Genital infections in gynecology

Lectures on Gynecology
Dr Magda Helmi

Genital infections are one of the most common reasons
for women of all age groups to present to a medical
practitioner.
Sexually transmitted infections form one subgroup of
infections, however the more common infections are
vulvovaginal candidiasis and bacterial vaginosis.
Chlamydia and gonorrhoea affect the sexually active
woman, with HlV.
These infections can be asymptomatic and can have
serious consequences to a woman’s fertility by causing
tubal infection and damage.
Appropriate diagnosis and treatment are fundamental
not only to provide symptom relief, but also to prevent
recurrences and long-term squeals

It is important to differentiate normal
physiological
changes from true infections. Thus, a thorough
history and examination with the back up of
laboratory testing is fundamental before a
diagnosis is made.
However, the sensitivity of clinical diagnosis
and testing in pelvic inflammatory disease
(PID)
can be low, so if there is a clinical suspicion of
PID,
empiric treatment is recommended.

Anatomy and physiology:
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 and 4.5 and lactobacilli (Figure 6.1a) are the most common
organisms present in the vagina. Following the menopause, the influence of
oestrogen is diminished making the vaginal epithelium atrophic with a more
alkaline pH of 7.0, the lactobacillus population declines and the vagina is
colonized by skin flora.
Physiological discharge occurs in response to hormonal levels during the
menstrual cycle. It is usually white and changes to a more yellowish colour due
to oxidation on contact with air.
There is increased mucous production from the cervix at the time of ovulation
followed by a thicker discharge/cervical plug under the influence of
progesterone. The discharge mainly consists of mucous, desquamated
epithelial cells, bacteria (lactobacillius) and fluid.
Ascending infection can occur from the vagina and cervix to the uterine cavity
and to the Fallopian tubes through direct spread or via the lymphatics leading
to severe pelvic inflammatory disease and pelvic peritonitis.
Infections can be broadly divided into lower and upper genital tract depending
on the site and affection of the infective organism.

 Vaginal and cervical
flora (all ><1000
magnified). Normal:
lactobacilli - seen as
large Gram-positive
rods
 - predominate.
Squamous epithelial
cells are Gram negative
with a large amount of
cytoplasm. (b)
Cnandidiasis: (c) (d) :

Lower genital tract
infections
Vulvovaginal candidiasis
Candida, a commensal organism, is found in
small population densities in the vaginal
ecosystems of nearly one third of healthy
women. Symptomatic infection arises,
however, when proliferation causes a shift
from colonization to frank adherence and
infection. It is caused by Candida albicans in
around 80-92 per cent of cases. Other non
albican species like C.tropicalis, C. glabmta,
C. krusei and C. parupsilosis can also cause
similar symptoms, although sometimes more
severe and recurrent. C. albicans is a diploid
fungus and is a common commensal in the
gut flora.
The patent complain of: Vulval itching and
soreness, thick curdy vaginal discharge
dyspareunia and dysuna. Vulval oedema,
vulvai excoriation, redness and erythema.
Normal vaginal pH,
there are speckled Gram-positive
spores and log pseudohyphae visible.
There are numerous polymorphs
present and the bacterial flora is
abnormal, resembling bacterial
vaginosis.

Microscopy of the discharge with
10% KOH will often reveal hyphae
or budding yeast in 50%-70% of
cases albicans organisms are
easiest to identify, as they have
long hyphae with blastospores
along their length and a terminal
cluster of chlamydiaspores . The
"atypical" species of yeast,
however, may only have features
of budding yeast (resembling
small snowmen), which are easily
obscured within surrounding
cellular debris.

The trichomonad parasite is a
flagellated protozoan that
causes up to 25% of vaginitis
cases. While trichomonas
infection is asymptomatic up to
50% of the time,when clinical
signs are present they include
irritation and soreness of the
vulva, perineum, and thighs,
with dyspareunia and dysuria.
Typically, the trichomonas
infection is accompanied by a
copious, greenish-yellow frothy
discharge. Unlike bacterial
vaginosis, it seems that
trichomonas is primarily a
sexually transmitted infection.

. The diagnosis is made by observation of
the following features (Table I):
A foul-smelling frothy discharge (present
in 35% of cases
Vaginal pH >4.5 (70% of cases)
Punctate cervical microhemorrhages
(25%)
Motile trichomonads on wet mount (50%-
75%)
Papanicolaou smear is quoted to be 70%
sensitive in identifying trichomonads.
The current primary treatment
recommendation is a single 2g dose of
oral metronidazole. For those who cannot
tolerate this single large dose, 500mg bid
for 7 days is equally efficacious if the
patient completes her regimen. The male
partner(s) must also receive treatment.

 Bacterial vaginosis: there is
an overgrowth of anaerobic
organisms, including
Gardnere/Ia vagina/is (small
Gram-variable cocci), and a
decrease in the numbers of
lactobacilli. A 'clue cell’ is
seen.
 On wet preparation of
vaginal fluid, absence of
WBCs and stippling of
epithelial cells support a
diagnosis of bacterial
vaginosis.

The diagnosis of BV requires the presence of at least 3 of the following 4 criteria.
A homogenous noninflammatory discharge (not many WBCs).
Vaginal pH >4.5.
Clue cells (bacteria attached to the borders of epithelial cells, >20 % of epithelial cells;
Whiff test positive for fishy or musty odor when alkaline KOH solution added to smear.
For years, oral metronidazole has been the primary indicated regimen. Other systemic options
include oral clindamycin.
Pap smear showing clue cells consistent with bacterial
vaginos

According to 2008 WHO estimates,
499 million new cases of curable
sexually transmitted infections (ie,
syphilis, gonorrhoea, chlamydia,
trichomoniasis) occur annually
throughout the world in adults aged 15-
49 years.
Tubal scarring as a result of PID can
cause infertility in 20%, ectopic
pregnancy in 9%, and chronic pelvic
pain in 18% of women[
Complicated PID resulting in tubo-ovarian
or pelvic abscess may
contribute to patient mortality.

PID is a complex polymicrobial disease that is
due to the ascending spread of pathogens from
the cervix or vagina, most
commonly Chlamydia, trachomatis or Neisseria
gonorrhoeae (60-75%) , which then spreads
into the endometrium, fallopian tubes, ovaries,
and adjacent structures.
Other pathogens include Mycoplasma
hominis, Haemophilus
influenzae,Streptococcus
pyogenes, Bacteroides species,
and Peptostreptococcus species. Less
commonly, direct spread from a nearby
infection such
as appendicitis ordiverticulitis may occur.
Hematogenous infection is a rare cause of PID
except in cases of tuberculous.
Douching is a potential risk factor for PID as it
can result in a change of the vaginal flora and
introduce bacteria from the vagina into the
upper reproductive organs. Usage of
intrauterine contraceptive device or
gynecologic interventions may also predispose
a patient to PID. Direct extension of infection
from adjacent viscera and uterine
instrumentation are more important risk factors
in postmenopausal PID

 Abdominal, pelvic pain and
dyspareunla.
 Mucopufulent vaginal
discharge
 Pyrexia (>38‘C).
 Heavy/ime.rmenslrual
bleedlng
 Pelvic tenderness and Tender
adnexal or palpable pelvic
mass,
 Generalized sepsis in severe
and sysmmic infection
 Tubal damage leading to tubal
occlusion, abscess and
hydrosalpinx.

Based on clinical findings:
Raised white cell count (neutrophilia
suggestive of acute inflammatory
process)
Reduced white cell count
(neutropenia in severe infections)
Raised C reactive protein and ESR
(erythrocyte sedimentation rate)
Adnexal masses on ultrasound
Laparoscopy is the gold standard to
give a definitive diagnosis, however,
in mild cases it may
not be very obvious.

 Depending on the severity of the infection, patients with mild/moderate
disease can be managed on an outpatient basis with easy access to hospital
admission if the infection becomes more severe. An intrauterine
contraceptive device, if present, should be removed and alternative
emergency contraception or other modes of contraception (combined pill,
oral/parenteral progesterone) should be offered. A
 pregnancy test should be done in all cases to rule out ectopic pregnancy.
 There are several differing antibiotic regimes that are used; however, the
following is recommended by the RCOG Green Top Guideline (2008) which
is evidence based.
Mild/moderate infection (outpatient treatment)
 Oral ofloxacin 400 mg twice a day + oral
 metronidazole 400 mg twice a day x 14 days
 Ceftriaxone 250 mg single intramuscular injection + oral doxycycline 100 mg
twice a day
 oral metronidazole 400 mg twice a day x 14 days
 Single intramuscular dose of ceftriaxone 250 mg azithrornycin 1 g/week x 2
weeks.
The data supporting the use of azithromycin are limited and should not be used
in isolation.

Causative organism
Herpes simplex virus type I (usually oral) or
type II (usually genital).
Clinical features
Painful vesicles and multiple ulcerations on
vulva, Retention of urine.
Diagnosis
Swab from ulcer, Serum from vesicle, Virus
seen on electron microscopy, Culture.
Treatment
Acyclovir 200 ml five times/ day
Famciclovir, Valaciclovir,
Analgesics and local unaesthetic gels

Causative organism:
Human papillomavirus, HPV6and11, HPV 16 and 18,
linked to cervical caner.
Clinical features:
Warty lesions on the vulva, vagina, cervix and perianal
area.
Also seen around mouth, lips and larynx if orogenital
contact.
Diagnosis:
Clinical examination:
Histology of removed wart Seen on cervical smear and
colposcopy
Treatment:
Podophyllin; local application twice a week, Surgical
excision, Laser, Cryotherapy.

Causative organism:
Treponema pallidum
Clinical features:
Primary syphilis: Painless ulcer/ulcers on vulva, vagina or cervix, Enlarged
groin/inguinal lymph nodes
Secondary syphilis: maculopapular, rash on palms and soles. Mucous
membrane ulcers, Generalized lymphadenopath, arthritis
Neurosyphilis: meningitis, strok, tabes dorsalis
Cardiovascular: aortic aneurysm
Congenital syphilis: intrauterine death, interstitial keratitis, VIII nerve
deafness, abnormal teeth
Diagnosis:
TPPA: Treponema pallidum particle agglutination.
TPHA: Treponema pallidum haemagglutinatio assay.
FTA: Fluorescent treponemal antibody.
Dark Held illumination: serum from base of ulcer + saline taken and seen
under the microscope. Spiral organisms with characteristic movements
are diagnostic
Treatment:
Penicillin mainstay of treatment Procaine, penicillin, 1.2 MU daily, i.m. x
12 days, Benzathine penicillin, 2.4 MU i.m. repeated after 7 days.
Doxycycline 100 mg bd x 14 days.
Erythromycin 500 mg qds x 14 days mm.

Causative organism:
Mycobacterium tuberculosis.
Clinical features:
Usually following pulmonary tuberculosis through blood and lymphatics,
Amenorrhoea (affects endometrium) Infertility (affects tube), Acute/ chronic pelvic
pain, Frozen pelvis due to severe multiple adhesions.
Diagnosis:
Histological confirmation from endometrium and Fallopian tube, Mantoux test, Heaf
test, Chest x-ray.
Treatment:
Rifampicin, Isoniazid, Pyrazinamide. Treatments can, last from six to 12 months.

Causative organism:
Haemophilus ducreyi.
Clinical features:
Painful shallow multiple ulcers, Regional
lymphadenopathy with suppuration.
Diagnosis:
Isolation of Ducrey’s bacillus on biopsy on
biopsy.
Treatment:
Single oral dose of azethromycin, Ceftriaxone,
Erythrofpycin.

Causative organism:
Klebsiella grarnulomatoses.
Clinical features:
Painless nodule.
Diagnosis:
Donovan bodies:intracellular inclusions seen in
phagocytes or histiocytes.
Treatment:
Erythromycin.

Painful ulcers, Local tissue, destruction, treated with Streptomycn,
tetracyclin

ONE IS TERMED LACTOBACILLOSIS OR
DÖDERLEIN CYTOLYSIS. THIS ENTITY IS
CHARACTERIZED BY AN OVERGROWTH OF
THE COMMENSAL LACTOBACILLI HENCE,
ON SALINE WET MOUNT, ONE FINDS AN
EXCESSIVE NUMBER OF BACILLI AMONG
THE BACKGROUND FLORA. THE PH IS
TYPICALLY LOW-NORMAL. TREATMENT,
THEREFORE, IS DIRECTED AT
CORRECTING THE DISRUPTION OF THE
VAGINAL ECOSYSTEM IN ORDER TO LIMIT
THE EXCESSIVE PROLIFERATION OF
THESE PROTECTIVE ORGANISMS.
INFLAMMATORY VAGINITIS, FEATURES A
VAGINAL PH ABOVE 4.2, LARGE NUMBERS
OF LEUKOCYTES, AND SOME PARABASAL
AND BASAL VAGINAL CELLS, WITH A
PAUCITY OF SUPERFICIAL SQUAMOUS
CELLS. CLINICIANS OFTEN FIND THAT
PATIENTS ARE INFECTED WITH GROUP A
OR GROUP B STREPTOCOCCUS
THEREFORE, BECAUSE INFECTION IS
SUSPECTED TO UNDERLIE THE
INFLAMMATION AND DESQUAMATION,
TREATMENTS DIRECTED AGAINST
BACTERIAL VAGINOSIS ARE
RECOMMENDED.

Genital infections in gynecology

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