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Genital tract infection.
Are one of the most common reasons for women of all age groups to present
to medical practitioner. It is important to differentiate normal physiological
changes from true infections. Thus, a good history & examination with lab,
testing is fundamental before diagnosis is made.
The vaginal epithelium is lined by stratified squamous epithelium during the
reproductive age group under the influence of oestrogen. The PH is usually
between (3.5-4.5)The lactobacilli are the most common organism present in
thevagina . after the menopause the influence of oestrogen is decline making
vaginal epithelium with more alkaline PH of 7 the lactobacilli conc. ,decline &
the vagina is colonized by skin flora.
The physiological discharge occur in response to hormonal levels during the
menstrual cycle . it's usually white & changes to a more yellowish color due to
oxidation on contact with air. There is increased mucous production from the
cervix at the time of ovulation followed by thicker discharge (cervical plug)
under the influence of progesterone The discharge mainly consist of mucous
desquamated epithelial cells , bacteria ( lactobacilli ) & fluid.
Lower GT Infection
Vulvovaginal candidiasis:
Its caused by infection with a yeast-like fungus, the most common being
candida albicans. It's STDs & C. albicans is common commensal in the gut
flora.
Predisposing factors:
1-pregnancy
2-high dose COCP
3-antibiotics
4-immunosuppresion
5-HRT
6-HIV
7-DM
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8-anaemia
Symptoms:
1.may be carried a symptomatically.
2.vulval itching & soreness.
3.dysuria & superficial dyspareunia.
D.DX:
1-contact dermatitis. 2-allergic reaction.
3-nonspecific vaginal infection.
Diagnosis:
1-characterstic appearance of the discharge.
a-vulval& vaginal erythema. vulval fissuring.
b-typical white plaques adherent to the vaginal wall.
2-wet film: microscopic detection of spores &pseudohyphae.
3-culture from perineal& HVS & LVS.
Complication:
It's unlikely to cause any significant complications unless the women is
severely immunocompromised.
Treatment :
a-General :
1.Avoid using any soaps & perfumes .
2.Change the high dose COP to low dose COP if symptoms persist changes to
POP.
3.Cheek blood sugar to rule out any DM .
4.Avoid recurrent courses of broad spectrum antibiotics.
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b-uncomplicated infection :
1.Clotrimazol either single pessary (500 mg) or a course of (100 mg) pessary
for (6 days).
2.Flucanazol (150 mg) single dose orally.
3.Itracanazol (200 mg) twice daily orally.
4.Nystatin cream &pessary.
Notes:
1.Topical imidazole have no adverse effect on pregnancy.
2.Oral imidazole are contraindicated in pregnancy.
3.No evidence for treatment of male partner.
c-Complicated infection :
Its occur in acute sever infection.DM ,& immunosuppression
& here the topical treatment extended to up 2 weeks.
d-Recurrent infection :
Its define at least 4 episodes of infection per a year.
The treatment include induction regimen to treat the acute episode followed
by maintenance regimen to treat further recurrence, flucanazole (150 mg) is
given in 3 doses orally every (72hrs) for the induction , followed by
maintenance dose of (150 mg) weekly for (6 months).
Cure rate is (90%) at (6 months) ,& (40%) at (1 years)
In pregnancy topical imidazole can be used for (2weeks) than weekly dose of
clotrimazole (500 mg) for (6-8 weeks).
Implications in pregnancy :
It's very common in pregnancy with no adverse affect
Topical imidazole not systematically absorbed so they are safe at all
gestations.
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Trichomonasvaginalis
Trichomonas is a flagellate protozon& can cause sever vulvovaginitis. It's
usually STD & recurrence occur if the male partner is not simultaneously
treated. It can cause UTI.
Symptoms:
1.Asymptomatic carriers in (10-15%).
2.Frothy yellowish greenish offensive smelling vaginal discharge.
3.Vulval itching & soreness.
4.Dysuria & superficial dysparunia& abdominal discomfort.
Diagnosis:
1.Cervix may have a "strawberry" appearance from punctate hemorrhage .
2.Wet mount where the discharge is mixed with normal saline & examine
under microscope show motile protozon.
3.Culture on Diamond medium.
Complication :
There is evidence that Trichomoas infection may enhance HIV transmission.
Treatment:
1.Both partners should be treated & screened from other STDs.
2.Refrain from sexual intercourse until partner.
3.Metronidazole (2gm) orally in a single dose or(500 mg) twice daily for
(7days), this is should be avoid in the first trimester of pregnancy.
4.Tinidazole (2gm) orally in a single dose.
Implications in pregnancy:
1-preterm lobar 2- low birth weight
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Bacterial vaginosis:
BV is an overgrowth of mixed anaerobes including Gardnerella& mycoplasma
hominis which replace the usually dominant vaginal lactobacilli. It's not STDs
but BV is reported to be more common with: TOP, IUCD, PID.
Symptoms:
1.May be asymptomatic carrier.
2.Fishy malodorous vaginal discharge
3. more prominent during & after menstruation.
4.Greyish –white vaginal discharge commonly adherent to vaginal wall.
Diagnosis:
Amsel criteria:
a.Vaginal PH of more then 4.5,
b.Whiff test release characteristic fishy smell on adding (10%KOH) .
c.Microscopic detection of clue cells (squamous epithelial cells with bacteria
adherent to their walls).
d.Creamy grayish white discharge .
There should be at least 3 criteria for the diagnosing BV Amsel criteria .
Hay /Isoncriteria:
Grade1=normal :LB predominate.
Grade2=intermediate :LB seen with the presence of Gardnerella
Grade3=BV: LB absent with predominance of Gardnerella.
Complications:
It has been associated with risk of pelvic infection after gynae, surgery.
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Treatment :
1.metronidazole (400mg) orally twice daily for 5days or (2gm) as a single dose
or intra vaginal gel applied at night for 5-7 days.
2.clindamycin (300mg) twice daily or vaginal cream (2%).
Implicationsin pregnancy:
trimester miscarriage.
nd
Mid or late 2
PROM or preterm lobar.
Syphilis :
Its caused by Treponemapallidum a spircchaete. Infection occurs in 3 stages:
Primary syphilis
: it occurs(10-90 days) post infection with painless genital
ulcer(chancre) & inguinal LAP(enlarged groin).
Secondary syphilis
: occurs within the first 2 years of infection, generalized
polymorphic rash affecting palms & soles, generalized LAP, genital
condylomalata& ant. Uveitis.
Tertiary syphilis
: presentin 40% of people infected for > 2 year. neurosyphilis –
tabesdorsalis& dementia.
CVS syphilis--aortic aneurysm.
Gummata—inflmmatory plaques or nodules.
Diagnosis:
1.smear from the primary lesion may demonstrate spirochaetes on dark field
microscopy.
2. serological testing :TPPA( particle agglutination), TPHA(haemagglutination
assay), FTA(fluorescent trep .Abs.
Treatment:
1-procaine penicillin (1.2 mu)daily I.M for 10 days.
2-benzathine penicillin (2.4 mu)single doseI.M repeated after 7 days.
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3-doxycycline(100mg) BD orally for (14 days).
4-erythromycin(500mg)OD orally for (14 days).
5-contact tracing.
6-refrain from sexual intercourse until partner is treated.
Implications in pregnancy:
1-preterm labor 2-still birth
nerve deafness, abnormal
th
congenital syphilis: IUD ,interstitial keratitis, 8
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teeth.
Human papilloma virus: "HPV"
Its DNA virus subtypes(6&11) cause genital warts (condylomataacuminata),
subtypes (16&18) are associated with CIN & cervical neoplasia .
Symptoms:
The majority are asymptomatic , it's may cause skin irritation or their presence
may be embarrassing.
Diagnosis:
The clinical appearance of lesion & cervical smear & colpscopy & biopsy of
lesion.
Complication:
risk of high grade CIN & cervical neoplasia.
Treatment:
1-podophyllin paint applied weekly .
2- podophyllotoxin solution applied twice daily , 3days a week for 4 weeks .
3-trichloroacetic acid repeated weekly .
4-cryotherapy with liquid nitrogen .
5-surgery (excision, diathermy or laser) .
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Implications in pregnancy:
Its tends to grow rapidly in pregnancy but regress after delivery
excision is not needed because highly vascular & cause bleeding
herpes simplex virus:
its DNA virus 2 types type 1(oral ) & type 2(genital).
Symptoms:
Primary HSV is usually the most sever & often result in flulike illness, inguinal
LAP , vulvitis & pain(may cause urinary retention)
Small , characteristic vesicles on the vulva .
Recurrent attacks are thought to result from reactivation of latent virus in the
sacral ganglia & are normally shorter & less sever they triggered by stress ,
sexual intercourse, menstruation
Diagnosis:
The history & appearance of the typical rash. Swab from ulcer& serum from
vesicles & culture .
Complications:
Meningitis, sacral radiculopathy(urinary retention & constipation transverse
myelities& disseminated infections.
Treatment:
There is no cure for genital herpes, treatment just reducing the duration &
severity of primary attack if given within 5 days of onset of symptoms.
1-Acyclovir (200mg) 5times per a day.
2-analgsia & local anesthetic gels & ice pack.
Implications in pregnancy:
Miscarriage , preterm lobar but no related congenital defects.
This lecture by dr .Nadia AL-Assady
CABOG-FIBOG