GENITAL TRACT INFECTIONS

The vulval and perineal skin is usually resistant to common infection. But the defence is lost
following constant irritation by the vaginal discharge or urine (urinary incontinence).
Furthermore, there may be atrophy or degenerative changes either in disease or following
menopause when the infection is more likely. The vulval infection can thus occur de novo or
may be affected secondarily, the primary site may be elsewhere in the adjacent structures. In
this section, only the lesions affecting primarily the vulva will be discussed. It is indeed
difficult to classify the vulval infection but the following etiological classification is of help.

I. Due to specific infection.

II. Due to sensitive reaction.
III. Due to vaginal discharge or urinary contamination.
PYOGENIC INFECTION (NON-GONOCOCCAL)

Vulval cellulitis: The causative organism is predominantly Staphylococcus aureus. The

vulva is swollen, red, and tender. There may be profuse exudation. The inflammation is
limited, in majority, upto the labiocrural fold. The patient complains of intense pain, itching
and problem in micturition. There may be excoriation of the skin due to scratching and
laceration. Treatment is effective by systemic antibiotics, local hot compress and analgesics.

Furunculosis: The infection affects the hair follicles of the mons and labia majora →
folliculitis → furunculitis. The offending organism is Staphylococcus aureus. If it is
recurrent, glycosuria should be excluded. Treatment is effective with systemic and local
antibiotics and local cleanliness.

Infection of sebaceous and apocrine glands: Infection of an apocrine or sebaceous gland

looks and presents the features of a boil. If it recurs, excision is to be done in the quiescent
state.

Impetigo: Impetigo is a pustular infection caused by Staphylococcus aureus or

Streptococcus. It may be localized to vulva or spread to other parts of the body, face, or
hands. Blebs should be incised or the crusts be removed aseptically. Systemic and local
antibiotics are to be prescribed.

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Erysipelas: This rare spreading cellulitis is caused by invasion of the superficial lymphatics
by b-haemolytic Streptococcus. There may be systemic constitutional symptoms. It responds
well to systemic broad spectrum antibiotics.

Intertrigo: Intertrigo is due to irritation and infection of retained secretions in the skinfolds
usually in an obese patient. It may also result from friction of the undergarments or sanitary
towels.

Treatment with local hygiene and local antiseptic application is quite effective. At times,
systemic antibiotics may have to be used.

VIRAL INFECTION

Herpes zoster: The causative agent is varicella zoster virus (VZV). This is due to re-
emergence of VZV from posterior nerve roots. It produces an inflammatory painful eruption
of groups of vesicles distributed over the skin corresponding to the course of peripheral
sensory nerves (dermatome). It is commonly unilateral but may extend to the thigh or buttock
of the same side. The vesicles may rupture or become dry with scab formation. It resolves
spontaneously in 3 weeks time.

Treatment is by analgesics to relieve pain and antibiotics to prevent secondary infection.

Acyclovir 800 mg orally five times daily for 7 days is recommended. Acyclovir cream (5%)
may be used locally for less severe infection.

Fungal Infection

Moniliasis

Ringworm:The causative organism is Tinea cruris. The lesions look bright red and
circumscribed. The fungus can be detected microscopically from scraping of the lesion.
Treatment is very effective with imidazole (clotrimazole or miconazole) cream. Some fungi
(Trichophyton rubrum) respond well to griseofulvin 500 mg twice daily by mouth for 4
weeks. Parasitic Infection

Threadworm:The causative organism is Oxyuris vermicularis. It is common in children.

Nocturnal perineal itching with evidences of perianal excoriation is observed. The parasite is
detected in the stool. Anthelmintic drugs such as mebendazole and local application of
gentian violet cures the condition.

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 INFECTIONS OF BARTHOLIN’S GLAND

Bartholin’s glands are the two pea sized (2 cm) glands, located in the groove between the
hymen and the labia minora at 5 O’Clock and 7 O’Clock position of the vagina.

Causative Organisms: Although Gonococcus is always in mind but more commonly other
pyogenic organisms such as Escherichia coli, Staphylococcus, Streptococcus, or Chlamydia
trachomatis or mixed types (polymicrobial) are involved.

Pathology: Both the gland and the duct are involved. The epithelium of the gland or the duct
gets swollen. The lumen of the duct may be blocked or remains open through which exudates
escape out.

Fate: The infection may resolute completely or an abscess is formed. In others, the infection
subsides only to recur in future. In such cases, the gland becomes fibrotic. Too often, the duct
lumen heals by fibrosis with closure of the orifice → pent up secretion of the gland →
formation of bartholin cyst. Thus, the end results of acute Bartholinitis are: (i) Complete
resolution (ii)Recurrence (iii) Abscess (iv) Cyst formation.

Clinical Features: Initially, there is local pain and discomfort even to the extent of difficulty
in walking or sitting. Examination reveals tenderness and induration of the posterior half of
the labia when palpated between thumb outside and the index finger inside the vagina. The
duct opening looks congested and secretion comes out through the opening when the gland is
pressed by fingers. The secretion should be collected with a swab for bacteriological
examination.

Treatment: Hot compress over the area and analgesics to relieve pain are instituted.
Systemic.

antibiotic like ampicillin 500 mg orally 8 hourly is effective or else appropriate antibiotic
according to the bacteriological sensitivity should be instituted.

Recurrent Bartholinitis: Periodic painful attacks cause problems in 5–10 percent women.
Excision of the gland with the duct may have to be done in the quiescent phase.

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BARTHOLIN’S ABSCESS

Bartholin’s abscess is the end result of acute bartholinitis. The duct gets blocked by fibrosis
and the exudates pent up inside to produce abscess. If left uncared for, the abscess may burst
through the lower vaginal wall. A sinus tract may remain with periodic discharge through it.

Clinical Features

The local pain and discomfort become intense. The patient cannot walk or even sit. Fever is
often associated. On examination, there is an unilateral tender swelling beneath the posterior
half of the labium majus expanding medially to the posterior part of the labium minus. The
overlying skin appears red and edematous.

Treatment: Rest is imposed. Pain is relieved by analgesics and daily sitz bath. Systemic
antibiotic— ampicillin 500 mg orally 8 hourly or tetracycline in chlamydial infection is
effective. Abscess should be drained at the earliest opportunity before it bursts spontaneously.
In case of recurrent Bartholin’s abscess, excision should be done in the quiescent phase after
the infection is controlled.

VAGINAL INFECTION (VAGINITIS)

o Vulvovaginitis in childhood.
o Trichomoniasis.
o Moniliasis.
o Vaginitis due to Chlamydia trachomatis.
o Atrophic vaginitis.
o Non-specific vaginitis.
o Toxic shock syndrome.
VULVOVAGINITIS IN CHILDHOOD

Inflammatory conditions of the vulva and vagina are the commonest disorders during
childhood. Due to lack of estrogen, the vaginal defence is lost and the infection occurs easily,
once introduced inside the vagina.

Etiology 

o Non-specific vulvovaginitis. 
o Presence of foreign body in the vagina. 

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 o Associated intestinal infestations—threadworm being the commonest. 
o Rarely, more specific infection caused by Candida albicans or Gonococcus may be
implicated.
Clinical Features:

The chief complaints are pruritus of varying degree and vaginal discharge. There may be
painful micturition. Inspection reveals soreness of the vulva. The labia minora may be
swollen and red. If a foreign body is suspected, a vaginal examination with an aural or nasal
speculum may help in diagnosis.

Investigations:

The vaginal discharge is collected with a platinum loop and two smears are taken, one for
direct examination and the other for Gram stain. A small amount may be taken with a pipette
for culture in Stuart’s media. To exclude intestinal infestation, stool examination is of help.
Vaginoscopy is needed to exclude foreign body or tumor in a case with recurrent infection.

Treatment:

In most cases, the cause remains unknown. Simple perineal hygiene will relieve the
symptoms. In cases of soreness or after removal of foreign body, estrogen cream is to be
applied locally, every night for two weeks. When the specific organisms are detected, therapy
should be directed to cure the condition.

TRICHOMONAS VAGINITIS

Vaginal trichomoniasis is the most common and important cause of vaginitis in the
childbearing period.

Causative Organism:

It is caused by Trichomonas vaginalis, a pear-shaped unicellular flagellate protozoa. It

measures 20µ long and 10µ wide (larger than a WBC). It has got four anterior flagellae and a
spear-like protrusion at the other end with an undulating membrane surrounding its anterior
twothird. It is actively motile.

Mode of Transmission The organism is predominantly transmitted by sexual contact, the

male harbors the infection in the urethra and prostate. The transmission may also be possible

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by the toilet articles from one woman to the other or through examining gloves. The
incubation period is 3–28 days.

Clinical Features

(a) There is sudden profuse and offensive vaginal discharge often dating from the last
menstruation. (b) Irritation and itching of varying degrees within and around the introitus are
common.

(c) There is presence of urinary symptoms such as dysuria and frequency of micturition.

(d) There may be history of previous similar attacks. Women with trichomoniasis should be
evaluated for other STDs including N. gonorrheae, C.trachomatis, and HIV.

Diagnosis

(a) Identification of the trichomonas is done by hanging drop preparation . If found negative
even on repeat examination, the confirmation may be done by culture.

(b) Culture of the discharge collected by swabsin Diamond’s TYM or Feinberg

Whittingtonmedium. In suspected cases, gonococcal or monilial infection should be
excluded.

Treatment

The treatment is very much effective with metronidazole. Metronidazole 200 mg thrice daily
by mouth is to be given for 1 week. A single dose regimen of 2 g is an alternative. Tinidazole
single 2 gm dose PO is equally effective. The husband should be given the same treatment
schedule for 1 week. Resistance to metronidazole is extremely rare. The husband should use
condom during coitus irrespective of contraceptive practice until the wife is cured.

CANDIDA VAGINITIS (MONILIASIS)

Causative Organism

Moniliasis is caused by Candida albicans, a grampositive yeast-like fungus

Clinical Features

The patient complains of vaginal discharge with intense vulvovaginal pruritus. The pruritis is
out of proportion to the discharge. There may be dyspareunia due to local soreness.

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Diagnosis:

Wet Smear of vaginal discharge is prepared. KOH solution (10%) is added to lyse the other
cells. Filamentous form of mycella, pseudohyphae can be seen under the microscope. Culture
in Nickerson’s or Sabouraud’s media— become positive in 24–72 hours

Women with recurrent vulvovaginitis, vaginal boric acid capsule (600 mg gelatin capusles) is
effective. Boric acid inhibits fungal cell wall growth.

Treatment: Corrections of the predisposing factors should be done, if possible. Local

fungicidal preparations commonly used are of the polyene or azole group. Nystatin,
clotrimazole, miconazole, econazole are used in the form of either vaginal cream or pessary.

CERVICITIS

The term cervicitis is reserved to infection of the endocervix including the glands and the
stroma. The infection may be acute or chronic.

ACUTE CERVICITIS

The endocervical infection usually follows childbirth, abortion, or any operation on cervix.
The responsible organisms are pyogenic.

Other common pathogens are : Gonococcus, Chlamydia trachomatis, Trichamonas

bacterial vaginosis, Mycoplasma and HPV, the first one being less common nowadays. The
organisms gain entry into the glands of the endocervix and produce acute inflammatory
changes. The infection may be localised or spread upwards to involve the tube or sidewards
involving the parametrium.

Clinical Features: The vaginal examination is painful. The cervix is tender on touch or
movements. Cervix looks edematous and congested. Mucopurulent discharge is seen
escaping out through the external os.

Prognosis:

(a)It may resolve completely.

(b)The infection may spread to involve the adjacent structures or even beyond that.

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(c) Becomes chronic. Treatment: High vaginal and endocervical swabs are taken for
bacteriological identification and drug sensitivity test. Appropriate antibiotics should be
prescribed. General measures are to be taken as outlined in acute pelvic infection

CHRONIC CERVICITIS

Chronic cervicitis is the commonest lesion found in women attending gynecologic outpatient.
It may follow an acute attack or usually chronic from the beginning. The endocervix is a
potential reservior for N. gonorrhoeae, Chlamydia, HPV, mycoplasma and bacterial
vaginosis.

Pathology:

The mucosa and the deeper tissues are congested, fibrosed, and infiltrated with leukocytes
and plasma cells. The glands are also hypertrophied with increased secretory activity. Some
of the gland mouths are closed by fibrosis or plugs of desquamated epithelial cells to cause
retention cyst— nabothian follicles (Fig. 18.4). Thus, in fact, it should be called chronic
endocervicitis as the ectocervix is protected by the overlying stratified squamous epithelium.
There is associated lacerated and everted endocervix, the so-called eversion or ectropion.

Clinical Features:

There may not be any symptom as it may be accidentally discovered during examination.
Excessive mucoid discharge, at times mucopurulent, is the predominant symptom. History of
contact bleeding may be present.

Treatment

Cervical scrape cytology to exclude malignancy is mandatory prior to any therapy.

(i) There is no place of antimicrobial therapy except in gonococcal or proved cases of

chlamydial infection or bacterial vaginosis.
(ii) The diseased tissue may be destroyed by electro or diathermy cauterization or
laser or cryosurgery. The ectropion is corrected by deep linear burns and the
coincidental ectopy may be coagulated
ENDOMETRITIS

During childbearing period, infection hardly occurs in the endometrium except in septic
abortion or puerperal sepsis and acute gonococcal infection. Endometrium is protected from

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infection due to vaginal and cervical defence and also due to periodic shedding of
endometrium.

Acute Endometritis

It almost always occurs after abortion or childbirth. The details of such infection has been
dealt on page 133. For details see author’s Textbook of Obstetrics Chapter 29. Treatment of
acute endometritis is similar to acute salpingitis for 14 days.

Chronic Endometritis

It is indeed rare for chronic endometritis to occur during reproductive period even following
acute PID and endometritis. This is because of cyclic shedding of endometrium.

Treatment:

The offending cause is to be removed or eradicated. Levofloxacin 500 mg PO daily for 14

days with Metronidazole 400 mg PO twice daily for 14 days are given.

ATROPHIC ENDOMETRITIS (Senile endometritis)

Following menopause, due to deficiency of estrogen, the defense of the uterocervicovaginal

canal is lost. There is no periodic shedding of the endometrium. As a result, organisms of low
virulence can ascend up to infect the atrophic endometrium. There is intense infiltration of
the endometrium with polymorphonuclear leukocytes and plasma cells. The endometrium
becomes ulcerated at places and is replaced by granulation tissues. The purulent discharge
either escapes out of the uterine cavity or may be pent up inside producing pyometra.

Clinical Features: The postmenopausal women complain of vaginal discharge, at times

offensive or even blood-stained. Pelvic examination reveals features of atrophic vaginitis.
Purulent discharge may be seen escaping out through the cervix. In presence of pyometra, the
uterus is enlarged; feels soft and tender.

Diagnosis

The diagnosis is confused with carcinoma of the endometrium which must be excluded prior
to treatment.In fact, pyometra may be present both in atrophic endometritis and endometrial
carcinoma. Ultrasonography (TVS) is helpful to the diagnosis. Diagnostic curettage should be
done and the endometrium is subjected to histological examination. If however, pyometra is

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present, drainage of pus by simple dilatation should be done first. After 1–2 weeks,
diagnostic curettage is to be done under cover of antibiotics.

Treatment: In women with recurrent attacks, hysterectomy should be done and the specimen
should be subjected to histological examination.

SALPINGITIS

Infection of the fallopian tube is called salpingitis.

The details of salpingitis has already been described in the chapter of pelvic infection. The
pathogenesis of salpingitis (acute and chronic) will be described in this section. The
following facts are to be borne in mind while dealing with salpingitis.

o The infection is usually polymicrobial in nature.

o Both the tubes are usually affected.
o Ovaries are usually involved in the inflammatory process and as such, the
terminology of salpingooophoritis is preferred.
o Tubal infection almost always affects adversely the future reproductive function
Etiology

I. Ascending infection from the uterus, cervix and vagina

Pyogenic organisms.
Sexually transmitted infections
II. Direct spread from the adjacent infection One or both the tubes are affected in
appendicitis, diverticulitis, or following pelvic peritonitis. The organisms are
usually E. coli or Streptococcus fecalis. Bacteroides fragilis is too often involved
whenever abscess is formed.
III. Tubercular
Complications of acute salpingitis:

(i) Pelvic or generalized peritonitis

(ii) Pelvis cellulitis
(iii) Pelvic thrombophlebitis
(iv) Pelvic abscess
(v) Tubo-ovarian abscess.

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CHRONIC SALPINGITIS

Pathology

o Hydrosalpinx.
o Pyosalpinx.
o Chronic interstitial salpingitis.
o Salpingitis isthmica nodosa.
Hydrosalpinx

Collection of mucus secretion into the fallopian tube is called hydrosalpinx.

Treatment of acute Salpingitis/ Peritonitis

Outpatient therapy:

Ofloxacin 400 mg PO twice daily for 14 days plus metronidazole 500 mg PO twice daily for
14 days (see Table 10.4) are given. Patient is admitted for inpatient therapy if there is no
response by 72 hours.

Inpatient therapy

(Temp >39°C, toxic look, lower abdominal guarding, and rebound tenderness). Clindamycin
900 mg IV 8 hourly, plus gentamicin 2 mg/kg IV, then 1.5 mg/kg IV every 8 hours are given.
This is followed by doxycycline 100 mg twice daily orally for 14 days. IV fluids to correct
dehydration and nasogastric suction in the presence of abdominal distension or ileus are
maintained. Laparotomy is done if there is clinical suggestion of abscess rupture.

OOPHORITIS

Isolated infection to the ovaries is a rarity. The ovaries are almost always affected during
salpingitis and as such the nomenclature of salpingo-oophoritis is preferred. The affection of
the ovary from tubal infection occurs by the following routes:

o Directly from the exudates contaminating the ovarian surface producing

perioophoritis.
o Through lymphatics of the mesosalpinx and mesovarium producing interstitial
oophoritis.
o Blood borne—mumps.

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 o Through the rent of the ovulation producing interstitial oophoritis.

If the organisms are severe, an abscess is formed and a tubo-ovarian abscess results. In
others, the ovaries may be adherent to the tubes, intestine, omentum, and pelvic peritoneum
producing tuboovarian mass (TO mass). Such a mass is usually bilateral.

Treatment

Acute: The outline of management protocol is the same like that of acute salpingitis of
pyogenic origin. Only when an abscess is pointing and easily accessible that it should be
drained surgically.

Chronic: The treatment is the same as for chronic salpingo-oophoritis. Deep pelvic short
wave diathermy may be tried to relieve pain and dyspareunia. Too often, all the measures fail,
hysterectomy decision may have to be considered even at an early age specially in women
whose family is completed.

REFERENCES

1. M. Fraser, A.Cooper “MYLES text book for Midwives” 15th edition, publisher
ELSEVIER,pp-681-685
2. Mudaliar and Menon’s “Clinical Gynecology ” 11th edition, published by Universities
Press private,limited.pp-672-674.
3. Harilal, “Gynecological textbook”,4 the edition, jaypee published by Univesity
Press,pp- 161-175.
4. J.Annamma, A Comprehensive textbook of midwifery and Gynecological
Nursing,Jaypee brothers 3rd edition.534-536
5. https://www.researchgate.net/publication/349106238_Genital_tract_infections

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