Lower Genital tract infections & STDs.ppt

Std

1. Lower Genital tract
infections & sexually
transmitted diseases

2. The Normal Vagina
The newborn vagina (until 1 month of age) is under the influence of
maternal estrogens:
Lining is stratified squamous epithelium with Glycogen.
After 1 month of age till puberty:
Lining becomes simple cuboidal without Glycogen.
At puberty:
Vaginal mucosa thickens and becomes lined by Stratified squamous epithelium
with Glycogen.
The normal vaginal flora is mostly aerobic, the most common is
hydrogen peroxide producing lactobacilli (Uses glucose from
glycogen), so Contaminated urine samples are due to Perineal skin
flora or due to Vaginal flora.
•The microbiology of vagina depends on:
1.Vaginal PH : normally <4.5 (3.8-4.2) in the reproductive age.
2.Availability of glucose for bacterial metabolism (Produces lactate).
So the vaginal PH is more alkaline Prepubertal or Post-menopausal.

3. •Normal vaginal secretions are:
1.Clear and odorless.
2.Floccular in consistency (Wool-like).
3.Usually located in the dependent portion of the
vagina (Posterior vaginal fornix) by Bivalve Speculum.
They are composed of vulvar secretions from
sebaceous, sweat, Bartholin and skene glands,
transudate from the vaginal wall, exfoliated vaginal &
cervical cells, cervical mucus (Endocervix which is
Glandular columnar and secretory), endometrial &
oviductal fluids.
The Normal Vagina

4. •DD of vaginal discharge according to age:
Pre-pubertal:
Infection.
Foreign body.
Reproductive age group:
Infection.
Menopause:
Cervical , Endometrial , Fallopian tubes and Ovarian
cancers.
Infection.

5. The Normal Vagina

6. Vaginal discharge analysis
Analysis of the vaginal secretions is done by wet mount preparation (On a slide then
add normal saline).
•Cells in the discharge:
1.Vaginal Squamous epithelial cells.
2.Clue cells : Epithelial cells , borders of which are obscured by Anaerobic bacteria (Gardnerella
vaginalis) : their number increases in some infections.
3.Some PMN cells.
If you add KOH ; this will lead to lysis of vaginal epithelial cells.
Gram stain reveals predominance of gram +ve rods (Lactobacilli).

7. Types of lesions
1.Vaginitis.
2.Vulval infections.
3.Ulcerative lesions.
4.Cervicitis.

8. It is usually characterized by:
1.Vaginal discharge.
2.Vulvar itching & irritation.
3.Vaginal odor.
4.Superficial dyspareunia.
•Diseases most frequently associated with vaginitis:
1.Bacterial vaginosis (Non-specific vaginitis).
2.Trichomoniasis.
3.Candidiasis.
These 3 categories can be differentiated by the signs
and symptoms and investigations (Wet mount).
Vaginitis

9. It has previously been referred to as nonspecific vaginitis or
Gardnella Vaginitis (Most common vaginitis).
An Alteration of normal vaginal bacterial flora that results in the
loss of hydrogen peroxide producing lactobacilli and an overgrowth
of predominantly anaerobic bacteria (Prevotella sp. & Mobiluncus
sp. In <1% normal vaginal flora), G. vaginalis & Mycoplasma
hominis.
It is hard to re-establish the growth of Lactobacillus; this is why
there is recurrence rate of bacterial vaginosis.
Unknown trigger of disturbance on normal vaginal flora.
Triggered by Repeated alkalanization of the vaginal PH:
–Frequent sexual intercourse.
–Use of vaginal douching.
Bacterial vaginosis

10. •The discharge is characterized by :
1.Homogenous milky or creamy (white to gray) discharge.
2.Smoothly & thinly coats the vaginal walls.
Bacterial vaginosis

11. Diagnosis by (Amsel criteria) any 3 of the following :
1.Fishy vaginal odor, that is particularly noticeable following
coitus & vaginal discharge present.
2.The PH of the secretions is > 4.5 (usually 4.7-5.7).
3.Microscopy of vaginal secretions reveals an increased number
of clue cells while leukocytes are absent. In advanced cases,
>20% of the epithelial cells are clue cells.
4.Whiff test: addition of 10% KOH to the vaginal secretions
releases fishy amine-like odor.
5.There are no symptoms or signs (Inflammed vagina or vulva) of
inflammation (NO WBC IN THE WET MOUNT PREPARATION).
Bacterial vaginosis

12. When a gram stain is used, determining the relative
concentration of lactobacilli, Gram negative & Gram-variable
rods & cocci (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.
If this infection occurs during pregnancy it is Associated with:
–Mid-trimester miscarriage.
–Preterm labour.
–Rupture of membranes.
–Endometritis.
Bacterial vaginosis

13. Treatment:
•Recommended Regimens for non-pregnant woman:
1.Metronidazole 500 mg orally twice a day for 7 days (GI upset + unpleasant
taste).
2.Metronidazole gel, 0.75%, one full applicator (5 g)intravaginally, once a day
for 5 days.
The overall cure range from 75%- 84% with the above regimens.
1.Clindamycin cream, 2%, one full applicator (5 g) Intravaginally at bedtime
for 7 days.
2.Clindamycin 300mg, orally twice daily for 7 days.
3.Clindamycin ovules, 100mg, intravaginally once at bedtime for 3 days.
4.Clindamycin is expensive!
5.Both Drugs are safe in pregnancy.
6.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
husband. Therefore, routine treatment of husbands is not recommended.
7.Not sexually transmitted!
Bacterial vaginosis

14.  It is caused by the sexually transmitted flagellated
parasite (Trichomonas Vaginalis): exists in trophozoite
form.
It often accompanies BV, which can be diagnosed in as
many as 60% of patients with Trichomonas vaginitis.
About 50% of women infected with Trichomoniasis don’t
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.
Trichomonas Vaginitis

15. Symptoms :
1.Principle symptom: Persistent vaginal discharge (profuse,
extremely frothy, greenish, foul smelling).
2.Symptoms of inflammation: Vaginal itching, irritation, pain and
Dyspareunia (Deep and Superficial).
3.Frequent, External painful dysuria, if urine touches inflamed
tissue (at the beginning of urine stream).
Signs:
1.Patchy redness of the genitals, including labia and vagina with
colpitis macularis (Strawberry cervix) may be observed.
2.Generalized vaginal erythema with multiple small petechiae
(Angry looking vagina).
Trichomonas Vaginitis

16. Petechial lesions on the cervix.
Strawberry
cervix(Pathognomonic for T.
Vaginitis)
Trichomonas Vaginitis
Profuse, extremely frothy,
greenish discharge.

17. Diagnosis:
It is usually performed by microscopy of vaginal secretions, but this method
has a sensitivity of only approximately 60%–70.
1.Microscopy of the secretions reveals motile trichomonads (have spikes) and
increased numbers of leukocytes.
2.Decreased number of Lactobacilli.
3.Clue cells may be present of the common association with BV.
4.The Whiff test may be positive.
5.The PH of the vaginal secretions is usually >5.
Trichomonas Vaginitis
Trichomonas :
Cone shaped centrally.
One side with spike.
Other side with flagella.

18. 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 trichomonas and is usually
available only in research studies.
Morbidity:
–Patients with T.V are at increased risk for postoperative cuff cellulitis
following hysterectomy (Removal of the Uterus and Cervix , adhere the
anterior and posterior vaginal wall creating a vaginal cuff).
–Pregnant women are at increased risk of PROM and preterm delivery.
Women should be tested for other STDs, mainly N. gonorrhea and chlamydia
trachomatis. Serologic testing for syphilis and HIV infection should also be
considered.
Trichomonas Vaginitis

19. Treatment:
1.Metronidazole 2 g orally in a single dose OR Tinidazole
2 g orally in a single dose.
2. Alternative Regimen Metronidazole 500 mg orally
twice a day for 7 days.
Both regimens are highly effective and have cure rates of
about 95%.
Both drugs are safe during pregnancy.
3.Husband should also be treated.
4.Patients should be instructed to avoid sex until they
and their husbands are cured.
5.Screening for other STDs is a must.
Trichomonas Vaginitis

20. An estimated 75% of women will have at least one
episode of VVC, and 40%–45% will have two or
more episodes.
 
Candida Albicans is responsible for 85-90% of
vaginal yeast infections (More in
immunocompetent patients).
Other species of candida, such as C.glabrata and C.
tropicalis (More in immunocompromised patients)
can cause vulvovaginal symptoms and tend to be
resistant to therapy.
Vulvovaginal Candidiasis (Monilial vaginitis)

21. Diagnosis :
•Symptoms:
1.Vaginal discharge which can vary from watery to homogenously thick that
typically resembles cottage cheese.
–Vulvar pruritus (More at night), vaginal soreness, Superficial dyspareunia,
vulvar burning and irritation may be present.
–External dysuria (Splash dysuria) may occur.
1.Signs:
1.Erythema & edema of the vulvar skin and labia.
2.Discrete pustulopapular peripheral lesions may be present.
3.The vagina may be erythematous with an adherent, whitish discharge
covering the whole vaginal wall.
4.The cervix appears normal.
Vulvovaginal Candidiasis (Monilial vaginitis)

22. Vulvovaginal Candidiasis (Monilial vaginitis)
This patient has Cervical Ectropion.
The discharge coats the vaginal walls.
The cervix is normal!
Thick , whitish discharge
resembling cottage cheese.

23. The PH of the vagina in patients with VVC is usually normal
<4.5.
The Whiff test is negative.
The results of the saline preparation of the vaginal
secretions usually are normal, although there may be a slight
increase in the number of inflammatory cells in severe cases.
Fungal elements (mycelia or budding yeast) appear in 80% of
cases.
Fungal culture is recommended to confirm the diagnosis in
case of +ve findings on examination but microscopy is
negative where presumptive diagnosis can be made.
Vulvovaginal Candidiasis (Monilial vaginitis)

24. Classification of VVC
Uncomplicated Complicated
Sporadic or infrequent in
occurrence
Recurrent symptoms
Mild to moderate symptoms Severe symptoms
Likely to be C.albicans Non albicans Candida
Immunocompetent women Immunocompromised women
( DM, immunosuppression)

25. Treatment:
•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. Short-course topical
formulations (Single dose and regimens of 1–3 days) effectively treat
uncomplicated VVC.
 
•Any of the following:
–Butoconazole 2% cream 5 g intravaginally for 3 days.
–Clotrimazole 1% cream 5 g intravaginally for 7–14 days.
–Clotrimazole 100 mg vaginal tablet for 7 days.
–Miconazole 2% cream 5 g intravaginally for 7 days, 200mg vaginal supp for 7 days.
Oral Agent: Fluconazole 150 mg oral tablet, one tablet in single dose for
uncomplicated VVC (Fluconazole is C/I during pregnancy).
•Complicated VVC:
An additional 150 mg dose of fluconazole given 72 hours after the first
dose.
Vulvovaginal Candidiasis (Monilial vaginitis)

26. Supportive care:
1.Women should be encouraged not to use soaps and Perfumes
on genital area.
2.Use cotton underwear.
3.Candidiasis is associated with high estrogen conditions
(Pregnancy , OCP) : Combined OCPs with rich estrogen should
be avoided, and switching to progesterone rich OCPs is
recommended.
4.Associated with DM (Blood sugar should be monitored).
5.Associated with the use of Broad spectrum antibiotics.
Vulvovaginal Candidiasis (Monilial vaginitis)

27. Caused by Human Papilloma virus (HPV) , mainly
type 6 &11 (Condyloma acuminata).
 Peak incidence among 15 -25 years , soon after
onset of sexual activity.
Soft , sessile (without pedicle), and or verrucous
lesions.
Usually multifocal & asymptomatic , although
itching, burning , bleeding & pain can occur.
External genital warts are highly contagious >75%.
Usually diagnosed clinically.
Genital warts

28. •In areas with high contact during sexual intercourse :
1.Posterior Forchette : Lower part of vaginal opening.
2.Vulva.
3.Could be seen inside the vagina and the cervix.
Genital warts

29. The goal of the treatment is the removal of the warts, it isn’t possible to eradicate the viral
infection.
Treatment is more successful in patients with small warts that have been present for less
than 1 year.
Treatment modalities:
–Cytotoxic agents (Podyphyllin , Podofilox) : Teratogenic.
–Keratolytic agents (Salicylic acid; leads to hypopigmentation).
–Surgical excision (If lesions are 1-2 in number or large in size).
–Cytodestructive techniques (Cryotherapy, Laser, Thermal cautery).
–Immune modulators (Interferon).
1.In the presence of active genital wart during pregnancy; This is contraindication for
vaginal delivery and should be delivered by CS because it can lead to Laryngeal
papillomatosis if transferred to the fetus.
Genital warts

30. Safe in pregnancy
Safe in pregnancy
Pregnancy category C
Genital warts

31. Caused by POX virus infection.
Spread by skin contact (STD) , autoinoculation (Scratching then
touching other parts of the body), fomites (Sharing of inanimate
objects).
Appearance of dome shaped papules with central umbilication , 2-5
mm diameter.
Usually asymptomatic but may be pruritic & become inflamed &
swollen .
It is usually self limited.
Only genital lesions are treated (same options of Genital warts
treatment).
Once you remove the lesion; the virus is eradicated.
Not transmitted to the fetus!
Molluscum Contagiosum

32. 1.Genital herpes (Most common cause).
2.Chancre (Syphilis).
3.Chancroid.
4.Granuloma inguinale.
5.Lymphogranuloma venereum.
Genital ulcers

33. Genital ulcers

34. Caused by HSV 2 but can be caused by HSV 1 due to oral
sex practices.
Presents as Painful vesicles on the labia that are
associated with inguinal lymphadenopathy, then slough
leaving a shallow ulcers with regular borders ( in the
epidermis only).
Transmitted by sexual intercourse , skin-to-skin contact or
vertical transmission to the baby and with body fluids
including the genital secretions.
Herpes is relative indication for cesarean section:
CS is indicated if ROM has occurred within 6 hours (No benefit
for CS after 6 hours).
Genital herpes

35. Diagnosis:
Grouped vesicles mixed with small ulcers with a history of similar
lesions (Pathognomonic).
Viral isolation (culture): High specificity, low sensitivity , 50% for
primary infection, 20% for recurrent infection.
Direct detection of virus (Tzcank smears, PCR)
Serology: Newer tests that are specific for type of virus (Herpes
Select 2, herpes glycoprotein for IgG, ELISA).
Treatment:
1
st
episode is treated with acyclovir (200 mg 5 times daily for 10
days), famciclovir, this will not eradicate the infection, recurrences
are common.
For patients with > 6 recurrences/year → daily suppressive
treatment is indicated (will not eliminate viral shedding and
transmission).
Genital herpes

36. Caused by T.pallidum which is gram negative
highly motile bacteria , spirochete in shape.
Presents as painless solitary ulcer (Chancre) , Deep
extending to the dermis with regular border and
associated with painless unilateral inguinal
lymphadenopathy (Usually in primary syphilis
infection).
The lesions disappear after 3 months.
Syphilis

37. Diagnosis:
Dark-field microscopy.
VDRL or RPR , FTA-ABS & TPPA.
Treatment:
Benzathine Penicillin G 2.4 million units IM x1 dose
 ,
repeated after 7 days , examine after 3 days , healing
after 2 weeks.
Patients may present with Jarish-Herxheimer Reaction
(Fever , Chills , Headache , Malaise , Arthralgia and
Myalgia) within 24 hours of treatment which is self
limited phenomenon.
Syphilis

38. Caused by Gram negative coccobacilli Hemophilus Ducreyi.
Presents as painful vesicular lesions (1-3 in number) then slough and
become deep ulcers with irregular border , associated with bleeding ,
foul smelling discharge and painful inguinal lymphadenopathy.
Associated with Bubo (Enlarged unilateral femoral and inguinal lymph
nodes) which appears as Grooved swelling.
Lymphogranuloma venereum:
Inguinal bubo without ulcers (Unilateral tender swelling in the groin area :inguinal
or femoral).
Caused by chlamydia L1 L2 L3.
Collection of grouped LNs.
More in heterosexuals.
Chancroid

39. Diagnosis:
Chancroid: culture for H.ducreyi (gram negative
coccobacilli)
The bacteria are often seen in short chains or parallel
arrays (‘school-of-fish’ or ‘fingerprint’ patterns).
Treatment (One of the following):
1.Azithromycin 1gm PO x1.
2.Ceftriaxone 250mg IM x1.
3.Erythromycin 500mg 4 times for 7 days.
4.Ciprofloxacin 500mg 1*2 for 3 days.
Chancroid

40. The cervix is made up of 2 types of cells:
1.The ectocervical epithelium (Stratified squamous) can become
inflamed by the same microorganisms that are responsible for
vaginitis.
2.The columnar glandular epithelium that secrets mucus can only
be infected by N.Gonorrheae & C.trachomatis.
Microbiology:
•Chlamydia and Neisseria infect:
–Urethra.
–Endocervix.
–Endometrium.
–Bartholin glands.
1.So they present with Urinary symptoms or genital symptoms.
Cervicitis

41. •Chlamydia:
G-ve intracellular cocci.
Caused by : C. trachomatis D or K serovars.
75% cases asymptomatic.
Commonly present with abnormal vaginal discharge, Dysuria,
intermenstrual spotting, postcoital bleeding.
Dysuria and Urethral discharge in males.
Diagnosis:
NAAT(nucleic acid amplification testing).
Growth on McCoy cell lines media.
Treatment (One of the following):
•Azithromycin 1gm orally (single dose).
•Doxycycline 100 mg orally twice daily for 7 days (C/I during
pregnancy).
Cervicitis

42. •Gonorrhea:
Caused by: N. gonorrhoeae (G-ve intracellular
diplococci).
Endocervical infection 50% asymptomatic.
Present with vaginal discharge, dysuria, abnormal
uterine bleeding.
Diagnosis:
Culture (Thayer Martin).
NAAT.
Treatment (One of the following):
•Cefixime 400mg single dose orally.
•Ceftriaxone 250mg IM single dose.
Cervicitis
+ Azithromycin
to cover
chlamydia

43. •Symptoms:
1.Asymptomatic.
2.Presents with Purulent vaginal discharge (Yellowish in
color).
3.Post-coital bleeding due to friability of the tissues.
4.Intermenstrual bleeding in some patients.
•Symptoms of endometritis include:
Abnormal uterine bleeding (Post-coital bleeding ,
Intermenstrual bleeding , Heavy periods).
Cervicitis

44. Diagnosis:
•The diagnosis of cervicitis is based on the finding of a :
1.Purulent endocervical discharge, generally yellow or green in color
(mucopus).
2.Sustained endocervical bleeding easily induced by gentle passage of a
cotton swab through the cervical os (because the infected endocervix is
friable tissue).
First clean the discharge by a gauze then introduce a cotton swab.
A purulent or mucopurulent endocervical exudate visible in the
endocervical canal or on an endocervical swab specimen.
Either or both signs might be present.
Cervicitis