Infections of the Genital Tract - Part I

Infections ofInfections of
the Genitalthe Genital
TractTract
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Doctors University College of Medicine
February 2016
@helenvmadamba CDUCM 2016

References

LECTURE OUTLINE
• Infections of the Vulva
• Bartholin’s gland abscess
• Ectoparasites
• Diseases characterized by Ulcers
• HPV and Anogenital Warts
• Infections of the Vagina
• Diseases Characterized by Vaginal Discharge
• Infections of the Cervix
• Diseases Characterized by Cervicitis

LECTURE OUTLINE
• Infections of the Upper Genital Tract
• Pelvic Inflammatory Disease
• Sexual Assault & STDs

The Five P’s
1. Partners
2. Practices
3. Prevention of
Pregnancy
4. Protection from
STDs
5. Past history of
STDs

INFECTIONS OF
THE VULVA
PART I

VULVA
• Stratified squamous epithelium with hair
follicles and sweat, sebaceous and
apocrine glands
• Also contains Bartholin’s and Skene’s
glands
• Vulvar skin is sensitive to hormonal,
metabolic and allergic influences
• Sensory nerve endings are more
numerous in the vulvar skin than in the
vagina

Most Prevalent Primary
Infections
• Herpes genitalis
• Condyloma acuminatum
• Molluscum contangiosum

Signs & Symptoms of
Vulvar Infection
• Vulvar itching and burning
• Erythema
• Edema
• Superficial skin ulcers of the vulva
• Skin fissures
• Excoriation

BARTHOLIN’S
GLANDS
• Located at entrance of
the vagina at 5 o’clock
and 7 o’clock
• most common cause:
cystic dilation of the
Bartholin’s duct
secondary to
nonspecific
inflammation or
trauma.
• women are usually
asymptomatic.

Infections of the
Bartholin’s Glands
• Cystic dilation of Bartholin’s duct
• Abscess of Bartholin’s gland
• Adenocarcinoma of Bartholin’s gland

INFECTIONS OF THE
BARTHOLIN’S GLANDS
• the cysts may vary from 1 to 8 cm in
diameter
• they are usually unilateral, tense, and
nonpainful.
• Signs of classic abscess:
• erythema, acute tenderness,
edema and occassionally
cellulitis of the surrounding
subcutaneous tissue.

Treatment:
• asymptomatic cysts in women under the
age of 40 do not need treatment.
• for a symptomatic cyst or abscess →
development of a fistulous tract from
the dilated duct to the vestibule.
• Classical surgical treatment – develop a
fistulous tract to “marsupialize” the duct

Marsupialization

Ectoparasites
• Pediculosis pubis
• Scabies
• Molluscum contangiosum

Pediculosis Pubis
• Pediculosis pedis is an infestation of the
crab louse, Phthirus pubis
• transmitted by close contact, towels or
beddings
• lice in pubic hair is the most contagious of
all STDs: 90% single exposure
• Confined to hairy areas of the vulva
• Major nourishment is human blood

Pediculosis Pubis
• Lifecycle: egg (nit), nymph, adult
• Diagnosis: microscopic slide by scratch
technique, place crust under drop of
mineral oil

Treatment of Pediculosis
Pubis
• permethrin (Nix Crème) 1% cream rinse, applied
to affected areas and washed off after 10
minutes
• Lindane (Kwell) 1% as shampoo, applied for 4
minutes then thoroughly washed off
• Side effect: Seizures when applied immediately after a
bath
• Not recommended for pregnant or lactating women
or children less than age 2
• pyrethrins with piperonyl butoxide applied to
affected areas and washed off after 10 minutes

CDC 2015 STD Guidelines

Scabies
• Scabies is a parasitic infection of the itch
mite, Sarcoptes scabiei, transmitted by
close contact, widespread over the body
without a predilection for hairy areas
• Itch mite travels rapidly over skin, able to
survive only ew ha fours away from
warmth of skin
• Severe but intermittent itching,
predominantly at night when skin is
warmer and mites are more active

Scabies
• Scabies present as papules, vesicles, or
burrows (pathognomonic), termed the
“great dermatologic imitator”
• Most commonly infected areas: hands,
wrists, breasts, vulva, buttocks, examine
under handheld magnifying lens
• Microscopic slides: scratch technique,
under mineral oil

Scabies

Treatment of Scabies
• Permethrin 5% applied to all areas of the
body from neck down and washed off
after 8 to 14 hours
• Ivermectin 0.2 mg/kg orally, repeated in
two weeks if necessary
• Lindane 1% 1 oz of lotion or 30g of cream
applied thinly to all areas of the body
from neck down and thoroughly washed
off after 8 hours.
• Antihistamine for pruritus

Pediculosis Pubis and
Scabies
• Treatment prescribed for sexual
contacts within previous 6 weeks and
other household contacts
• Clothing and bedding should be
decontaminated
• Permethrin 1% cream rinse for pubic lice
• Permethrin 5% cream for scabies

Molluscum
contagiosum
• Asymptomatic viral disease primarily of
the vulvar skin
• Caused by the poxvirus and is spread by
close contact. Poxvirus does not grow on
mucous membranes.
• Common generalized skin disease in
adults with immunodeficiency,
especially HIV infection.

Molluscum contagiosum
• Characteristic skin lesion –
umbilicated papule.
• Small nodules or domed
papules - 1 to 5 mm in
diameter.
• “Water wart”
• Incubation period is 2 to 7
weeks

• Infected women = 1 to 20 solitary
lesions randomly distributed over the
vulvar skin.
• Diagnosis
• simple inspection
• white waxy material from inside the nodule
should be expressed in a microscopic slide
• Findings: intracytoplasmic molluscum
bodies (Wright’s or Giemsa stain)

• Major complication: bacterial
superinfection
• A self limiting infection
• Treatment of individual papules:
• Decrease transmission
• Autoinoculation of the virus

• Injection of LA – subdermal wheal,
evacuation of caseous material and the
nodule excised with a sharp dermal
curet.
• Chemically treated with either ferric
subsulfate (Monsel’s solution) or 85%
trichloroacetic acid – base of papule.
• Alternative: cryosurgery or
electrocautery

Human Papillomavirus
• Anogenital warts

Condyloma
Acuminatum
• Most common viral STD due to Human
Papillomavirus (HPV) infection
• Non-oncogenic, or low-risk HPV types 6
and 11 are the cause of genital warts
and recurrent respiratory
papillomatosis.
• More than 50% of sexually active
persons become infected at least once
in their lifetime.

Prevention
•Two HPV vaccines:
• a bivalent vaccine (Cervarix)
containing HPV types 16 and 18
• a quadrivalent vaccine (Gardasil)
containing HPV types 6,11, 16
and 18.

Prevention
• Both vaccines offer protection
against HPV types that cause 70%
of cervical cancers.
• QHPV protects against HPV types
that cause 90% of genital warts
(approved for use in males and
females 9-26 years)

Counseling
• A diagnosis of HPV in one sex partner is
not indicative of sexual infidelity in the
other partner.
• Sexually active persons can lower their
chances of getting HPV by limiting their
number of partners.
• Genital warts commonly recur after
treatment, especially in the first 3
months.
CDC 2010 STD Treatment Guidelines

Counseling
• Women should get regular Pap tests as
recommended, regardless of vaccination
or genital wart history.
• If one sex partner has genital warts,
both sex partners benefit from getting
screened for other STDs.
• Refrain from sexual activity until the
warts are gone or removed.
CDC 2010 STD Treatment Guidelines

Cervical cancer
screening
• Current guidelines from USPSTF and
ACOG recommend that cervical
screening begin at age 21 years.
• ACS recommends that women start
cervical screening after 3 years of
initiating sexual activity but by no later
than age 21 years.

Diseases
Characterized by
Genital Ulcers
• Genital herpes
• Granuloma inguinale (Donovanosis)
• Lymphogranuloma venereum (LGV)
• Chancroid
• Syphilis

Chancroid
• Painful genital ulcer
• Tender suppurative inguinal
adenopathy
• Diagnosis: identification of H. ducreyi

• Probable diagnosis
• Patient has one or more painful genital
ulcers
• No evidence of T. pallidum infection by
darkfield exam
• Clinical presentation, appearance of genital
ulcer and +/- regional lymphadenopathy
• Test for HSV on ulcer is negative

Genital HSV Infection
• Most are caused by HSV-2
• Painful multiple vesicular / ulcerative
lesions
• Absent in many infected patients

Diagnosis
• Cell culture
• PCR
• Type specific serologic test

• Type specific serologic test
• Recurrent genital symptoms or atypical
symptoms with negative HSV culture
• Clinical diagnosis of genital herpes without
laboratory confirmation
• A partner with genital herpes

MANAGEMENT OF
GENITAL HERPES
• Antiviral chemotherapy offers clinical benefits
to most symptomatic patients and is the
mainstay of management.

Suppressive Therapy
for Recurrent Genital Herpes
•Suppressive therapy reduces the frequency of genital herpes
recurrences by 70%–80%
•many persons receiving such therapy report having experienced
no symptomatic outbreaks

Episodic Therapy
for Recurrent Genital Herpes
Effective episodic treatment of recurrent herpes requires
initiation of therapy within 1 day of lesion onset or during
the prodrome that precedes some outbreaks.

• Severe HSV disease
• Acyclovir 5-10mg /kg IV every 8 hours for 2-
7 days until with clinical improvement then
PO antiviral therapy to complete at least 10
days

Granuloma Inguinale
• Klebsiella granulomatis
(Calymmatobacterium granulomatis)
• Painless, slowly progressive ulcerative
lesions on genitals or perineum
• No regional lymphadenopathy

• Diagnosis:
• Visualization of dark staining Donovan
bodies on tissue crush preparation or
biopsy

Lymphogranuloma
Venereum
• C. trachomatis serovars L1, L2 or L3
• tender inguinal and / or femoral
lymphadenopathy
• unilateral

MANAGEMENT

Syphilis
• Treponema pallidum
• Primary, secondary, neurologic, tertiary
infection

Primary Syphilis:
Chancre

Secondary Syphilis:
Palmar/Plantar Rash

Secondary Syphilis:
Condyloma lata

Secondary Syphilis:
Nickel/Dime Lesions

Tertiary Syphilis:
Gummatous Lesions

• Diagnostic:
• Non treponemal tests
• Venereal Disease Research Laboratory
• RPR
• Treponemal tests
• Fluorescent treponemal antibody absorbed (FTA-
ABS) tests
• T. pallidum passive particle agglutination (TP-PA)
assay

Treatment for Primary and Secondary
Syphilis

Treatment for Latent Syphilis

These slides will be uploaded onto
http://www.slideshare.net/HelenMadamba

Infections of the Genital Tract - Part I

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