Transcript Genital Tract Infections

Genital Tract
Infections
A. Alobaid, MBBS, FRCS(C), FACOG
Consultant, Gynecologic Oncology
Assistant professor, KSU
Medical Director, Women’s Specialized Hospital
King Fahad Medical City
The normal vaginal flora is
predominately aerobic organisms
 The most common is the H+ peroxide
producing lactobacilli
 The normal PH is <4.5
 Normal vaginal secretions ↑ in the
middle of the cycle because of ↑ in the
amount of cervical mucus
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Bacterial Vaginosis (BV)
It is caused by alteration of the normal
flora, with over-growth of anaerobic
bacteria
 It is triggered by ↑ PH of the vagina
(intercourse, douches)
 Recurrences are common
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Bacterial Vaginosis (BV)
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Diagnosis:
Fishy odor (especially after intercourse)
Gray secretions
Presence of clue cells
PH >4.5
+ve whiff test (adding KOH to the vaginal
secretions will give a fishy odor)
Bacterial Vaginosis (BV)
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Treatment:
Flagyl 500mg Po Bid for one week (95%
cure)
Flagyl 2g PO x1 (84% cure)
Flagyl gel PV
Clindamycin cream PV
Clindamycin PO
Treatment of the partner is not
recommended
Trichomonas Vaginalis
It is an anaerobic parasite, that exists
only in trophozite form
 60% of patients also have BV
 70% of males will contract the disease
with single exposure
 Patients should be tested for other
STDs (HIV, Syphilis)
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Trichomonas Vaginalis
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Diagnosis:
Profuse, purulent malodorous discharge
It may be accompanied by vulvar pruritis
Secretions may exudate from the vagina
If severe → patchy vaginal edema and
strawberry cervix
PH >5
Microscopy: motile trichomands and ↑
leukocytes
Clue cells may if BV is present
Whiff test may be +ve
Trichomonas Vaginalis
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Treatment:
Falgyl PO (single or multi dose)
Flagyl gel is not effective
The partner should be treated
Candidiasis
75% of women will have at least once
during their life
 45% of women will have two or more
episodes/year
 90% of yeast infections are secondary
to Candida Albican
 Other species (glabrata, tropicalis)
tend to be resistant to treatment
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Candidiasis
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Predisposing factors:
Antibiotics: disrupting the normal
flora by ↓ lactobacilli
Pregnancy (↓ cell-mediated
immunity)
Diabetes
Candidiasis
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Diagnosis:
Vulvar pruritis and burning
The discharge vary from watery to thick cottage
cheese discharge
Vaginal soreness and dysparunea
Splash dysuria
O/E: erythema and edema of the labia and vulva
The vagina may be erythematous with adherent
whitish discharge
Cervix is normal
PH< 4.5budding yeast or mycelia on microscopy
The culture will confirm the diagnosis
Candidiasis
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Treatment:
Topical Azole drugs (80-90% effective)
Fluconazole is equally effective (Diflucan
150mg PO x1), but symptoms will not
disappear for 2-3 days
1% hydrocortisone cream may be used as
an adjuvant treatment for vulvar irritation
Chronic infections may need long-term
treatment (6 months) with weekly
Fluconazole
Inflammatory Vaginitis
Diffuse exudative discharge with
epithelial cells exfoliation
 The cause is uncertain but could be
Strept
 The treatment is with clindamycin
cream
 30% of patients will have relapse
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Atrophic Vaginitis
In post-menopausal women
 May be accompanied by purulent
discharge, dysparunea and post-coital
bleeding
 It is treated with topical Estrogen
cream
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Cervicitis
Neisseria Gonorrhea and Chlamydia
Trachomatis infect only the glandular
epithelium and are responsible for
mucopurulent endocervisitis (MPC)
 Ectocx epithelium is continuous with
the vaginal epithelium, so
Trichomonas, HSV and Candida may
cause ectocx inflammation
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Cervicitis
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Tests for Gonorrhea (culture on
Thayer- martin media) and Chlamydia
(ELISA, direct IFA) should be
performed
Pelvic Inflammatory Disease
(PID)
Ascending infection, ? Up to the
peritoneal cavity
 Organisms: Chlamydia, N Gonorrhea
 Less often: H Influenza, group A
Strept, Pneumococci, E-coli
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PID
Diagnosis: difficult because of wide
variation of signs and symptoms
 Clinical triad: fever, pelvic pain and
cervical motion and adnexal
tenderness
 Cervical motion tenderness indicate
peritoneal inflammation
 Patients may or may not have
mucopurulent discharge
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PID
PID
Tubo-ovarian Abscess
(TOA)
End-stage PID
 Causes agglutination of pelvic organs
(tubes, ovaries and bowel)
 75% of patients respond to IV
antibiotics
 Drainage may be necessary
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Genital ulcer disease
Mostly caused by HSV or Syphilis,
then chancroid, LGV, and granuloma
inguinale (donovanosis)
 Other causes: abrasions, drug
eruptions, cancer and behcet’s
disease
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Genital ulcer disease
Have to R/O syphilis by serology, dark
field examination or direct IF for
Treponema pallidum
 Culture for HSV
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Genital ulcer disease
Genital ulcer disease
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Still ¼ of the diagnosis is made by clinical
examination only:
Syphilis: non-painful, min. tender ulcer, not
accompanied by LAP
HSV: grouped vesicles mixed with ulcers
with a history of similar lesions
Chancroid: 1-3 extremely painful ulcers
with tender inguinal LAP
LGV: inguinal bubo without ulcers
Genital ulcer disease
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Treatment:
Chancroid: Azithromycin 1gm PO x1,
ceftazidime 250mg IM x1, or Erythromycin
Herpes: 1st episode is treated with acyclovir,
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)
Syphilis: Benzathine Pen G 2.4 million units
IM x1 dose
Genital Warts
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Condyloma accuminata secondary to HPV
infection (usually 6&11), these are nononcogenic types
Usually at areas affected by coitus
(posterior fourchette)
75% of partners are infected when exposed
Recurrences after treatment are secondary
to reactivation of subclinical infection
Genital Warts
HIV
20-25% of patients are women
 36% is secondary to heterosexual
transmission
 Median age between HIV infection
and AIDS is 10 years
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HIV
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Diagnosis: by HIV1 antibody test,
screening by ELISA, if +ve → confirm by
western blot
95% of the antibody is detected within 6
months of the infection
Patients are referred to a an infectious
disease specialist for treatment
CD4 is the best indicator of disease
progression
Thank you