Genital

tract infection
Objectives
To list possible causes of GTI
Describe character of the different
discharges
List the possible diagnostic tools and
treatment modalities
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. ‫ﻣﻦ ﻋﻨﺪﻱ ﺍﺳﺘﺮﻭﺟﻴﻦ ﻣﻌﻨﺎﻫﺎ‬
stratified squamus ‫ﻋﻨﺪﻱ‬
.epi

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: due to low estrogen

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 cuff ‫ﺗﺼﻴﺮ ﻋﺪﻧﺎ ﺣﺎﻟﻪ ﻧﺴﻤﻴﻬﺎ ﺍﻝ‬
alteration in flora ‫ ﺍﻧﺸﺎﻝ ﻓﺤﻴﺼﻴﺮ ﻋﺪﻧﺎ‬secretions ‫ﻻﻧﻮ ﺟﺰء ﻣﻦ ﺍﻝ‬
 ▪Any Discharge
colour?
Vaginal discharge : odor?
time?

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.

due to peak of Estrogen

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.
Clue cells are vaginal squamous epithelial cells coated with the anaerobic gram-variable
coccobacilli Gardnerella vaginalis and other anaerobic bacteria causing bacterial
vaginosis.
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 preterm labour

= = of endometritis following termination

of pregnancy.
Increase risk of pelvic infection after hysterectomy.
g

Treatment of recurrent BV
Pt. kept on once or twice a month on oral or
topical metronidazol.
Candidiasis -->Not STD

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
-->flaring of candida
Microscopic exam. Reveal the presence of
pseudohyphae and mycelia.
Culture is not routinly recommended except in
those with failed empric treatment.
RISK FACTORS: -->causes for Recurrent Candidiasis

--immune suppression
--HIV-- ---underlying dermatosis
--DM ----broadspectrum AB
--vaginal douching
--pregnancy
--cocp and increase oestrogen
CLASSIFICATION :
‫ﺳﺆﺍﻝ ﺍﺳﻲ‬
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: Total duration one week

--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.
Trichomoniasis:
It is a STD
-can be asym.for several months
In men it is often asym.but may present as non
gonococcal urethritis.(70% of male are asym.)
C/F
In female present with severe vulvovaginitis
,purulent and s.t offensive vx discharge and in
many case BV develop as well.the parasite is a
marker of high risk sexual behaviour and co
infection with other STD is common esp.N.G.
The parasite has prediction for sq.epith.
Exam;
Yellow-green vx discharge with inflammation s.t
extend out to the vulva and adjacent
skin.punctate haemorrhage occur on the cx
giving the appearance of STRAWBERRY CX (due
to subepith.haemorrhage.)
Dx:
Incubation of T.vaginlis require 3days -4
wks(vx,urethra,cx,UB)can be infected.no
symp.may be present for up to 50% of
female.and such colonization may persist for
months or years .
In those with compliant:
green severe
1-c/f(discharge+signs of vulvovaginitis)
with severe itching and excoriation
2-strawberry cx on exam.
3-microscopic identification of the parasite in saline
prepration .parasite is ant. Flagellated ,motile,an
aerobic protozoa.they are oval in shape slightly
larger than WBC and become less mobile with
cooling ,so the slide should be read within 20
min.sensitivity is 60%
Vx PH RISE.
NAAT ----sensitive and specific
Screen for other STD AND THE PARTNER.
TREATMENT:
Metronidazole single 1 gm oral
= 500 mg *2 for 7 days
Tinidazol 2g oral single dose
Rx partner
BARTHOLIN ABSCESS:bartholin glands situated on
either side of vaginal opening .if the opening of the
gland closed –cyst----if infected---abscess
Treatment AB +marsupilisation.
 marsupilisation
•-->suturing the cyst wall with the lining epithelium
•-->if doesn't suture it
you will end with recurrent Bartholin abcess
UPPER GENITAL TRACT INFECTION(PID):
Term used to describe upper GT
infection(endometritis,parametritis,salpingitis,o
ophoritis).these infection usually spread from
the cx and vx , through lymphatics,bowel,blood
born.80% of microorganisms are STD either GC
or chlamydia+secondary invadors such as
bacteroids and mycoplasma.
PID is an important condition because it result
oin tubal damage and infertility and ectopic preg
and chronic pelvic pain .
Chlamydia trachomatis:
It is the commonest bacterial STD in the
developed country esp. in female less than 25
years.many infection are asym.(50% in male,80%
in female).in male it is the most common cause of
non gonococcurethritis.in female it cause
cervivisitis and PID.genital strains can colonize the
throat and can cause conjuctivitis.
Chlamydia T. :
Small bacterium ,obligate intracellular pathogen
.serotypes (A—C) cause trachoma,D—K cause
genital ,L1—L3 lymphogranuloma venereum.
 MCQ
The infectious particles are the elementary bodies
that infect the columner epith. They gain entry to the
cells by binding to specific surface receptors .once
they enter the cell ----inclusion bodies which contain
metabolically active reticulate bodies .these divide by
binary fission .after 48 hours reticulate bodies
condens into elementary bodies which are released
from the cells.heavily infected cells die but it is the
inflammatory response to infection that cause most
of the damage.cell mediated immunity is the
important type of immunity in controlling infections
,antibodies are serovar specific.
cell mediated immunity is cause of Damage not the Bacteria
Dx: samples from endocx (columnar epith.)
ELISA—limited sensitivity
PCR AND LCR ---more sensitive(APPLIED TO
URINE AND VAGINAL SAMPLES)
TREATMENT:
Doxycycline 100mg*2 for 7 days
Azithromycin 1 gm single dose
+ 1g of Flagyl

Ofloxacin 400mg daily for 7 days

In pregnancy
Azithromycin 1 gm single dose
Erthryromycin 500mg *2 for 14 days
Gonorrhoea (GC)
Decline incidence (1%)
50% of female are asym,while 70% of male are
sym(severe urethritis,dysuria and green urethral
discharge)
Organism is Gm –ve diplococci which colonize
columnar and cuboidal epith
Protective immunity not appear to develop.
No reliable serologic test for GC
High resistant strains for penicilline appear because
of bad use of AB.
DX
Observing Gm –ve intracellular diplococci on gram
stained smears from urethra an,cx and rectal swab.
DNA based detection tests are available for
screening .but culture is necessory for AB
sensitivity test.
Rt:
Amoxycillin 1gm with probenecid 2gm –single
dose
Ciprofloxacin 500mg as single dose
Azithromycin 1gm single dose
Ceftriaxone 250 mg as single dose i.m
Cefixime 400mg as single dose
Mention the Single Dose used for
▪Chlamydia➡Azithromycin
▪GC ➡Azithromycin

DDX of Adenxial mass

-->Tube
-->Ovary
-->Broad Ligament
 PID
Ascending infection from lower genital tract to the
uterus result in the development of endometritis and
1

may be runs asym.or causing m.c irregularity

2
(intermenstrual bleeding ).involvement of fallopian
tube (salpingitis)started first at the mucosa with
inflammation ,redness and swelling and destruction
of the cilia.PMN invade the submucosa with
inflammatory cell infiltration and exudation which
fills the lumen of the tube and adhesion formation
between the mucosal folds---extension to the serosa
----pus exudes from the fimbriae to the ovaries and
adenexae.at lap. The tubes appears red and swollen
In mild cases and in severe cases the tubes are fixed
to the adjacent structures by adhesions .with pelvic
peritonitis all organs are congested with multiple
adhesions producing inflammatory mass(tubo
ovarian abscess)-----destuction of fimbriae ,fixation
of uterus and dilation of tubes with fluid
accummulation-(hydrosalpinx) and pus
(pyosalpinx).
Risk factors:douching,substance abuse,multiple
partner,young age,other STD, previous pid,endocx
swab +ve for GC or chlamydia .
c/f
Silent PID--- dx at lap. – see adhesion of prior
infection
Acute PID:
CRITERIA TO DX ACUTE PID:
In female who develop symp.during M.C or following
it the most recent recommonded criteria :lower
abdomenal pain with uterine and adenxial tenderness
or cervical tenderness.one or more of the following
enhances dxitic specificity:
1- oral temp .more than 38.3
2-mucopurulent cx or vx discharge
3-abundant WBC on cx secretion exam.
4-increase ESR or C-RP
5- presence of cx GC or chlamydia
Symptoms and physical findings:
Presenting symptoms may include lower
abdomenal pain and or pelvic pain ,yellow vx
discharge
,menorrhagia,fever,chills,N&V,dysmenorrhoea
&dyspareunia,urinary symptoms.during bimanual
exam. Female have pelvic organ tenderness ,cx
excitation +ve,lower abdomenal tenderness and
rebound tenderness.laproscope is the gold
standard method for the dx ,u/s (tubo ovarian
abscess and exclude other pathology)
Chronic PID;
HSTOLOGIC DX(described for female with hx of
acute PID who have pelvic pain )
Treatment:
Early dx and treatment of acute PID can relief
sympt.and decrease its sequelae (tubal
damage,infertility,ectopic preg,chronic pelvic pain
,abscess formation)
1-OUTPATIENT :
for female with mild –moderate clinical sympt.
Oral regimens: cover GC, Chlamydia + anerobes ‫ﻧﺤﺎﻭﻝ‬
A:ofloxacin 400mg once /d for 14 days
+/- metronidazole 500mg *2 for 14 days
B:ceftriaxone 250 mg i.m once +doxycyclin 100mg
oral *2 for 14 days +/- metronidazole 500mg *2 for 14
days
Parental regimens :
Indicated in female whith severe PID, failure of oral
treatment after 72 hrs
a:clindamycin900mgi.v every 8hrs +gentamycin
5mg/kg single daily dose
B: levofloxacin 500mg i.v once daily +/- metronidazole
500mg i.v every 8 hrs.
Genital ulcer
D dx-------infective (HSV, primaty syphilis,LGV,
chancroid, ,HIV)
----------non infective(apthus,trauma,skin
disease,Behcet disease,dermatosis)
HSV
TYPE 1 CAUSE ORAL LESION
Type 2 cause genital .
50% of genital caused by type 1
Primary infection present 3 wks after acquision of
virus with wide spread involvement of the vulva,
vx,and cx.painful vesicle develop—unite—multiple
ulcers.
Periurethral involvement may cause urinary retension
and this may also be partly due to sacral n
involvement.if seen very early primary HSV may only
affect a smaal part of the vulva(confused as
recurrence) and the coarse of antivirus for 5 days may
be effective
The dx confirmed by taking serum from the vesicle
with small gauge needle and syringe or by cotton swab
and examned under microscope
Treatment
Analgesia and bathing in salt water
Llignocaine gel on sore area,antiviral acyclovir 200 mg
5 times daily for 5 days,other antiviral like famciclover
and valaciclover have greater bioavailability but are
expensive.
Recurrent herps
HSV colonise the dorsal root ganglion and establish
a latent infection producing infectionintermittently
along the axons to the skin.vesicles and ulcers then
occur usually occur in the same area.
Recurrent infection may be asym.
:trivial ulcer resembling small abrasion,
:localized clusters of vesicles and ulcers
over an area of 1-2 cm
:in pregnancy and decreased immunity –
large and wide spread infection
Treatment of recurrence :antivirus is not
helpful,female advise to clean the area and avoid
sex .contact
Those with frequent recurrence more than 6-8
/year kept on long term suppression with acyclovir
400mg twice /day
Complication of HSV:
1- psychological distress(LIFE LONG INFECTION)
2-aseptic meningitis
3-herpetic kertitis and blidness
4-vertical transmission to the fetus -->During Active Herpes
SYPHILIS:SYSTEMIC DISEASE,STD, caused by
treponema pallidum
The first manefistation of venereal syphilis is
kissing ulcer
PAINLESS ULACER (chancre) at the site of
inoculation ,it is usually single but can be multiple .
The regional L.N enlarge ,in female the
commonest site for chncre is the cx it may
therefore unnoticed .a chncre usually arise 3-6 wks
after infection ,painless and resolve without
treatment .chancre usually had rubbery
consistancy.---
Secondary s. can arise as the chancre disappear or
up to 6 months later.this is manifested by systemic
eruption (palm and sole ) maculopapular rash and
non itchy.mucus patches and linear ulcers (snail
track) are seen on the mucosal surfaces
.generalized LAP,alopecia,arthritis ,meningitis.
Aafter many years neurosyphilis develop.
Dx:dark field microscopy(spiral organism move and
bend in special pattern
Serologic test:FTA(fluorscent treponaemal ab test
this is most sensitive test.
TPHA(trep.pal.haemagglutination test
VDRL these test may be –ve in early disease .in
secondary s. the serologic test are +ve
Treatment:
Procaine pencillin 1.2 million unit daily i.m for 12
days
Benzathine pencillin 2.4 mu i.m repeated after 1 wk.
Doxycyclin 100mg *2 for 14 days
Erythromycin 500*4 for 14 days
Other d.dx ----read in the book
Warty lesion:
Human papilloma virus :certain strain of HPV infect the
genital area and are STD. the virus can infect the
prrineum,vx,vulva,cx and rectum.warts are frequently
multiple and slowly growing and can spread directly to
the perianal skin.majority of genital warts caused by
types (6,11)less oncogenic than (16,18)causing flat wart
and linked to ca cx .
Treatment:cryotherapy
Application of podophyllin once or twice /wk up to 6
wks.cure rate 60%.purified extract of podophyllotoxin
twice/d for 3 days with application of petrollium jelly to
near by skun .surgical treatment for intractable
cases:laser,electrocautary,or scissor excision.
Molluscum contagiosum:
Pox virus causing painless pearl shape lesion with a dimple in
,the middle up to 5 mm in diameter .common in childhood
and clear after few months .adult acquire the infection by
STD infection resolve with cryoyherapy, currete ,application
of phenol.
HIV IN GYNAE.: IMP
HIV is a retrovirus , single stranded RNA,it suppress cell
mediated immunity,mainly transmitted by intercourse.
Gynaecologic manifestations:
1-HPV flourish and genital warts persist despite aggressive
treatment.
2-persistant HPV –cervical ca, VIN Vaginal Intraepithelial Neoplasia
3-increase postpartum endometritis flaring of infection ‫<ﻳﺸﺒﻪ ﺍﻟﺒﺮﺍﻳﻤﺮﻱ‬--
4-wide spread and severe secondary HSV. ‫ﻻﻥ ﺍﺣﻨﺎ ﻛﻠﻨﺎ ﺍﻧﻮ ﺍﻟﺴﻜﻨﺪﺭﻱ ﺍﻗﻞ ﺍﻟﻤﻔﺮﻭﺽ‬
5-PID needs longer coarse of AB.
most common endemic country -->India

TUBERCULOSIS: mycobacterium can spread to the

genital organ via blood sream or through lymphatics
.ther is always TB else where us pulmonary.granuloma
develop in the fallopian tube (100% involvement of the
tube ) and then to other genital organs .infection may
remain subclinical and presenting as amenorrhoea
,infertility,or PID,.ENDOMETRIUM involved in 80%,
ovaries 20-30%,abnormal uterine bleeding in 10-40%.
ex,. Normal in many females but an adenxial mass or
fixation of pelvic organs may be detected .dx.can be
confirmed by D&C during the secretory phase and
sending the sample in N/S.
Treatment :anti TB
1.Mycobacterium Tb
Hematogenous spread(most common)

2.Genital Tract TB
always secondry to other Types of TB

3.TUBES(100%)Affected

4.How we suspect Genital Tract TB?

▪Hx
(Secondry ammenorrhea due to destruction of Endometrium)
(Infertility)

▪DX
Laprascope➡Granuloma
and Take 2 Biopsies
1➡Send in Normal saline(not formalin) for Mycobacterium Tuberculosis
2➡Send in formaline to exclude other Infections

▪Best Time for Biopsy

in the Secretory phase(Before Menses)
NOT after menses..Why?
Bcz after menses,the Endometrium has been shedded so the Bacteria has been
shedded with ir
*Barthoiln Abscess➡Marsupllisation
*Strawberry cervix➡Trichomonas
*Chlamydia➡not Itchy
*TB➡irregular menses