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كلية الطب
⁄
جامعة بابل المرحلة الخامسة
د
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نسرين مالك
Gynaecology
Genital Tract Infections
The Objectives
1-Understand the importance of sexually transmitted infections (STIs) in gynaecology.
2- To know the testing, diagnosis and transmission of common STIs and blood-borne viruses.
3- How to provide support to the patients to enable them to undertake screening.
4- Learn how to take a sexual history.
5-Understand the diagnosis of and screening for HIV.
6- To know that human immunodeficiency virus (HIV) is, manageable condition .Describe the care for the
HIV-positive mother and child
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(I)-Lower genital tract infection:-
1- candidiasis
:-
Candida vulvovaginitis accounts for approximately one-third of vaginitis cases. It is generally not
considered a sexually transmitted disease (STD). Candida albicans is responsible for 80 to 92 percent of
episodes of vulvovaginal candidiasis .
Vulvar pruritus is the dominant feature of vulvovaginal candidiasis. Women may also complain of dysuria ,
soreness, irritation, and dyspareunia. There is often little or no discharge; that which if present is typically
white and clumpy (curd-like) which may smell yeasty, but in some cases there may be itching and redness.
Physical examination:- often reveals erythema of the vulva and vaginal mucosa and vulvar odema. The
discharge is classically described as thick, adherent, and "cottage cheese-like." However, it may also be thin
and loose, indistinguishable from the discharge of other types of vaginitis. Some patients, primarily those
with Candida glabrata infection, have little discharge and often only erythema on vaginal examination .
The pH of the vaginal fluid is usually normal ,between 3.5-4.5. The microscopy(show speckled Gram-
positive spores and long pseudohyphae ), and culture of the vaginal fluid can confirm a diagnosis.

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Factors predisposing to vaginal candidiasis:-
1-Immunosuppressive conditions like HIV, immunosupressive therapy ,e.g. steroids.and others,
2-Diabetes mellitus, 3-Vaginal douching, bubble bath, shower gel, and tight clothing.
4-Increase oestrogen, 5-Pregnancy, 6-High- dose combined oral contraceptive pill,
7-Underlying dermatosis e.g. eczema. 8- Broad-spectrum antibiotic therapy.
Treatment:-.
Application of a topical imidazole (clotrimazole,or miconazole) vaginally for 3-7 days .
Vaginal nystatin is another option, but requires prolonged therapy (7 to 14 days). Oral therapy ( azoles
group) are preferred by some women particularly if treatment needed at time of menstruation. A single dose
of 150 mg tablet of fluconazole is usually effective. The azole group are contraindicated in pregnant women
as high dose therapy has been associated with embryopathy.
2-Bacterial vaginosis (BV):-
BV is not due to a single organism. Instead it represents a complex change in the vaginal flora characterized
by a reduction in concentration of the normally dominant hydrogen-peroxide producing lactobacilli.flora is
observed, together with an elevation of vaginal pH to above 4.5. The existence of a vaginal epithelial
biofilm consisting of Gardnerella vaginalis and other species has been more recently described. The absence
of inflammation is the basis of the term "vaginosis" rather than "vaginitis" .
Higher prevalence is generally reported in women undergoing elective termination of pregnancy.
BV is not considered a sexually transmitted disease (STD) but it is probably commoner in women
with STIs, also has been reported in virgins., other risk factors include douching, black race,
smoking having a new sexual partner and receiving oral sex .The condition often arises
spontaneously around the time of menstruation and may resolve spontaneously in mid cycle.
Clinical features:-
Approximately 50 to 75 percent of women with BV are asymptomatic . Those with
symptoms present with an unpleasant, "fishy smelling" discharge that is more noticeable after coitus. The
discharge is off-white, thin, and homogeneous.
Dysuria and dyspareunia are rare, while pruritus, erythema, and inflammation are typically absent. BV can
be associated with cervicitis (endocervical mucopurulent discharge or easily induced bleeding), with or
without concomitant chlamydial or gonococcal infection,as BV is associated with a number of pathologies
including pelvic inflammatory disease (PID), posthysterectomy vaginal cuff cellulitis .And increased risk of
HIV acquisition is observed in women at with BV.

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Effect on pregnancy:-
The exact mechanism by which BV affects pregnancy outcomes is not known, but BV starts as a local
vaginal bacterial infection, which then leads to a deciduitis, then possibly to intra-amniotic infection
(amnionitis). This deciduitis or amnionitis increases inflammatory cytokines such as interleukin (IL)-1 and
tumor necrosis factor and then releases either prostaglandins known to cause uterine contractions or
proteases that may lead to second trimester abortion, PROM, or preterm labour.
Diagnosis
:-Proposed that by using Amsels criteria standardized to three out of four of the following:-
1-Vaginal discharge pH greater than 4.5.
2- Homogeneous discharge adherent to the vaginal wall.
3- Release of a fishy smell immediately upon mixture of discharge with 10 percent KOH solution.
4- Clue cells on a wet mount.
BV can also diagnosed from a Gram- stained vaginal smear. Large numbers of Gram positive and Gram
negative cocci are seen , with reduced or absent large Gram positive bacilli( Lactobacilli).
Treatment of BV :-
Oral metronidazole 400 mg twice a day for 5,or a 2 gram as a single dose.
Other type of treatment is oral clindamycin 300 mg twice a day for 5 days. Alternative treatment is
clindamycin 2 percent vaginal cream taken once daily for seven days, or 75 percent for
metronidazole gel taken twice a day for five days .Treatment indicated in women with symptoms or
those in whom it is diagnosed and elect for treatment – especially prior to gynaecological
surgical procedures. Women with BV should be advised that vaginal douching or excessive genital
washing should be avoided.
3-Trichomoniasis:-
Trichomoniasis is a sexually transmitted infection. It is caused by a single-cell parasite Trichomonas
vaginalis (TV) lives and multiplies in men, but hardly ever causes symptoms in men(mean
asymptomatic). Thus, a woman is often re-infected by her (male) partner who isn’t aware of any
symptoms. Women also may not know they have trichomoniasis for days or months and can spread
the STI to their partner. About 30% of women have symptoms of discharge or burning with
urination. The parasite affects the vagina, urethra (the canal that carries urine from the bladder to

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outside the body like fistula), some evidence of an association with pregnancy outcome: preterm
birth, low birthweight and maternal postpartum sepsis, although further research is require.
Signs and symptoms of trichomoniasis:-
Trichomoniasis in women ranges from an asymptomatic
carrier state to a severe acute inflammatory disease. The signs of trichomoniasis may include a
yellow-gray-green, frothy vaginal discharge with a foul odor, associated with burning, pruritus,
dysuria, frequency, and dyspareunia (pain during intercourse). Postcoital bleeding can occur. The
symptoms may be worse during menstruation.
Physical examination:- Often reveals erythema of the vulva and vaginal mucosa; the classic green-yellow
frothy discharge is observed in 10 to 30 percent of affected women. Punctate hemorrhages may be visible on
the vagina and cervix ("strawberry cervix", ).
Diagnosis
:-By using a cotton swab to take a sample of vaginal discharge and do some tests. the
trichomonas parasite may be seen under the microscope. Trichomonas may be suspected by the results of a
Pap smear.Trichomoniasis can also be diagnosed by a culture.
The gold standard is a nucleic acid amplification test (NAAT) preferably on a vaginal or endocervical
swab or on urine, with sensitivities and specificities reaching over 95%, depending on the specimen
and the test. Some NAATs also detect Neisseria gonorrhoea and Chlamydia trachomatis on the same
sample.
Treatment:-
Oral metronidazole 400 mg twice daily for five days ,other regimen is 2 g single dose, or
tinidazle 500 mg once daily for 5 days ,or 2g as a single dose. The antibiotics should be given for both
woman and her partner. . And they should avoid sexual intercourse until both are completely cured.
4-Bartholin's abscess
:- Bartholin's glands are situated on either side of the vagina, their ducts
are opened into the vestibule, and the function is fluid secretion to lubricate the vaginal walls during
intercourse. Cysts can develop if the ducts opening become blocked; these present as painless
swellings. If they become infected, a Bartholin's abscess develops. Examination reveals a hot, tender
abscess adjacent to the lower part of the vagina. Surgical treatment is required, this is usually done
by marsupilization and antibiotic therapy and send for culture . Culture may yield a variety of
organisms, including Neisseria gonorrhoeae, streptococci, staphylococci, mixed anaerobic organisms
or Escherichia coli .If the women aged over 40 years , a biopsy of the cyst wall should be sent for
histological examination to exclude carcinoma.
5-Infestations:-
Pubic lice and scabies are transmitted by close bodily contact.
References:-
1-Margaret Kingston, Genitourinary problems Gynecology by Ten Teachers, 2 0th Edition ,9,177-195.
2-Jonathan D.C. Ross, Acute Pelvic Infection,Dewhurst’s Textbook of Obstetrics & Gynaecology Ninth Edition
,2018;45: 611-620.