This document provides an overview of common presentations, infections, and non-infectious causes of gynaecological infections. It discusses vulvovaginal candidiasis, trichomoniasis, bacterial vaginosis, herpes, and other infections. It outlines the history, examination, investigations, treatment, and management of various conditions. Key points include common symptoms of pruritus and discharge, differentiating physiological from pathological discharge, and investigating underlying causes through history, examination, and testing vaginal samples.

1. Dr. Nilar Win
Gynaecological infection
Quick recall for final professional exam

2. Common presentation
Pruritus vulvae
Vaginal discharge
Pelvic inflammatory disease

4. Infections and Infestation Non-infectious causes
• Vulvovaginal candidiasis
• Trichomoniasis
• Bacterial Vaginosis
• Herpes simplex
• Pubic lice (Phthirus pubis)
• Scabies (Sarcoptes scabiei
hominis)
• Thread worm (Enterobius
vermicularis)
Dermatological
Refer to the International Society for the Study of Vulvar Disease (ISSVD
2006 classification) along with hidradenitis suppurativa
Neoplastic conditions
Squamous: VIN (Warty, Basaloid, Mixed)
Non-squamous: Paget’s disease, Tumours of melanocytes
Hormonal
Atrophic vaginitis, breast feeding
Urinary or faecal incontinence
Systemic causes: secondary to renal (chronic renal failure),
Haematologic (Iron deficiency, Polycythaemia rubra vera,
Hypereosinophilic syndrome, essential thrombocythemia,
Myelodysplastic syndrome), Hepatic (Cholestasis), Endocrine
(Hyperthyroidism, Hypothyroidism, Diabetes mellitus,
Hyperparathyroidism, Hypoparathyroidism), Malignancies (Hodgkin’s
disease, Leukaemia, carcinoid syndrome),Immunosuppression leading
to vulvovaginal candidiasis
Psychosexual disorders
Others: regrowth of pubic hair after shaving

5. 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

6. • 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

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

8. • Affects 75% of women in reproductive years with the peak incidence at 20-40 years,
• 90% cases are due to Candida albicans
• 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: Spores & hyphae on direct microscopy. Vaginal swab for C&S. If positive culture, and exclude
diabetes.

9. Budding yeasts and Hyphae

10. Curdy white discharge on vaginal wall

11. • Diagnosis
• Clinical diagnosis
• Gram stain or a wet preparation (saline, 10% KOH) of vaginal discharge hyphae, or
pseudohyphae or budding yeasts. 10% KOH will improve visualization and sensitivity of the test.
• Culture of vaginal discharge will show positive for one of the yeast species. A culture is indicated
if results come back negative for the Gram or wet stain with persistent symptoms.
*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.

12. • 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.

14. • 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.

15. Pubic lice
Genital herpes

17. 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

18. • Normal vaginal discharge
o in reproductive-aged women
o 1 to 4 mL fluid (per 24 hours)
o white or transparent
o thick or thin
o mostly odourless
o formed by mucoid endocervical secretions in combination with sloughing epithelial cells, normal vaginal flora, and vaginal transudate.
o may become more noticeable at times ("physiological leukorrhea"), such as at mid-menstrual cycle close to the time of ovulation or
during pregnancy or use of estrogen-progestin contraceptives.
o Diet, sexual activity, medication, and stress can also affect the volume and character of normal vaginal discharge.
*Although normal discharge may be yellowish, slightly malodorous, and accompanied by mild irritative symptoms, it is not accompanied
by pruritus, pain, burning or significant irritation, erythema, local erosions, or cervical or vaginal friability. The absence of these signs and
symptoms helps to distinguish normal vaginal discharge from discharge related to a pathological process, such as vaginitis or cervicitis.
*The fluctuating levels of oestrogen and progesterone during the menstrual cycle affects the consistency and composition of the
physiological discharge. Oestrogen makes the discharge thin and clear for easy passage of sperm through the cervix at the time of
ovulation. Progesterone makes the discharge thick and sticky after ovulation.
*The vaginal environment maintains its stability by the action of commensal organisms. Lactobacilli colonize the vagina since puberty
under the influence of oestrogen. These are responsible for converting glycogen to lactic acid, maintaining a vaginal pH of around 4.5.
Other commensal organisms are streptococci, enterococci and coagulase negative staphylococci. A few other organisms which are part of
the normal flora, but are associated with vaginal infections, include, anaerobic Bacteroides, anaerobic cocci, Gardenella vaginalis,
Candida, Ureaplasma urealyticum and Mycoplasma species.

20. 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 Trichomonas 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.

21. Dysuria or dyspareunia – These symptoms can be suggestive of inflammatory disorders such as infection
or allergy as well 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
Estrogen status – Low estrogen levels can cause genitourinary syndrome of menopause (ie, vulvovaginal
atrophy) that presents with symptoms of vaginitis. Other symptoms include vaginal dryness and
dyspareunia. In addition to menopausal women, hypoestrogenic women include those who are postpartum,
lactating, or taking antiestrogenic drugs. Some women develop relatively low estrogen levels related to
contraceptive use. Menopausal women receiving systemic hormone therapy may not have adequate estrogen
levels for vaginal health and thus remain prone to atrophic vaginitis.

22. • Sexual practices –Women who are homosexual or bisexual are at increased risk of BV. Women with a new sexual partner
have an increased risk of acquiring sexually transmitted infections such as 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, chemical, or allergic irritation may cause vulvovaginal symptoms (pruritus, burning)
mistakenly attributed to an infectious source. Vaginal symptoms can result from irritants (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) that produce acute and chronic hypersensitivity reactions, including
contact dermatitis. Careful assessment of the woman's personal practices is the best way to detect potential irritants and
allergens in her environment and habits unhealthy for the vulvar skin. Patient symptom/contact diaries may be helpful
• Medical history – Does the patient have a history of an oral mucosal, ocular, cutaneous, or systemic disease that could
affect the vulvovaginal area? Eg- Herpes simplex virus and Behçet syndrome can cause vulvovaginal ulcers. Women with
diabetes are prone to vulvovaginal candidiasis. Women with HIV are prone to vaginal infections. After transplantation, graft
versus host disease can cause vaginal irritation, discharge, ulceration, and stenosis. Stevens-Johnson syndrome and toxic
epidermal necrolysis have potentially severe vulvovaginal sequelae.
• Surgical history –recent transvaginal surgery or repair of perineal lacerations from childbirth. Vaginal symptoms may be
related to a foreign body, bacterial infection, granulation tissue, or vaginal fistula.

23. 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
o Erosive lichen planus, lichen sclerosus or mucous membrane pemphigoid changes in vulvovaginal
architecture (eg, scarring) by a chronic inflammatory process
o Candidiasis, dermatosis pain with application of pressure from a cotton swab ("Q-tip test") on the labia or at
the vaginal introitus caused by an inflammatory process
• *Speculum examination is performed to evaluate the vagina, any vaginal discharge, and the cervix.

24. Q-tip test

25. • Vagina
o A foreign body (Eg, retained tampon or condom)often associated with vaginal discharge, intermittent bleeding or spotting,
and/or an unpleasant odour due to inflammation and secondary infection. Removal of the foreign body is generally adequate
treatment. Antibiotics are rarely indicated.
o Vaginal warts skin-coloured or pink and range from smooth flattened papules to a verrucous, papilliform appearance. When
extensive, they can be associated with vaginal discharge, pruritus, bleeding, burning, tenderness, and pain.
o Granulation tissue or surgical site infection  vaginal discharge or bleeding after hysterectomy or after childbirth.
o Necrotic or inflammatory changes associated with malignancy in the lower or upper genital tract vaginal discharge or spotting
o The presence of multifocal rounded macular erythematous lesions (like a spotted rash or bruise), purulent discharge, and
tenderness suggests erosive vulvovaginitis, which can be caused by trichomoniasis or one of several non-infectious
inflammatory etiologies.
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. At-risk patients include those who are
postpartum, post-hysterectomy, post-surgery for prolapse, or have a history of inflammatory bowel disease or radiation
therapy to the pelvis.

26. • Cervix
o Cervical inflammation with a normal vagina is suggestive of cervicitis rather than vaginitis.
o The cervix in women with cervicitis is usually erythematous and friable, with a mucopurulent discharge.
• *Cervical erythema in cervicitis should be distinguished from ectropion, which represents the normal
physiologic presence of endocervical glandular tissue on the exocervix. Ectropion is more common in
women taking estrogen-progestin contraceptives and during pregnancy. Ectropion may increase the
volume of normal vaginal discharge.
• Bimanual examination
o Women with vaginitis who also have pelvic or cervical motion tenderness are further evaluated for pelvic
inflammatory disease.
o Adnexal masses could represent a cyst or malignancy.
o While bimanual examination can also identify pelvic muscle spasm and tenderness reflecting pelvic muscle
dysfunction, these entities are not usually associated with abnormal vaginal discharge.

27. Investigation
• Vaginal pH
o Measurement of vaginal pH is the single most important finding that drives the diagnostic process and should always be determined.
o A pH test stick (or pH paper if available) is applied for a few seconds to the vaginal sidewall (to avoid contamination by blood, semen, or
cervical mucus, which pool in the posterior fornix and distort results).
o Alternatively, the vaginal sidewall can be swabbed with a dry swab and then the swab rolled onto pH paper (if available). The pH of the
specimen is stable for approximately two to five minutes at room temperature. The swab should not be premoistened, as the moistening
liquid can affect pH.
o An elevated pH in a premenopausal woman suggests infections such as BV (pH > 4.5) or trichomoniasis (pH 5-6), and helps to
exclude Candida vulvovaginitis (pH 4-4.5).
o In postmenopausal women in whom estrogen levels are low, the pH of the normal vaginal secretions is ≥4.7. The higher pH is due to less
glycogen in epithelial cells, reduced colonization of lactobacilli, and reduced lactic acid production.
 *Vaginal pH may be altered (usually to a higher pH) by contamination with lubricating gels, semen, blood,
douches, and intravaginal medications. In pregnant women, leakage of amniotic fluid raises vaginal pH.

28. • Microscopy
• A sample of the patient's vaginal discharge is obtained with a cotton swab, smeared onto a slide, and evaluated
under a microscope with both saline and potassium hydroxide in the steps below. Subsequent treatment is
determined by the findings of the microscopic evaluation.
• Saline wet mount
o Vaginal discharge is generally sampled with a plastic or wood vaginal/cervical scraper or a cotton-tipped swab.
o The sample of vaginal discharge is mixed with 1-2 drops of 0.9 % normal saline solution at room temperature on a glass
slide.
o Cover slips are then placed on the slides, which are examined under a microscope at low and high power.
o Microscopy should be performed within 10-20 minutes of obtaining the sample to reduce the possibility of loss of
motility of any trichomonads.
o Microscopic examination of normal vaginal discharge reveals a predominance of squamous epithelial cells, rare
polymorphonuclear leukocytes (PMNs), and Lactobacillus species morphotype.
o Excess PMNs without evidence of yeast, trichomonads, or clue cells suggest cervicitis or non-infectious or
inflammatory vaginitis.
• Potassium hydroxide wet mount
o The addition of 10 % potassium hydroxide (KOH) to the wet mount of vaginal discharge destroys cellular
elements, thus it is helpful for identifying hyphae and budding yeast for the diagnosis of candidal vaginitis.
o Amine test – Smelling ("whiffing") the slide immediately after applying KOH is useful for detecting the fishy
(amine) odor of BV.

29. • Swab taking
• High vaginal swab (HVS)
o taken from the lateral wall or posterior fornix of the vagina under direct vision.
o should be placed in Amies transport medium with charcoal
o It should only be obtained if there is a clinical need for testing and not as a routine with speculum examination. It should be
obtained when symptoms do not lead to a diagnosis. *Abnormal discharge in pregnancy, postpartum, post-termination and post
instrumentation should always be swabbed. Similarly, if there is recurrence of symptoms or possible treatment failure then a swab
should be obtained.
• Endocervical swab (ECS)
o The STIs Neisseria gonorrhoeae and Chlamydia trachomatis must always be considered in sexually active individuals with
vaginitis since females with STIs may go on to develop pelvic inflammatory disease and its potential complications. One-
quarter of the specimens positive for BV or Candida vulvovaginitis also tested positive for an STI (Neisseria gonorrhoeae,
Chlamydia trachomatis, or Trichomonas vaginalis).
o Any woman with new or multiple sexual partners, a symptomatic sexual partner, or an otherwise unexplained cervical or vaginal
discharge that contains a high number of PMNs should be tested for these organisms by culture or an alternative sensitive test.
o Clean the cervical os with a disposable swab and discard it. Then, insert ECS into the cervical os and rotate firmly.
o The swab should then be placed in Amies transport medium with charcoal.
o It is mainly used in the investigation of Chlamydia and gonorrhoea. The swab is sent for NAAT (nucleic acid amplification
testing). Some labs are now analysing these samples for BV and TV.

30. • Culture
o Candida grows best on Sabouraud agar (95% growth on culture). Its growth can be classified as light, medium or heavy.
o Culture was considered the gold standard for detecting T. Vaginalis before NAAT (nucleic acid amplification testing) took
its place.
o Culture should be undertaken in patients with negative microscopy despite symptoms and those with apparent recurrent
disease.
• NAAT (nucleic acid amplification tests)
o effective in detecting Chlamydia and gonorrhoea and also BV
*Intrauterine contraceptive devices (IUCDs)
 Removal of the IUD should be considered and may be associated with better short-term clinical
outcomes. The decision to remove the IUD needs to be balanced against the risk of pregnancy in those
who have had otherwise unprotected intercourse in the preceding 7 days. Hormonal emergency
contraception may be appropriate for some women in this situation.
 The entire device should be sent to microbiology.
 Infections may be polymicrobial with the isolation of both Gram positive and Gram negative aerobic and anaerobic
organisms. Actinomyces species, particularly Actinomyces israelii, may be significant isolates.
 IUCDs are only cultured where there are clinical indications of PID or other inflammatory conditions.

31. Bacterial vaginosis
• the commonest cause of vaginal discharge in women; during their childbearing period.
• The condition is associated with a 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: Most carriers are asymptomatic carrier (in most cases) or associated with many pathological
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.

32. 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.

33. Clinical criteria
(Amsel)**clinical use
Nuget score (Score 0-10) Hay Ison criteria (Grade 0-4)
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)
*Gran stain : estimate the
concentration
of lactobacilli (Long gram
positive rods) and the
gram negative anaerobes
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.
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.

34. • 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)

35. Trichomonas vaginalis
• The flagellate protozoan; Usually acquired through sexual contact.
• Presentation: asymptomatic in 70-85% of cases, abnormal vaginal discharge, pruritus and
dysuria are the main symptoms. The characteristic feature of the infection is the strawberry
cervix (friable, erythematous cervix with punctate areas of exudate). Urethral infection is present
in 90% of cases. But, isolating the protozoan from just the urethra is just below 5% of cases.
• *Screening for T. vaginalis in asymptomatic women is not recommended. Screening can be
considered in asymptomatic women who are at high risk for infection. These include patients
• with multiple sexual partners, drug abusers and patients with a history of STIs.

37. • Diagnosis
• NAAT gold standard; d detects the protozoal RNA with a high sensitivity and specificity of 95-
100%
• Direct microscopy (magnification x400)method of choice for screening. A wet preparation
has a low sensitivity of 50-70%. Vaginal discharge mixed with a drop of saline on a glass slide.
T. vaginalis lose their motility quickly, therefore the wet preparation should be read within 10
minutes of collection. Acridine orange when used as a stain for films was found more sensitive
than unstained wet preparations. This method is more practical due to its lower cost compared
to NAAT.
• Culture  vaginal discharge is preferred compared to a urine specimen, as 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

38. • Indications for Treatment:
o Testing positive for T. vaginalis, regardless of symptoms
o Treatment of sexual partners
• Recommended regimen:
o A single dose of 2 g metronidazole orally OR
o A single dose of 2 g tinidazole orally (metro better than tini) OR
o Twice daily 500 mg metronidazole orally 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, a 500 mg metronidazole twice daily oral dose for 7 days is recommended.
o If this management fails, then 2 g metronidazole or 2 g tinidazole for 7 days is advisable. Susceptibility to
metronidazole or tinidazole should be tested if there is no cure after 1 week of treatment.
o Intravaginal tinidazole, plus high dose 2e3 g daily oral tinidazole, could be considered for highly resistant strains.
o Expert opinion should be sought.
*Alcohol, sexual intercourse or vaginal douching may hinder the effectiveness of treatment. Alcohol should not be consumed during treatment up to
24 hours after completion of a course of metronidazole, or 72 hours after completion of a tinidazole course, as it may precipitate a disulfiram-like
reaction. Sexual intercourse should be avoided during and at least for one week after treatment. Douching is not recommended as it alters the
vaginal flora and increases the risk of infection.

40. • 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

41. • 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

42. Symptoms Signs
• lower abdominal pain which is typically
bilateral
• deep dyspareunia
• abnormal vaginal bleeding, including post
coital, inter-menstrual and menorrhagia
• abnormal vaginal or cervical discharge which
is often purulent
• lower abdominal tenderness which is usually
bilateral
• adnexal tenderness on bimanual vaginal
examination
• cervical motion tenderness on bimanual
vaginal 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.

43. • 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 also supports the diagnosis but is non-specific
o Ultrasound abdomen and pelvis
o Test to exclude differential diagnoses: Urine analysis or FME, Urine pregnancy test

44. Cogwheel sign resulting from
thickened endo-salpingeal folds.
Tubo-ovarian complex

45. 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

46. • 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.

47. Flow chart for treatment
of Tubo-ovarian abscess

48. • 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

49. • 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.

50. 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_type=default&display_rank=1