Lower genital tract infections

Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE

Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
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Main Reference

´Comprehensive Gynecology 7th edition, 2017

(Lobo RA, Gershenson DM, Lentz GM, Valea FA
editors); chapter 23, Genital tract infections
Outline

´ Infections of the vulva

´ Infections of the vagina
´ Infections of the cervix
Infections of the vulva
ore the initial focus of this chapter is on clinical presenta- Box 23.1 Causes of Vulvar Pruritus and Irritation
nd the differential diagnosis of vulvitis, vaginitis, and cer- Acute:
Contact Dermatitis
ic shock syndrome (TSS) and syphilis are also discussed in
Allergic
apter. Although the most devastating pathologic processes Irritant
hese diseases occur in sites other than the genital tract,
ten obtain entry into the body through the vulvar, rectal, Infections
l, or cervical epithelium. Candidiasis
Scabies
ny of the infections discussed in this chapter may be
Human papilloma virus
ed through sexual contact and are termed sexually transmit- Molluscum contagiosum
ctions (STIs). STIs often coexist—for example, Chlamydia Trichomoniasis
matis and Neisseria gonorrhoeae. When one disease is sus-
appropriate diagnostic methods must be used to detect Chronic:
nfections.
Cause of
Contact Dermatitis
Centers for Disease Control and Prevention (CDC) regu- Allergic
vises management protocols for STIs. Recommendations and Irritant

vulvar pruritus
tions in this edition are based on the 2015 CDC guidelines.
s are urged to consult updates in the online CDC guidelines
Vulvar Dystrophies
Lichen planus
/www.cdc.gov) because bacterial sensitivities and epidemio-
and irritation
Lichen sclerosis
oncerns may lead to changes in treatment protocols. Lichen simplex chronicus
Psoriasis
Infections
ECTIONS OF THE VULVA Candidiasis
Human papillomavirus
in of the vulva is composed of a stratified squamous epithe- Neoplasia
ontaining hair follicles and sebaceous, sweat, and apocrine Paget disease
The subcutaneous tissue of the vulva also contains spe- Vulvar cancer
structures such as the Bartholin glands. Similar to skin
Atrophy
ere on the body, the vulvar area is subject to primary and
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors);
chapter 23, Genital tract infections
 INFECTIONS OF BARTHOLIN GLANDS
´ Bartholin glands are two rounded, pea-sized glands deep in the
perineum that are not palpable unless enlarged.
´ Bartholin glands are located at the entrance of the vagina at 5 and
7 o’clock, in the groove between the hymen and the labia minora.
´ Mucinous secretions from Bartholin glands provide moisture for the
epithelium of the vestibule.
´ The most common cause of Bartholin gland enlargement is cystic
dilation of the Bartholin duct à typically caused by distal obstruction
secondary to non-specific inflammation or trauma.
´ differential diagnosis: mesonephric cysts of the vagina and epithelial
inclusion cysts.
´ Mesonephric cysts are generally more anterior and cephalad in the
vagina
´ Epithelial inclusion cysts are more superficial.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 INFECTIONS OF BARTHOLIN GLANDS
´ The cysts may vary from 1 to 8 cm in diameter and are
usually unilateral, tense, and nonpainful.
´ abscess of a Bartholin gland tends to develop rapidly
over 2 to 4 days presenting with difficulty in ambulation
and sitting.
´Acute pain and tenderness can be severe, secondary
to enlargement, hemorrhage, or secondary infection.
´signs : erythema, acute tenderness, edema and,
occasionally, cellulitis
´Positive cultures from Bartholin gland abscesses are
often polymicrobial and contain a wide range of
bacteria similar to the normal flora of the vagina.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 INFECTIONS OF BARTHOLIN GLANDS
´ Asymptomatic cysts in women younger than 40
years do not need treatment.
´ Simple incision and drainage of a Bartholin gland
cyst or abscess is not recommended because
recurrence after incision and drainage is frequent.
´ The surgical treatment of choice is marsupialization
to develop a fistulous tract from the dilated duct to
the vestibule.
´ An elliptical wedge of tissue is excised over the cyst
just proximal to the hymenal ring.
´ 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.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 be challenging because of the rich vascular supply to the region
and may be accompanied by morbidity, including intraopera-
INFECTIONS OF BARTHOLIN GLANDS tive hemorrhage, hematoma formation, fenestration of the labia,
postoperative scarring, and associated dyspareunia. It is best to
use regional block or general anesthesia for excision. Excision of
´ An alternative surgical approach is to insert a Word a Bartholin gland for recurrent infection should be performed
when the infection is quiescent (Heller, 2014; Kessous, 2013;
catheter, a short catheter with an inflatable Foley Khanna, 2010; Li, 2011; Wechter, 2009 ).
balloon, through a stab incision into the abscess
and leave it in place for 4 to 6 weeks
´ Women older than 40 years with gland
enlargement require a biopsy to exclude
adenocarcinoma of the Bartholin gland.
´ Excision of a Bartholin duct and gland is indicated
for persistent deep infection, multiple recurrences
of abscesses, or recurrent enlargement of the
gland in women older than 40 Bartholin
Figure 23.1 years. abscess. The mass is tender and fluctuant
and is situated on the lower lateral aspect of labium minus at Figure 23.2 Word catheters before and after inflation. They are
5 o’clock. (From Kaufman RH. Cystic tumors. In: Kaufman RH, used to develop a fistula from a Bartholin cyst or abscess to the
Faro S, eds. Benign Diseases of the Vulva and Vagina. 4th ed. St. Louis: vestibule. (From Friedrich EG. Vulvar Disease. 2nd ed. Philadelphia:
Mosby–Year Book; 1994.) WB Saunders; 1983.)

Obstetrics & Gynecology Books Full

Comprehensive Gynecology 7th edition, 2017
 PEDICULOSIS PUBIS
´ the skin of the vulva is a frequent site of
infestation by animal parasites, the two
most common being the crab louse and
the itch mite.
´ Pediculosis pubis is an infestation by the
crab louse, Phthirus pubis.
´ the crab louse is also called the pubic
louse and is a different species from the
body or head louse.
´ Lice in the pubic hair are the most
contagious of all STIs, with over 90% of
sexual partners becoming infected
following a single exposure.
Comprehensive Gynecology 7th edition, 2017
´ The louse’s life cycle has three stages:
egg (nit), nymph, and adult. The entire life
cycle is spent on the host.
 PEDICULOSIS PUBIS

´ The predominant clinical symptom of

louse infestation is constant pubic
pruritus caused by allergic
sensitization.
´ Examination of the vulvar area
without magnification demonstrates
eggs and adult lice and pepper
grain feces adjacent to the hair
shafts
´ For definitive diagnosis, one can
make a microscopic slide by
scratching the skin papule with a
needle and placing the crust under
a drop of mineral oil.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 close physical contact should be treated at the same time as the
infected woman, regardless of whether they have symptoms.
Bedding and clothing should be decontaminated (i.e., machine
washed, machine dried using the heat cycle, or dry cleaned) or
removed from body contact for at least 72 hours. Fumigation of

SCABIES
living areas is not necessary. Importantly, women and physicians
should not confuse the 1% cream rinse of permethrin dosage

´ Scabies is a parasitic infection of the itch mite,

Sarcoptes scabiei.
´ transmitted by close contact; Unlike louse infestation,
scabies is an infection that is widespread over the
body, without a predilection for hairy areas.
´ the adult female itch mite digs a burrow just beneath
the skin à pathognomonic sign Figure 23.5 Skin scrapings of unexcoriated papules fortuitously
disclose adults, larvae, eggs, and fecal pellets, any of which would
be diagnostic of scabies. (From Orkin M, Howard IM. Scabies. In:

´ the predominant clinical symptom of scabies is severe

Holmes KK, Mårdh PA, Sparling PF, et al, eds. Sexually Transmitted
Diseases. New York: McGraw-Hill; 1984.)

but intermittent itching à more intense pruritus occurs

at night when the skin is warmer and the mites are Obstetrics & Gynec

more active.
´ Scabies has been termed the great dermatologic
imitator, and the differential diagnosis includes almost
all dermatologic diseases that cause pruritus.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 SCABIES
´ therapy currently recommended is permethrin, 1%
cream rinse, applied to affected areas and washed
o after 10 minutes, or pyrethrins, with piperonyl
butoxide applied to the affected area and washed
off after 10 minutes.
´ An antihistamine will help alleviate pruritus.
´ To avoid reinfection by pediculosis pubis or scabies,
treatment should be prescribed for sexual contacts
within the previous 6 weeks and other close
household contacts.
´ Bedding and clothing should be decontaminated
(i.e., machine washed, machine dried using the
heat cycle, or dry cleaned) or removed from body
contact for at least 72 hours.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 infected woman, regardless of whether they have symptoms. superinfection. The umbilicated papules may resemble furunc
Bedding and clothing should be decontaminated (i.e., machine when secondarily infected.
washed, machine dried using the heat cycle, or dry cleaned) or Molluscum contagiosum is usually a self-limiting infecti

MOLLUSCUM CONTAGIOSUM removed from body contact for at least 72 hours. Fumigation of
living areas is not necessary. Importantly, women and physicians
should not confuse the 1% cream rinse of permethrin dosage
and spontaneously resolves after a few months in immunocom
petent individuals. However, treatment of individual papu
will decrease sexual transmission and autoinoculation of t
virus. After injection of local anesthesia, the caseous material
´ chronic localized infection consisting of flesh-colored,
dome-shaped papules with an umbilicated center.
´ molluscum is spread by direct skin-to-skin contact.
´ it is primarily an asymptomatic disease of the vulvar skin,
and, unlike most STIs, it is only mildly contagious.
´ Widespread infection in adults is most closely related to
underlying cellular immunodeficiency, such as during an
HIV infection, chemotherapy or corticosteroid
administration.
´ To confirm diagnosis à white waxy material from inside the
nodule may be expressed on a23.5
Figure microscopic slidepapules
Skin scrapings of unexcoriated à fortuitously
intracytoplasmic molluscumdisclose
bodies with
adults, larvae, eggs,Wright oranyGiemsa
and fecal pellets, of which would Figure 23.6 Papule of molluscum contagiosum with umbilicated
be diagnostic of scabies. (From Orkin M, Howard IM. Scabies. In: center. (From Brown ST. Molluscum contagiosum. In Holmes KK,
stain confirms the diagnosis.Holmes KK, Mårdh PA, Sparling PF, et al, eds. Sexually Transmitted Mårdh PA, Sparling PF, et al, eds. Sexually Transmitted Diseases.
Diseases. New York: McGraw-Hill; 1984.) New York: McGraw-Hill; 1984.)
´ the major complication of molluscum contagiosum is
bacterial superinfection
´ Molluscum contagiosum is usually a self-limiting infection
Obstetrics & Gynecology Books Full
and spontaneously resolves after a few months in
immunocompetent individuals
Comprehensive Gynecology 7th edition, 2017
a debilitating physical disease, it may present a psychological symptoms. On average, a woman will have four recurrences dur-
burden. Excellent online patient education and support can be ing the first year and, in 50% of women, the first recurrence
Genital Ulcers
found www.ashastd.org. occurs within 6 months of the initial infection. The probability

Table 23.1 Clinical Features of Genital Ulcers

Type
Lymphogranuloma
Parameter Syphilis Herpes Chancroid Venereum Donovanosis
Incubation period 2-4 wk (1-12 wk) 2-7 days 1-14 days 3 days-6 wk 1-4 wk (up to 6 mo)
Primary lesion Papule Vesicle Papule or pustule Papule, pustule, or Papule
vesicle
Number of lesions Usually one Multiple, may coalesce Usually multiple, may Usually one Variable
coalesce
Diameter (mm) 5-15 1-2 2-20 2-10 Variable
Edges Sharply demarcated Erythematous Undermined, ragged, Elevated, round or oval Elevated, irregular
Elevated, round or oval irregular
Depth Superficial or deep Superficial Excavated Superficial or deep Elevated
Base Smooth, nonpurulent Serous, erythematous Purulent Variable Red and rough (beefy)
Induration Firm None Soft Occasionally firm Firm
Pain Unusual Common Usually very tender Variable Uncommon
Lymphadenopathy Firm, nontender Firm, tender, often Tender, may sup- Tender, may suppurate,
Pseudoadenopathy bilateral purate, usually loculated, usually
bilateral unilateral unilateral

From Holmes KK, Mårdh PA, Sparling PF, et al, eds. Sexually Transmitted Diseases, 2nd ed. New York: McGraw-Hill, 1990.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Genital Herpes
´ recurrent viral infection that is incurable and highly
contagious
´ herpes is transmitted during episodes of asymptomatic
shedding
´ two distinct types of HSV: type 1 (HSV-1) and type 2 (HSV-
2).
´ HSV-1 is the most commonly acquired genital herpes in
women younger than 25 years and, in some series, HSV-1
may cause lower genital tract infection in 13% to 40% of
patients.
´ Genital HSV-1 is transmitted from orolabial lesions to the
vulva during oral-genital contact or from genital to genital
to genital contact with a partner with genital HSV-1.
´ paresthesia of the vulvar skin followed by the eruption of
multiple painful vesicles, which progress to shallow,painful
superficial ulcers over a large area of the vulva.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 withIfthe
heraverage
primaryrate
HSV-2 infection wasslightly
of recurrence severe, she
lesswill have
than onerecur-
episo
rences
per year approximately
(Phipps, twice as often,
2011; Tronstein, 2011).with a shorter time to
recurrence intervals compared with women with milder initial
episodes of the disease. In contrast, if the initial pelvic infection

Genital Herpes
was HSV-1, there is a 55% chance of a recurrence within 1 year,
with the average rate of recurrence slightly less than one episode
per year (Phipps, 2011; Tronstein, 2011).

´ the ulcers usually heal spontaneously without scarring

´ Most symptomatic women have severe vulvar pain,
tenderness, and inguinal adenopathy and
Figure 23.7 Recurrent herpes genitalis. Superficial ulcers are
simultaneous involvement of the vagina and cervix is noted following rupture of vesicles. (From Kaufman RH, Faro S.
Herpes genitalis: clinical features and treatment. Clin Obstet Gynec
common 1985;28:152-163.)
Figure 23.7 Recurrent herpes genitalis. Superficial ulcers are
noted following rupture of vesicles. (From Kaufman RH, Faro S.
´ Systemic symptoms, including general malaise and Herpes genitalis: clinical features and treatment. Clin Obstet Gynecol.
1985;28:152-163.)

fever
´ symptoms of vulvar pain, pruritus, and discharge peak
between days 7 and 11 of the primary infection.
´ Recurrent genital herpes is a local disease with less
severe symptoms. On average, a woman will have
four recurrences during the first

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
Figure 23.8 Primary herpes involving the cervix. A necrotic
 If her(Phipps,
per year primary HSV-2 infection was2011).
2011; Tronstein, severe, she will have recur- pe
rences approximately twice as often, with a shorter time to A
recurrence intervals compared with women with milder initial ne
episodes of the disease. In contrast, if the initial pelvic infection ho

Genital Herpes
was HSV-1, there is a 55% chance of a recurrence within 1 year, re
with the average rate of recurrence slightly less than one episode la
per year (Phipps, 2011; Tronstein, 2011).
cl
de
fu
´ the clinical diagnosis of genital herpes is often ul
in

made by simple clinical inspection. 80

tu
m

´ Herpetic ulcers are painful when touched with a

is
he
th
cotton-tipped applicator, whereas the ulcers of Figure 23.7 Recurrent herpes genitalis. Superficial ulcers are
to
he
syphilis are painless. noted following rupture of vesicles. (From Kaufman RH, Faro S.
Herpes genitalis: clinical features and treatment. Clin Obstet Gynecol. to
ev
1985;28:152-163.)
fu
´ the most accurate and sensitive technique for Figure 23.7 Recurrent herpes genitalis. Superficial ulcers are
or
di
identifying herpes virus is the polymerase chain noted following rupture of vesicles. (From Kaufman RH, Faro S.
Herpes genitalis: clinical features and treatment. Clin Obstet Gynecol.
(3
co
reaction (PCR) assay.
1985;28:152-163.) ci
at
H

´ the Western blot assay for antibodies to herpes ar

ca
is the most specific method for diagnosing in
co
recurrent herpes, as well as unrecognized or en
subclinical infection. 1.
2.
3.
In
le
vi
ep

of
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FAFigure
editors);
23.8 chapter 23,involving
Primary herpes Genital tractA infections
the cervix. necrotic to
exophytic mass is seen on posterior lip. This was clinically thought an
 Genital Herpes
´ Treatment of HSV-1 or HSV-2 may be used for
three different clinical scenarios:
´ 1. Primary episode
´ 2. Recurrent episode
´ 3. Daily suppression
´ Antiviral therapy is recommended for in all
patients with primary episodes.
´ Episodic therapy for recurrences can shorten the
duration of the outbreak if started within 24 hours
of prodromal symptoms or lesion appearance.
´ antiviral medication should be started as early as
possible during the prodrome, and definitely
within 24 hours of the appearance of lesions.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Genital Herpes
´ CDC recommends that acyclovir or other suppressive drugs be
discontinued after 12 months of suppressive therapy to determine
530 Part III the
GENERAL GYNECOLOGY
subsequent rate of recurrence for each individual woman

Table 23.2 Antiviral Treatment for Herpes Simplex Virus in the Nonpregnant Patient
Antiviral Agent
Indication Valacyclovir Acyclovir Famciclovir
First clinical episode 1000 mg bid, 7-10 days 200 mg five times/day; or 400 mg tid, 250 mg tid, 7-10 days
7-10 days
Recurrent episodes 1000 mg daily, 5 days; or 500 mg bid, 400 mg tid, 5 days; 800 mg bid, 5 days; 125 mg bid, 5 days
3 days or 800 mg tid, 2 days 500 mg once then 250 mg bid,
2 days; 1000 mg bid, 1 day
Daily suppressive 1000 mg daily (≥10 recurrences/year) or 400 mg bid 250 mg bid
500 mg daily (≤9 recurrences/year)

Data from Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;
64(RR-03):1-137. bid, Twice per day; tid, three times per day.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Granuloma Inguinale (Donovanosis)
´ also known as donovanosis, is a chronic,
ulcerative, bacterial infection of the skin and
subcutaneous tissue of the vulva.
´ can be spread sexually and through close
nonsexual contact. However, it is not highly
contagious, and chronic exposure is usually
necessary to contract the disease.
´ caused by an intracellular, gram-negative,
nonmotile, encapsulated rod, Klebsiella
granulomatis.
´ initial growth is a nodule that gradually progresses
into a painless, slowly progressing ulcer surrounded
by highly vascular granulation tissue à The ulcer
has a beefy red appearance, and it bleeds easily
when touched.
´
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Granuloma Inguinale (Donovanosis)
´ the ulcers are painless and without
regional adenopathy. Typically, multiple
nodules are present, resulting in ulcers
that grow and coalesce and, if
untreated, will eventually destroy the
normal vulvar architecture.
´ diagnosis may also be established by
identifying Donovan bodies in smears
and specimens taken from the ulcers
´ Donovan bodies appear as clusters of
dark-staining bacteria with a bipolar
(safety pin) appearance found in the
cytoplasm of large mononuclear cells.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Granuloma Inguinale (Donovanosis)
´ CDC recommends azithromycin 1 g orally
once a week or 500 mg daily for 3 weeks
and until all lesions have healed.
´ Alternative antibiotic regimens include the
following:
1. doxycycline, 100 mg orally, twice daily
for a minimum of 3 weeks;
2. ciprofloxacin, 750 mg orally twice daily;
3. erythromycin base, 500 mg orally four
times daily;
4. trimethoprim-sulfamethoxazole (TMP-
SMZ), one double-strength tablet orally
twice daily.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Lymphogranuloma Venereum 23 Genital Tract Infections 531

double-strength tablet orally twice daily. Therapy should be

´ This sexually transmitted infection is

continued until the lesions have healed completely. Alternative
antibiotic therapy such as an aminoglycoside has been used in
refractory cases. Rarely, medical therapy fails and surgical exci-

caused by serotypes L1, L2, and L3 sion is required. Co-infection with another sexually transmitted
pathogen is a distinct possibility. Sex partners of women who
have granuloma inguinale should be examined if they have had
of C. trachomatis. sexual contact during the 60 days preceding the onset of symp-
toms (Workowski, 2015).

´ In women, the vulvaLymphogranuloma

is the
Lymphogranuloma mostVenereum
venereum (LGV) is a chronic infection of
lymphatic tissue produced by Chlamydia trachomatis. It is found
frequent site of infection, butfewer thanthe
most commonly in the tropics. Cases occur infrequently in the
United States, with 150 new cases being reported each

urethra, rectum, andmost cervix may

year, most of which occur in men. In women, the vulva is the
frequent site of infection, but the urethra, rectum, and cervix
may also be involved. This sexually transmitted infection is caused

also be involved. byin high-risk

serotypes L1, L2, and L3 of C. trachomatis. Serologic studies
populations have found that subclinical infection is
common. The incubation period is between 3 and 30 days.
There are three distinct phases of vulvar and perirectal LGV.
The primary infection is a shallow, painless ulcer that heals rap-
idly without therapy. It is typically located on the vestibule or
labia but occasionally in the periurethral or perirectal region. Figure 23.10 Lymphogranuloma venereum bubo with groove
One to 4 weeks after the primary infection, a secondary phase sign. (From Friedrich EG. Vulvar Disease. 2nd ed. Philadelphia: WB
marked by painful adenopathy develops in the inguinal and Saunders; 1983.)
perirectal areas. Two thirds of women have unilateral adenop-
athy and 50% have systemic symptoms, including general Fluoroquinolone-based treatments may also be effective, but
malaise and fever. When the disease is untreated, the infected extended treatment intervals are likely required (Workowski,
nodes become increasingly tender, enlarged, matted together, 2015).
and adherent to overlying skin, forming a bubo (tender lymph Antibiotic therapy cures the bacterial infection and prevents
nodes). A classic clinical sign of LGV is the double genitocrural further tissue destruction. However, fluctuant nodes should be
fold, or groove sign (Fig. 23.10), a depression between groups aspirated to prevent sinus formation. Rarely, incision and drain-
of inflamed nodes. Within 7 to 15 days, the bubo will rupture age of infected nodes are necessary to alleviate inguinal pain.
spontaneously and form multiple draining sinuses and fistulas. The late sequelae of the destructive tertiary phase of LGV often
Comprehensive Gynecology 7th edition, 2017 (Lobo
TheseRA,are Gershenson
classic signs of the DM,
tertiaryLentz
phase ofGM, Valea
the infection. FA editors);
require extensivechapter 23, Genital
surgical reconstruction. It is tract infections
important to
Extensive tissue destruction of the external genitalia and ano- administer antibiotics during the perioperative period.
 double-strength tablet orally twice daily. Therapy should be
continued until the lesions have healed completely. Alternative
antibiotic therapy such as an aminoglycoside has been used in
refractory cases. Rarely, medical therapy fails and surgical exci-
sion is required. Co-infection with another sexually transmitted
pathogen is a distinct possibility. Sex partners of women who
have granuloma inguinale should be examined if they have had
sexual contact during the 60 days preceding the onset of symp-

Lymphogranuloma Venereum
toms (Workowski, 2015).

Lymphogranuloma Venereum
Lymphogranuloma venereum (LGV) is a chronic infection of
lymphatic tissue produced by Chlamydia trachomatis. It is found
most commonly in the tropics. Cases occur infrequently in the
United States, with fewer than 150 new cases being reported each
year, most of which occur in men. In women, the vulva is the
most frequent site of infection, but the urethra, rectum, and cervix
may also be involved. This sexually transmitted infection is caused
by serotypes L1, L2, and L3 of C. trachomatis. Serologic studies

´ There are 3 distinct phases of vulvar and perirectal LGV:

in high-risk populations have found that subclinical infection is
common. The incubation period is between 3 and 30 days.
There are three distinct phases of vulvar and perirectal LGV.
The primary infection is a shallow, painless ulcer that heals rap-
idly without therapy. It is typically located on the vestibule or

´ the primary infection: shallow, painless ulcer that heals rapidly without
labia but occasionally in the periurethral or perirectal region. Figure 23.10 Lymphogranuloma venereum bubo with groove
One to 4 weeks after the primary infection, a secondary phase sign. (From Friedrich EG. Vulvar Disease. 2nd ed. Philadelphia: WB
marked by painful adenopathy develops in the inguinal and Saunders; 1983.)
perirectal areas. Two thirds of women have unilateral adenop-

therapy; typically located on the vestibule or labia athy and 50% have systemic symptoms, including general
malaise and fever. When the disease is untreated, the infected
nodes become increasingly tender, enlarged, matted together,
Fluoroquinolone-based treatments may also be effective, but
extended treatment intervals are likely required (Workowski,
2015).
and adherent to overlying skin, forming a bubo (tender lymph Antibiotic therapy cures the bacterial infection and prevents
nodes). A classic clinical sign of LGV is the double genitocrural further tissue destruction. However, fluctuant nodes should be

´ a secondary phase: painful adenopathy that develops in the inguinal and

fold, or groove sign (Fig. 23.10), a depression between groups
of inflamed nodes. Within 7 to 15 days, the bubo will rupture
spontaneously and form multiple draining sinuses and fistulas.
aspirated to prevent sinus formation. Rarely, incision and drain-
age of infected nodes are necessary to alleviate inguinal pain.
The late sequelae of the destructive tertiary phase of LGV often

perirectal areas
These are classic signs of the tertiary phase of the infection. require extensive surgical reconstruction. It is important to
Extensive tissue destruction of the external genitalia and ano- administer antibiotics during the perioperative period.
rectal region may occur during the tertiary phase. This tissue
destruction and secondary extensive scarring and fibrosis may Chancroid
result in elephantiasis, multiple fistulas, and stricture forma- Chancroid is a sexually transmitted, acute, ulcerative disease of the

´the infected nodes become tender, enlarged, matted together, and

tion of the anal canal and rectum. vulva caused by Haemophilus ducreyi, a highly contagious, small,
Diagnosis is established by detecting C. trachomatis by culture, nonmotile, gram-negative rod. Chancroid is a common disease in
direct immunofluorescence, or nucleic acid detection from the developing countries but infrequent in the United States. Epide-
pus or aspirate from a tender lymph node. Chlamydia serology

adherent to overlying skin, forming a bubo (tender lymph nodes).

miologic studies have suggested that chancroid tends to occur in
(complement fixation titers >1:64) can support the diagnosis in clusters and may account for a substantial portion of genital ulcer
the appropriate clinical context. However, the diagnostic useful- cases when present. However, difficulty in making the diagnosis
ness of serologic methods other than complement fixation and may cause underreporting. The clinical importance of chancroid
some microimmunofluorescence procedures remains unclear. In has been enhanced by reports that the genital ulcers of chancroid

´groove sign: double genitocrural fold à a depression between groups

the absence of specific LGV diagnostic testing, patients should facilitate the transmission of HIV infection.
be treated based on the clinical presentation, including procto- The soft chancre of chancroid is always painful and tender. In
colitis or genital ulcer disease with lymphadenopathy. The differ- comparison, the hard chancre of syphilis is usually asymptom-
ential diagnosis of LGV includes syphilis, chancroid, granuloma atic. On Gram stain, this facultative anaerobic bacterium exhib-

of inflamed nodes. à classic sign of LGV inguinale, bacterial lymphadenitis, vulvar carcinoma, genital
herpes, and Hodgkin disease.
The CDC recommends doxycycline, 100 mg twice daily
its a classic appearance of streptobacillary chains, or what has
been described as an extracellular school of fish. The incubation
period is short, usually 3 to 6 days. Tissue trauma and excoria-
for at least 21 days, as the preferred treatment. An alterna- tion of the skin must precede initial infection because H. ducreyi
tive therapy choice is erythromycin base, 500 mg four times is unable to penetrate and invade normal skin.

´ tertiary phase : bubo ruptures spontaneously and form multiple draining

daily orally for 21 days. Azithromycin, 1 g orally once weekly The initial lesion is a small papule. Within 48 to 72 hours,
for 3 weeks, is probably effective, but clinical data are lacking. the papule evolves into a pustule and subsequently ulcerates.

sinuses and fistulas à classic signs of extensive tissue destruction of the Obstetrics & Gynecology Books Full

external genitalia and anorectal region may occur during the tertiary
phase.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Lymphogranuloma Venereum
23 Genital Tract Infections

´ Diagnosis is established by detecting

double-strength tablet orallyC.
twice daily. Therapy should be
continued until the lesions have healed completely. Alternative
trachomatis by culture, direct
antibiotic therapy such as an aminoglycoside has been used in
refractory cases. Rarely, medical therapy fails and surgical exci-
immunofluorescence, or sionnucleic acid with
is required. Co-infection detection
another sexually transmitted
pathogen is a distinct possibility. Sex partners of women who
from the pus or aspirate from a tender
have granuloma inguinale shouldlymph
be examined ifnode.
they have had
sexual contact during the 60 days preceding the onset of symp-
toms (Workowski, 2015).
´ In the absence of specific LGV diagnostic testing,
Lymphogranuloma Venereum
patients should be treated basedvenereum
Lymphogranuloma on the (LGV) clinical
is a chronic infection of
lymphatic tissue produced by Chlamydia trachomatis. It is found
presentation most commonly in the tropics. Cases occur infrequently in the
United States, with fewer than 150 new cases being reported each
year, most of which occur in men. In women, the vulva is the
´ Treatment: most frequent site of infection, but the urethra, rectum, and cervix
may also be involved. This sexually transmitted infection is caused
by serotypes L1, L2, and L3 of C. trachomatis. Serologic studies
´ CDC recommends doxycycline, 100 mg twice
in high-risk populations have found that subclinical infection is
common. The incubation period is between 3 and 30 days.
daily for at least 21 days, as the preferred
There are three distinct phases of vulvar and perirectal LGV.
The primary infection is a shallow, painless ulcer that heals rap-
treatment. idly without therapy. It is typically located on the vestibule or
labia but occasionally in the periurethral or perirectal region. Figure 23.10 Lymphogranuloma venereum bubo with groove
One to 4 weeks after the primary infection, a secondary phase
´ An alternative therapy choice is erythromycin
sign. (From Friedrich EG. Vulvar Disease. 2nd ed. Philadelphia: WB
marked by painful adenopathy develops in the inguinal and Saunders; 1983.)
perirectal areas. Two thirds of women have unilateral adenop-
base, 500 mg four times daily orally for 21 days.
athy and 50% have systemic symptoms, including general Fluoroquinolone-based treatments may also be effective, but
malaise and fever. When the disease is untreated, the infected extended treatment intervals are likely required (Workowski,
nodes become increasingly tender, enlarged, matted together, 2015).
and adherent to overlying skin, forming a bubo (tender lymph Antibiotic therapy cures the bacterial infection and prevents
Comprehensive Gynecology 7th edition, 2017 (Lobonodes).
RA, A Gershenson DM,
classic clinical sign Lentz
of LGV is theGM,
doubleValea FA
genitocrural editors); chapter
further tissue 23, However,
destruction. Genitalfluctuant
tract nodes
infections
should be
fold, or groove sign (Fig. 23.10), a depression between groups aspirated to prevent sinus formation. Rarely, incision and drain-
 Chancroid
´ Chancroid is a sexually transmitted, acute,
ulcerative disease of the vulva caused by
Haemophilus ducreyi, a highly contagious,
small, nonmotile, gram-negative rod.
´ the soft chancre of chancroid is always painful
and tender.
´ the hard chancre of syphilis is usually
asymptomatic.
´ Gram stain: facultative anaerobic bacterium
with a classic appearance of streptobacillary
chains (extracellular school of fish).
´ Tissue trauma and excoriation of the skin must
preceed initial infection because H. ducreyi is
unable to penetrate and invade normal skin.
Comprehensive Gynecology 7th edition, 2017
 Chancroid
´ the initial lesion is a small papule. Within 48 to 72
hours, the papule evolves into a pustule and
subsequently ulcerates.
´ the extremely painful ulcers are shallow, with a
characteristic ragged edge, and usually occur in
the vulvar vestibule and rarely in the vagina or
cervix.
´ ulcers have a dirty, gray, necrotic, foul-smelling
exudate and lack induration at the base (the soft
chancre).
´ approximately 50% of women develop acutely
tender inguinal adenopathy (a bubo) which is
typically unilateral.
´ Fluctuant nodes should be treated by needle
aspiration to prevent rupture or by incision and
drainage if larger than 5 cm.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Chancroid

´ A definitive diagnosis of chancroid requires the identification of H.

ducreyi on special culture media that are not widely available from
commercial sources;
´ the clinical diagnosis is made in a woman with painful vulvar ulcers
after excluding other common STIs that produce vulvar ulcers,
including genital herpes, syphilis, LGV, and donovanosis.
´ Treatment: CDC recommends the following:
´ azithromycin, 1 g orally in a single dose; or
´ ceftriaxone, 250 mg intramuscular (IM) in a single dose; or
´ ciprofloxacin, 500 mg orally twice daily for 3 days; or
´ erythromycin base, 500 mg orally three times daily for 7 days.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 532 Part I I I G E N E R A L G Y N E C O LO G Y

Syphilis The extremely painful ulcers are shallow, with a characteristic

ragged edge, and usually occur in the vulvar vestibule and rarely
in the vagina or cervix. The ulcers have a dirty, gray, necrotic,
foul-smelling exudate and lack induration at the base (the soft
chancre). Multiple papules and ulcers may be in different phases
of maturation secondary to autoinoculation. Within 2 weeks of
an untreated infection, approximately 50% of women develop
´ chronic, complex systemic disease produced by acutely tender inguinal adenopathy, a bubo, which is typically
unilateral. Fluctuant nodes should be treated by needle aspiration
the spirochete Treponema pallidum. to prevent rupture or by incision and drainage if larger than 5 cm.
A definitive diagnosis of chancroid requires the identification
of H. ducreyi on special culture media that are not widely avail-
´ T. pallidum is an anaerobic, elongated, tightly able from commercial sources; even when these media are used,
sensitivity is less than 80%. No FDA-approved PCR test for
wound spirochete. H. ducreyi is available in the United States, but this testing can
be performed by clinical laboratories that have developed their
own PCR test and conducted a Clinical Laboratory Improve- Figure 23.11 Dark-field microscopic appearance of Treponema
´ Because of its extreme thinness, T pallidum is ment Amendments (CLIA) verification study. Sometimes, the
clinical diagnosis is made in a woman with painful vulvar ulcers
pallidum. (From Larsen SA, McGrew BE, Hunter EF, et al. Syphilis
serology and dark field microscopy. In: Holmes KK, Mårdh PA,
difficult to detect by light microscopy à after excluding other common STIs that produce vulvar ulcers,
including genital herpes, syphilis, LGV, and donovanosis.
Sparling PF, et al, eds. Sexually Transmitted Diseases. New York:
McGraw-Hill; 1984.)

therefore the presence of spirochetes is Due to antibiotic resistance to tetracyclines and sulfonamides,
the CDC recommends the following: azithromycin, 1 g orally in membranes. The incubation period is from 10 to 90 days, with
diagnosed by use of specially adapted a single dose or ceftriaxone, 250 mg intramuscular (IM) in a
single dose or ciprofloxacin, 500 mg orally twice daily for 3 days;
an average of 3 weeks. They replicate every 30 to 36 hours, which
accounts for the comparatively long incubation period.
techniques, dark-field microscopy, or direct or erythromycin base, 500 mg orally three times daily for 7 days.
Sexual partners should be treated in a similar fashion. Successful
Syphilis is a moderately contagious disease. Approximately
3% to 10% of patients contract the disease from a single sex-
fluorescent antibody tests antibiotic therapy results in symptomatic and objective improve-
ment within 5 to 7 days of initiating therapy. Large ulcers may
ual encounter with an infected partner. Similar studies have
documented that 30% of individuals become infected during a
require 2 to 3 weeks to heal, with clinical resolution of lymph- 1-month exposure to a sexual partner with primary or secondary
´ Patients are contagious during primary, adenopathy slower than that of ulcers. Buboes respond at a
slower rate than skin ulcers (Workowski, 2015). Approximately
syphilis. Patients are contagious during primary, secondary, and
probably the first year of latent syphilis. Syphilis can be spread
secondary, and probably the first year of latent 10% of women whose ulcers initially heal have a recurrence at
the same site. Women with HIV infection have an increased rate
by kissing or touching a person who has an active lesion on the
lips, oral cavity, breast, or genitals. Case transmission can occur
syphilis. of failure to the standard treatments for chancroid and there-
fore often require more prolonged therapy. Co-infection with
with oral-genital contact.
The diagnosis of syphilis is complicated by the fact that the

´ Syphilis can be spread by kissing or touching a

another ulcer causing an STI should be considered, especially in organism cannot be cultivated in  vitro. Definitive diagnosis is
women lacking an appropriate response to treatment. via darkfield microscopy to detect T. palladium in lesion exu-
date or tissue. T. palladium detection kits are not commercially
person who has an active lesion on the lips, oral
Syphilis available, but some labs provide locally developed PCR tests.

cavity, breast, or genitals.spirochete Treponema pallidum. The infection initially involves

Syphilis is a chronic, complex systemic disease produced by the Therefore presumptive diagnosis and screening rely on sero-
logic tests. There are two types of serologic tests, the nonspecific
mucous membranes. Syphilis remains one of the important STIs nontreponemal and the specific antitreponemal antibody tests.
in the United States, and epidemiologists speculate that only The nontreponemal tests, such as the Venereal Disease Research
Comprehensive Gynecology 7th edition, 2017 (Lobo RA,
one Gershenson
of four new cases ofDM, Lentz
syphilis GM,
is reported. Valea
Early syphilis FA
is a editors);
Laboratorychapter
(VDRL) slide23, Genital
test and the rapid tract infections
plasma reagin (RPR)
cofactor in the transmission and acquisition of HIV and, cur- card test are inexpensive and easy to perform. They are used as
 The extremely painful ulcers are shallow, with a characteristic
ragged edge, and usually occur in the vulvar vestibule and rarely
in the vagina or cervix. The ulcers have a dirty, gray, necrotic,
foul-smelling exudate and lack induration at the base (the soft

Syphilis
chancre). Multiple papules and ulcers may be in different phases
of maturation secondary to autoinoculation. Within 2 weeks of
an untreated infection, approximately 50% of women develop
acutely tender inguinal adenopathy, a bubo, which is typically
unilateral. Fluctuant nodes should be treated by needle aspiration
to prevent rupture or by incision and drainage if larger than 5 cm.
A definitive diagnosis of chancroid requires the identification
´ Definitive diagnosis is via darkfield microscopy to
of H. ducreyi on special culture media that are not widely avail-
able from commercial sources; even when these media are used,

detect T. palladium in lesion exudate or tissue.

sensitivity is less than 80%. No FDA-approved PCR test for
H. ducreyi is available in the United States, but this testing can
be performed by clinical laboratories that have developed their
own PCR test and conducted a Clinical Laboratory Improve-
´ Presumptive diagnosis and screening rely on
Figure 23.11 Dark-field microscopic appearance of Treponema
ment Amendments (CLIA) verification study. Sometimes, the pallidum. (From Larsen SA, McGrew BE, Hunter EF, et al. Syphilis
clinical diagnosis is made in a woman with painful vulvar ulcers serology and dark field microscopy. In: Holmes KK, Mårdh PA,
serologic tests: after excluding other common STIs that produce vulvar ulcers,
including genital herpes, syphilis, LGV, and donovanosis.
Sparling PF, et al, eds. Sexually Transmitted Diseases. New York:
McGraw-Hill; 1984.)
Due to antibiotic resistance to tetracyclines and sulfonamides,
nonspecific nontreponemal tests: VDRL and RPR (used as screening
an average of 3 weeks.tests
the CDC recommends the following: azithromycin, 1 g orally in
and everyindex
membranes. The incubation period is from 10 to 90 days, with
a single dose or ceftriaxone, 250 mg intramuscular (IM) in a
They replicate ofwhich
30 to 36 hours,
treatment response) single dose or ciprofloxacin, 500 mg orally twice daily for 3 days;
accounts for the comparatively long incubation period.
or erythromycin base, 500 mg orally three times daily for 7 days.
Syphilis is a moderately contagious disease. Approximately

• false-positive results: recent febrile illness, pregnancy, immunization, chronic active

Sexual partners should be treated in a similar fashion. Successful
3% to 10% of patients contract the disease from a single sex-
antibiotic therapy results in symptomatic and objective improve-
ual encounter with an infected partner. Similar studies have
ment within 5 to 7 days of initiating therapy. Large ulcers may
documented that 30% of individuals become infected during a
hepatitis, malaria, sarcoidosis, intravenous (IV) drug use, HIVexposure
infection, advancing
require 2 to 3 weeks to heal, with clinical resolution of lymph-
1-month to a sexual partner with primary or secondary
adenopathy slower than that of ulcers. Buboes respond at a
syphilis. Patients are contagious during primary, secondary, and
age, acute herpes simplex, and autoimmune diseases probably suchtheas first lupus erythematosus
slower rate than skin ulcers (Workowski, 2015). Approximately
year of latent or
syphilis. Syphilis can be spread
10% of women whose ulcers initially heal have a recurrence at
by kissing or touching a person who has an active lesion on the
rheumatoid arthritis. the same site. Women with HIV infection have an increased rate
lips, oral cavity, breast, or genitals. Case transmission can occur
of failure to the standard treatments for chancroid and there-
with oral-genital contact.
fore often require more prolonged therapy. Co-infection with The diagnosis of syphilis is complicated by the fact that the
another ulcer causing an STI should be considered, especially in organism cannot be cultivated in  vitro. Definitive diagnosis is
• false-negative result: occurs in women in whom there is an excess of anticardiolipin
women lacking an appropriate response to treatment. via darkfield microscopy to detect T. palladium in lesion exu-
date or tissue. T. palladium detection kits are not commercially
antibody in the serum,Syphilis
termed the prozone phenomenon.
Syphilis is a chronic, complex systemic disease produced by the
available, but some labs provide locally developed PCR tests.
Therefore presumptive diagnosis and screening rely on sero-
spirochete Treponema pallidum. The infection initially involves logic tests. There are two types of serologic tests, the nonspecific
mucous membranes. Syphilis remains one of the important STIs nontreponemal and the specific antitreponemal antibody tests.
• Women with immunocompromise also may have false-negative tests because of their
in the United States, and epidemiologists speculate that only
one of four new cases of syphilis is reported. Early syphilis is a
The nontreponemal tests, such as the Venereal Disease Research
Laboratory (VDRL) slide test and the rapid plasma reagin (RPR)
inability to produce the antibodies detected by these screening tests.
cofactor in the transmission and acquisition of HIV and, cur-
rently, 25% of new syphilis cases occur in persons co-infected
card test are inexpensive and easy to perform. They are used as
screening tests for the disease, typically become positive 4 to
with HIV. Even with mandatory screening, congenital syphilis 6 weeks after exposure, and also are a useful index of treatment
 Syphilis
532 Part I I I G E N E R A L G Y N E C O LO G Y

´ If a nonspecific test result

The extremely ispainful
positive, the
ulcers are shallow, with a characteristic
significance of this result must or cervix.be
ragged edge, and usually occur in the vulvar vestibule and rarely
in the vagina The ulcers have a dirty, gray, necrotic,

confirmed by a specificchancre). antitreponemal

foul-smelling exudate and lack induration at the base (the soft
Multiple papules and ulcers may be in different phases
of maturation secondary to autoinoculation. Within 2 weeks of
tests: fluorescent-labeled
an untreatedTreponema
infection, approximately 50% of women develop
acutely tender inguinal adenopathy, a bubo, which is typically
antibody absorption unilateral.
(FTA-ABS) Fluctuant nodes test
should be and
treated by needle aspiration
to prevent rupture or by incision and drainage if larger than 5 cm.
the micro- hemagglutination assay for
A definitive diagnosis of chancroid requires the identification
of H. ducreyi on special culture media that are not widely avail-
antibodies to T. pallidum (MHA-
less than 80%.TP)
able from commercial sources; even when these media are used,
sensitivity is No FDA-approved PCR test for
H. ducreyi is available in the United States, but this testing can
´ false-positive results: lupus be performed by clinical laboratories that have developed their
own PCR test and conducted a Clinical Laboratory Improve- Figure 23.11 Dark-field microscopic appearance of Treponema

erythematosus
ment Amendments (CLIA) verification study. Sometimes, the pallidum. (From Larsen SA, McGrew BE, Hunter EF, et al. Syphilis
clinical diagnosis is made in a woman with painful vulvar ulcers serology and dark field microscopy. In: Holmes KK, Mårdh PA,
after excluding other common STIs that produce vulvar ulcers, Sparling PF, et al, eds. Sexually Transmitted Diseases. New York:
including genital herpes, syphilis, LGV, and donovanosis. McGraw-Hill; 1984.)
´ A woman with a positive reactive Due to antibiotic resistance to tetracyclines and sulfonamides,
the CDC recommends the following: azithromycin, 1 g orally in membranes. The incubation period is from 10 to 90 days, with
treponemal test usually will have this a single dose or ceftriaxone, 250 mg intramuscular (IM) in a
single dose or ciprofloxacin, 500 mg orally twice daily for 3 days;
an average of 3 weeks. They replicate every 30 to 36 hours, which
accounts for the comparatively long incubation period.
positive reaction for her lifetime, or erythromycin base, 500 mg orally three times daily for 7 days.
Sexual partners should be treated in a similar fashion. Successful
Syphilis is a moderately contagious disease. Approximately
3% to 10% of patients contract the disease from a single sex-
regardless of treatment or activity of the
antibiotic therapy results in symptomatic and objective improve-
ment within 5 to 7 days of initiating therapy. Large ulcers may
ual encounter with an infected partner. Similar studies have
documented that 30% of individuals become infected during a
disease require 2 to 3 weeks to heal, with clinical resolution of lymph-
adenopathy slower than that of ulcers. Buboes respond at a
1-month exposure to a sexual partner with primary or secondary
syphilis. Patients are contagious during primary, secondary, and
slower rate than skin ulcers (Workowski, 2015). Approximately probably the first year of latent syphilis. Syphilis can be spread
10% of women whose ulcers initially heal have a recurrence at by kissing or touching a person who has an active lesion on the
the same site. Women with HIV infection have an increased rate lips, oral cavity, breast, or genitals. Case transmission can occur
Comprehensive Gynecology 7th edition, 2017 (LoboofRA, Gershenson
failure DM, Lentz
to the standard treatments GM, Valea
for chancroid and there-FA editors); chapter
with oral-genital contact. 23, Genital tract infections
fore often require more prolonged therapy. Co-infection with The diagnosis of syphilis is complicated by the fact that the
 23 Genital Tract Infections 533

Table 23.3 Potential Causes of Biologic False-Positive Results in Syphilis Serology

Biologic False-Positive Reaction
Cause Acute Chronic
Physiologic Pregnancy Advanced age, multiple blood transfusions
Infectious Varicella, vaccinia, measles, mumps, infectious mononucleosis, HIV, tropical spastic paraparesis, leprosy,* tuberculosis,
herpes simplex, viral hepatitis, HIV seroconversion illness, malaria,* lymphogranuloma venereum, trypanosomiasis,*
cytomegalovirus, pneumococcal pneumonia, Mycoplasma kala-azar*
pneumoniae, chancroid, lymphogranuloma venereum,
psittacosis, bacterial endocarditis, scarlet fever, rickettsial
infections, toxoplasmosis, Lyme disease, leptospirosis,
relapsing fever, rat bite fever
Vaccinations Smallpox, typhoid, yellow fever
Autoimmune Systemic lupus erythematosus, discoid lupus, drug-induced
disease lupus, autoimmune hemolytic anemia, polyarteritis
nodosa, rheumatoid arthritis, Sjögren syndrome,
Hashimoto thyroiditis, mixed connective tissue disease,
primary biliary cirrhosis, chronic liver disease, idiopathic
thrombocytopenic purpura
Other IV drug use, advanced malignancy hypergammaglobu-
linemia, lymphoproliferative disease

Data from Nandwani R, Evans DTP. Are you sure it’s syphilis? A review of false-positive serology. Int J STD AIDS. 1995;6:241; Hook EW III, Marra CM. Acquired syphilis in
adults. N Engl J Med. 1992;326:1062.
*Biologic false-positive reaction resolves with resolution of infection.
HIV, Human immunodeficiency virus.

Comprehensive Gynecology th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
autoimmune diseases7 such as lupus erythematosus or rheuma- ulcer is primary or secondary syphilis depends on the identifica-
 Syphilis
´ Clinically, syphilis is divided into primary,
secondary, and tertiary stages:
´ Primary syphilis:
´ a papule, which is usually painless, appears at the
site of inoculation 2 to 3 weeks after exposure. à
soon ulcerates to produce the classic chancre
that is a painless ulcer, with a raised indurated
margin and a nonexudative base
´ the chancre is solitary, painless, and found on the
vulva, vagina, or cervix
´ Nontender and firm regional adenopathy is
present during the first week of clinical disease.
´ Within 2 to 6 weeks, the painless ulcer heals
spontaneouslyà Hence, many women do not
seek treatment
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Syphilis
´ Secondary syphilis:
´ If primary syphilis is untreated, approximately 25% of
individuals develop secondary syphilis
´ result from hematogenous dissemination of the
spirochetes.
´ systemic symptoms may occur such as rash, fever,
headache, malaise, lymphadenopathy, and
anorexia.
´ the classic rash of secondary syphilis is red macules
and papules over the palms of the hands and the
soles of the feet
´ Vulvar lesions of condyloma latum are large, raised,
flattened, grayish white areas
´ On wet surfaces of the vulva, soft papules often
coalesce to form ulcers à larger than herpetic ulcers
and are not tender unless secondarily infected.
 Syphilis
´ Latent syphilis:
´ Follows after secondary syphilis, and varies in duration from 2
to 20 years
´ characterized as positive serology without symptoms or signs
of disease.
´ Women with syphilis in the primary or secondary stages and
during the first year of latent syphilis are believed to be
infectious.
´ Most women diagnosed with syphilis are detected via positive
blood tests during the latent stage of the disease.
´ Early latent syphilis is an infection of 1 year or less.
´ All other cases are referred to as late latent or latent syphilis of
unknown duration.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Syphilis
´ Tertiary phase
´ devastating in its potentially destructive
effects on the central nervous,
cardiovascular, and musculoskeletal
systems.
´ manifestations of late syphilis include optic
atrophy, tabes dorsalis, generalized
paresis, aortic aneurysm, and gummas of
the skin and bones.
´ A gumma is similar to a cold abscess, with
a necrotic center and the obliteration of
small vessels by endarteritis.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Syphilis
´ Treatment:
´ Parenteral penicillin G is the drug of choice for
syphilis.
´ CDC recommends 2.4 million units of benzathine
penicillin G IM in one dose for early syphilis
(primary and early latent secondary syphilis).
´ Patients who are allergic to penicillin should
receive oral tetracycline, 500 mg every 6 hours for
14 days, or
´ doxycycline, 100 mg orally twice a day for 2
weeks.
´ Approximately 60% of women develop an acute
febrile reaction associated with flulike symptoms
such as headache and myalgia within the first 24
hours after parenteral penicillin therapy for early
syphilis (Jarisch-Herxheimer reaction)

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Box 23.2 Centers for Disease Control and Prevention experience relapses of secondary syphilis. Women
Recommended Treatment of Syphilis (2014) sustained fourfold increase in nontreponemal te
failed treatment or become reinfected. They should
Early Syphilis (primary, secondary, and early latent syphilis and evaluated for concurrent HIV infection. Whe
of less than 1 year in duration)
retreated, the recommendation is three weekly injec
Recommended regimen: Benzathine penicillin G, 2.4 million U IM,
one dose
zathine penicillin G, 2.4 million units IM. For long
Alternative regimen (penicillin-allergic nonpregnant patients): up, the same serologic tests should be ordered. O
Doxycycline, 100 mg orally bid for 2 wk or tetracycline, 500 mg test should be obtained from the same laboratory
orally qid for 2 wk and RPR tests are equally valid, but RPR titers tend
higher than VDRL titers. With successful treatmen
Late Latent Syphilis (>1 year in duration, gummas, and
cardiovascular syphilis)
titer will become nonreactive or, at most, be rea
Recommended regimen: Benzathine penicillin G, 7.2 million U lower titer within 1 year. There is a 1% to 2% ch
total, administered as three doses of 2.4 million U IM at 1-wk woman will not exhibit a fourfold titer decline, an
intervals are considered therapeutic failures. They should
Alternative regimen (penicillin-allergic nonpregnant patients): Patients with syphilis lasting longer than 1 year
Doxycycline 100 mg orally 2 times a day for 2 wk if <1 year, quantitative VDRL titers for 2 years following the
otherwise, for 4 wk; or tetracycline, 500 mg orally qid for 2 wk their titers will decline more slowly. A specific tes
if <1 year; otherwise, for 4 wk such as the FTA-ABS, remains reactive indefinitely.
Neurosyphilis all women with a first attack of primary syphilis s
Recommended regimen: Aqueous crystalline penicillin G, 18-24 negative nonspecific serology within 1 year, and w
million U daily, administered as 3-4 million U IV every 4 hr, for for secondary syphilis should have a negative ser
10-14 days 2 years. If they are not, treatment failure, reinfecti
Alternative regimen: Procaine penicillin, 2.4 million U IM daily, for current HIV infection should be investigated.
10-14 days plus probenecid, 500 mg PO qid for 10-14 days Syphilis often involves the CNS. There is no est
Syphilis in Pregnancy nostic test that is a gold standard for neurosyphilis.
Recommended regimen: Penicillin regimen appropriate for stage of neurosyphilis is based on a combination of clin
of syphilis. Some experts recommend additional therapy (e.g., reactive serologic tests, and abnormalities of cerebr
second dose of benzathine penicillin, 2.4 million U IM) 1 wk serology, cell count, or protein. Infection of the C
after the initial dose for those who have primary, secondary, or chetes may occur during any stage of syphilis. W
early latent syphilis
undergo a cerebrospinal fluid examination if they
Alternative regimen (penicillin allergy): Pregnant women with
a history of penicillin allergy should be skin-tested and
rologic or ophthalmologic signs or symptoms, evid
desensitized tertiary syphilis, treatment failures, and HIV infec
latent syphilis or syphilis of an unknown duration. T
Syphilis in HIV-Infected Patients syphilis, the CDC recommends aqueous crystalline
Primary and secondary syphilis: Benzathine penicillin G, 2.4
18 to 24 million units daily, administered as 3 to 4
million U IM. Some experts recommend additional treat-
ments, such as three weekly doses of benzathine penicillin G.
IV every 4 hours for 10 to 14 days. An alternative re
Penicillin-allergic patients should be desensitized and treated caine penicillin, 2.4 million units IM daily, plus pro
with penicillin mg orally four times daily for 10 to 14 days. The du
Latent syphilis (normal CSF examination): Benzathine penicillin G, these regimens for neurosyphilis is shorter than that o
7.2 million U as three weekly doses of 2.4 million U each used for late syphilis in the absence of neurosyph
Data from Workowski KA, Bolan GA, Centers for Disease Control and Prevention.
some experts administer benzathine penicillin, 2.4
th
Comprehensive Gynecology 7 Sexually
edition, 2017 (Lobo
transmitted diseasesRA, Gershenson
treatment guidelines, DM,
2015. Lentz
MMWR GM,
RecommValea
Rep. FA editors);
IM, after chapter
completion 23,ofGenital tract infections
either regimen to provide
2015;64(RR-03):1-137. total duration of therapy (Workowski, 2015).
 Syphilis
´ Treatment:
´ Women who have a sustained fourfold increase in
nontreponemal test titers have failed treatment or
become reinfected à should be retreated and
evaluated for concurrent HIV infection.
´ When women are retreated, the recommendation is
three weekly injections of benzathine penicillin G, 2.4
million units IM.
´ With successful treatment, the VDRL titer will become
nonreactive or, at most, be reactive, with a lower titer
within 1 year.
´ all women with a first attack of primary syphilis should
have a negative nonspecific serology within 1 year, and
women treated for secondary syphilis should have a
negative serology within 2 years à if they are not,
treatment failure, reinfection, and concurrent HIV
infection should be investigated.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Neurosyphilis
´ Syphilis often involves the CNS.
´ the diagnosis of neurosyphilis is based on a combination of clinical findings,
reactive serologic tests, and abnormalities of cerebrospinal fluid, serology,
cell count, or protein.
´ CDC recommends aqueous crystalline penicillin G, 18 to 24 million units
daily, administered as 3 to 4 million units IV every 4 hours for 10 to 14 days.
´ An alternative regimen is procaine penicillin, 2.4 million units IM daily, plus
probenecid, 500 mg orally four times daily for 10 to 14 days.
´ It is important for all women with syphilis to be tested for HIV infection.
Simultaneous syphilis and HIV infections alter the natural history of syphilis,
with earlier involvement of the CNS.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
Infections of the vagina
 VAGINITIS
´ Vaginal discharge is the most common symptom in gynecology.
´ Other symptoms associated with vaginal infection include superficial dyspareunia,
dysuria, odor, and vulvar burning and pruritus.
´ the three common causes of vaginitis are (1) a fungus (candidiasis), (2) a protozoon
538 (Trichomonas),
Part III GENERALand
GYNECOLOGY
(3) a disruption of the vaginal bacterial ecosystem leading to
bacterial vaginosis.
Table 23.5 Typical Features of Vaginitis
Condition Symptoms and Signs* Findings on Examination* pH Wet Mount Comment
Bacterial Increased discharge Thin, whitish gray, homoge- >4.5 Clue cells (>20%) shift in flora Greatly decreased
vaginosis† (white, thin), neous discharge, cocci, Amine odor after adding lactobacilli
Increased odor sometimes frothy potassium hydroxide to Greatly increased cocci
wet mount Small curved rods
Candidiasis Increased discharge Thick, curdy discharge <4.5 Hyphae or spores Can be mixed infection
(white, thick)‡ Vaginal erythema with bacterial vaginosis,
Dysuria T. vaginalis, or both, and
Pruritus have higher pH
Burning
Trichomoniasis§ Increased discharge Yellow, frothy discharge, >4.5 Motile trichomonads More symptoms at higher
(yellow, frothy) with or without vaginal or Increased white cells vaginal pH
Increased odor cervical erythema
Dysuria
Pruritus

From Eckert LO. Clinical practice: acute vulvovaginitis. N Engl J Med. 2006;355(12):1244-1252.
 BACTERIAL VAGINOSIS
´ Bacterial vaginosis is the most prevalent cause of symptomatic vaginitis
´ Bacterial vaginosis reflects a shift in vaginal flora from lactobacilli-
dominant to mixed flora, including genital mycoplasmas, G. vaginalis,
and anaerobes, such as peptostreptococci, and Prevotella and
Mobiluncus spp.
´ Currently, bacterial vaginosis is described as a “sexually associated”
infection rather than a true sexually transmitted infection.
´ Histologically, there is an absence of inflammation in biopsies of the
vagina—thus the term vaginosis rather than vaginitis.
´ Bacterial vaginosis has been associated with upper tract infections,
including endometritis, pelvic inflammatory disease, postoperative
vaginal cuff cellulitis, and multiple complications of infection during
pregnancy, such as preterm rupture of the membranes, endomyometritis,
decreased success with in vitro fertilization, and increased pregnancy
loss of less than 20 weeks’ gestation.
BACTERIAL VAGINOSIS
´ the most frequent symptom is an unpleasant vaginal odor, which patients
describe as musty or fishy odor à often stronger following intercourse, when
the alkaline semen results in a release of aromatic amines.
´ vaginal discharge associated with bacterial vaginosis is thin and gray-white.
´ Speculum examination reveals that the discharge is mildly adherent to the
vaginal walls
´ the four criteria (AMSEL’s CRITERIA) for the diagnosis of bacterial vaginosis are
´ (1) a homogeneous vaginal discharge is present;
´ (2) the vaginal discharge has a pH of 4.5 or higher;
´ (3) the vaginal discharge has an amine-like odor when mixed with potassium
hydroxide (whiff test);
´ (4) a wet smear of the vaginal discharge demonstrates clue cells more than 20% of
the number of the vaginal epithelial cells.
*For the clinician, three our of four criteria are sufficient for a presumptive diagnosis.
If available, Gram staining of vaginal secretion is an excellent diagnostic method.
540 BACTERIAL VAGINOSIS
Part III GENERAL GYNECOLOGY

´ Treament:
Table 23.7 Centers for Disease Control and Prevention Recommendations for Treatment of Acute Vaginitis (2015)
Disease Drug Dose
Bacterial vaginosis* Metronidazole (Flagyl) 500 mg PO, bid for 7 days†
Tinidazole 2-g dose PO daily for 2 days
Tinidazole 1-g dose PO daily for 5 days
0.75% metronidazole gel (Metrogel) One 5-g application intravaginally daily for 5 days‡
2% clindamycin cream (Cleocin vaginal) One 5-g application intravaginally every night for 7 days
Clindamycin 300 mg PO, bid for 7 days
Clindamycin ovules 100 mg intravaginally every night for 3 days
Vulvovaginal Candidiasis, Uncomplicated
Intravaginal therapy‡ § Azoles
2% butoconazole cream (Mycelex-3) 5 g/day for 4 days§
2% sustained-release butoconazole cream One 5-g dose
(Gynazole)
´ Recurrent1%bacterial
clotrimazole vaginosis (three or more
cream (Mycelex-7) episodes
5 g for 7-14 days§ in the previous year): 10
days vaginal metronidazole,
Clotrimazole (Gyne-Lotrimin 3)followed by twice-
Two 100-mgweekly use of 0.75%
vaginal tablets/day for 3 days; one 500-mg
metronidazole gel for 16 weeks vaginal tablet
2% miconazole cream 5 g/day for 7 days§
´ Concurrent treatment
Miconazole of the male partnerOne
(Monistat-7) is not
100-mgrecommended at for
vaginal suppository/day this time.
7 days §

Miconazole (Monistat-3) One 200-mg vaginal suppository/day for 3 days

Miconazole (Monistat-1) One 1200-mg vaginal suppository§
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
6.5% tioconazole ointment (Monistat 1-day) One 5-g dose§
 TRICHOMONAS VAGINAL INFECTION

´ caused by the anaerobic flagellated protozoon, T. vaginalis

´ thiis infection is a highly contagious STI;
´ 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.
´ primary symptom of Trichomonas vaginal infection is profuse/copious
vaginal discharge.
´ the classic discharge of Trichomonas infection is termed frothy (with
bubbles) and often has an unpleasant odor.
´ the classic sign of a strawberry appearance of the upper vagina and cervix is
rare and is noted in less than 10% of women.
´ Previously, culture was considered the gold standard to detect T. vaginalis,
and wet prep was the most commonly performed diagnostic test
´ Nucleic acid amplification tests (NAATs) are 3-5x times more sensitive than
wet prep. NAAT can be performed on vaginal secretions or urine.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 TRICHOMONAS VAGINAL INFECTION

´ Nitroimidazoles are the only class of drugs recommended for

treatment of Trichomonas vaginitis.
´ A single oral dose (2 g) of metronidazole or tinidazole is
recommended.
´ An alternate regimen is metronidazole, 500 mg orally, twice
daily for 7 days.
´ Metronidazole is safe in all trimesters of pregnancy. Patients
should be warned that nitroimidazoles inhibit ethanol
metabolism. Women should avoid alcohol for 24 hours after
metronidazole and 72 hours after tinidazole therapy to avoid
a disulfiram-like reaction.
´ Topical therapy for Trichomonas vaginitis is not recommended
because it does not eliminate disease reservoirs in Bartholin and
Skene glands.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 CANDIDA VAGINITIS
´ produced by a ubiquitous, airborne, gram-positive fungus.
´ more than 90% of cases are caused by Candida albicans
´ When the ecosystem of the vagina is disturbed, C. albicans can become
an opportunistic pathogen.
´ Hormonal factors, depressed cell-mediated immunity, and antibiotic use
are the 3 most important factors that alter the vaginal ecosystem.
´ hormonal changes associated with pregnancy and menstruation favor
growth of the fungus.
´ the prevalence of Candida vaginitis increases throughout pregnancy,
probably as a result of the high estrogen levels.
´ Lactobacilli inhibit the growth of fungi in the vagina. therefore when the
relative concentration of lactobacilli declines, rapid overgrowth of
Candida spp. occurs.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 CANDIDA VAGINITIS

´ Broad-spectrum antibiotics, especially those that

destroy lactobacilli (e.g., penicillin, tetracycline,
cephalosporins), are notorious for precipitating
acute episodes of C. albicans vaginitis.
´ the most important host factor is depressed cell-
mediated immunity (Women who take
exogenous corticosteroids and women with AIDS )
´ the greatest enigma of this condition is the
recurrence rate after an apparent cure, varying
from 20% to 80%.
´ Approximately 3% to 5% of these women
experience recurrent vulvovaginal candidiasis
(RVVC) à four or more documented episodes in 1
year.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 CANDIDA VAGINITIS

´ Pruritus is the predominant symptom

´ the vaginal discharge is white or whitish
gray, highly viscous, and described as
granular or occular, with no odor.
´ During speculum examination, a cottage
cheese–type discharge is often visualized,
with adherent clumps and plaques (thrush
patches) attached to the vaginal walls.
´ e vaginal pH associated with this infection is
below 4.5, in contrast to bacterial vaginosis Source: Loyola University Medical Education Network

and Trichomonas vaginitis, which are

associated with an elevated pH.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 CANDIDA VAGINITIS
´ diagnosis is established by obtaining a wet
smear of vaginal secretion and mixing this
with 10% to 20% potassium hydroxide
´ alkali rapidly lyses red blood cells and
inflammatory cells.
´ Active disease is associated with lamentous
forms, mycelia, or pseudohyphae, rather than
spores.
´ vaginal culture for Candida is particularly
useful when a wet mount is negative for M
hyphae, but the patients have symptoms and ti
R
discharge or other signs suggestive of vul- Figure 23.20 Microscopic appearance of vaginal smear in a case
of vaginal candidiasis (potassium hydroxide preparation, yeast
vovaginal candidiasis on examination. cells and pseudomycelia; × 320). (From Merkus JM, Bisschop MP, v
Stolte LA. The proper nature of vaginal candidosis and the problem u
´ Fungal culture may also be useful for women of recurrence. Obstet Gynecol Surv. 1985;40:493-504.) p
c
who have recently treated themselves with
detect C. albicans on a wet mount is 80% when semiquantitative o
an antifungal agent culture growth is 3 to 4+, but only 20% when culture growth is o
 CANDIDA VAGINITIS Box 23.3 Classification of Vulvovaginal Candidiasis (VVC)
Uncomplicated VVC Complicated VVC
! Sporadic or infrequent ! Recurrent vulvovaginal
vulvovaginal candidiasis candidiasis
and or
q Treatment: CDC recommends placing ! Mild to moderate vulvovaginal ! Severe vulvovaginal
the woman into an uncomplicated or candidiasis candidiasis
complicated category to guide and or
! Likely to be C. albicans ! Non-albicans candidiasis
treatment and or
! Women with uncontrolled
women diabetes, debilitation, or
immunosuppression

´ A number of azole vaginal preparationsModified

and from Workowski KA, Bolan GA, Centers for Disease Control and Preven-
a single oral agent,
tion. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm
fluconazole, are approved for treatment.
Rep. 2015;64(RR-03):1-137.
Figure 23.20 Microscopic appearance of vaginal smear in a case
´ In
of vaginal patients
candidiasis withhydroxide
(potassium uncomplicated
preparation, yeast vulvovaginal candidiasis, topical antifungal
cells andagents vulvovaginal candidiasis, topical antifungal agents are typically
are× 320).
pseudomycelia; typically used
(From Merkus JM, for 1 to
Bisschop MP,3 days, orfor
used a 1single
to 3 oral
days, or a doseoral
single ofdose
fluconazole.
of fluconazole. Patient
Stolte LA. The proper nature of vaginal candidosis and the problem
´ For patients
of recurrence. Obstet Gynecolwith complicated vaginitis, preference,
Surv. 1985;40:493-504.) topical response
azolestoare prior recommended
therapy, and cost shouldfor
guide the
7 to 14 days. If using oral therapy, a second choice of therapy
dose of(Workowski,
fluconazole2015). (150 mg)
For patients with complicated vaginitis, topical azoles are rec-
given 72 hours after the first dose is recommended.
detect C. albicans on a wet mount is 80% when semiquantitative ommended for 7 to 14 days. If using oral therapy, a second dose
culture growth is 3 to 4+, but only 20% when culture growth is of fluconazole (150 mg) given 72 hours after the first dose is
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
2+. Hence, a negative smear does not exclude Candida vulvovag- recommended.
 CANDIDA VAGINITIS

´ In women with RVVC, the resolution of symptoms typically

requires longer duration of therapy.
´ 7 – 14 days of topical therapy or three doses of oral fluconazole
3 days apart (e.g., days 1, 4, and 7) are options.
´ After this initial treatment, maintenance therapy will help
prevent recurrence of symptoms.
´ Oral fluconazole (e.g., 100-, 150-, or 200-mg dose) weekly for 6
months is typically first-line treatment.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Table 23.6 Diagnostic Tests Available for Vaginitis
Test Sensitivity (%) Specificity (%) Comments
Bacterial Vaginosis
pH >4.5 97 64
Amsel’s criteria 92 77 Must meet three of four clinical criteria (pH >4.5, thin
watery discharge, >20% clue cells, positive whiff
test), but similar results achieved if two of four
criteria meet Nugent criteria; Gram stain morphology
score (1-10) based on lactobacilli and other
morphotypes; score of 1-3 indicates normal flora,
score of 7-10 bacterial vaginosis; high interobserver
reproducibility
Pap smear 49 93
Point-of-care tests
QuickVue Advance, pH + amines 89 96 Positive if pH >4.7
QuickVue Advance, G. vaginalis 91 >95 Tests for proline iminopeptidase activity in vaginal
fluid; if used when pH >4.5, sensitivity is 95% and
specificity is 99%
OSOM BV blue 90 <95 Tests for vaginal sialidase activity
Candida
Wet mount
Overall 50 97
Growth of 3-4 + on culture 85 C. albicans a commensal agent in 15%-20% of women
Growth of 1 + on culture 23
pH ≤4.5 Usual If symptoms present, pH may be elevated if mixed
infection with bacterial vaginosis or T. vaginalis
present
Pap smear 25 72
Trichomonas vaginalis
Wet mount 45-60 95 Increased visibility of microorganisms with a higher
burden of infection
Culture 85-90 >95
pH >4.5 56 50
Pap smear 92 61 False-positive rate of 8% for standard Pap test and 4%
for liquid-based cytologic test
Point-of-care test: OSOM 83 98.8 10 min required to perform tests for T. vaginalis
antigens

From Eckert LO. Clinical practice: acute vulvovaginitis. N Engl J Med. 2006;355(12):1244-1252.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
Because there are no effective means of replacing lactobacilli,
 TOXIC SHOCK SYNDROME
´ Toxic shock syndrome (TSS) is an acute febrile illness produced by a
bacterial exotoxin, with a fulminating downhill course involving
dysfunction of multiple organ systems.
´ the cardinal features: abrupt onset and rapidity with which the
clinical signs and symptoms may present and progress.
´ A woman with TSS may develop a rapid onset of hypotension
associated with multiorgan system failure.
´ S. aureus was isolated from the vagina in more than 90% of these
cases.
´ Nonmenstrual TSS may be a sequelae of focal staphylococcal
infection of the skin and subcutaneous tissue, often following a
surgical procedure.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 TOXIC SHOCK SYNDROME
´ 3 requirements for the development of classic TSS:
´ (1) the woman must be colonized or infected with S. aureus
´ (2) the bacteria must produce TSS toxin 1 (TSST-1) or related toxins
´ (3) the toxins must have a route of entry into the systemic
circulation.
´ signs and symptoms of TSS are produced by the exotoxin
named toxin 1.
´ gynecologists should have a high index of suspicion for TSS in a
woman who has an unexplained fever and a rash during or
immediately fol lowing her menstrual period.
´ the the patient experiences an abrupt onset of a high
temperature associated with headache, myalgia, sore throat,
vomiting, diarrhea, generalized skin rash, and often
hypotension.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Box 23.4 Case Definition of Toxic Shock Syndrome even in the absence of a posit
with TSS caused by methici
1. Fever (temperature 38.9° C [102° F]) clindamycin plus vancomyc
2. Rash characterized by diffuse macular erythroderma divided doses) or linezolid (6
3. Desquamation occurring 1-2 wk after onset of illness (in survivors)
is used. If the diagnosis is qu
4. Hypotension (systolic blood pressure ≤90 mm Hg in adults) or
orthostatic syncope
an aminoglycoside to obtain
5. Involvement of three or more of the following organ systems: ative sepsis. Antibiotic thera
a. Gastrointestinal (vomiting or diarrhea at onset of illness) the course of an individual e
b. Muscular (myalgia or creatine phosphokinase level twice underlying cause of toxic sho
normal) the infected site should be d
c. Mucous membrane (vaginal, oropharyngeal, or conjunctival with mupirocin to decrease
hyperemia) applying half of the ointmen
d. Renal (BUN or creatinine level ≥ twice normal or ≥5 WBCs/ nostril and the other half in
HPF in absence of UTI) for 5 days.
e. Hepatic (total bilirubin, SGOT, or SGPT twice normal level)
In summary, the treatment
f. Hematologic (platelets ≤100,000/mm3)
g. Central nervous system (disorientation or alteration in con-
involvement of individual orga
sciousness without focal neurologic signs when fever and a temperature higher than 38.9
hypotension are absent) cians should be aware of the f
h. Cardiopulmonary (adult respiratory distress syndrome, pul- syndrome. The foundation of
monary edema, new onset of second- or third-degree heart and aggressive management b
block, myocarditis) the disease may progress.
6. Negative throat and cerebrospinal fluid cultures (a positive It is possible to decrease the
blood culture for Staphylococcus aureus does not exclude a case) the use of catamenial product
7. Negative serologic test results for Rocky Mountain spotted to change tampons every 4 to
fever, leptospirosis, rubeola
external pads is also good preve
From Centers for Disease Control (CDC). Toxic-shock syndrome, United States, ally accept the recommendati
1970-1982. MMWR Morb Mortal Wkly Rep. 1982;31:201. sleep. The incidence of TSS ha
BUN, Blood urea nitrogen; HPF, high-powered field; SGOT, serum glutamic-oxa-
loacetic transaminase; SGPT, serum glutamic-pyruvic transaminase; UTI, urinary removal of super-absorbing ta
tract infection; WBC, white blood cell count. by Tierno and Hanna reporte
safest choice to avoid menstru
Finally, there are cases of st
Boxth 23.5 Laboratory Abnormalities in Early Toxic Shock
Comprehensive Gynecology 7 edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections to
dromes that are secondary
Syndrome
 TOXIC SHOCK SYNDROME
´ the most characteristic manifestations of TSS are the skin
changes.
´ During the first 48 hours, the skin rash appears similar to
intense sunburn.
´ During the next few days, the erythema will become more
macular and resemble a drug-related rash.
´ From days 12 to 15 of the illness, there is a fine, flaky
desquamation of skin over the face and trunk, with sloughing
of the entire skin thickness of the palms and soles.

´ During pelvic examination, patients complain of

tenderness of the external genitalia and vagina.

Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 Finally, there are ca
Box 23.5 Laboratory Abnormalities in Early Toxic Shock
dromes that are secon
Syndrome
group A streptococcu
Present in >85% of patients ent exotoxins have be
Coagulase-positive staphylococci in cervix or vagina the two most common
Immature and mature polymorphonuclear cells >90% of WBCs cases involve massive
Total lymphocyte count <650/mm3
One of the most dist
Total serum protein level <5.6 mg/dL
Serum albumin level <3.1 g/dL
ing skin infection is th
Serum calcium level <7.8 mg/dL area. Older women a
Serum creatinine clearance >1 mg/dL nocompromised are a
Serum bilirubin level >1.5 mg/dL streptococcal infection
Serum cholesterol level ≤120 mg/dL drome. The mortality
Prothrombin time >12 seconds secondary to group A
Present in >70% of patients LeRiche, 2012).
Platelet count <150,000/mm3
Pyuria >5 WBCs/HPF
Proteinuria ≥2+
BUN >20 mg/dL CERVICITIS
Aspartate aminotransferase (formerly SGOT) >41 U/L
Cervicitis, an inflamm
From Chesney PJ, Davis JP, Purdy WK, et al. Clinical manifestations of toxic shock
and stroma, can be as
syndrome. JAMA. 1981;246:746.
BUN, Blood urea nitrogen; HPF, high-powered field; SGOT, serum glutamic-
temic disease, neoplasi
oxaloacetic transaminase; WBCs, white blood cells. important to consider
Results were available for at least 18 patients per category with the followingfocuses on infectious o
exceptions: cervicovaginal cultures (12 patients), cholesterol level (15 patients),The cervix acts as a
and prothrombin time (14 patients).
flora of the vagina and
cavity and oviducts. C
th
Comprehensive GynecologyWomen
7 edition, with
2017 (Lobo
TSSRA,caused
Gershenson
byDM, Lentz GM, Valea FA editors); chapter
methicillin-susceptible S. 23,
pleGenital tractbarrier;
physical infectionsit
 TOXIC SHOCK SYNDROME
´ the management of a classic case of severe TSS demands an
intensive care unit and the skills of an expert in critical care
medicine.
´ the first priority is to eliminate the hypotension produced by the
exotoxin.
´ Copious amounts of IV fluids are given while pressure and
volume dynamics are centrally monitored.
´ Mechanical ventilation is required for women who develop
adult respiratory distress syndrome.
´ When the woman is initially admitted to the hospital, it is
important to obtain cervical, vaginal, and blood cultures for S.
aureus.
´ it is prudent to wash out the vagina with saline or dilute iodine
solution to diminish the amount of exotoxin that may be
absorbed into the systemic circulation.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
 TOXIC SHOCK SYNDROME
´Treatment:
´ Women with TSS caused by methicillin-susceptible S. aureus should be
treated with clindamycin, 600 mg IV every 8 hours, plus nafcillin or oxacillin,
2 g IV every 4 hours.
´ Most experts recommend a 1- to 2-week course of therapy with an
antistaphylococcal agent such as clindamycin or dicloxacillin even in the
absence of a positive S. aureus culture.
´ In patients with TSS caused by methicillin-resistant S. aureus (MRSA):
clindamycin plus vancomycin (30 mg/kg/day IV in two divided doses) or
linezolid (600 mg oral or IV every 12 hours) is used.
´ the infected site should be drained and débrided. Treatment with 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.
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
CERVICITIS
 CERVICITIS
´ can be associated with trauma, inflammatory systemic disease, neoplasia, and
infection.
´ the cervix (and cervical mucus) acts as a barrier between the abundant bacterial
flora of the vagina and the bacteriologically sterile endometrial cavity and
oviducts.
´ Cervical infection can be ectocervicitis or endocervicitis. Ectocervicitis can be viral
(HSV) or from a severe vaginitis (e.g., strawberry cervix associated with T. vaginalis
infection) or C. albicans.
´ Endocervicitis may be secondary to infection with C. trachomatis or N.
gonorrhoeae.
´ Infection of the endocervix becomes a major reservoir for sexual and perinatal
transmission of pathogenic microorganisms.
´ Primary endocervical infection may result in secondary ascending infections,
including pelvic inflammatory disease and perinatal infections of the membranes,
amniotic fluid, and parametria.
 MUCOPURULENT CERVICITIS 546 Part III GENERAL GYNECOLOGY

Often, the woman is asymptomatic, even though the cervix

is colonized with organisms. The cervix is a potential reservoir
for Neisseria gonorrhoeae, Chlamydia trachomatis, HSV, human
papillomavirus, and Mycoplasma spp. Cervical infection can
be ectocervicitis or endocervicitis. Ectocervicitis can be viral
´ 2 simple, definitive, objective criteria have been developed to (HSV) or from a severe vaginitis (e.g., strawberry cervix associ-
ated with T. vaginalis infection) or C. albicans. Endocervicitis
establish mucopurulent cervicitis: may be secondary to infection with C. trachomatis or N. gonor-
rhoeae. Bacterial vaginosis and Mycoplasma genitalium have also
been associated with endocervicitis. Infection of the endocervix
´ 1. gross visualization of yellow mucopurulent material on a becomes a major reservoir for sexual and perinatal transmission
of pathogenic microorganisms. Primary endocervical infection
white cotton swab ( may result in secondary ascending infections, including pelvic
inflammatory disease and perinatal infections of the membranes,
amniotic fluid, and parametria.

´ 2. presence of 10 or more PMN leukocytes per microscopic The histologic diagnosis of chronic cervicitis is so prevalent
that it should be considered the norm for parous women of

field (magnification, × 1000) on Gram-stained smears

reproductive age. The histopathology of endocervicitis is charac-
terized by a severe inflammatory reaction in the mucosa and sub-
mucosa. The tissues are infiltrated with a large number of PMNs
obtained from the endocervix. A and monocytes and, occasionally, there is associated epithelial Figure 23.21 Mucopurulent cervicitis demonstrated by a cotton
necrosis. Physiologically, there is a resident population of a small swab test.
number of leukocytes in the normal cervix. Thus the emphasis is
´ Symptoms that suggest cervical infection include vaginal on a severe inflammatory reaction by a large number of PMNs.
This section focuses on mucopurulent cervicitis and techniques
discharge, deep dyspareunia, and postcoital bleeding. to diagnose common cervical infections.

´ the physical sign of a cervical infection is a cervix that is

MUCOPURULENT CERVICITIS
The diagnosis of cervicitis continues to rely on symptoms, exam-
hypertrophic and edematous. ination, and microscopic evaluation. Two simple, definitive,
objective criteria have been developed to establish mucopurulent
cervicitis—gross visualization of yellow mucopurulent material
´ C. trachomatis and N. gonorrhea are the most common cause on a white cotton swab (Fig. 23.21) and the presence of 10 or
more PMN leukocytes per microscopic field (magnification, ×
of cervical infection in many women with mucopurulent 1000) on Gram-stained smears obtained from the endocervix.
Alternative clinical criteria that may be used are erythema and
cervicitis edema in an area of cervical ectopy or associated with bleeding
secondary to endocervical ulceration or friability when the endo-
cervical smear is obtained. Women may also report increased Figure 23.22 Patient with C. trachomatis mucopurulent cervicitis
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson
vaginalDM, Lentz
discharge GM, Valea
and intermenstrual FA editors);
vaginal bleeding. chapter
with resolution23, Genital tract infections
post treatment.
The prevalence of mucopurulent cervicitis depends on
 MUCOPURULENT CERVICITIS 546 Part III GENERAL GYNECOLOGY

Often, the woman is asymptomatic, even though the cervix

is colonized with organisms. The cervix is a potential reservoir
for Neisseria gonorrhoeae, Chlamydia trachomatis, HSV, human
´ Gold standard for diagnosis: NAAT papillomavirus, and Mycoplasma spp. Cervical infection can
be ectocervicitis or endocervicitis. Ectocervicitis can be viral
(HSV) or from a severe vaginitis (e.g., strawberry cervix associ-
´ When mucopurulent cervicitis is clinically diagnosed, ated with T. vaginalis infection) or C. albicans. Endocervicitis
may be secondary to infection with C. trachomatis or N. gonor-
empirical therapy for C. trachomatis is recommended rhoeae. Bacterial vaginosis and Mycoplasma genitalium have also
been associated with endocervicitis. Infection of the endocervix
for women at increased risk of this common STI (age <25 becomes a major reservoir for sexual and perinatal transmission
of pathogenic microorganisms. Primary endocervical infection
years, new or multiple sex partners, unprotected sex). may result in secondary ascending infections, including pelvic
inflammatory disease and perinatal infections of the membranes,
amniotic fluid, and parametria.
´ Recommended regimens for presumptive cervicitis The histologic diagnosis of chronic cervicitis is so prevalent
that it should be considered the norm for parous women of

therapy include:
reproductive age. The histopathology of endocervicitis is charac-
terized by a severe inflammatory reaction in the mucosa and sub-
mucosa. The tissues are infiltrated with a large number of PMNs
and monocytes and, occasionally, there is associated epithelial
´ azithromycin, 1 g orally in a single dose
Figure 23.21 Mucopurulent cervicitis demonstrated by a cotton
necrosis. Physiologically, there is a resident population of a small swab test.
number of leukocytes in the normal cervix. Thus the emphasis is
on a severe inflammatory reaction by a large number of PMNs.
´ doxycycline, 100 mg orally twice daily for 7 days This section focuses on mucopurulent cervicitis and techniques
to diagnose common cervical infections.

´ Add gonococcal treatment if theMUCOPURULENT

prevalence CERVICITISis over

5% in the population assessed. The diagnosis of cervicitis continues to rely on symptoms, exam-
ination, and microscopic evaluation. Two simple, definitive,
objective criteria have been developed to establish mucopurulent
´ Women treated for chlamydia should be instructed to cervicitis—gross visualization of yellow mucopurulent material
on a white cotton swab (Fig. 23.21) and the presence of 10 or
abstain from sexual intercourse for 7 days after single- more PMN leukocytes per microscopic field (magnification, ×
1000) on Gram-stained smears obtained from the endocervix.

dose therapy or until completion of the 7-day regimen Alternative clinical criteria that may be used are erythema and
edema in an area of cervical ectopy or associated with bleeding
secondary to endocervical ulceration or friability when the endo-
cervical smear is obtained. Women may also report increased Figure 23.22 Patient with C. trachomatis mucopurulent cervicitis
Comprehensive Gynecology 7th edition, 2017 (Lobo RA, Gershenson
vaginalDM, Lentz
discharge GM, Valea
and intermenstrual FA editors);
vaginal bleeding. chapter
with resolution23, Genital tract infections
post treatment.
The prevalence of mucopurulent cervicitis depends on
 Cefixime, 400 mg PO, single dose
Bacterial vaginosis has also been associated with mucopurulent plus
cervicitis; cervicitis resolved with bacterial vaginosis treatment Azithromycin 1 g orally in a single doses, preferably under direct
(Workowski, 2015). observation
Modified from Workowski KA, Bolan GA, Centers for Disease Control and Preven-
23 Genital
DETECTION OF PATHOGENIC Tract Infections
CERVICAL 547
tion. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm
Rep. 2015;64(RR-03):1-137.
BACTERIA
Neisseria gonorrhoeae
been Nucleic
Boxacid23.6 amplification testing (NAAT)
Centers for Disease Control and of the urine or vagi-
Prevention Box 23.7 Recommended Regimens for Treatment of
NA nal secretions is the most sensitive and specific diagnostic tool
Recommended Dual Treatment of Uncomplicated
Chlamydial Infection
rsis- for identifying gonorrheal infections. Urine tests should be first Azithromycin, 1 g PO, single dose*
void (either theGonococcal
first void inInfections
morning of or the Cervix,
at least Urethra,
1 hour since and
last
but Rectum in Adults (2014)
void). This technique allows for the sensitive detection of DNA
or
Doxycycline, 100 mg PO bid for 7 days
no particles originating from
Ceftriaxone, 250 mg IM,the urethra
single dose or endocervix, which fall Alternative Regimens
ited into the vaginal pool and vestibule.
or, if not an option Erythromycin base, 500 mg PO qid for 7 days
ing. Most women who are colonized with N. gonorrhoeae are or
Cefixime, 400
asymptomatic. mg PO, single
Therefore it is dose
important to screen women at
lent high plus
risk for gonorrheal infection routinely. Screening of high-
Erythromycin ethylsuccinate, 800 mg PO qid for 7 days
or
ment Azithromycin 1 g orally in a single doses, preferably
risk individuals is the primary modality to control the disease. under direct Ofloxacin, 300 mg PO bid for 7 days
Gonorrheal observation
NAAT results are over 95% sensitive and specific. or
Antibiotic-resistant gonorrhea culture (GC) is problematic. Levofloxacin, 500 mg PO once daily for 7 days
Modified from Workowski KA, Bolan GA, Centers for Disease Control and Preven-
CDC STD Treatment Guidelines (2015) recommend dual
tion. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Modified from Workowski KA, Bolan GA, Centers for Disease Control and Preven-
therapy with ceftriaxone 250 mg once IM and azithromycin 1 g tion. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm
Rep. 2015;64(RR-03):1-137.
orally in a single dose, preferably under direct observation, for Rep. 2015;64(RR-03):1-137. bid, Twice per day; qid, four times per day.
all GC infections (Boxes 23.6 and 23.7). Routine co-treatment *Consider concurrent treatment for gonococcal infection if prevalence of gonor-
rhea is high in the patient population under assessment.
using two antimicrobials with different mechanisms of action,
agi- such Box
as aComprehensive
cephalosporin
23.7 Recommended plus azithromycin,
Gynecology 7th edition,may
Regimens 2017slow
(Lobo
for Treatment theRA,selec-
of Gershenson DM, Lentz GM, Valea FA editors); chapter 23, Genital tract infections
Outline

´ Infections of the vulva

´ Infections of the vagina
´ Infections of the cervix
Thank you!
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