Genital Tract Infections

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Genital Tract Infections

• A. Alobaid, MBBS, FRCS(C), FACOG
• Consultant, Gynecologic Oncology
• Assistant professor, KSU
• Medical Director, Womens Specialized Hospital
• King Fahad Medical City

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• The normal vaginal flora is predominately aerobic
  organisms
• The most common is the H peroxide producing
  lactobacilli
• The normal PH is lt4.5
• 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)

• Diagnosis
• Fishy odor (especially after intercourse)
• Gray secretions
• Presence of clue cells
• PH gt4.5
• ve whiff test (adding KOH to the vaginal
  secretions will give a fishy odor)

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Bacterial Vaginosis (BV)

• 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

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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

• 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 gt5
• Microscopy motile trichomands and ? leukocytes
• Clue cells may if BV is present
• Whiff test may be ve

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Trichomonas Vaginalis

• Treatment
• Falgyl PO (single or multi dose)
• Flagyl gel is not effective
• The partner should be treated

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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

• Predisposing factors
• Antibiotics disrupting the normal flora by ?
  lactobacilli
• Pregnancy (? cell-mediated immunity)
• Diabetes

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Candidiasis

• 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
• PHlt 4.5budding yeast or mycelia on microscopy
• The culture will confirm the diagnosis

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Candidiasis

• 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

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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

• Tests for Gonorrhea (culture on Thayer- martin
  media) and Chlamydia (ELISA, direct IFA) should
  be performed

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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
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PID
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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 behcets 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
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Genital ulcer disease

• 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

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Genital ulcer disease

• 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 gt 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

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Genital Warts

• Condyloma accuminata secondary to HPV infection
  (usually 611), these are non-oncogenic 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

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Genital Warts
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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

• 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

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• Thank you