GYNECOLOGY EXIMIUS

LOWER GENITAL TRACT INFECTIONS 2021

DR. MARITES BUTARAN FEBRUARY 2020
Infections of the vulva Bartholin gland cyst
Vulva • 2% of adult women develop enlargements of one or both glands.
• stratified squamous epithelium • Distal obstruction secondary to non-specific inflammation or
• hair follicles trauma - most common cause is cystic dilation of the bartholin
• sebaceous glands duct.
• sweat glands • Obstruction → continued secretion of glandular fluid → cystic
• apocrine glands dilation.
• bartholin glands • Most are asymptomatic
o specialized structures in the subcutaneous tissue • May vary from 1-8 cm dm
• Sensitive to hormonal and allergic influences • Usually unilateral, tense, and non-painful
• Primary and secondary bacterial, viral, parasitic, or fungal • Most cysts are unilocular
infections • Chronic or recurrent cysts: occasionally are multiple
• Vulvar pruritus 10% of outpatient gynecology visits. compartments.
o Infection or contact dermatitis
• Acute onset and short duration, itching or burning Clinical presentation
• Skin fissures and excoriation • abscess develop rapidly over 2 to 4 days with difficulty in
o Signs of infection caused by the woman’s scratching as ambulation.
a result of irritation from a vaginal discharge • acute pain and tenderness:
o Manifestation of a primary dermatologic disease. o Severe and are secondary to rapid enlargement,
hemorrhage, or secondary infection.
Causes of vulvar pruritus and irritation • signs of classic abscess:
Acute o Erythema, acute tenderness, edema and, occasionally,
Contact dermatitis Infections cellulitis of the surrounding subcutaneous tissue.
• Allergic • Candidiasis • without therapy, most abscesses rupture spontaneously by
• Irritant • Scabies 3rd/4th day.
• Human papilloma virus • unilateral or bilateral infection in most cases is not caused by sti.
• Molluscum contagiosum • (+) cultures: polymicrobial and contain a wide range of bacteria
• Trichomoniasis similar to the normal flora of the vagina.
Chronic
Contact dermatitis Infections Differential diagnosis of vulvar cysts
• Allergic • Candidiasis 1. Mesonephric cysts
• Irritant • Human papillomavirus • Generally more anterior and cephalad in the vagina
Vulvar dystrophies Neoplasia 2. Epithelial inclusion cysts
• Lichen planus • Paget disease • More superficial
• Lichen sclerosis • Vulvar cancer 3. Rarely confused with:
• Lichen simplex Atrophy • Lipoma, fibroma, hernia, vulvar varicosity, or hydrocele
chronicus
• Psoriasis Treatment
• Asymptomatic cysts women <40 years do not need treatment.
Bartholin glands infections • Simple incision and drainage: not recommended
Bartholin glands
• two rounded, pea-sized glands deep in the perineum Ø Marsupialization
• not palpable unless enlarged. • Surgical treatment of choice
• Drain via ducts 2 cm long lined by transitional epithelium and • To develop a fistulous tract from the dilated duct to the
located at the entrance of the vagina at 5 and 7 o’clock, in the vestibule.
groove between the hymen and the labia minora. • An elliptical wedge of tissue is excised over the cyst just
• mucinous secretions provide moisture for the epithelium of the proximal to the hymenal ring.
vestibule. • A cruciate incision is made into the cyst wall, and the edges
of the duct or abscess are everted and sutured to the
surrounding skin with interrupted absorbable sutures
forming an epithelialized pouch that provides ongoing
drainage for the gland.
• recurrence rate: 5% to 10%.

TRANSCRIBERS Group 7 1 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
Ø Word catheter
• an alternative surgical approach is to insert a, a short
catheter with an inflatable foley balloon, through a stab
incision into the abscess and leave it in place for 4 to 6
weeks. During this period, a tract of epithelium will form.
Ø Antibiotics
• Are not necessary unless there is an associated cellulitis
surrounding the bartholin gland abscess. Diagnosis
• All procedures above performed with local anesthesia. • Examination of the vulvar area without magnification
Ø Biopsy demonstrates eggs and adult lice, and “pepper grain” feces
• Women >40 years with gland enlargement adjacent to the hair shaft
• To exclude adenocarcinoma of the bartholin gland. • Definitive diagnosis: microscopy
Ø Excision ü (obtain specimen by scratching the skin papule with a
• indicated for persistent deep infection, multiple needle and placing the crust under a drop of mineral oil)
recurrences of abscesses, or recurrent enlargement of the
gland in women older than 40 years.
• Best to use regional block or general anesthesia for
excision.
• excision recurrent infection should be performed when the
infection is quiescent
• challenging because of the rich vascular supply to the
region and may be accompanied by
morbidity─intraoperative hemorrhage, hematoma Treatment
formation, fenestration of the labia, postoperative scarring, • Kill both the adult parasite and eggs
and associated dyspareunia. • Permethrin 1% cream rinse (nix crème)
o Applied to affected areas and washed off after ten
Pediculosis pubis minutes
• Crab louse or pubic louse phthirus pubis • Lindane 1% shampoo(kwell)
• Hairy areas of the vulva, occasionally in the eyelids o Applied for 4 minutes then washed off
• Travels slowly • Pyrethrins with piperonyl butoxide
• Transmitted by direct sexual contact
• Non-sexual transmission also documented Molluscum contagiosum
• Most contagious of all std’s • Etiologic agent : Pox virus
o >90% of sexual partners infected after single exposure • Chronic localized infection
• Major nourishment is the human blood • Spread by skin to skin contact, autoinoculation or by fomites
• Life cycle has 3 stages: • Widespread infection closely related to underlying cellular
o Eggs (nit)– deposited at the base of the hair follicle immunodeficiency (hiv infection, chemotherapy or
o Nymph corticosteroid administration)
o Adult parasite - dark gray when alimentary tract empty
• predominant clinical symptom of infestation: Clinical presentation
o Constant itching in the pubic area due to allergic • Characteristic appearance of lesion: flesh-
sensitization colored small nodules or domed papules
• pruritus may occur within 24 hrs after a reinfection usually 1-5 mm in diameter with umbilicated
center
• Complication – superinfection

Diagnosis
• Microscopy of the white waxy material from inside the nodule:
intracytoplasmic molluscum bodies with wright or giemsa stain
• Clinical

TRANSCRIBERS Group 7 2 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
Treatment • Vulvar pain, pruritus, and discharge peak between days 7 and
• Self-limiting infection 11 of the primary infection
• Individual papules • Typical woman experiences severe symptoms for~14 day
o Injection of local anesthetic à evacuation of caseous
material Recurrent genital herpes
o Excision of nodule with a sharp dermal curette • Local disease with less severe symptoms.
o Base of the papule chemically treated with ferric subsulfate • Woman = average four recurrences during first year
(monsel solution) or 85% tca o 50% of women, the first recurrence occurs within 6
months of the initial infection.
Genital ulcers • Probability and frequency of recurrence = related to the hsv
serotype.
o 80% of women with an initial genital hsv-2 infection
will experience a recurrence within 12 months
o If her primary hsv-2 infection was severe, she will have
recurrences approximately twice as often, with a
shorter time to recurrence intervals compared with
women with milder initial episodes of the disease.
o In contrast, if the initial pelvic infection was hsv-1,
there is a 55% chance of a recurrence within 1 year,
with the average rate of recurrence slightly less than
one episodeper year
Genital herpes • Vulvar involvement is usually unilateral, attacks last an average
• Recurrent viral infection of 7 days, and viral shedding occurs for approximately 5 days.
• Incurable and highly contagious • The ability to culture herpesvirus successfully from recurrent
• 75% of sexual partners of infected individuals contracting the herpetic ulcers is 40%.
disease • A common feature of recurrence is a prodromal phase of
• Among the most frequently encountered stis sacroneuralgia, vulvar burning, tenderness, and pruritus for a
• 2 distinct types few hours to 5 days before vesicle formation.
• Type 1 (hsv-1) = epithelium above the waist • Extragenital sites of recurrent infection are common. The
• Type 2 (hsv-2) = ulceration below waist herpesvirus resides in a latent phase in the dorsal root ganglia of
s2, s3, and s4.
Primary herpes • Clinical diagnosis
o History
• incubation period is between 3 and 7 days (average, 6 days)
o Pe
• paresthesia of the vulvar skin è eruption of multiple painful
Ø Simple clinical inspection
vesiclesè shallow, superficial ulcers over a large area of vulva.
Ø Vulvar ulcers
• Patients experience multiple crops of ulcers for 2 to 6 weeks.
Ø Herpes vs syphilis = herpetic ulcers are painful when
• Ulcers usually heal spontaneously without scarring
touched with a cotton-tipped applicator, whereas the
• Viral shedding may occur for 2 to 3 weeks after vulvar lesions
ulcers of syphilis are painless
appear
• Laboratory
• During primary infections, positive cultures for herpesvirus may
o Viral cultures
be obtained from lesions in 80% of women.
Ø Useful in confirming diagnosis in primary episodes
• Most symptomatic women have severe vulvar pain, tenderness,
when culture sensitivity is 80%, but less useful in
and inguinal adenopathy and simultaneous involvement of the
recurrent episodes
vagina and cervix is common
Ø Most cultures will become positive within 2 to 4 days
• Systemic symptoms:
of inoculation
o General malaise and fever
o PCR
o experienced by 70% of women
Ø Most accurate and sensitive technique for identifying
• CNS infection
herpesvirus
o Rare
o Serologic
o Mortality rate from herpes encephalitis = ~50%
Ø Helpful in determining whether a woman has been
• Urethra and bladder
infected in the past with herpesvirus
o Acute urinary retention è necessitating
catheterization.

TRANSCRIBERS Group 7 3 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
1. Western blot assay (antibodies to herpes) Lymphogranuloma venereum
o Most specific method for diagnosing recurrent herpes, as • Chronic infection of lymphatic tissue produced by chlamydia
well as unrecognized or subclinical infection. trachomatis.
o Not widely available and are difficult to perform • Vulva = most frequent site of infection
• Incubation period = 3 and 30 days.
2. Type-specific hsv serologic assays
o Useful in the following situations: Diagnosis:
Ø recurrent genital symptoms or atypical • Culture, direct immunofluorescence,
symptoms, with negative hsv cultures; • Nucleic acid detection from the pus or aspirate from a tender
Ø clinical diagnosis of genital herpes without lymph node.
laboratory confirmation; or Drug of choice
Ø partner with genital herpes Doxycycline, 100 mg twice daily for at least 21 days
• Hsv serologic testing should be considered for persons
presenting for an sti evaluation, especially for those with Three distinct phases of vulvar and perirectal LGV
multiple sex partners or hiv infection and at increased risk for hiv
1. Primary infection
acquisition. Screening for hsv-1 orhsv-2 in the general • Shallow, painless ulcer that heals rapidly without therapy.
population is not indicated.
• Vestibule or labia, occasionally in the periurethral or
perirectal region
3. Elisa and immunoblot tests 2. Secondary phase
4. Rapid serologic point-ofcare tests
• One to 4 weeks after the primary infection
5. Screening test
• Painful adenopathy in inguinal and perirectal areas.
• 2/3 women have unilateral adenopathy
Treatment
• 50% have systemic symptoms, including general malaise
and fever.
3. Tertiary phase
• Infected nodes become increasingly tender, enlarged,
matted together, and adherent to overlying skin, forming a
bubo (tender lymph nodes).
• Classic clinical sign = double genitocrural fold, or groove sign
= depression between groups of inflamed nodes.
• Extensive tissue destruction of the external genitalia and
anorectal region may occur
Granuloma inguinale (donovanosis)
• Chronic, ulcerative, bacterial infection of the skin and
• Tissue destruction and secondary extensive scarring and fibrosis
subcutaneous tissue of the vulva.
may result in elephantiasis, multiple fistulas, and stricture
• Common in tropical climates
formation of the anal canal and rectum.
• Spread sexually and through close nonsexual contact.
• Incubation period: 1 to 12 weeks.
Chancroid
• Causative agent: intracellular, gram-negative, nonmotile,
• Sexually transmitted, acute, ulcerative disease of the vulva
encapsulated rod, klebsiella granulomatis
caused by Haemophilus ducreyi.
• Nodule → gradually progresses painless →slowly progressing
• Genital ulcers of chancroid facilitate the transmission of HIV
ulcer
infection.
• Surrounded by highly vascular granulation tissue.
• Soft chancre = painful and tender
• Ulcer = beefy red appearance
• Hard chancre = usually asymptomatic
• Chronic form: scarring and lymphatic obstruction, which
• Gram stain = classic appearance of streptobacillary chains
produces marked enlargement of the vulva.
(extracellular school of fish)
• Donovan bodies = bipolar (safety pin) appearance
• Incubation period = 3 to 6 days
• Doc: azithromycin 1 g orally once a week or 500 mg daily for 3
• Tissue trauma and excoriation of the skin must precede initial
weeks and until all lesions have healed.
infection
• Sex partners of women who have granuloma inguinale should be
• Small papule→48 to 72 hours→evolves into a pustule and
examined if they have had sexual contact during the 60 days
subsequently ulcerates
preceding the onset of symptoms.
• ulcers are shallow, ragged edge, dirty, gray, necrotic, foul-
smelling exudate and lack induration at the base
• Doc: azithromycin, 1 g orally in a single dose

TRANSCRIBERS Group 7 4 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
o Ceftriaxone, 250 mg intramuscular (im) single dose • vulvar lesions of condyloma latum are large, raised, flattened,
o Ciprofloxacin, 500 mg orally twice daily for 3 days grayish white areas
o Erythromycin base, 500 mg orally three times daily for o Soft papules often coalesce to form ulcers.
7 days. o Larger than herpetic ulcers and are not tender unless
secondarily infected.
o A woman with syphilis is most infectious during the
first 1 to 2 years of disease, with decreasing infectivity
thereafter.

Latent stage of syphilis

• Duration from 2 to 20 years;
Syphilis
• Positive serology without symptoms or signs of disease
• Treponema pallidum
• Infectious
• Initially: mucous membranes
• Early latent syphilis is an infection of 1 year or less.
• Ip: 10 to 90 days, (aveof 3 weeks) w/ replication every 30 to 36
• Late latent or latent syphilis of unknown duration.
hours
o Women who have been sexually active with latent
• Early syphilis àcofactor in the transmission and acquisition of
syphilis should have a pelvic examination to discover
hiv.
potential lesions involving the vagina or cervix
• Moderately contagious disease: primary, secondary, and
probably the first year of latent syphilis.
Tertiary phase of syphilis
• Transmission: kissing or touching a person who has an active
lesion on the lips, oral cavity, breast, or genitals. • Potentially destructive effects on the central nervous,
cardiovascular, and musculoskeletal systems.
• 33% of patients who are not appropriately treated during the
primary, secondary, or latent phases of the disease
o Optic atrophy,
o Tabes dorsalis,
o Generalized paresis,
o Aortic aneurysm,
o Gummas of the skin and bones.
Ø A gumma is similar to a cold abscess, with a
necrotic center and the obliteration of small
vessels by endarteritis.

Primary syphilis
Diagnosis
• Painless papule appears at the site of inoculation 2 to 3 weeks
• Syphilis should be included in the differential diagnosis of all
after exposure.
genital ulcers and cutaneous rashes of unknown origin, and all
• Chancre: painless ulcer, 1 to 2 cm, with a raised indurated
women diagnosed with syphilis should be screened for hiv.
margin and a non-exudative base
• Definitive diagnosis: dark field microscopy
o Solitary, found on the vulva, vagina, or cervix, although
o to detect t. Palladium in lesion exudate or tissue
extragenital primary lesions, including
• Two types of serologic tests
o 5% of patients: lesions of the mouth, anal canal, and o Nonspecific nontreponemal
breast nipple, have been reported in approximately
o Specific antitreponemal antibody tests
o Nontender and firm regional adenopathy is present
during the first week of clinical disease. Non-treponemal tests
o Within 2 to 6 weeks, the painless ulcer heals
• Venereal disease research laboratory (vdrl) slide test
spontaneously
• Rapid plasma reagin (rpr)
• Advantage:
Secondary syphilis
o Inexpensive and easy to perform
• 25% primary syphilis is untreated
o Screening tests for the disease, typically become
• hematogenous dissemination of the spirochetes.
positive 4 to 6 weeks after exposure
• systemic disease that develops between 6 weeks and 6 months
o Useful index of treatment response.
(average, 9 weeks) after the primary chancre.
• Biologic false-positive results,
• an untreated attack of secondary syphilis will last 2 to 6 weeks,
o Recent febrile illness, pregnancy, immunization,
such as rash, fever, headache, malaise, lymphadenopathy, and
chronic active hepatitis, malaria, sarcoidosis,
anorexia

TRANSCRIBERS Group 7 5 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
intravenous (iv) drug use, hiv infection, advancing age, million U IV every 4 500 mg PO qid for
acute herpes simplex, andautoimmune diseases such hr, for 10-14 days 10-14 days
as lupus erythematosus or rheumatoid arthritis
• False-negative Syphilis in Pregnancy Penicillin regimen Pregnant women
o In the serumàprozone phenomenon appropriate for with a history of
stage of syphilis. penicillin allergy
Antitreponemal tests Some experts should be skin-
• More sensitive recommend tested and
o Fluorescent-labelled treponema antibody absorption additional therapy desensitized
(fta-abs) (e.g., second dose of
o The microhemagglutination assay for antibodies to t. benzathine
Pallidum (mhatp). penicillin, 2.4 million
§ Mha-tp does not have as high a rate of U IM) 1 wk after the
false-positive results as the fta-abs initial dose for those
• False-positive results occur in women with lupus erythematosus who have primay,
secondary, or early
Treatment latent syphilis
• Parenteral penicillin g 7 to 14 days
o drug of choice for syphilis. Syphilis in HIV- - Primary and secondary syphilis: Benzathine
• Benzathine penicillin g im Infected Patients penicillin G, 2.4 million U IM. Some experts
o 2.4 million units of in one dose for early syphilis (primary recommend additional treatments, such as
and early latent secondary syphilis). three weekly doses of benzathine penicillin
• allergic to penicillin G.
o Oral tetracycline 500 mg every 6 hours for 14 days, - Penicillin-allergic patients should be
o Doxycycline 100 mg orally twice a day for 2 weeks. desensitized and treated with penicillin
• Jarisch-herxheimer reaction: Latent syphilis (normal CSF examination):
o 60% of women develop an acute febrile reaction associated Benzathine penicillin G, 7.2 million U as three
with flulike symptoms such as headache and myalgia within weekly doses of 2.4 million U each
the first 24 hours after parenteral penicillin therapy for
early syphilis.
Recommended Alternative regimen Vaginitis
regimen • Vaginal discharge – most common symptom in gynecology
Early Syphilis Benzathine penicillin (penicillin-allergic • Symptoms associated w/ vaginal infection
(primary, secondary, G, 2.4 million U IM, nonpregnant o Superficial dyspareunia
and early latent one dose patients): o Dysuria
syphilis of less than Doxycycline, 100 mg o Odor
1 year in duration) orally bid for 2 wk or o Vulvar burning and pruritus
tetracycline, 500 mg • Most common cause of vaginitis
orally qid for 2 wk o Fungus (candidiasis), protozoan (trichomonas)
o A disruption of the vaginal bacterial ecosystem leading to
Late Latent Syphilis Doxycycline 100 mg Benzathine penicillin bacteria vaginosis
(>1 year in duration, orally 2 times a day G, 7.2 million U • Vaginal environment (dynamic ecosystem)
gummas, and for 2 wk if <1 year, total, administered o Ph: 4.0 (premenopausal women)
cardiovascular otherwise, for 4 wk; as three doses of 2.4 Ø Estrogen – stimulates glycogen content of vaginal
syphilis) or tetracycline, 500 million U IM at 1-wk epithelial cells
mg orally qid for 2 intervals Ø Lactobacillus – regulator of normal vaginal flora,
wk if <1 year; inhibits adherence of bacteria to vaginal epithelial cells
otherwise, for 4 wk • Measurement of vaginal acidity
o One of the most helpful diagnostic aids in the differential
Neurosyphilis Aqueous crystalline Procaine penicillin, diagnosis of vaginitis
penicillin G, 18-24 2.4 million U IM • Ph >5.0
million U daily, daily, for 10-14 days o Bacterial vaginosis
administered as 3-4 plus probenecid, o Trichomonas infection
o Atrophic vaginal discharge

TRANSCRIBERS Group 7 6 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
• Ph <4.5 • Normal vaginal secretions
o Physiologic discharge o White floccular or curdy, and odorless
o Fungal infection o Physiologic discharge – normally present only in the
• Cervical mucus and semen dependent portions of the vaginal discharge
o Neutral to basic ph • Pathologic discharge – usually involve the anterior and lateral
o Temporarily change normal acidity walls of vagina
o Semen – buffer vaginal acidity for 6 to 8 hours • Fungal infections – thick, white, curdy, patchy discharge
• Vaginal pH – slightly higher in postmenopausal • Trichomonas & bacterial vaginosis – gray white discharge with
• Vaginal discharge thin and usually profuse; foul odor
o Cervical and vaginal epithelial cells Bacterial vaginosis
o Normal bacterial flora • Most prevalent cause of symptomatic vaginitis
o Water • Reflects shift in vaginal flora from lactobacilli-dominant to mixed
o Electrolytes flora
o Other chemicals • “sexually associated” infection
• Bacterial organisms = 108 – 109 colonies/ml of vaginal fluid • Risk factors
o Anaerobe and aerobe o New or multiple sexual partners
Aerobic bacteria Anaerobic bacteria – 80% o Woman – woman intercourse
Lactobacilli Preptococcus o Douching
Diptheroids Peptostreptococcus o Social stress
Streptococci Bacteroids o Lack of hydrogen peroxide-producing lactobacilli
Staphylococcus epidermidis Candida and mycoplasma • More common in lesbian couples who share sex toy without
Gardnerella vaginalis – common inhabitants of cleaning between use
Mc gram negative bacillus asymptomatic women • Histologically - Absence of inflammation
– e. Coli • Associated with upper tract infections
o Endometritis
o Pid
o Postoperative vaginal cuff cellulitis
• Multiple complications during pregnancy
o Prom
o Endomyometritis
o Decreased success with in vitro fertilization
o Increase pregnancy loss
• Unpleasant vaginal odor – most frequent symptom
o Stronger after intercourse because of alkaline semen à
release of aromatic amines
• Bacterial vaginosis (discharge)
o Thin
o Mildly adherent
o Frothy
o Pruritus and vulvar irritation (rare)
• Wet smear- Clumps of bacteria and clue cells

TRANSCRIBERS Group 7 7 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
• Trichomonas is a hardy organism and will survive for up to 24
hours on a wet towel and up to 6 hours on a moist surface
Symptoms
• Most women are asymptomatic.
• But when symptomatic, primary symptom of trichomonas
vaginal infection is profuse vaginal discharge
Diagnosing bacterial vaginosis • Erythema and edema of the vulva and vagina. Vulvar skin
1. Homogeneous vaginal discharge is present • Involvement is limited to the vestibule and labia minora, which
2. Vaginal discharge has a ph of 4.5 or higher helps distinguish it from the more extensive vulvar involvement
3. Vaginal discharge has an amine-like odor when mixed with of candida vulvovaginitis.
potassium hydroxide (whiff test) • T. Vaginalis is associated with upper genital tract infections,
4. Wet smear of the vaginal discharge demonstrates clue cells including infections after delivery, surgery, abortion, pelvic
more than 20% of the number of the vaginal epithelial cells inflammatory disease, preterm delivery, infertility, and cervical
• Gram staining dysplasia treatment.
o Excellent diagnostic method Discharge color may be white, gray,
• Colorimetric test yellow, or green, and the classic
o Detects proline iminopeptidase has been developed for discharge of trichomonas infection is
office use termed frothy (with bubbles) and
• Enzyme levels in vaginal fluid are elevated often has an unpleasant odor.
• Vaginal bacterial culture - no role in the evaluation

Treatment Classic sign of a strawberry

appearance of the upper vagina and
• Decrease anaerobes with antibiotic therapy and hope the
woman will regenerate her own lactobacilli cervix is rare and is noted in less than
• Single-dose oral therapy of 2 g of metronidazole is no longer 10% of women
recommended because of high failure rates
• Alternative Diagnostics
o Tinidazole - 2g po for 3 days or 1g po for 5 days • Nucleic acid amplification tests (naats)
o Clindamycin - 300 mg po bid for 7 days o Are three to five times more sensitive than wet prep.
o Clindamycin ovules – 100 mg intravaginally once at bedtime • Culture – gold standard
for 3 days
Treatment
• Nitroimidazoles
o Are the only class of drugs recommended treatment
o A single oral dose (2 g) of metronidazole or tinidazole
is recommended.
• metronidazole
o Alternate regimen is, 500 mg orally, twice daily for 7
days.
o Safe in all trimesters of pregnancy
• Tinidazole
o Is a second-generation nitroimidazole and has a longer
half-life of 24 hours.
o Category c drug in pregnancy.

Candida vaginitis
Trichomoniasis • Candida vaginalis
• Is caused by the anaerobic flagellated protozoon,t. Vaginalis , a o Produced by a ubiquitous, airborne, grampositive fungus. In
unicellular organism that is normally fusiform in shape. Three to most populations, more than 90% of cases are caused by
five flagella extend from one end of the organism and provide candida albicans
active movement of the protozoon o Candida organisms develop filamentous (hyphae and
• The most prevalent nonviral, nonchlamydial sti of women pseudohyphae) and ovoid forms, termed conidia, buds, or
• The incubation period is 4 to 28 days. spores. The filamentous forms of c. Albicans have the ability
to penetrate the mucosal surface and become intertwined

TRANSCRIBERS Group 7 8 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
with the host cells (fig. 23.19). This results in dose of fluconazole (150 mg) given 72 hours after the first dose
secondaryhyperemia and limited lysis of tissue near the site is recommended.
of infection. • In women with rvvc, the resolution of symptoms typically
requires longer duration of therapy. Seven to 14 days of topical
Risk factors therapy or three doses of oral fluconazole 3 days apart (e.g., days
• Hormonal factors, depressed cell-mediated immunity, and 1, 4, and 7) are options. After this initial treatment, maintenance
antibiotic use therapy will help prevent recurrence of symptoms. Oral
o Are the three most important factors that alter the fluconazole (e.g., 100-, 150-, or 200-mg dose) weekly for 6
vaginal ecosystem. months is typically first-line treatment. However, topical
• Lactobacilli treatments used intermittently as a maintenance regimen may
• Obesity be considered.
• Debilitating disease
Toxic shock syndrome
Symptoms • Acute febrile illness produced by a bacterial exotoxin, with a
• Fungal vaginitis usually presents as a vulvovaginitis. fulminating downhill course involving dysfunction of multiple
• Pruritus is the predominant symptom. Depending on the degree organ systems.
of vulvar skin involvement, pruritus may be accompanied by • May develop a rapid onset of hypotension associated with
vulvar burning, external dysuria, and dyspareunia. multiorgan system failure.
• The vaginal discharge is white or whitish gray, highly viscous, • More than 95% of the reported cases of TSS were diagnosed in
granular or floccular, with no odor. previously healthy, young (<30 years), menstruating females.
• The vulvar signs include erythema, edema, and excoriation. With
extensive skin involvement, pustules may extend beyond the line Etiology
of erythema. • S. Aureus
• Speculum examination o was isolated from the vagina in more than 90% of
o cottage cheese–type discharge is often visualized, these cases.
with adheren clumps and plaques (thrush patches) • Tampon use- remains a risk factor for TSS. Women who develop
attached to the vaginal walls. TSS are
o clumps, or raised plaques, are usually white or yellow. o More likely to have used higher absorbency tampons
• Candida vaginitis o Several cycle days of tampons
o Vaginal ph below 4.5 o Kept a single tampon in for a longer period of time.
• Bacterial vaginosis and trichomonas vaginitis • 50% of cases- not related to menses.
o Elevated vaginal ph • May be a sequelae of focal staphylococcal infection of the skin
and subcutaneous tissue, often following a surgical procedure.
Diagnosis • Occasionally severe postoperative infections by streptococcus
• Koh pyogenes produce a similar streptococcal toxic shock−like
• Nickerson or sabouraud medium syndrome.
o These cultures will become positive in 24 to 72 hours. • Usually within the first 48 hours.

Requirements for the development of classic TSS

1. Woman must be colonized or infected with s. Aureus
2. Bacteria must produce TSS toxin 1 (tsst-1) or related toxins, and
3. Toxins must have a route of entry into the systemic circulation.

Route of infection
• The signs and symptoms of TSS are produced by the exotoxin
named toxin 1.
• Toxin 1 is a simple protein with a molecular weight of 22,000 kda
and is accepted as the underlying cause of the disease.
• In patients with uncomplicated vulvovaginal candidiasis, topical • Act as superantigens, molecules that activate up to 20% of t cells
antifungal agents are typically used for 1 to 3 days, or a single at once, resulting in massive cytokine production.
oral dose of fluconazole. Patient preference, response to prior • Rarely are blood cultures positive for s. Aureus in a woman with
therapy, and cost should guide the choice of therapy TSS
• For patients with complicated vaginitis, topical azoles are • thus the exotoxin is believed to be absorbed directly from the
recommended for 7 to 14 days. If using oral therapy, a second vagina.

TRANSCRIBERS Group 7 9 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
• It is possible that microulcerations produced by use of tampons
facilitate the toxin’s entry into the systemic circulation.
• The risk of nonmenstrual TSS is definitely increased in women
who use barrier contraceptives such as a diaphragm, cervical
cap, or a sponge containing nonoxynol 9.

Signs and symptoms

• High index of suspicion for TSS in a woman who has an
unexplained fever and a rash during or immediately following
her menstrual period.
• First 24 hours: most women experience a prodromal flulike
illness
• Between days 2 and 4 of the menstrual period: abrupt onset of
a high temperature associated with headache, myalgia, sore
throat, vomiting, diarrhea, generalized skin rash, and often
hypotension.
• Clinically, many women present with a forme fruste of TSS, with Differential diagnosis
low-grade fever and dizziness rather than hypotension. • Rocky mountain spotted fever
• Most characteristic manifestations of TSS are the skin changes. • Streptococcal scarlet fever
o First 48 hours: skin rash appears similar to intense sunburn • Leptospirosis
o Next few days: erythema will become more macular and
resemble a drug-related rash Management
o Days 12 to 15 of the illness: fine, flaky desquamation of skin • The first priority is to eliminate the hypotension produced by the
over the face and trunk, with sloughing of the entire skin exotoxin.
thickness of the palms and soles o Copious amounts of iv fluids are given
o The vaginal mucosa is hyperemic during the initial phase of o Pressure and volume dynamics are centrally
the syndrome monitored.
o During pelvic examination, patients complain of tenderness • Respiratory distress syndrome
of the external genitalia and vagina. o Mechanical ventilation is required
• More than 90% of women with TSS experience myalgia, • When the woman is initially admitted to the hospital
vomiting, and diarrhea o it is important to obtain cervical, vaginal, and blood
cultures for s. Aureus.
• Wash out the vagina with saline or dilute iodine solution to
diminish the amount of exotoxin that may be absorbed into the
systemic circulation.
• Methicillin-susceptible s. Aureus
o Clindamycin, 600 mg iv every 8 hours, plus nafcillin or
oxacillin, 2 g iv every 4 hours
• Antistaphylococcal agent
o Recommend a 1- to 2-week course of therapy
o Clindamycin or dicloxacillin even in the absence of a
positive s. Aureus culture.
• Methicillin-resistant s. Aureus (MRSA)
o Clindamycin plus vancomycin (30 mg/kg/day iv in two
divided doses) or linezolid (600 mg oral or iv every 12
hours)
• If the diagnosis is questionable, it is best to include
o Aminoglycoside to obtain coverage for possible gram-
• Many abnormal laboratory findings are associated with the
negative sepsis.
disease and, again, they reflect the severity of involvement of
• Toxic shock syndrome secondary to skin infection
individual organ systems
o Infected site should be drained and débrided
o Mupirocin to decrease colonization is recommended,
applying half of the ointment from a single-use tube
into one nostril and the other half into the other nostril
twice daily for 5 days.

TRANSCRIBERS Group 7 10 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
Summary and perinatal transmission of pathogenic
• Treatment of TSS depends on the severity of involvement of microorganisms.
individual organ systems. o Primary endocervical - infection may result in
• Not all patients develop a temperature higher than 38.9° c and secondary ascending infections, including pelvic
hypotension inflammatory disease and perinatal infections of the
• The foundation of treatment of the disease is prompt and membranes, amniotic fluid, and parametria.
aggressive management because of the rapidity with which the
disease may progress. Mucopurulent cervicitis
• Women should be encouraged to change tampons every 4 to 6 • Diagnosis of cervicitis rely on symptoms, examination, and
hours. microscopic evaluation. Two simple, definitive, objective criteria
• The incidence of TSS has decreased dramatically with the have been developed to establish mucopurulent cervicitis—
removal of super-absorbing tampons from the market. o Gross visualization of yellow mucopurulent material
• A study by tierno and hanna reported that all-cotton tampons on a white cotton swab
are the safest choice to avoid menstrual TSS. o Presence of 10 or more pmn leukocytes per
• There are cases of streptococcal toxic shock–like syndromes that microscopic field on gram-stained smears obtained
are secondary to life-threatening infections with group a from the endocervix.
streptococcus (streptococcus pyogenes). • Alternative clinical criteria that may be used
• Older women, diabetic or immunocompromised o Erythema and edema in an area of cervical ectopy or
o Much greater risk to develop invasive streptococcal associated with bleeding secondary to endocervical
infection and streptococcal toxic shock–like syndrome. ulceration or friability when the endocervical smear is
• Mortality rate: 30% when tss is secondary to group a obtained. Women may also report increased vaginal
streptococcal infections discharge and intermenstrual vaginal bleeding

Cervicitis Symptoms
• An inflammatory process in the cervical epithelium and stroma, • More than 60% of women with this disease are asymptomatic.
can be associated with trauma, inflammatory systemic disease, • Vaginal discharge
neoplasia, and infection. Although it is clinically important to • Deep dyspareunia
consider all causes of inflammation, this section focuses on • Postcoital bleeding
infectious origins. • The physical sign of a cervical infection is a cervix that is
hypertrophic and edematous.
Cervix
• Acts as a barrier between the abundant bacterial flora of the C. Trachomatis
vagina and the bacteriologically sterile endometrial cavity and • Is the cause of cervical infection in many women with
oviducts. mucopurulent cervicitis
• Cervical mucus • Depending on the geographic region, gonorrhea is also an
o Much more than a simple physical barrier; it exerts a important cause of mucopurulent cervicitis. .
bacteriostatic effect. Mucus may also act as a • Mucopurulent cervicitis is present in approximately 40% to 60%
competitive inhibitor with bacteria for receptors on of women in whom no cervical pathogen can be identified. Thus
the endocervical epithelial cells this condition often persists following adequate broad-spectrum
o Cervical mucus also contains antibodies and antibiotic therapy.
inflammatory cells that are active against various • The presence of active herpes infection is correlated with
sexually transmitted organisms. ulceration of the ectocervix but not with mucopus.
• Reservoir for • Mucopurulent cervicitis is clinically diagnosed
o Neisseria gonorrhoeae, chlamydia trachomatis, hsv, o Empirical therapy for c. Trachomatis is recommended
human papillomavirus, and mycoplasma spp. for women at increased risk of this common sti (age
• Ectocervicitis <25 years, new or multiple sex partners, unprotected
o Can be viral (hsv) or from a severe vaginitis (e.g., sex).
strawberry cervix associated with t. Vaginalis o If the prevalence of n. Gonorrhoeae is more than 5%,
infection) or c. Albicans. concurrent therapy for n. Gonorrhoeae is indicated.
• Endocervicitis o Concomitant trichomoniasis should also be treated if
o May be secondary to infection with c. Trachomatis or detected, as should bacterial vaginosis.
n. Gonorrhoeae. o If presumptive treatment is deferred, the use of a
o Bacterial vaginosis and mycoplasma genitalium have sensitive nucleic acid test for c. Trachomatis and n.
also been associated with endocervicitis. Infection of Gonorrhoeae is needed.
the endocervix becomes a major reservoir for sexual

TRANSCRIBERS Group 7 11 of 12
 GYNECOLOGY EXIMIUS
LOWER GENITAL TRACT INFECTIONS 2021
DR. MARITES BUTARAN FEBRUARY 2020
Treatment
• Presumptive cervicitis therapy
o Azithromycin, 1 g orally in a single dose, or
o Doxycycline, 100 mg orally twice daily for 7 days,
o Adding gonococcal treatment if the prevalence is over
5% in the population assessed.
• Women treated for chlamydia should be instructed to abstain
from sexual intercourse for 7 days after single-dose therapy or
until completion of the 7-day regimen.

Mycoplasma genitalium
• Noncultivable
• Has been associated in women with mucopurulent cervicitis by
dna testing.
• Empiric treatment for m. Genitalium in cases of persistent
cervicitis after standard treatment may be considered but should
be done in consultation with a specialist.
• There is no fda-approved diagnostic test for m. Genitalium
• Some research laboratories may have pcr-based testing.
• Bacterial vaginosis has also been associated with mucopurulent
cervicitis; cervicitis resolved with bacterial vaginosis treatment

Detection of pathogenic cervical bacteria Chlamydia trachomatis

Neisseria gonorrhoe • As with gonorrhea, the gold standard of techniques used to
• Nucleic acid amplification testing (naat) of the urine or identify c. Trachomatis infection is naat.
vaginal secretions is the most sensitive and specific o C. Trachomatis also attaches to the columnar
diagnostic tool for identifying gonorrheal infections. Urine epithelium. Hence, vaginal specimens should not
tests should be first void (either the first void in morning or be collected from women who have had a
at least 1 hour since last void). hysterectomy.
• This technique allows for the sensitive detection of dna • Dacron, rayon, or calcium alginate swab
particles originating from the urethra or endocervix, which o Is placed in the endocervical canal. It is rotated for
fall into the vaginal pool and vestibule. 15 to 20 seconds to abrade the columnar
• Gonorrheal naat results are over 95% sensitive and specific. epithelium gently. The cytobrush, which was
• Antibiotic-resistant gonorrhea culture (gc) is problematic. developed primarily to enhance sampling of
• Cdc std treatment guidelines (2015) endocervical cells for cytology, has been found to
o Recommend dual therapy with ceftriaxone 250 be the optimal instrument for appropriate
mg once im and azithromycin 1 g orally in a single sampling for chlamydia culture as well.
dose, preferably under direct observation, for all • Chlamydial antigen detection is insensitive and nonspecific
gc infections compared with naat and is no longer recommended.
o Routine co-treatment using two antimicrobials • C. Trachomatis infection is frequently asymptomatic.
with different mechanisms of action, such as a Chlamydial screening programs have been successful at
cephalosporin plus azithromycin, may slow the decreasing the prevalence of the disease.
selection and spread of antibiotic-resistant gc. • For all women with a chlamydial or gonorrheal infection
Based on experience with other microbes that partners should be treated. Patients should be instructed to
developed antimicrobial resistance rapidly, refer all sex partners of the past 60 days for evaluation and
• Azithromycin is preferred to doxycycline treatment and to avoid sexual intercourse until therapy is
• Because of the convenience and compliance advantages of completed and they and their partner have resolution of
single-dose therapy and the substantially higher prevalence symptoms.
of gonococcal resistance to tetracycline than to • If a woman is unsure whether her partner will be treated,
azithromycin in tracked isolates delivery of antibiotic therapy (by prescription or
medication) is an option.
• All women with c. Trachomatis, n. Gonorrhoeae, or
mucopurulent cervicitis of unknown origin need evaluation
to rule out pelvic inflammatory disease

TRANSCRIBERS Group 7 12 of 12