lower genital tract infection

GENITAL TRACT INFECTION

Lower GTI
At birth the vagina is lined by stratified sq.epith.under the influnce of maternal oestrogen.
This lining is changed to simple cuboidal in young female with neutral PH.
This lining become stratified sq. epith.with low PH at puberty under the influence of oestrogen.
Atrophic changes occur at menopause with rise in PH.

Vaginal discharge can arise from LGT or UGT.

LGT discharge could be:
1-physiological
2- bacterial vaginosis(BV)
3-candidiasis
4-tichomonas vaginalis
Normal flora:
Normal flora includes multiple aerobic,facultative
And anaerobic species.they exist in a symbiotic relationship.the function and reason of its existanc is not known.

Aerobic----GM+VE---lactobacilli,stph auerus,----

GM-VE----E-coli.,proteus,------
Anaerobic GM+VE---clostridium sp,peptostreptoco.
GM-VE---bacteroids,bacteroid fragills
Yeast candida albicans,other spp.


Vaginal PH:
Vaginal ph is acidic (4-4.5) .this acidity arise from the production of lactic acid ,fatty acid and other organic acid by lactobacilli from the glycogen in the mucosa .this glycogen content decrease in menopause---decrease acid----rise PH.

Altered flora:

1-young girls and postmenopauseal female have lower prevalance of lactobacilli compared with reproductive age female.
2-M.C may alter the flora especially during first half
3-broad spectrum AB may result in symptoms due to candida spp.

4-after hysterectomy and removal of the CX result in increase in anaerobic spp.

Vaginal discharge :
1—physiological:
Normal discharge is white ,become yellowish on cntact with air due to oxidation.it consist of :
--desequmated cells from vagina and cx
--mucus from cx glands
--bacteria (95% lactobacilli)
--fluid transudate from the vaginal wall.
Its PH IS acidic.this discharge increase normally at midcycle,pregnancy and female using COCP.

2- BACTERIAL VAGINOSIS:

BV is the COMMONEST cause of abnormal discharge in female of child bearing age.prevalance(12%).it is not considered to be STD.when BV develops the anaerobic bacteria become more predominant and increase up to thousand fold accompanied by inrease in PH (4.5-7) and disappearance of lactobaciili.
Commomest organismwith BV are –gardenella vaginalis,bacteroids,mobiluncus spp.,mycoplasma hominis.


We don’t know what tiggers these changes but certain risk factors are contributable to BV e.g vaginal douching,black race,smocking,IUCD,multiple sex partners.
The main symptoms fo BV is an offensive fishy smell discharge ,thin homogenus,adherent to vaginal wall.white or yellow .the smell mainly noticed around MC and following intercourse.
The dx commonly made in clinical practice using
AMSEL CRITERIA.

AMSEL CRITERIA:

1--Vaginal ph alkaline more than 4.5
2—release of fishy smell on addition of alkaline (10%)KOH .(whiff test)
3—special discharge on examination
4—presence of CLUE CELLS on microscopy.
Samle of vaginal discharge is taken with a cotton swab and mixed with few drops of normal saline on a slide .on microscope we see the vaginal epith. Cells are covered with bacteria to the extent that the cell borders are blurred and nnuclei are not visible.

Tretment of BV :

3 regimens of treatment are proposed for BV in non pregnant female ,cure rate (80-90%) at one week but 30% recur within 3 months.
Metronidazole 500mg oral *2 daily for 7 days.
Metronidazole(0.75%) gel --- 5gm intravaginally once daily for 5 days.
Clindamycin cream2%---5gm vaginally for 5 days.

Implication of BV in gynae.and obs.:

Increase risk of second trimester miscarriage .
Increase risk of PTL
= = of endometritis following termination of pregnancy.
Increase risk of pelvic infection after hysterectomy.


Treatment of recurrent BV
Pt. kept on once or twice a month on oral or topical metronidazol.

Candidiasis

More than 75% of female had at least one episod of candida ,few had recurrent(more than 4 /year).
-organism carried under nail,gut ,vx and skin.
--80% caused by c.albicans,
-classical presentation:
Itching ,soreness of vagina and vulva with cheesy like white discharge which may smell yeasty.vulvar erthyema ,oedema and excoriation are common findings.
--PH of vagina normal

Microscopic exam. Reveal the presence of pseudohyphae and mycelia.

Culture is not routinly recommended except in those with failed empric treatment.
RISK FACTORS:
--immune suppression
--HIV-- ---underlying dermatosis
--DM ----broadspectrum AB
--vaginal douching
--pregnancy
--cocp and increase oestrogen


CLASSIFICATION :
Uncomplicated --complicated
-sporadic -recurrent
-mild to moderate - severe
-caused by albicans spp. -- non albicans spp.
-non immune suppressed --immne suppressed

Treatment:

Local treatment is better than systemic to decrease side effect.differrent doses and duration

Intra vaginal agents:

--clotrimozole:1% cream ,5 gm vaginally 7-14 days
:100mg tablet vaginally for 7 days
--miconazole :2% cream,5gm vaginally for 7 days
:100mg supp.for 7 days
:200mg supp.for 3 days
:1200 mg once only
nystatin :100 000 unit tablet vaginally for 14 days
Oral agent 150mg oral. Treatment of recurrent is with once or twice per month for 6 months.