This document discusses various infections of the female genital tract. It begins by explaining that genital tract infections are a major public health problem, particularly in developing countries, as they can cause infertility, ectopic pregnancy, chronic pelvic pain, and other issues. The document then discusses defenses of different parts of the genital tract against infection. It proceeds to describe common lower and upper genital tract infections like bacterial vaginosis, candidiasis, trichomoniasis, and their symptoms, causes, diagnostic criteria and treatment options. The document concludes by briefly mentioning other sexually transmitted infections like herpes, syphilis, chancroid, and genital warts.

1. DR HINA HAROON
MCPS TRAINEE
OBS AND GYNAE DEPARTMENT
IMC NESCOM

4.  They are recognized as a public health
problem ranking 2nd after maternal mortality
and morbidity .
 It causes a loss of healthy life among women
of reproductive age in developing countries .
 They can have serious consequences
including infertility, ectopic pregnancy
,chronic pelvic pain ,abortion, menstrual
disorders and pregnancy loss .

5. CERVICAL DEFENCE
 Mucus plug.
 Effect of mucus.
UTERINE DEFENCE
 Cystic shedding of endometrium.
TUBAL DEFENSE
 Integrated mucus and epithelial cilia.
 Peristalsis of tube and also the movement of cilia
toward the uterus.

6. VULVAL DEFENCE
 Apposition of cleft by labia.
 Bartholin gland .
 Fungicidal apocrine glands secretions .
 Resistance of vulva and perineal skin .
VAGINAL DEFENCE
 Apposition of ant and post wall with its
transverse rugae.
 Estrogen.
 Dordelins bacilli.

7.  The vaginal area of genital tract is protected
against infection by its normally low PH(3.5
to4.0).
 This enviornment is maintained by the action
of Dordelien’s bacilli (a part of normal flora)
and hormonal estrogen.

8.  LOWER REPRODUCTIVE TRACT INFECTIONS:
It affect the outer genitals and reproductive
organs .Infections in the area of vulva, vagina
and cervix.
 UPPER REPRODUCTIVE TRACT INFECTIONS :
These are infections in uterus, fallopian tubes
and ovaries.

9.  TYPES OF LESIONS
 Vaginitis
 Ulcerative lesions
 Vulval lesions
 Cervicitis
 Bartholin gland infection

10.  Pruritis
 Vaginal discharge
 Pain
 Dyspareunia
 Itching
 Odour
 Irritation
 Burning

13. Vaginitis is actually an infection of vagina .
3 main common causes of vaginitis is infection
with .
1. Bacterial infections (Bacterial Vaginosis) .
50%
2. Protozoan (Trichomoniasis ).
25%
3. Fungus (Candidiasis).
25%

14.  The most common cause of vaginitis
reported in 5 to 50% of females.
 Cause by the disruption of balance of bacteria
in vagina and replaced by over growth of
certain bacterias and replacement of normal
H2O2 –producing bacteria LACTOBACILLUS
in the vagina with high concentrations of
anaerobic bacteria(e.g Prevotella sp and
Mobiluncus sp).G Vaginalis and Mycoplasma
Hominis .

15.  Associated with
 Multiple male and female partner ‘
 A new sex partner .
 Lack of condom use .
 Lack of vaginal lacto bacilli .
 Women who have never been sexually active
can be affected.
 Women with BV are at increased risk for the
acquisition of STD s.

16.  3 of the following symptoms or sign
 Homogeneous ,thin,white discharge , that
smoothly coats the vaginal wall .
 Presence of clue cells on microscopy
 PH of vaginal fluids >4.5
 A fishy odour before and after addition of
10% KOH.

17. Gram stain morphacilli bology score (1-10)
based on lactobacilli and other morphotypes .
 A score 1-2 indicates normal flora
 A score 7-10 bacterial vaginosis

18.  DIAGNOSTIC CRITERIA
 BV can be diagnosed by the use of clinical criteria or gram
staining by using HAY ISON OR NUGENT CRITERIA .Clinical
criteria required 3 of the following symptoms and signs
(Amsel’s criteria less common in practice ).
 Homogeneous thin ,white vaginal discharge that smoothly
coats the vaginal walls.
 Presence of clue cells (epithelial cells with borders obscured
by small bacteria)on microscopic examination.
 PH of vaGINA GREATER THAN 4.5
 A FISHY odour of vaginal discharge before or after addition of
10% KOH (i.e WHIFF TEST).

19.  Bacterial Vaginosis is associated with many
pathologies
 1.Pid
 2.Post hysterectomy vaginal cough cellulitis’
 In pregnancy
 A)preterm birth
 B) rupture of membrane
 C)miscarriage.
 3.Increase risk of HIV.

20. TREATMENT
 All women who have have symtomatic disease
require treatment
 RECOMMENDED REGIMEN FOR NONPREGNANT
PATIENTS.
 Metronidazole 500mg orally twice a day for 7
days
 OR
 Metronidazole gel 0.75%one full applicator 5g
intravaginally once a day for 5 days
 OR
 Clindamycin cream 2%one full applicator 5 g
intravaginally bed time for 7 days

21. MANAGEMENT OF SEX PARTNER
The result of clinical trials indicates that a
woman’s response to therapy and the
likelihood of relapse or recurrence are not
affected by treatment of sex
partners.Therefore routine treatment of
sexual partner is not necessary .
SPECIAL INSTRUCTION
Women with bacterial vaginosis should be
instructed to avoid excessive washing and
vaginal douching.

22.  It is caused by a protozoan t vaginalis .
 Many infected women have symptoms
characterized by a diffuse mal odour yellow
vaginal discharge ,with vulval irritations .
 However some women have minimal
symptoms or no symptoms .

23. 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 same woman .Symptoms can be worse during
pregnancy or right before or after menstruation .
 Principle symptoms persistent vaginal discharge
(profuse ,extremely frothy, greenish, foul; smelling).
 Vaginal itching ,irritation and pain .
 Patchy redness of genitals including labia and vagina.
 Frequent painful dysuria.
 generalize vaginal erythema with multiple small
petechiae.

24. DIAGNOSTIC CONSIDERATION
 Diagnosis of vaginal trichomoniasis is usually
performed by microscopy of vaginal secretions but
the method has sensitivity of only 60 to 70 % and
require immediate evaluation of wet preparation slide
for optimal result .
 Culture is most common sensitive and specific .
 DNA probe test which detect genetic material (DNA)
of trichomonas organism. This test is done only in
researches.
 The GOLD STANDARD is NAATs preferably on a
vaginal or endo cervical swab or on urine with
sensitivity or specificity reaching 95%.

25. RECOMMENDED REGIMENS
 Metronidazole 2 g orally in a single dose .
OR
 Tinidazole 2 g orally in a single dose .
ALTERNATIVE REGIMEN
 Metronidazole 500mg orally twice a day for 7
days

26. MANAGEMENT OF SEX PARTNER
 Sex partners of T Vaginalis should be treated
they should be advised to avoid sex until they
and there partner are cured .

27.  VVC is usually caused by a yeast Candida
Albicans and occasionally with other Candida
species.
 An estimated 75% of women will have at least
one episode of VVC and 40 to 50% will have
2 or more episodes .

28. TYPICAL SYMPTOMS
 PRURITIS
 VAGINAL SORENESS
 DYSPAREUNIA
 EXTERNAL DySURIA
None of the symptom is specific for VVC .
ABNORMAL VAGINAL DISCHARGE
White curd like cheesy vaginal discharge

29.  SUSEPTIBILITY
=Uncontrolled DM
=Immunocompromised patients
=Pregnancy

30.  DIAGNOSTIC CRITERIA
Based on
1- CLINCAL FEATURES
External dysuria ,vulvular pruritis ,pain, swelling,
redness. Signs include vulvular edema, fissures,
thick curdy vaginal discharge
2-DEMONSTRATION OF CANDIDA MYCELIA
Either a wet preparation (saline ,10% KOH) or GM
staining of vaginal discharge demonstrate yeast
or pseudo-hyphea and culture shows positive
test of yeast.
3-NORMAL VAGINAL PH <4.5

31.  TREATMENT OF VVC
Short course single topical formulation single dose and
regimen of 1 to 3 days .
Topically applied azole drugs are more effective than
nystatin ‘
RECOMMENDED REGIMEN
= Intra vaginal agents
Butoconazole 2% cream 5g intravaginally for 3 days .
Clotrimazole 1% cream 5gm intravaginally 7 to 14 days
.
Clotimazole 100mg vaginal tab for 7 days .
Miconazole 2% cream 5 g intravaginal for 7 days
=ORAL AGENTS
Fluconazole 150mg oral tab single dose

32.  Genital herpes .
 Chancre (syphilis).
 Chancroid
 Granuloma inguinale
 Lymphogranuloms venereum
 Tubercular ulcer

33.  GENITAL HERPES IS CAUSED BY HERPES SIMPLEX
VIRUS 1 AND HERPES SIMPLEX 2
 HSV-1
Genital orolabial but increasing cause of genital
herpes .
 HSV -2
Almost entirely genital
>95% of recurrent genital lesions
=Primary infections
=Recurrent infections
=Latency

34. HORIZONTAL TRANSMISSION
 Intimate sexual contact
 Aerosol and fomite transmission is rare .
VERTICAL TRANSMISSION
 Maternal –infant via infected cervico-vaginal
secretions, blood or amniotic fluid at birth .
AUTOINOCULATION
 From one site to another

35.  LOCAL -clusters of small, painful blisters ,
that ulcerate and crust outside of mucous
membrane .
 Itching , dysuria ,vaginal discharge, inguinal
adenopathy , bleeding from cervicitis .

36.  Reactivation of virus
 Mild self limited
 Localized lasting 6 to 7 days
 Shedding 4 to 5 days
 Prodorme 1-2 days

37.  VIRAL ISOLATION (culture)
◦ High specificity, low sensitivity
 50% for primary infection
 20% for recurrent infection
 Direct detection of virus (Tzcank smears,
PCR)
 Serology
◦ Newer test that are specific for type of virus (Herpes
select 2, Herpes glycoprotein For IgG, ELISA)

38. It is treated with ORAL ANTIVIRAL DRUGS LIKE
 VALACYCLOVIR
 FAMCICLOVIR
 ACYCLOVIR

39.  Caused by T.Pallidum
 Transmitted through contact with chancre,
condyloma lata or mucosal lesion
 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

40.  Non tender inguinal lymphadenopathy
frequently present
 Secondary syphilis may be presen as
condyloma lata
 Diagnosed by: Dark field microscopy, VDRL or
RPR, FTA-ABS

41.  Caused by Hemophilus ducreyi
 Lesion starts as multiple vesico pustules over
vulva, vagina and cervix, then sloughs to
form shallow ulcers
 Lesion painful, tender with foul purulent and
hemorrhagic discharge may be present

42.  Caused by Chlamydia trachomatis (L
serotypes)
 Painless papule, pustule or ulcer in vulva or
cervix
 Classical clinical sign: groove sign – a
depression between the groups of inflamed
nodes

43.  Caused by POX virus infection.
 Spread by skin contact,autoinoculations anf
fomites .
 Appearance of dome shape papules with
central umbilication 2-5mm diameter.
 Usually asymptomatic but may be pruritic and
becomr inflammed and swollen .
 It is ususally self limited.

44.  GENITAL WARTS ;
These are caused by Human Papilloma Virus
(HPV) mainly type 6 and 11 .
Also called Condyloma Acuminata.
Peak incidence among 15 to 25 yr age soon
after onset of sexual activity.
Soft sessile or verrucous lesions.
Usually multifocal &asymptommatic aithough
itching ,burning ,pain and bleeding can occur
Usually diagnosed clinically.

45. TREATMENT MODALITIES;
 Application of cytotoxic or keratolytic agents which includes
 Salicylic acid
 Imiquimod
 Podofilax
 Trichloroacetic acid
surgical excision /cyto destruction technique and immune
modulator.
 freezing with liquid Nitrogen
 electrocautry
 surgical removal
 laser surgery

46. Cervix is made up of two type of epithelium l
!-Squamous epithelium .
2-Glandular epithelium .
ETIOLOGICAL AGENTS
The cause of cervical inflammation depend on
epithelium affected .
Ectoepithelium become inflammed by same
microorganism that causes vaginitis
Trichomonas , candida and HSV causes
inflammation of ectocervix .
Neiserria gonorrhea and Chlamydia causes
infection of glandular epithelium .

47. SYMPTOMS
 Vaginal discharge
 Deep dyspareunia
 Post coital bleeding
 Urinary problems
SIGNS
 On examination there will be purulent
endocervical discharge generally yellow green
 Cervix is hypertrophied and edematous

48.  DIAGNOSIS
Diagnosis is made on microscopy of purulent
discharge
=Screening of gonorrhea and chlamydia
should be considered .
The microbial etiology of endocervicitis is
unknown in about 50 % of cases in which
neither gonorrhea nor chlamydia detected

49. Causative agent: C TRACHOMATIS
 75% cases asymptomatic .
 Commonly present with abnormal vaginal
discharge ,burning with urination , spotting ,
post coital bleeding .
 Diagnosed by NAAT (nucleic acid
amplification testing)

50.  Causative agent : N. gonorrhea
 Most common infected site is endocervix
 50% asymptomatic
 Present with vaginal discharge ,dysuria and
abnormal vaginal bleeding .
 Diagnosed by culture and NAAT .

51.  Treatment of cervicitis includes the regimen
recommended for the treatment of
chlamydia and gonorrhea. All sexual partners
should be treated with a similar regimen .
 NEISSSERIA GONORRHEA ENDOCERVICITIS
=cefexime 400 mg orally single dose or
=Ceftriaxone 125 mg I/M single dose
=ciprofloxacin 500mg orally single dose
Levofloxacin 250 mg orally single dose

52.  CHLAMYDIA TRACHOMATIS ENDOCERVICITIS
=AZITHROMYCIN 1 G ORALLY SINGLE DOSE
=Doxycycline 100 mg orally twice a day for 7
days
=levofloxacin 500mg orally daily for 7 days

53. THANK YOU!