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 كلية الطب

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                                       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

 
(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.

 




رفعت المحاضرة من قبل: Ahmed monther Aljial
المشاهدات: لقد قام 3 أعضاء و 98 زائراً بقراءة هذه المحاضرة








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