genital infection in gynecology

1. Lower genital tract
infection
Prepared by: Nibal Shawabkeh
Supervised by: Dr. Saada Jaber
1

2. Introduction
 In young females
2
Vagina is lined with simple
cuboidal epithelium
Ph is neutral
Colonized by organism
similar to skin commensals

3.  At puberty under the effect of oestrogen :
3
Stratified squamous epithelium
develops
Lactobacilli become the
predominant organism
Ph 3.5-4.5
After menopause :
Atrophic changes occur
Bacterial flora similar to that of
skin
Ph again rise to 7

4. Physiological discharge
 It is important to differentiate normal physiological changes from true infections .
 Normal vaginal discharge
 Physiological discharge increase due to :
1. Increased mucus production from the cervix in mid cycle under the effect of
progesterone .
2. Pregnancy
3. Combined oral contraceptive pills
4
White , become yellowish on
contact with air
Consist of desquamated epithelial
cells , mucus , bacteria and fluid
Form as transudate from the
vaginal wall

5. Genital
tract
infection
Upper Lower
Bacterial Fungal Viral Parasite
5

6. Vaginitis
 is the most common gynecologic condition encountered in out patient
clinics.
 defined as the spectrum of conditions that cause vulvovaginal symptoms
such as itching, burning, irritation, and abnormal discharge.
 The most common causes :
6
bacterial
vaginosis
(40-45%)
vulvovaginal
candidiasis
(20-25%)
Trichomonias
is (15-20%)

7. 7 Bacterial vaginosis
Most common cause of vaginitis in
premenopausal women
Represents a complex change vaginal flora
•Decrease in lactobacilli
•Increase in gardnerella vaginalis,
mycoplasma hominis, anaerobic G- rods
Exact mechanism by which change takes
place is unclear

8. Clinical Features
50% are
asymptomatic
Unpleasant,
“fishy smelling”
discharge
Itching and
inflammation
are uncommon
More prominent
during and
following
menstruation
Creamy or
greyish – white
vaginal
discharge
8

9. Amsel Criteria
Homogenous, grayish-whitish discharge
Vaginal pH > 4.5
Positive Whiff test
Clue cells on wet mount
9
There should be at least 3 criteria for diagnosing BV.
 Clue cells are the most reliable predictor of BV

10. Wet mount
 Sample vaginal discharge from the posterior fornix
 pH
 Microscopy
 Leukocytes, lactobacilli, clue cells, yeast, or trichomonads
 Whiff test – 10% KOH
 Characteristic fishy (amine) odor of BV
10

11. 11 Clue Cells
Are epithelial cells which
are covered with bacteria
giving a characteristic
stippled appearance on
examination

12. Hay/ ison criteria
 The modified Ison‐Hay scoring system suggests five grades of flora
12
Grade 0
• epithelial cells with no bacteria
Grade 1
• normal vaginal flora (lactobacillus morphotypes alone)
Grade II
• reduced numbers of lactobacillus morphotypes with a
mixed bacterial flora
Grade III
• mixed bacterial flora only, few or absent lactobacillus
morphotypes
Grade IV,
• Gram positive cocci only.

13. Nugent criteria
 Based on the proportion of anaerobic species
 0–3 is considered negative for BV
 4–6 is considered intermediate
 7+ is considered indicative of BV.
13

14. Therapy
 May resolve spontaneously
 Metronidazole
 Oral divided doses achieve early clinical cure in excess of 90%, cure rates of
approx 80% at four weeks
 400mg PO twice a day for 5 days
 metro-gel applied at night for between 5-7days .
 Single dose therapy (2gm) achieves same early clinical cure, but known to have
a higher relapse rate
14

15.  Clindamycin : 300 mg twice daily for 7 days or topical vaginal cream
 Pseudomembranous colitis
 Vaginal cream weakens condoms
 ? Preferred choice in pregnancy
15

16. Pregnancy & BV
 Presence of BV in the 1st trimester can lead to late second trimester
miscarriages and preterm labour
 Women with a previous history of 2nd trimester loss of preterm delivery ,
should examined for BV and if it +ve , they should be treated .
 Metronidazole is safe in pregnancy
 Avoid large doses .
16

17. Vulvovaginal candidacies
 About 1/3 of vaginitis cases
 Up to 75% of premenopausal women have at least one episode
 Rare before menarche, but 50% will have it by age 25
 Less common in postmenopausal women, unless taking estrogen
17

18. Candida albicans
 Causes the majority of yeast infections (80-92%)
 is a yeast commonly found in the vagina, mouth and on skin
 it is an opportunistic pathogen and can cause yeast infections and thrush
when there is a change in the body's normal flora (antibiotics, for example).
18

19. 19 Predisposing factors

20. Other non-albican species
 C. Tropicalis
 C.glabrata
 C. Krusei
 C.parapsilosis
20

21. Sign and symptoms
Vulvar/vaginal
pruritis
“Burning”
when they void
(externally)
Irritation,
soreness,
dyspareunia
White, clumpy
discharge
Normal vaginal
ph
Vulvar
oedema
21

22. Wet Mount in Vulvovaginal candidacies
 pH 4- 4.5 (normal)
 Yeast buds or spores or hyphae
 KOH prep destroys cellular elements to facilitate recognition of budding
yeasts or hyphae (sensitivity 70%)
 Negative in up to 50% of culture proven candidal infections
22

23. Treatment
 Most uncomplicated infections improve with therapy within 2 days
 Severe infections may require up to 14 days to improve
 Most tx achieve clinical cure rates in excess of 80%
 No one therapy or route of administration better than any other
23

24. Uncomplicated infection
 Oral imidazoles such as
 fluconazole , single dose 150 mg .
 Itraconazole 200 mg twice a day for one day .
Contraindicated in pregnancy
 Local topical application
 Clotrimazole
Single dose 500 mg
Or course of a 100 mg pessary over 6 days
24

25. Complicated
Topical treatment extend up to 2 weeks
Recurrent
 At least 4 episodes of infection per year / or positive microscopy of
moderate to heavy growth of candida albicans .
1. Induction regimen ( fluconazole 150 mg given in 3 doses oraly
every 72 hours )
2. Maintenance dose ( 150 mg weekly for 6 months ) .
 In pregnancy
Topical imidazole can be used for 2 weeks for induction followed by a
weekly dose of clotrimazole 500 mg for 6-8 weeks
25

26. Trichomonas vaginalis
 Affects 2 – 3 million American
women annually
 3rd most common vaginitis
 Flagellated protozoan
 Infects vagina, urethra and
paraurethral glands
 Virtually always sexually
transmitted
26

27. Clinical Features
Ranges from
asymptomatic infxn
to severe, acute
inflammatory
disease
Purulent,
malodorous, thin,
frothy discharge
Dysuria (external),
dyspareunia and
pruritis are common
“strawberry cervix”
Itching & vulval
sorness
27

28. Wet Mount
 Trichomonads seen only in 50 – 70%
 Elevated pH
 Can increase leukocytes
28

29. Treatment
 Treat both partners
 Both should screened for other sexually transmitted infections
 Metronidazole 2gm x 1 or 500mg bid x 7 days
 Avoid topical therapy
 Treat sexual partners simultaneously
 If refractory to treatment
 Retreat with 7 day course
 If fails again, try 2gm dose daily x 3 – 5 days
 Assure compliance with partner/culture
29

30. 30 Gonorrhea
Etiologic agent: Neisseria
gonorrhoeae
Gram-negative intracellular
diplococcus
Infects mucus-secreting
epithelial cells

31. Risk Factors
Multiple or new
sex partners or
inconsistent
condom use
Urban residence
in areas with
disease
prevalence
Adolescents,
females
particularly
Lower socio-economic
status
Use of drugs
31

32. Transmission
Male to female via semen
Female to male urethra
Rectal intercourse
Oral sex (pharyngeal infection)
Perinatal transmission (mother to infant)
32

33. Infection in women
 Most infections are asymptomatic
 Cervicitis – inflammation of the cervix
 Urethritis – inflammation of the urethra
33

34. Clinical features
Non-specific symptoms:
abnormal vaginal
discharge, intermenstrual
bleeding, dysuria, lower
abdominal pain, or
dyspareunia
Clinical findings:
mucopurulent or purulent
cervical discharge, easily
induced cervical
bleeding
50% of women with
clinical cervicitis have no
symptoms
Incubation period
unclear, but symptoms
may occur within 10 days
of infection
34

35. Diagnostic Methods
 Culture tests
 NAATs ( nucleic acid
amplification test )
 Nucleic acid
hybridization tests
35

36. 36 Treatment
Treatment for Uncomplicated Infections of the Cervix,
Urethra, and Rectum
Contraindicated in pregnancy and children. Not recommended for infections acquired in
California, Asia, or the Pacific, including Hawaii.

37. Special Considerations:
Pregnancy
 Pregnant women should NOT be treated with quinolones or tetracyclines
 Treat with alternate cephalosporin
 If cephalosporin is not tolerated, treat with spectinomycin 2 g IM once
37

38. Follow-Up
 A test of cure is not recommended if a recommended regimen is
administered.
 If symptoms persist, perform culture for N. gonorrhoeae.
 Any gonococci isolated should be tested for antimicrobial susceptibility.
38

39. syphilis
 Sexually acquired infection
 Etiologic agent: Treponema pallidum
 Disease progresses in stages
 May become chronic without treatment
39

40. Transmission
 Sexual and vertical
 Most contagious to sex partners during the primary and secondary stages
40

41. Microbiology
 Etiologic agent:
Treponema pallidum,
subspecies pallidum
 Corkscrew-shaped, motile
microaerophilic
bacterium
 Cannot be cultured in
vitro
 Cannot be viewed by
normal light microscopy
41

42. Treponema pallidum on darkfield
microscopy
42

43. Pathology
Penetration:
T. pallidum enters the body via skin and mucous
membranes through abrasions during sexual contact
Also transmitted transplacentally
Dissemination:
Travels via the lymphatic system to regional lymph
nodes and then throughout the body via the blood
stream
Invasion of the CNS can occur during any stage of
syphilis
43

44. Primary Syphilis
 Primary lesion or "chancre" develops at the site of
inoculation
 Regional lymphadenopathy: classically rubbery,
painless, bilateral
 Serologic tests for syphilis may not be positive during
early primary syphilis
44

45. chancre
Progresses from macule to papule to ulcer
Typically painless, indurated, and has a clean base
Highly infectious
Heals spontaneously within 1 to 6 weeks
25% present with multiple lesions
45

46. 46

47. Secondary Syphilis
 Secondary lesions occur 3 to 6 weeks after the primary
chancre appears; may persist for weeks to months
 Primary and secondary stages may overlap
 Mucocutaneous lesions most common
 Serologic tests are usually highest in titer during this stage
47

48. Manifestations:
Rash (75%-100%)
Lymphadenopathy
(50%-86%)
Alopecia (5%)
Condylomata lata
(10%-20%)
Mucous patches
(6%-30%)
Malaise
48

49. 49

50. Latent Syphilis
 Host suppresses the infection enough so that no
lesions are clinically apparent
 Only evidence is positive serologic test for syphilis
May occur between primary and secondary stages,
between secondary relapses, and after secondary
stage
Categories:
 Early latent: <1 year duration
 Late latent: 1 year duration
50

51. Tertiary (Late) Syphilis
Approximately 30% of untreated patients
progress to the tertiary stage within 1 to 20 years
Rare because of the widespread availability
and use of antibiotics
Manifestations
Gummatous lesions
Cardiovascular syphilis
51

52. 52

53. Congenital Syphilis
 Occurs when T. pallidum is transmitted from a pregnant woman
with syphilis to her fetus
 May lead to
 Transmission to the fetus in pregnancy can occur during any
stage of syphilis
 Fetal infection can occur during any trimester of pregnancy
53
stillbirth,
neonatal death,
infant disorders such as deafness, neurologic impairment,
and bone deformities

54. 54

55. Neurosyphilis
 Occurs when T. pallidum invades the CNS
 May occur at any stage of syphilis
 Can be asymptomatic
 Early neurosyphilis
 Clinical manifestations include acute syphilitic meningitis,
meningovascular syphilis, ocular involvement
 Late neurosyphilis
 Clinical manifestations include general paresis, tabes dorsalis, ocular
involvement
55

56. Neurosyphilis - Spirochetes in Neural
Tissue
56

57. Aspects of Syphilis Diagnosis
1. Clinical history
2. Physical examination
3. Laboratory diagnosis
57

58. Clinical History
Assess:
 History of syphilis
 Known contact to an early case of syphilis
 Typical signs or symptoms of syphilis in the past 12 months
 Most recent serologic test for syphilis
58

59. Physical Examination
 Oral cavity
 Lymph nodes
 Skin of torso
 Palms and soles
 Genitalia and perianal area
 Neurologic examination
59

60. Laboratory Diagnosis
 Identification of Treponema pallidum in lesions
 Darkfield microscopy
 Direct fluorescent antibody - T. pallidum (DFA-TP)
 Serologic tests
 Nontreponemal tests
 Treponemal tests
60

61. Therapy for Primary, Secondary, and
Early Latent Syphilis
Benzathine penicillin G 2.4 million units IM in a
single dose for 12 days
If penicillin allergic:
Doxycycline 100 mg orally twice daily for 14 days, or
Tetracycline 500 mg orally 4 times daily for 14 days
61

62. Therapy for Late Latent Syphilis or
Latent Syphilis of Unknown Duration
Benzathine penicillin G 7.2 million units total,
administered as 3 doses of 2.4 million units IM
each at 1-week intervals
If penicillin allergic:
Doxycycline 100 mg orally twice daily for 28 days OR
Tetracycline 500 mg orally 4 times daily for 28 days
62

63. End of Lecture
May 2014
63