg bd for 7 days or

o Oral metronidazole 2 gm single dose or

o 0.75% Metronidazole gel: one full applicator (5 g) intravaginally, once daily for 5 days, or

o 2% Clindamycin cream: one full applicator (5 g) intravaginally at bedtime for 7 days (Clindamycin cream may
affect latex condom and diaphragm and reduce their effectiveness for 5 days after its use)
Trichomonas vaginalis
• Flagellate protozoan; STI

• Presentation:

• 70-85% of cases→ asymptomatic

• abnormal vaginal discharge, pruritus and dysuria

• Strawberry cervix (friable, erythematous cervix with punctate areas of exudate)

• Urethral infection

• Screening can be done in asymptomatic women who are at high risk for infection such as
multiple sexual partners, drug abusers and patients with a history of STIs.
Diagnosis

• NAAT→ gold standard

• Direct microscopy (wet mount microsocpy)→method of choice for screening (more

practical due to its lower cost compared to NAAT).

* T. vaginalis lose their motility quickly, it should be read within 10 minutes of collection.

• Culture of vaginal discharge (urine culture is less specific)

• Immunomodulation: OSOM Trichomonas Rapid Test and the Affirm VP III.

• Cervical smear Pap tests can incidentally detect T. vaginalis, but their false positive
and false negative rates make them unreliable as a diagnostic tool
• Indications for Treatment:
o Testing positive for T. vaginalis, regardless of symptoms
o Treatment of sexual partners

• Recommended regimen:
o A single dose of P.O 2 g metronidazole OR
o A single dose of P.O 2 g tinidazole (metro better than tini) OR
o P.O 500 mg metronidazole bd for 7 days

*Metronidazole gel is less effective due to its low absorption rate and is not recommended for treatment.

• Persistent or recurrent T. Vaginalis

o Avoid single dose therapy for treatment of persistent or re-infection with T. Vaginalis.
o If the single dose of 2 g metronidazole fails→ give P.O 500 mg metronidazole bd for 7 days
o If this fails→ 2 g metronidazole or 2 g tinidazole for 7 days (Susceptibility to metronidazole or
tinidazole should be tested if there is no cure after 1 week of treatment)

o Intravaginal tinidazole, plus high dose P.O 2-3 g daily tinidazole, could be considered for
highly resistant strains.
PELVIC INFLAMMATORY DISEASE
 Risk factors
• History of PID

• Gonorrhoea or Chlamydia infection (active infection or history of past infection)

• Bacterial vaginosis

• Early age at first sexual intercourse

• Multiple sexual partners

• Male partners with gonorrhoea or chlamydia infection or STI

• Contraception: non-barrier methods of contraception or use of intrauterine devices

• Diabetes or immunocompromised patients

• Low-socioeconomic status
Causal organisms of PID and TO abscess
• Chlamydia trachomatis (sexually transmitted)

• Neisseria gonorrhoeae (sexually transmitted)

• Escherichia coli (Enterobacteriaceae)

• Bacteroides (Anaerobe)

• Peptococcus (Anaerobe)

• Peptostreptococcus (Anaerobe)

• Actinomyces (usually associated with the presence of an intrauterine device)

• Pelvic tuberculosis (rare – reported with co-existing HIV)

• Gardnerella vaginalis

• Streptococccus agalactiae

• Mycoplasma genitalium

• Haemophilus influenzae

• Streptococcus pyogenes
Clinical presentation of PID
Symptoms Signs
• lower abdominal pain which is typically bilateral • lower abdominal tenderness which is usually
• deep dyspareunia bilateral
• abnormal vaginal bleeding, including post coital, • adnexal tenderness on bimanual vaginal
inter-menstrual and menorrhagia examination
• abnormal vaginal or cervical discharge which is • cervical motion tenderness on bimanual vaginal
often purulent examination
• fever (>38°C)

Complications
Women with HIV: more severe symptoms associated with PID but respond well to standard antibiotic
therapy
Tubo-ovarian abscess (inflammatory mass involving the tube and/or ovary characterised by the presence
of pus)
Fitz-Hugh-Curtis syndrome comprises right upper quadrant pain associated with perihepatitis which occurs
in some women with PID.
• Differential diagnosis of lower abdominal pain in a young woman includes:
• Ectopic pregnancy

• Acute appendicitis (Cervical movement pain present in 1/4 of women)

• Endometriosis

• Complications of an ovarian cyst e.g. torsion or rupture

• Urinary tract infection

• Investigation
o Testing for gonorrhoea and chlamydia in the lower genital tract (absence of infection at this site does not
exclude PID)

o Screening for sexually transmitted infections including HIV

o An elevated ESR or C reactive protein (non-specific)

o Ultrasound abdomen and pelvis

o Test to exclude differential diagnoses: Urine analysis or FME, Urine pregnancy test
 Cogwheel sign resulting from
Tubo-ovarian complex
thickened endo-salpingeal folds.
Treatment : outpatient versus inpatinet

• Outpatient therapy for clinically mild to moderate PID

* A diagnosis of PID, and empirical antibiotic treatment, should be considered and usually offered in age < 25 years
sexually active woman who has recent onset, bilateral lower abdominal pain associated with local tenderness on
bimanual vaginal examination, in whom pregnancy has been excluded.

1. IM Ceftriaxone 500mg single dose followed by oral doxycycline 100mg bd plus metronidazole 400mg bd for 14
days OR

2. Oral ofloxacin 400mg bd plus oral metronidazole 400mg bd for 14 days OR

3. IM Ceftriaxone 500 mg immediately, followed by azithromycin 1 g/week for 2 weeks OR

4. Oral moxifloxacin 400mg once daily for 14 days

• Criteria for Admission and parenteral therapy
• a surgical emergency cannot be excluded
• lack of response to oral therapy
• clinically severe disease
• presence of a tuboovarian abscess
• intolerance to oral therapy

• pregnancy

1. IV Ceftriaxone 2g daily plus IV doxycycline 100mg bd (oral doxycycline may be used if tolerated) followed by oral
doxycycline 100mg bd plus oral metronidazole 400mg bd for a total of 14 days OR

2. IV Clindamycin 900mg tds plus IV gentamicin (2mg/kg loading dose) followed by 1.5mg/kg tds [a single daily
dose of 7mg/kg may be substituted]) followed by either oral clindamycin 450mg qid or oral doxycycline 100mg
bd plus oral metronidazole 400mg bd to complete 14 days OR

3. IV Ofloxacin 400mg bd plus IV metronidazole 500mg tds for 14 days OR

4. IV Ciprofloxacin 200mg BD plus IV (or oral) doxycycline 100mg bd plus IV metronidazole 500mg tds for 14 days

*Intravenous therapy should be continued until 24 hours after clinical improvement and then switched to oral.
Flow chart for treatment
of Tubo-ovarian abscess
• Surgical Management
o Laparoscopy: adhesiolysis and draining pelvic abscesses

o Ultrasound guided aspiration of pelvic fluid collections: less invasive and may be equally effective.

• Sexual Partners
•Contact tracing: Current male partners of women with PID should be contacted and offered health advice and
screening for gonorrhoea and chlamydia (tracing of contacts within a 6 month period of onset of symptoms is
recommended but this time period may be influenced by the sexual history)

• Gonorrhoea or chlamydia diagnosed in the male partner should be treated appropriately

• Because many cases of PID are not associated with gonorrhoea or chlamydia, broad spectrum empirical therapy
should also be offered to male partners e.g. azithromycin 1g single dose

• If screening for gonorrhoea is not available additional specific antibiotics effective against Neisseria gonorrhoeae
should be offered e.g. IM ceftriaxone 500mg single dose
• Follow Up

• Review at 72 hours is recommended, particularly for those with a moderate or severe clinical
presentation, and

• Should show a substantial improvement in clinical symptoms and signs. Failure to do so suggests the
need for further investigation, parenteral therapy and/or surgical intervention.

• Further review 2-4 weeks after therapy to ensure:

• adequate clinical response to treatment

• compliance with oral antibiotics

• screening and treatment of sexual contacts

• awareness of the significance of PID and its sequelae

• repeat pregnancy test, if clinically indicated.

• Repeat testing for gonorrhoea or chlamydia after 2 to 4 weeks in those in whom persisting symptoms,
antibiotic resistance pattern (gonorrhoea only), compliance with antibiotics and/or tracing of sexual
contacts indicate the possibility of persisting or recurrent infection.
References

1. Gopal, G., Hadoura, E., & Mahmood, T. (2016). Pruritus vulvae. Obstetrics,
Gynaecology & Reproductive Medicine, 26(4), 95-100.
2. Rice, A., ElWerdany, M., Hadoura, E., & Mahmood, T. (2016). Vaginal
discharge. Obstetrics, Gynaecology & Reproductive Medicine, 26(11), 317-323.
3. Munro, K., Gharaibeh, A., Nagabushanam, S., & Martin, C. (2018). Diagnosis and
management of tubo‐ovarian abscesses. The Obstetrician & Gynaecologist, 20(1),
11-19.
4. UK National Guideline for the Management of Pelvic Inflammatory Disease 2011
5. https://www.uptodate.com/contents/approach-to-females-with-symptoms-of-
vaginitis?search=vaginal%20discharge&source=search_result&selectedTitle=1~150&usage_ty
pe=default&display_rank=1
GOOD LUCK