(replacement of the normal vaginal flora by an overgrowth of anaerobic microorganisms, mycoplasmas, and Gardnerella vaginalis), . (vaginalis) (usually caused by Candida albicans).
The established benefits of therapy for BV in nonpregnant women are to 1) relieve vaginal symptoms and signs of infection and 2) reduce the risk for infectious complications after abortion or hysterectomy. Other potential benefits might include a reduction in risk for other infections (e.g., HIV and other STDs). All women who have symptomatic disease require treatment.
Lower genital tract infection
LOWER GENITAL TRACT
DR MOTIUR RAHMAN
Dept of OBG & GYNAE
ESI-PGIMSR & ESIC MEDICAL
COLLEGE , JOKA
Lower genital tract infections means
infections of VULVA , VAGINA ,&
Symptoms caused by lower genital tract
infections are among the most common
presenting complaints of gynecological
Ecosystem in vagina
pH in vagina: 3.5-4.0
Vaginal flora: lactobacilli ;acidogenic
Vaginitis is usually characterized by pruritus,
vaginal discharge and/or vulvar itching and
irritation, vaginal odor & dyspareunia might be
present. The three diseases most frequently
associated with vaginitis are :
Bacterial Vaginosis (BV) is the name of a
condition in women where the normal
balance of bacteria in the vagina is
disrupted and replaced by an overgrowth
of certain bacteria. It is sometimes
accompanied by discharge, odor, pain,
itching, or burning.
BV is a polymicrobial clinical syndrome
resulting from replacement of the
normal H2O2–producing Lactobacillus
sp. in the vagina with high
concentrations of anaerobic bacteria
(e.g., Prevotella sp. and Mobiluncus
sp.), G. vaginalis, and Mycoplasma
homogeneous, thin, white discharge
BV can be diagnosed by the use of clinical criteria or Gram
stain. Clinical criteria require three of the following symptoms or signs(Amsel
homogeneous, thin, white discharge that smoothly coats
the vaginal walls;
presence of clue cells (epithelial cells with borders obscured by small
bacteria) on microscopic examination;
pH of vaginal fluid >4.5; and
a fishy odor of vaginal discharge before or after addition
of 10% KOH (i.e., the whiff test).
When a Gram stain is used, determining the relative
concentration of lactobacilli (long Gram-positive rods), Gram
negative and Gram-variable rods and cocci (i.e., G.
vaginalis,Prevotella, Porphyromonas, and peptostreptococci),
and curved Gram-negative rods (Mobiluncus)
Culture of G. vaginalis is not recommended as a diagnostic tool
because it is not specific.
Obtaining a sample of the discharge The whiff test
All women who have symptomatic disease require treatment.
Recommended Regimens for nonpregnant woman
Metronidazole 500 mg orally twice a day for 7 days
Metronidazole gel, 0.75%, one full applicator (5 g)
intravaginally, once a day for 5 days
Clindamycin cream, 2%, one full applicator (5 g)
Intravaginally at bedtime for 7 days
Management of Sex Partners
The results of clinical trials indicate that a woman’s response to
therapy and the likelihood of relapse or recurrence are not
affected by treatment of her sex partner(s). Therefore, routine
treatment of sex partners is not recommended.
Trichomoniasis is caused by the
protozoan T. vaginalis.
Many infected women have symptoms
characterized by a diffuse,
malodorous, yellow-green vaginal
discharge with vulvar irritation.
However, some women have minimal
or no symptoms.
Note the "Frothy" Discharge
seen around the cervix.
SIGNS AND SYMPTOMS
About 50% of women infected with trichomoniasis do not
have symptoms. The severity of discomfort varies greatly from
woman to woman and from time to time in the same woman.
Symptoms can be worse during pregnancy or right before or
after a menstrual period.
Principle symptom-persistent vaginal discharge (profuse,
extremely frothy, greenish, foul smelling)
Vaginal itching, irritation, and pain.
Patchy redness of the genitals, including labia and vagina.
Frequent, painful dysuria, if urine touches inflamed tissue.
Generalized vaginal erythema with multiple small petechiae
Diagnosis of vaginal trichomoniasis is usually performed
by microscopy of vaginal secretions, but this method has a
sensitivity of only approximately 60%–70% and requires
immediate evaluation of wet preparation slide for optimal
Culture is the most sensitive and specific commercially available
method of diagnosis. In women in whom trichomoniasis is
suspected but not confirmed by microscopy, vaginal secretions
should be cultured for T. vaginalis.
DNA probe test, which detects genetic material (DNA) of the
Trichomonas organism. This test is rarely needed to identify
trich and is usually available only in research studies.
Metronidazole 2 g orally in a single dose
Tinidazole 2 g orally in a single dose
Metronidazole 500 mg orally twice a day for 7 days
Management of Sex Partners
Sex partners of patients with T. vaginalis should be treated.
Patients should be instructed to avoid sex until they and their
sex partners are cured.
VVC usually is caused by C. albicans but occasionally is
caused by other Candida sp. or yeasts.
An estimated 75% of women will have at least one
episode of VVC, and 40%–45% will have two or more
Typical symptoms of VVC include:
None of these symptoms is specific for VVC.
Abnormal vaginal discharge:
White, "curd-like“, cheesy vaginal
Sporadic or infrequent VVC
Likely to be Candida albicans
Women with uncontrolled diabetes, debilitation, or are
immunosuppression, or those who are pregnant.
Diagnostic Considerations in Uncomplicated VVC
1 Clinical features
external dysuria and vulvar pruritus, pain,swelling, and redness. Signs include
vulvar edema, fissures,excoriations, or thick curdy vaginal discharge.
2 Demonstration of candidal mycelia
either 1) a wet preparation (saline, 10% KOH) or Gram stain of vaginal
discharge demonstrates yeasts or pseudohyphae or 2) a culture or other test
yields a positive result for a yeast species.
3 Normal vaginal pH<4.5
Treatment for Uncomplicated VVC
Short-course topical formulations (i.e., single dose and
regimensof 1–3 days) effectively treat uncomplicated VVC.
The topically applied azole drugs are more effective than
nystatin. Treatment with azoles results in relief of symptoms and
negative cultures in 80%–90% of patients who complete
Recommended Regimens for Uncomplicated VVC
Butoconazole 2% cream 5 g intravaginally for 3 days*
Clotrimazole 1% cream 5 g intravaginally for 7–14 days*
Clotrimazole 100 mg vaginal tablet for 7 days
Miconazole 2% cream 5 g intravaginally for 7 days*
Fluconazole 150 mg oral tablet, one tablet in single dose
Caused by Human Papilloma virus(HPV)
, mainly type 6 & 11 .
Also called condyloma acuminata.
Peak incidence among 15 -25 yrs , soon
after onset of sexual activity.
Soft , sessile, and or verrucous lesions.
Usually multifocal & asymptomatic ,
although itching , burning , bleeding &
pain can occur.
Usually diagnosed clinically.
Treatment modalities : application of
cytotoxic or keratolytic agents , surgical
excision ,cytodestructive techniques &
Caused by POX virus infection
Spread by skin contact ,
Appearance of dome shaped papules
with central umbilication , 2-5 mm
Usually asymptomatic but may be
pruritic & become inflammed & swollen .
It usually self limited.
Caused by ectoparasite Phthirus pubis
Intense pruritus in the affected area ,
sometimes associated with
Diagnosis is made by gross visualization
of lice , larvae in pubic hair or
microscopic identification of crablike lice
Caused by Sarcoptes scabiei var
Transmitted by close contact
Insidious onset of severe intermittent
Characteristic lesion is burrow , 1-10 mm
curving tract that serves to house the
Diagnosed clinically & appearance of
HSV – 1
Mostly oro-labial, but increasing cause of
HSV – 2
Almost entirely genital
> 95% of recurrent genital lesions
Intimate sexual contact (oral/genital)
Aerosol and fomite transmission is rare
Maternal-infant via infected cervico-vaginal
secretions, blood or amniotic fluid at birth
From one site to another
Local – clusters of small, painful blisters
that ulcerate and crust outside of
Itching, dysuria, vaginal discharge, inguinal
adenopathy, bleeding from cervicitis
Reactivation of virus
Localized, lasting 6-7 days
Shedding: 4-5 days
Prodrome: 1-2 days
Viral isolation (culture)
High specificity, low sensitivity
50% for primary infxn
20% for recurrent infxn
Direct detection of virus (Tzcank smears,
Newer tests that are specific for type of
virus (HerpesSelect 2, herpes glycoprotein
for IgG, ELISA)
Caused by T. pallidum
Transmitted through contact with
chancre , condyloma lata or mucosal
Primary , secondary , tertiary syphilis
stages occur over years to decades ,
with periods of inactive or latent disease.
Primary syphilis presents as hard ,
painless , solitary chancre.
Non tender inguinal lymphadenopathy
Secondary syphilis may be present as
Diagnosed by : dark-field microscopy ,
VDRL or RPR , FTA-ABS
Caused by Hemophilus ducreyi
Lesion starts as multiple vesicopustules
over vulva , vagina & cervix . then
sloughs to form shallow ulcers.
Lesion painful , tender with foul purulent
& hemorrhagic discharge may be
Caused by Chlamydia trachomatis ( L
Painless papule, pustule or ulcer in vulva
Classical clinical sign : “groove sign” – a
depression between the groups of
Caused by Calymmatobacterium
Hypertrophic ulcer , margins are rolled &
Presence of “Donovan body”
Two types of cells line of cervix: flat, skin-like
cells (squamous cells) and glandular cells that
The same organisms responsible for vaginitis,
can cause cervicitis.
Cervicitis is an inflammation of the cervix
Most cases of cervicitis are caused by infection
with sexually transmitted diseases, including
gonorrhea and chlamydia
Two major diagnostic signs characterize acute cervicitis:
1) a purulent or mucopurulent endocervical exudate visible in the
endocervical canal or on an endocervical swab specimen and
2) sustained endocervical bleeding easily induced by gentle
passage of a cotton swab through the cervical os.
Either or both signs might be present.
Some patients is asymptomatic, but some women complain of
an abnormal vaginal discharge and intermenstrual vaginal
Causative agent : C. trachomatis
75% cases asymptomatic
Commonly present with abnormal
vaginal discharge, burning with urination,
spotting, postcoital bleeding.
Diagnosed by NAAT(nucleic acid
Causative agent : N. gonorrhoeae
Most common infected site endocervix
Present with vaginal discharge, dysuria,
abnormal uterine bleeding
Diagnosed by culture & NAAT
Bartholin’s duct cyst and
Causes: obstruction of main duct of
Bartholin’s gland result in retention of
secretion and cystic dilatation.
Cause of obstruction: infection ,
inspissated mucous, congenital
narrowing of duct
Sign and symptoms:
Some of them have no symptoms, once
the abscess formed, patient will feel
pain, tenderness, and dyspareunia.
Surrounding tissues become edematous
and inflamed, fluctuant, tender mass is
Drainage of infected cyst or abscess;
Excision of the cyst may be required in