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Lower genital tract infection

By Int. Sarisa Supawimon

Lower genital tract infection
‡ Vaginal Infections ‡ Cervicitis ‡ Genital Ulcer Disease

The Normal Vagina
‡ Vaginal secretions
± Sebaceous, sweat, Bartholin ± Skene glands ± Exfoliated vaginal and cervical cells ± Cervical mucus ± Endometrial and oviductal fluid ± Micro-organisms & their metabolic products

The Normal Vagina
‡ Normal vaginal secretions
± Floccular in consistency ± White in color ± Usually located in the dependent portion of the vagina (posterior fornix)

‡ Normal flora is mostly aerobic ‡ The most common : hydrogen peroxide± producing lactobacilli ‡ pH is lower than 4.5 which is maintained by the production of lactic acid

Vaginal Infections
‡ Bacterial Vaginosis ‡ Trichomonas Vaginitis ‡ Vulvovaginal Candidiasis

is 100-1.000 times higher than in normal women .Bacterial Vaginosis ‡ Nonspecific vaginitis ‡ Gardnella vaginitis ‡ Most common form of vaginitis in the United States ‡ Alteration of normal vaginal bacterial flora (hydrogen peroxide±producing lactobacilli overgrowth anaerobic bacteria) ‡ mechanism by which change takes place is unclear ‡ Concentration of anaerobes.

Bacterial Vaginosis .

Adverse sequelae ‡ ‡ ‡ ‡ ‡ Increased risk for pelvic inflammatory disease Postabortal PID Postoperative cuff infections after hysterectomy Abnormal cervical cytology Pregnant women with BV are at risk for ± ± ± ± Premature rupture of the membranes Preterm labor and delivery Chorioamnionitis Postcesarean endometritis .

.7) ‡ Microscopy : increased number of clue cells and leukocytes are conspicuously absent.5 (usually 4.Diagnosis ‡ Fishy odor (particularly noticeable following coitus) ‡ Vaginal discharge ± Gray ± Thinly coat the vaginal walls ‡ pH of these secretions is higher than 4.7-5. ‡ The addition of KOH to the vaginal secretions (the ³whiff´ test) fishy. aminelike odor.

Clue Cells .

75%.) ‡ Metronidazole gel.Treatment ‡ Metronidazole ± 500 mg 1x2 for 7 days (Patients should be advised to avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter. (5 g) intravaginally once or twice daily for 5 days . ± 0.

one applicator full (5g) intravaginally at bedtime for 7 days ± Clindamycin bioadhesive cream. 300 mg. intravaginally once at bedtime for 3 days ± Clindamycin cream : 2%.Treatment ‡ Clindamycin in the following regimens : ± Clindamycin. 100 mg. 100 mg intravaginally in a single dose ‡ Treatment of the male sexual partner has not been shown to improve therapeutic response (not recommended) . 2%. 1x2 for 7 days ± Clindamycin ovules.

Trichomonas vaginalis ‡ Transmission rate is high : 70% ‡ It often accompanies BV : 60% ‡ Symptoms and signs may be much milder in patients with a small inocula of trichomonads ‡ Trichomonas vaginitis often is asymptomatic .Trichomonas Vaginitis ‡ Caused by the sexually transmitted. flagellated parasite.

0 ‡ Microscopy : motile trichomonads and increased numbers of leukocytes. a patchy vaginal erythema and colpitis macularis (³strawberry´ cervix) may be observed. malodorous vaginal discharge that may be accompanied by vulvar pruritus. ‡ pH of the vaginal secretions is usually higher than 5. ‡ The whiff test may be positive. purulent. ‡ Clue cells may be present because of the common association with BV. . ‡ In patients with high concentrations of organisms.Diagnosis ‡ Profuse.

strawberry cervix Trichomonas vaginalis .

. ± metronidazole 2 g once daily for 5 days ± tinidazole. 2 g. in a single dose for 5 days. ‡ The sexual partner should also be treated. ‡ If repeated treatment is not effective.Treatment ‡ Metronidazole is the drug of choice ± a single-dose (2 g orally) ± a multidose (500 mg 1x2 for 7 days) ‡ Women who do not respond to initial therapy should be treated again with metronidazole. 500 mg 1x2 for 7 days.

Vulvovaginal Candidiasis ‡ 75 % of women experience at least one episode of vulvovaginal candidiasis ‡ Candida albicans is responsible for 85% to 90% of vaginal yeast infections. ‡ Patients with symptomatic disease usually have an increased concentration of Micro-organisms (>104/mL) compared with asymptomatic patients (<103/mL) ‡ Rare before menarche. unless taking estrogen . but 50% will have it by age 25 ‡ Less common in postmenopausal women.

sponge) .Predispose factors ‡ ‡ ‡ ‡ ‡ ‡ Antibiotic use Pregnancy Diabetes Immunocompromised host OCPs Contraceptive devices (IUD.

dyspareunia. vulvar burning. Vaginal soreness. irritation External dysuria (³splash´ dysuria) may occur when micturition leads to exposure of the inflamed vulvar and vestibular epithelium to urine. The cervix appears normal. . The vagina erythematous with an adherent. ‡ PV : Erythema and edema of the labia and vulvar skin. whitish discharge.Diagnosis ‡ Symptoms ± ± ± ± ± ± ± vulvar pruritus vaginal discharge (typically resembles cottage cheese).

. either budding yeast forms or mycelia.Diagnosis ‡ pH is usually normal < 4.5 ‡ Fungal elements. appear in as many as 80% of cases. ‡ A presumptive diagnosis can be made in the absence of fungal elements confirmed if the pH and the saline preparation evaluations are normal and the patient has increased erythema based on examination of the vagina or vulva.

Vulvovaginal Candidiasis .

Classification of Vulvovaginal Candidiasis .

‡ oral antifungal agent : fluconazole. ‡ Patients should be advised that their symptoms will persist for 2-3 days so they will not expect additional treatment. .Treatment ‡ Topically applied azole drugs ± Relief of symptoms and negative cultures in 80%90% ± Symptoms resolve in 2-3days. has been approved for the treatment of VVC. used in a single 150 mg dose.

‡ Adjunctive treatment with a weak topical steroid. ‡ Patients with complications also can be treated with a more prolonged topical regimen lasting 10 to 14 days. may be helpful in relieving some of the external irritative symptoms.Complicated Vulvovaginal Candidiasis ‡ Women with complicated VVC benefit from an additional 150 mg dose of fluconazole given 72 hours after the first dose. . such as 1% hydrocortisone cream.

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. ‡ 90% of women with RVVC will remain in remission.Recurrent Vulvovaginal Candidiasis ‡ fluconazole :150 mg every 3 days for 3 doses ‡ Maintained fluconazole 150 mg weekly for 6 months.

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‡ Ectocervical epithelium can become inflamed by the same micro-organisms that are responsible for vaginitis. candida.Cervicitis ‡ Cervix : two different types of epithelial cells: squamous epithelium & glandular epithelium. N. trachomatis infect only the glandular epithelium . gonorrhoeae and C. ‡ Trichomonas. and HSV can cause inflammation of the ectocervix. ‡ Conversely.

generally yellow or green in color and referred to as ³mucopus´ ‡ Intracellular gram-negative diplococci. the presumptive diagnosis is chlamydial cervicitis. leading to the presumptive diagnosis of gonococcal endocervicitis.Diagnosis ‡ Based on the finding of a purulent endocervical discharge. . ‡ If the Gram stain results are negative for gonococci.

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Treatment all sexual partners be treated with a similar antibiotic regimen .

) .Genital Ulcer Disease ‡ Most common : genital HSV or syphilis ‡ Chancroid is the next most common ‡ Followed by the rare occurrence of lymphogranuloma venereum (LGV) and granuloma inguinale (donovanosis). (These diseases are associated with an increased risk for HIV infection.

± culture for Haemophilus ducreyi ‡ Even after complete testing. the diagnosis remains unconfirmed in one fourth of patients with genital ulcers.Evaluation ‡ Evaluation of a patient with a genital ulcer should include ± darkfield examination or direct immunofluorescence testing for Treponema pallidum ± culture or antigen testing for HSV. .

‡ Therefore.Diagnosis ‡ A diagnosis based on history and physical examination alone often is inaccurate. all women with genital ulcers should undergo a serologic test for syphilis .

‡ confirmatory treponemal test²fluorescent treponemal antibody absorption (FTA ABS) ‡ microhemagglutinin²T. ‡ venereal disease research laboratory (VDRL) test. is likely to be syphilis. especially if the ulcer is indurated. .Syphilis ‡ A painless and minimally tender ulcer. ‡ Lab to diagnose syphilis ‡ nontreponemal rapid plasma reagin (RPR) test. pallidum (MHA TP).

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Treatment ‡ penicillin G is the preferred treatment of all stages of syphilis. ± The Jarisch-Herxheimer reaction²an acute febrile response accompanied by headache. . myalgia.4 million units intramuscularly in a single dose. patients should be advised of this possible adverse reaction. secondary. or early latent syphilis. ± Benzathine penicillin G. and other symptoms²may occur within the first 24 hours after any therapy for syphilis. 2. is the recommended treatment for adults with primary.

g.Treatment ‡ Latent syphilis is defined as those periods after infection with T. ‡ Patients with latent syphilis of longer than 1 year's duration or of unknown duration should be treated with intramuscularly each. ‡ Quantitative nontreponemal serologic tests should be repeated at 6 months and again at 12 months. ‡ All patients with latent syphilis should be evaluated clinically for evidence of tertiary disease (e. and iritis). aortitis. gumma. pallidum when patients are seroreactive but show no other evidence of disease. at 1 week intervals. .. neurosyphilis.

± Culture is the most sensitive and specific test. ‡ Nevertheless. laboratory confirmation of the findings is recommended. .Genital herpes ‡ Grouped vesicles mixed with small ulcers. ‡ Because false-negative results are common with HSV cultures. sensitivity 100% in the vesicle stage ± 89% in the pustular stage ± 33% in patients with ulcers. are almost always pathognomonic of genital herpes. particularly with a history of such lesions. type-specific glycoprotein G-based antibody assays are useful in confirming a clinical diagnosis of genital herpes.

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‡ Daily suppressive therapy ± acyclovir. 250 mg twice daily. or ± valacyclovir.400 mg orally 3 times a day. ‡ Although these agents provide partial control of the symptoms and signs of clinical herpes. 1 orally twice a day for 7-10 days or until clinical resolution is attained. 400 mg orally twice daily or ± famciclovir. . 1 g orally once a day reduces the frequency of HSV recurrences by at least 75% among patients with six or more recurrences of HSV per year.Treatment ‡ Herpes A first episode of genital herpes should be treated with ± acyclovir. or ± famciclovir. or ± valacyclovir. 250mg orally three times a day.

the most likely diagnosis is LGV. .Chancroid ‡ One to three extremely painful ulcers. ‡ The adenopathy is fluctuant. accompanied by tender inguinal lymphadenopathy. ‡ If no ulcer is present. ‡ An inguinal bubo accompanied by one or several ulcers is most likely chancroid.

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erythromycin base. which can be expected to heal within 2 weeks unless it is unusually large. 250 mg intramuscularly in a single dose. ‡ Patients should be reexamined 3-7 days after initiation of therapy to ensure the gradual resolution of the genital ulcer. . 500 mg orally twice a day for 3 days. 500 mg orally 4 times daily for 7 days. ciprofloxacin.Treatment ‡ Chancroid Recommended regimens ± ± ± ± azithromycin 1 g orally in a single dose ceftriaxone.

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granuloma inguinale (donovanosis). lymphogranuloma venereum .

more than 75% of sexual partners develop when exposed. ‡ External genital warts are highly contagious. ‡ Infection may be latent or may cause a wart. . allowing direct contact between the viral particles from an infected man and the basal layer of the epidermis of his susceptible sexual partner.Genital Warts ‡ Human papillomavirus (HPV) infection ‡ Occur in areas most directly affected by coitus : the posterior fourchette and lateral areas on the vulva. ‡ Minor trauma associated with coitus can cause breaks in the vulvar skin.

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‡ Recurrences more often from reactivation of subclinical infection than reinfection by a sex partner. it is not possible to eradicate the viral infection. ‡ Most successful : small warts & present for less than 1 year. .Treatment ‡ The goal of treatment is removal of the warts.

Treatment ‡ Selection of a specific treatment regimen depends on the ± anatomic site ± size ± number of warts ± efficacy ± convenience ± potential adverse effects .