This document discusses lower genital tract infections, including types of lesions, common symptoms, and the vaginal ecosystem. It describes vaginitis, bacterial vaginosis (BV), trichomoniasis, vulvovaginal candidiasis, and other vulvar infections. For each condition, it discusses signs/symptoms, diagnosis, and treatment recommendations. It also covers cervicitis, chlamydia, gonorrhea, and Bartholin's gland cysts/abscesses. The document provides detailed information on classifying, diagnosing, and managing common lower genital tract infections.

1. LOWER GENITAL TRACT
INFECTIONS
DR MOTIUR RAHMAN
PGT
Dept of OBG & GYNAE
ESI-PGIMSR & ESIC MEDICAL
COLLEGE , JOKA

2.  Lower genital tract infections means
infections of VULVA , VAGINA ,&
CERVIX.
 Symptoms caused by lower genital tract
infections are among the most common
presenting complaints of gynecological
patients .

3. TYPE OF LESIONS
 VAGINITIS :
 ULCERATIVE LESIONS :
 VULVAL INFECTIONS :
 CERVICITIS :
 BARTHOLIN GLAND INFECTION :

4. COMMON SYMPTOMS
 Pruritus
 Vaginal discharge
 Pain
 Dyspareunia
 Itching
 Odor
 Irritation
 Burning

5. Ecosystem in vagina
 Estrogen
 pH in vagina: 3.5-4.0
 Vaginal flora: lactobacilli ;acidogenic
corynebacteria

6. VAGINITIS
 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
Trichomoniasis
Candidiasis

7. Bacterial Vaginosis
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.

8. Bacterial Vaginosis
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
hominis.
 Bacterial
Vaginosi
s Picture
Bacterial Vaginosis
homogeneous, thin, white discharge

9. Bacterial Vaginosis
Diagnostic Considerations
BV can be diagnosed by the use of clinical criteria or Gram
stain. Clinical criteria require three of the following symptoms or signs(Amsel
criteria)
 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).

10. Bacterial Vaginosis
Diagnostic Considerations
 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.

11. Bacterial Vaginosis
Obtaining a sample of the discharge The whiff test

12. Bacterial Vaginosis
 Treatment
All women who have symptomatic disease require treatment.
Recommended Regimens for nonpregnant woman
Metronidazole 500 mg orally twice a day for 7 days
OR
Metronidazole gel, 0.75%, one full applicator (5 g)
intravaginally, once a day for 5 days
OR
Clindamycin cream, 2%, one full applicator (5 g)
Intravaginally at bedtime for 7 days

13. Bacterial Vaginosis
 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.

14. Trichomonas Vaginitis
 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.

15. Trichomonas Vaginitis
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

16. Trichomonas Vaginitis
Diagnostic Considerations
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
results.
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.

17. Trichomonas Vaginitis
Recommended Regimens
Metronidazole 2 g orally in a single dose
OR
Tinidazole 2 g orally in a single dose
Alternative Regimen
Metronidazole 500 mg orally twice a day for 7 days

18. Trichomonas Vaginitis
.
 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.

19. Vulvovaginal Candidiasis
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
episodes.
.

20. Vulvovaginal Candidiasis
Typical symptoms of VVC include:
pruritus,
vaginal soreness,
dyspareunia,
external dysuria.
None of these symptoms is specific for VVC.
Abnormal vaginal discharge:
White, "curd-like“, cheesy vaginal
discharge.

21. Vulvovaginal Candidiasis
Uncomplicated VVC
 Sporadic or infrequent VVC
 Mild-to-moderate VVC
 Likely to be Candida albicans
 Nonimmunocompromised women
Complicated VVC
 Recurrent VVC
 Severe VVC
 Nonalbicans candidiasis
 Women with uncontrolled diabetes, debilitation, or are
immunosuppression, or those who are pregnant.

22. Vulvovaginal Candidiasis
Uncomplicated VVC
Diagnostic Considerations in Uncomplicated VVC
Based on
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

23. Vulvovaginal Candidiasis
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
therapy.

24. Vulvovaginal Candidiasis
Recommended Regimens for Uncomplicated VVC
 Intravaginal Agents:
Butoconazole 2% cream 5 g intravaginally for 3 days*
OR
Clotrimazole 1% cream 5 g intravaginally for 7–14 days*
OR
Clotrimazole 100 mg vaginal tablet for 7 days
OR
Miconazole 2% cream 5 g intravaginally for 7 days*
 Oral Agent:
Fluconazole 150 mg oral tablet, one tablet in single dose

25. VULVAR INFECTIONS
GENITAL WARTS
 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.

26.  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 &
immune modulators.

27. MOLLUSCUM
CONTAGIOSUM
 Caused by POX virus infection
 Spread by skin contact ,
autoinoculation,fomites.
 Appearance of dome shaped papules
with central umbilication , 2-5 mm
diameter.
 Usually asymptomatic but may be
pruritic & become inflammed & swollen .
 It usually self limited.

28. PEDICULOSIS PUBIS
 Caused by ectoparasite Phthirus pubis
 Intense pruritus in the affected area ,
sometimes associated with
maculopapular lesions.
 Diagnosis is made by gross visualization
of lice , larvae in pubic hair or
microscopic identification of crablike lice
under oil.

29. SCABIES
 Caused by Sarcoptes scabiei var
hominis.
 Transmitted by close contact
 Insidious onset of severe intermittent
pruritus .
 Characteristic lesion is burrow , 1-10 mm
curving tract that serves to house the
mite.
 Diagnosed clinically & appearance of
burrow

30. GENITAL ULCER
 Genital herpes
 Chancre (syphilis)
 Chancroid
 Granuloma inguinale
 Lymphogranuloma venereum
 Tubercular ulcer

31. GENITAL HERPES
 HSV – 1
 Mostly oro-labial, but increasing cause of
genital herpes
 HSV – 2
 Almost entirely genital
 > 95% of recurrent genital lesions
 Primary infections
 Recurrent infections
 Latency

32.  Horizontal Transmission
 Intimate sexual contact (oral/genital)
 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

33.  Local – clusters of small, painful blisters
that ulcerate and crust outside of
mucous membranes
 Itching, dysuria, vaginal discharge, inguinal
adenopathy, bleeding from cervicitis

34. Recurrent herpes
 Reactivation of virus
 Mild, self-limited
 Localized, lasting 6-7 days
 Shedding: 4-5 days
 Prodrome: 1-2 days

35. Diagnosis
 Viral isolation (culture)
 High specificity, low sensitivity
 50% for primary infxn
 20% for recurrent infxn
 Direct detection of virus (Tzcank smears,
PCR)
 Serology
 Newer tests that are specific for type of
virus (HerpesSelect 2, herpes glycoprotein
for IgG, ELISA)

36. SYPHILIS(CHANCRE)
 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.

37.  Non tender inguinal lymphadenopathy
frequently present.
 Secondary syphilis may be present as
condyloma lata.
 Diagnosed by : dark-field microscopy ,
VDRL or RPR , FTA-ABS

38. CHANCROID
 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
present.

39. LYMPHOGRANULOMA
VENERUM
 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.

40. GRANULOMA INGUINALE
 Caused by Calymmatobacterium
granulomatis
 Hypertrophic ulcer , margins are rolled &
elevated
 Presence of “Donovan body”
confirmatory

41. CERVICITIS
 Two types of cells line of cervix: flat, skin-like
cells (squamous cells) and glandular cells that
secrete mucus.
 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

42.  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
bleeding.

43. CLAMYDIA
 Causative agent : C. trachomatis
 75% cases asymptomatic
 Commonly present with abnormal
vaginal discharge, burning with urination,
spotting, postcoital bleeding.
 Diagnosed by NAAT(nucleic acid
amplification testing)

44. GONORRHEA
 Causative agent : N. gonorrhoeae
 Most common infected site endocervix
 50% asymptomatic
 Present with vaginal discharge, dysuria,
abnormal uterine bleeding
 Diagnosed by culture & NAAT

45. Bartholin’s duct cyst and
abscess
 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

46. 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
usually palpable.

47. Treatment:
 Drainage of infected cyst or abscess;
 Antibiotics;
 Excision of the cyst may be required in
recurrent cases.

48. THANK
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