gynecology
oj
kk
Total Lectures :17
Dr. Maad
LOWER GENITAL TRACT
INFECTION part 2
Lec . 2
Done by :
Ali Faleh
2016-2017
مكتب اشور لالستنساخ
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
1
By : Ali Faleh
Defence Mechanism Against Ascent of Infection (Natural Barrier
)
Vulva:
– Apocrine glands: modified sweat glands → fungicidal acid
– Apposition of labia closes introitus
Vagina:
– Apposition of anterior and posterior walls
– Stratified squamous epithelium resistant to infection
– Vaginal acidity
– Flora: the G+ve
Doderlein’s bacilli
splits glycogen into lactic acid
Cervix
: closed by bacteriolytic cervical mucus
Uterus:
Periodic endometrial shedding during menstruation eliminates any infection
Variations in The Efficacy of Defence Mechanism
• With Age:
During childhood and after the menopause
– Estrogen deficiency →
glycogen and Doderlein bacilli → absent vaginal
acidity.
– Endometrium poorly developed or atrophic and does not undergo cyclic
shedding.
• With menstruation:
– Absent cervical mucus plug
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
2
By : Ali Faleh
– Lowered vaginal acidity by alkaline menstruation.
•
During the puerperium
:
– Uterus, cervix & vagina widely opened
– Vaginal acidity neutralized by alkaline lochia
– Raw placental site
– Lacerations
– Low general resistance
VAGINITIS
PRIMARY VAGINITIS
• During childhood: Vulvovaginitis of children
• During the reproductive period:
– Trichomonas infection
– Monilia infection
– Bacterial vaginosis
– Puerperal infection
– Others; Gonococcal, T.B. syphilis, bilharziasis
• Post menopausal: Senile vaginitis
SECONDARY VAGINITIS
• Spread from
– Urinary conditions: Vesico-vaginal fistula
– Rectal conditions: Recto-vaginal fistula and complete perineal tear
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
3
By : Ali Faleh
• Mechanical irritation (pessary or tampon)
• Chemical irritation (drugs and douches)
• BACTERIAL VAGINOSIS
(Non-specific Vaginitis, Gardnerella Vaginitis)
• Incidence:
– The most common cause of vaginitis
– 12-25%
– 32-64% of women in clinics for STDs.
• Organism:
– Alternation of normal flora; decrease lactobacilli and increase Gardnerella
and anaerobes.
• Mode of infection:
– Sexual transmission
Clinical Picture
:
• Symptoms:
– 50% may be asymptomatic
– Discharge: thin excessive greyish frothy malodorous
– Pruritis
• Signs:
– Characteristic discharge and vulvovaginitis
• Investigations:
• Fresh drop:
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
4
By : Ali Faleh
– Clue cells; vaginal epithelium with obscured borders due to attachment of
the organism
• Culture:
– Casman’s agar
– Blood agar at 10% CO
2
• Gram stain:
– gram -ve rods, absent lactobacilli
• Whiff test:
– Discharge + 10% KOH → fishy odour
Diagnosis:
•
Amsel’s criteria
: (3 of the following criteria)
– Thin homogeneous discharge on examination.
– pH of discharge > 4.5.
– Whiff test: vaginal discharge + 10% KOH → "amine-like" or "fishy" odor.
– Clue cells on microscopy,
• Gram-stained vaginal smear
• Culture of vaginal secretions has no place in the diagnosis of BV.
Treatment
:
• A) Intravaginal preparations;
Clindamycin cream 2% at bed time for 7 days
Metronidazole once daily for 5 days
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
5
By : Ali Faleh
• B) Oral regimens:
Metronidazole as a single 2 gm dose
Clindamycin 300 mg twice daily for 7 days
• C) Sexual partner should be treated if infection is recurrent
• D) During pregnancy;
Clindamycin may be used throughout pregnancy
Metronidazole may be used after the first trimester
Trichomonas Vaginitis
• the 3
rd
most common cause for vaginitis
• Organism: Trichomonas vaginalis,
– ovoid, motile, flagellated protozoon,
– 4 anterior flagellae and an axostyle,
– 20mm in length and 10mm in width
– flourishes in weak acid medium pH 5.5-6.5.
• Sites of infection:
– Vagina, urethra, Skene’s tubules, bladder and cervix
• Mode of infection:
– Sexual intercourse
– Contaminated towels and instruments
• Clinical picture: Incubation period 3-28 days
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
6
By : Ali Faleh
• Symptoms:
– Often manifests after menstruation; vaginal pH is raised
– Profuse yellowish, frothy malodorous vaginal discharge
– Pruritis vulvae
– Vaginal soreness
– Dysparunia and dysuria
Signs:
– Vulvitis (redness, hotness, oedema)
– Vagina: red, oedematous, tender with punctate haemorrhage (strawberry
vagina)
– Cervix: Strawberry like, sometimes eccentric erosion
– The characteristic discharge (forthy, yellowish, maloderous…….. etc)
Investigations:
– Fresh smear: Shows the organism and leucocytes
– Stained film: Giemsa stain
– Culture on Finberg-Whittington media
Treatment:
– Metronidazole tablets (Flagyl):
• 500 mg/12 h for 10 days OR
• 2 gm single dose
– Protozole and Tinedazole:
• 2 gm single dose
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
7
By : Ali Faleh
• Clotrimazole, vaginal pessaries used during pregnancy and lactation in stead of
metronidazole.
• The husband should be treated at the same time
Monilia Vaginitis (Candidiasis)
• Organism:
– Candida albicans causes 90% of cases.
– C. tropicalis and C. glabrata cause 10% of cases.
– Flourishes in acidic media.
• Incidence:
– The second most common cause of vaginitis.
Mode of infections:
• May be present in the vagina and flourish
– with predisposing factors
vaginal acidity
– or suppression of other vaginal flora.
• Sexual intercourse.
Predisposing factors:
• Antibiotics →
the lactobacilli that increase Candida growth
• Oral contraceptives →
glycogen
• Pregnancy high oestrogen level →
glycogen
• Steroids and immunosuppressives lower immunity
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
8
By : Ali Faleh
• Male partner infection
• Diabetes →
glycogen deposition and low immunity
• Lack of proper hygiene
Clinical Picture:
Symptoms:
– Discharge: thick, scanty, white, curd-like, adherent
– Burning sensation in the vagina
– Itching and scratching sensation on the vulva.
– Dyspareunia and dysuria
• Signs:
– Vulvitis: redness, oedema, itching
– Vaginitis: red, tender vaginal, with adherent plaques
– Characteristic discharge
Investigations:
• Fresh drop with added 10% KOH
– G+ve spores and long pseudohyphae on wet preparation microscopic
examination.
• Stained film with methylene blue
• Culture of Feinberg-Whittington media
Treatment:
– Vaginal Antifungal preparations
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
9
By : Ali Faleh
• Vaginal suppositories or intravaginal creams with special applicator available as
either a single dose, a 3-day course, or a 7-day course
• Agents include clotrimazole, miconazole, and tioconazole preparations
Oral antifungal treatment
• Fluconazole; Single oral dose 150 mg, for treatment of uncomplicated cases
• Ketoconazole; 200 mg twice a day for 5 days, for recurrent cases. Treatment can
be repeated on special schedules along a period of 3 -6 months, for chronic cases.
Vulvovaginitis of Children
• Microorganism:
– E. coli, Strept, Staph, gonococci, Candida, Trichomonas
• Predisposing factors:
– Foreign body , (oxyuris)
– Decreased vaginal acidity
– Poor hygiene
• Mode of infection: Infected towels
Clinical picture:
– Symptoms:
• Purulent, sometimes bloody, vaginal discharge,
• Itching, pain, sometimes dysuria
– Signs:
• Foul discharge, vulvitis, vaginitis
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
10
By : Ali Faleh
Investigations:
– U.S. ± X-ray to detect foreign body
– Investigations to detect oxyuris, culture and sensitivity of discharge
Treatment:
– Treatment of oxyuris,
– Removal of foreign body
– Systemic antibiotics
– Local cleanliness with diluted antiseptics
– Estrogen: Ethinyl estradiol 10
g/12 hours for 2 weeks, followed by 10
g/day for another 2 weeks
Senile Vaginitis
• Organisms:
– Various cocci and gram-negative bacilli
• Clinical Picture:
– Symptoms:
• Purulent vaginal discharge sometimes spotting
• Pruritis: Dyspareunia
– Signs:
– Atrophy of vulva and vagina with areas of vaginal ulcerations
– Purulent (sometimes bloody) discharge
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
11
By : Ali Faleh
•
Investigations
:
– Exclude genital malignancy by Pap smear and fractional current
– Culture and sensitivity of the discharge
•
Treatment
:
– Antibiotics; ampicillin, cephalosporines,…… etc
– Topical estrogen cream and hormone replacement therapy
– Lactic acid 1% vaginal douches
Acute Cervicitis
• Acute inflammation of the endocervical glands and underlying tissues.
Cause:
– Gonococcal
– Chlamydial
– Puerperal
– Post-abortive
– Post-operative infection, after instrumentation or cervical dilatations,
cauterization or trachelorraphy (i.e. repair of a lacerated cervix)
Clinical Picture:
• Symptoms:
– Mucopurulent discharge
– Mild fever
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
12
By : Ali Faleh
– Dyspareunia and backache
• Signs:
– The cervix is red swollen with mucopurulent discharge
– Marked tenderness on moving the cervix
• Investigations:
– Culture and sensitivity of the discharge
• Treatment:
– Antibiotics , according to organism (broad spectrum)
• Complications:
– Commonly turns chronic infection due to the racemose nature of the
cervical glands
– Secondary vaginitis
– Spread to:
• upper genital tract
• parametrium
• urinary tract
Chronic Cervicitis
CLINICAL PICTURE:
• Symptoms
– Mucopurulent discharge
– Congestive dysmenorrhea and menorrhagia (pelvic congestion)
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
13
By : Ali Faleh
– Backache (spread of infection along the uterosacral ligament)
– Contact bleeding (cervical erosion)
– Dyspareunia (parametritis)
– Infertility (hostile cervical discharge)
– Frequency of micturition (cystitis)
– Manifestations of septic focus
•
Signs by Speculum examination
→
– Mucopurulent discharge coming out from the cervix (Endocervicitis)
– Cervical erosion
– Mucous polypi: reddish pedunculated small (hyperplasia of endocervical
epithelium)
– Nabothian follicles: small blue or yellowish cysts projecting on the
portiovaginalis (distended blocked cervical glands)
– Swollen, hyperaemic cervix (Chronic hypertrophic cervicitis)
– Ectropion: the anterior and posterior lips of the cervix are everted due to
bilateral cervical tears.
•
Investigations:
– Exclusion of malignancy
– Culture and sensitivity of the discharge.
• Treatment:
– Oral or vaginal Antibiotics
– Cervical Cauterization
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
14
By : Ali Faleh
– Trachelorraphy: to treat cervical tears
– Conization in suspicious lesions
Cervical Erosion (Ectopy)
• A bright red area around the external os due to replacement of the stratified
squamous epithelium of the ectocervix with endocervical columnar epithelium,
which is thin and shows the underlying blood vessels.
Etiology
• Chronic Cervicitis:
– Infected discharge produces denuded area around external os.
– Columnar epithelium grows from the cervical canal to cover the denuded
area
• Congenital erosion:
– Persistence of the intra-uterine condition where the columnar epithelium
covers an area on the ectocervix.
• Hormonal erosion:
– Excess estrogen causes the columnar epithelium to grow and replace the
stratified squamous epithelium
Clinical Picture:
• Symptoms:
– Mucous discharge
– Contact bleeding
– Symptoms of chronic cervicitis if present
• Signs:
Lower GENITAL TRACT INFECTION part 2 Dr. Maad
[Year]
15
By : Ali Faleh
– Vaginal examination: Velvety sensation and occasional contact bleeding
– Speculum examination:
– Flat erosion: red area.
– Papillary erosion; raised folds.
– Follicular erosion; glandular distension
Investigations: Vaginal and cervical smears exclude malignancy
Treatment:
• Hormonal erosion: NO ttt except if the case persists for more than three months.
• Antibiotics to treat associated infection.