1. Infections of
Infections of
the Genital
the Genital
Tract
Tract
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Doctors University College of Medicine
February 2016
@helenvmadamba CDUCM 2016
3. 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
@helenvmadamba CDUCM 2016
4. LECTURE OUTLINE
• Infections of the Upper Genital Tract
• Pelvic Inflammatory Disease
• Sexual Assault & STDs
@helenvmadamba CDUCM 2016
5. The Five P’s
1. Partners
2. Practices
3. Prevention of
Pregnancy
4. Protection from
STDs
5. Past history of
STDs
@helenvmadamba CDUCM 2016
7. 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
@helenvmadamba CDUCM 2016
9. Signs & Symptoms of
Vulvar Infection
• Vulvar itching and burning
• Erythema
• Edema
• Superficial skin ulcers of the vulva
• Skin fissures
• Excoriation
@helenvmadamba CDUCM 2016
10. 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.
@helenvmadamba CDUCM 2016
11. Infections of the
Bartholin’s Glands
• Cystic dilation of Bartholin’s duct
• Abscess of Bartholin’s gland
• Adenocarcinoma of Bartholin’s gland
@helenvmadamba CDUCM 2016
12. 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.
@helenvmadamba CDUCM 2016
13. 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
@helenvmadamba CDUCM 2016
16. 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
@helenvmadamba CDUCM 2016
17. Pediculosis Pubis
• Lifecycle: egg (nit), nymph, adult
• Diagnosis: microscopic slide by scratch
technique, place crust under drop of
mineral oil
@helenvmadamba CDUCM 2016
18. 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
@helenvmadamba CDUCM 2016
20. 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
@helenvmadamba CDUCM 2016
21. 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
@helenvmadamba CDUCM 2016
23. 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
@helenvmadamba CDUCM 2016
25. 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
@helenvmadamba CDUCM 2016
26. 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.
@helenvmadamba CDUCM 2016
27. 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
@helenvmadamba CDUCM 2016
28. Molluscum contagiosum
• 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)
@helenvmadamba CDUCM 2016
29. Molluscum contagiosum
• Major complication: bacterial
superinfection
• A self limiting infection
• Treatment of individual papules:
• Decrease transmission
• Autoinoculation of the virus
@helenvmadamba CDUCM 2016
30. Molluscum contagiosum
• 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
@helenvmadamba CDUCM 2016
32. 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.
@helenvmadamba CDUCM 2016
33. 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.
@helenvmadamba CDUCM 2016
34. 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)
@helenvmadamba CDUCM 2016
39. 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
@helenvmadamba CDUCM 2016
40. 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
@helenvmadamba CDUCM 2016
41. 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.
@helenvmadamba CDUCM 2016
44. Chancroid
• Painful genital ulcer
• Tender suppurative inguinal
adenopathy
• Diagnosis: identification of H. ducreyi
@helenvmadamba CDUCM 2016
45. • 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
@helenvmadamba CDUCM 2016
51. • 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
@helenvmadamba CDUCM 2016
52. MANAGEMENT OF
GENITAL HERPES
• Antiviral chemotherapy offers clinical benefits
to most symptomatic patients and is the
mainstay of management.
@helenvmadamba CDUCM 2016
53. 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
@helenvmadamba CDUCM 2016
54. 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.
@helenvmadamba CDUCM 2016
56. • 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
@helenvmadamba CDUCM 2016
76. These slides will be uploaded onto
http://www.slideshare.net/HelenMadamba
@helenvmadamba CDUCM 2016
77. Infections of
Infections of
the Genital
the Genital
Tract
Tract
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Doctors University College of Medicine
February 2016
@helenvmadamba CDUCM 2016
