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Genital Infection

The Normal Vagina


composed of vulvar secretions from sebaceous, sweat, Bartholin, and Skene glands; transudate from the vaginal wall; exfoliated vaginal and cervical cells; cervical mucus; endometrial and oviductal fluids; and micro-organisms and their metabolic products. biochemical processes that are influenced by hormone levels.

The Normal Vagina


increase in the middle of the menstrual cycle because of an increase in the amount of cervical mucus These cyclic variations do not occur when oral contraceptives are used and ovulation does not occur.

The Normal Vagina


1. Superficial cell the main cell type in women of reproductive age, predominate when estrogen stimulation is present 2. Intermediate cell predominate during the luteal phase because of stimulation by progestogen 3. Parabasal cell predominate in the absence of either hormone, a condition that may be found in postmenopausal women who are not receiving hormonal therapy.

Superficial, Intermediate, Parabasal cell

High power H&E showing the different layers of squamous cells in the cervix. From the basement membrane to the outermost layer that lies within the vagina, there are the youngest squamous cells in the basal layer, then (increasing in age) the parabasal, intermediate and the superficial layer. http://micro2tele.com/2013/01/20/histoquarterly-cervix/

The Normal Vagina


Mostly aerobic six different species of bacteria the most common of which is hydrogen peroxideproducing lactobacilli. pH and the availability of glucose for bacterial metabolism

The Normal Vagina


lower than 4.5, which is maintained by the production of lactic acid. Estrogen-stimulated vaginal epithelial cells are rich in glycogen. Vaginal epithelial cells break down glycogen to monosaccharides, which can then be converted by the cells themselves, and lactobacilli to lactic acid.

The Normal Vagina


Normal vaginal secretions are floccular in consistency, white in color, and usually located in the dependent portion of the vagina (posterior fornix).

Bacterial Vaginosis
alteration of normal vaginal bacterial flora that results in the loss of hydrogen peroxide producing lactobacilli and an overgrowth of predominantly anaerobic bacteria the concentration of anaerobes, as well as G. vaginalis and Mycoplasma hominis, is 100 to 1,000 times higher than in normal women. Lactobacilli are usually absent.

Bacterial vaginosis (BV) has previously been referred to as nonspecific vaginitis or Gardnella vaginitis.

Bacterial Vaginosis. One of the main symptoms is liquid discharge that gives the patient the sensation of wetness

Bubbly discharge due to bacterial vaginosis in a 28 years old patient during the 30 th weeks of pregnancy

Peterson, Eiko, Infection in Obstetrics and Gynecology : Textbook and Atlas, Georg Thiem Verlag, 2006, Page 124 http://books.google.co.id/books?id=sw_6Lozgd8QC&pg=PA122&dq=atlas+bakterial+vaginosis&hl=en&sa=X&ei= umY8UaGxDI3RrQfJ1oGoBA&redir_esc=y#v=onepage&q=atlas%20bakterial%20vaginosis&f=false

Trigger? Postulat??
repeated alkalinization of the vagina, which occurs with frequent sexual intercourse or use of douches, plays a role. After normal hydrogen peroxideproducing lactobacilli disappear, it is difficult to reestablish normal vaginal flora, and recurrence of BV is common.

Women with BV are at increased risk


pelvic inflammatory disease (PID) postabortal PID postoperative infections after hysterectomy, abnormal cervical cytology Pregnant women with BV are at risk for premature rupture of the membranes preterm labor and delivery chorioamnionitis, postcesarean endometritis

Diagnosis
A fishy vaginal odor vaginal discharge are present Vaginal secretions are gray and thinly coat the vaginal walls The pH of these secretions is higher than 4.5 (usually 4.7 to 5.7) increased number of clue cells, and leukocytes are conspicuously absent

Clue cell

clue cells are superficial vaginal epithelial cells with adherent bacteria, usually Gardnerella vaginalis, which obliterates the crisp cell border when visualized microscopically
Kafi, SK, Bacterial Vaginosis, Sudan Journal of medical Science, Volume 7, 1st March 2012 http://www.sudjms.net/issues/7-1/html/10)Bacterial%20Vaginosis.htm

Diagnosis
The addition of KOH to the vaginal secretions (the whiff test) releases a fishy, aminelike odor. Culture of G. vaginalis is not recommended as a diagnostic tool because of its lack of specificity.

Treatment
Metronidazole 500mg orally twice a day for 7 days, avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter. Metronidazolegel, 0.75%, one applicator (5 g) intravaginally once or twice daily for 5 days.

Treatment
Clindamycincream, 2%, one applicator full (5 g) intravaginally at bedtime for 7 days Clindamycin, 300 mg, orally twice daily for 7 days Clindamycin ovules, 100 mg, intravaginally once at bedtime for 3 days Clindamycin bioadhesive cream, 2%, 100 mg intravaginally in a single dose Treatment of the male sexual partner has not been shown to improve therapeutic response and thereforeis not recommended.

Trichomonas Vaginitis
sexually transmitted, flagellated parasite, Trichomonas vaginalis

Trichomonas vaginalis in vaginal discharge Copyright Gary E. Kaiser, All Rights Reserved,Updated: March 3, 2001 http://faculty.ccbcmd.edu/courses/bio141/lecguide/unit3/protozoa/tricho.html

Trichomonas Vaginitis
transmission rate is high; 70% of men contract the disease after a single exposure to an infected woman, which suggests that the rate of male to-female transmission is even higher. only in trophozoite form, is an anaerobe that has the ability to generate hydrogen to combine with oxygen to create an anaerobic environment.

Trophozoite

A trophozite of Trichomonas vaginalis from culture. The four flagella and single nucleus are visible. The dark median rod is the axostyle which is characteristic of the trichomonads; approximate size = 26 m.

http://www.icp.ucl.ac.be/~opperd/parasites/tricho.htm

Diagnosis
Local immune factors and inoculum size influence the appearance of symptoms. profuse, purulent, malodorous vaginal discharge vulvar pruritus patchy vaginal erythema and colpitis macularis (strawberry cervix) pH of the vaginal secretions is usually higher than 5.0. Microscopy of the secretions reveals motile trichomonads and increased numbers of leukocytes Clue cells may be present because of the common association with BV. The whiff test may be positive.

Strawberry cervix

Colpitis macularis ( strawberry cervix )


http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=4&cat3=492&stype=d

Pregnant women with trichomonas vaginitis


increased risk for premature rupture of the membranes and preterm delivery Because of the sexually transmitted nature of trichomonas vaginitis, women with this infection should be tested for other sexually transmitted diseases (STDs), particularly Neisseria gonorrhoeae and Chlamydia trachomatis. Serologic testing for syphilis and human immunodeficiency virus (HIV) infection should also be considered

Treatment
Metronidazole is the DOC. 95% single-dose (2 g orally) multidose (500 mg twice daily for 7 days) The sexual partner should also be treated. Metronidazole gel do not respond to initial therapy treated again with metronidazole, 500 mg, twice daily for 7 days. If repeated treatment is not effective single 2g dose of metronidazole once daily for 5 days or tinidazole, 2 g, in a single dose for 5 days

http://www.ispub.com/journal/the-internet-journal-of-advanced-nursing-practice/volume-6-number-1/differentiation-of-the-vaginoses-bacterialvaginosis-lactobacillosis-and-cytolytic-vaginosis.html#sthash.xKhubDsF.dpbs

Vulvovaginal Candidiasis
75% at least 1 episode 45% 2 or more episode 85 90% vaginal yeast infection: Candida albicans C. glabarata, C. tropicalis resistant to th/ pruritus and inflammation minimal invasion of the lower genital tract epithelial cells toxin or enzyme Hypersensitivity

Vulvovaginal Candidiasis
symptomatic disease (>104/mL) asymptomatic patients (<103/mL)

Pregnancy and diabetes are both associated with a qualitative decrease in cell-mediated immunity, leading to a higher incidence of candidiasis.

Diagnosis
vaginal discharge that typically resembles cottage cheese.

Recurrent vulvovaginal candidiasis is defined as four or more episodes in a year. By Dr Louise Newson http://www.gponline.com/Clinical/article/1004744/Basics---Recurrent-vaginalcandidiasis/

DIagnosis
The discharge can vary from watery to homogeneously thick Vaginal soreness, dyspareunia, dysuria, vulvar burning, irritation erythema and edema of the labia and vulvar skin pH of the vagina in patients with VVC is usually normal (<4.5) The whiff test is negative.

Treatment
A presumptive diagnosis absence of fungal elements confirmed by microscopy if the pH and the results of the saline preparation evaluations are normal and the patient has increased erythema based on examination of the vagina or vulva

fungal culture is recommended to confirm the diagnosis

Treatment
Topically applied azole drugs are the most commonly available treatment for VVC and are more effective than nystatin An oral antifungal agent, fluconazole, used in a single 150-mg dose Women with complicated VVC benefit from an additional 150-mg dose of fluconazole given 72 hours after the first dose complication Women with complicated VVC benefit from an additional 150-mg dose of fluconazole given 72 hours after the first dose topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irritative symptoms

Recurrent Vulvonaginal Candidiasis


4 episode or more Persistent irritatine symptoms : burning, itching, diagnosis should be confirmed by direct microscopy of the vaginal secretions and by fungal culture.

Recurrent Vulvonaginal Candidiasis


a remission of chronic symptoms with fluconazole (150 mg every 3 days for 3 doses). suppressive dose of this agent (fluconazole, 150 mg weekly) for 6 months.

Inflamatory Vaginitis
characterized by diffuse exudative vaginitis, epithelial cell exfoliation, and a profuse purulent vaginal discharge Unknown, but Gram stain findings reveal a relative absence of normal long gram-positive bacilli (lactobacilli) and their replacement with gram-positive cocci, usually streptococci. pH of the vaginal secretions is uniformly higher than 4.5

Vaginitis caused by a group A streotococci

http://books.google.co.id/books?id=sw_6Lozgd8QC&pg=PA122&dq=atlas+vaginitis&hl=en&sa= X&ei=kjQ9UbOCD8uGrAfrtICYCQ&ved=0CCoQ6AEwAA#v=onepage&q=atlas%20vaginitis&f=fals e

Treatment
2% clindamycin cream, one applicator full (5 g) intravaginally once daily for 7 days. Relapse 30% of patients, who should be retreated with intravaginal 2% clindamycin cream for 2 weeks. When relapse occurs in postmenopausal patients, supplementary hormonal therapy should be considered

Atrophic Vaginitis
Estrogen maintenance of normalnvaginal ecology Purulent vaginal discharge incresed :
o Menopause o naturally or secondary to surgical removal of the ovaries

Atrophic Vaginitis
Dyspareunia, post coital bleeding Loss of the rugae Vaginal mucosa maybe in somewhat friable in are predominance of parabasal epithelial cells and an increased number of leukocytes.

Senile vaginitis in a 57 years old patient after topical estrogen aplication

Atropic vaginitis in a 47 years old patient with petechiae bleeding

http://books.google.co.id/books?id=sw_6Lozgd8QC&pg=PA128&dq=atlas+atrophic+vaginitis &hl=en&sa=X&ei=XDY9UbuFGM3jrAersYHQDA&ved=0CDYQ6AEwAA#v=onepage&q=atlas%20 atrophic%20vaginitis&f=false

Treatment
stopical estrogen vaginal cream 1 g of each day for 1 to 2 weeks Systemic estrogen therapy should be considered to prevent recurrence of this disorder.

Cervicitis
cervix : squamous epithelium and glandular epithelium. ectocervical squamous Trichomonas, candida, and HSV Glandular epitelium N. gonorrhoeae and C. trachomatis

Diagnosis
a purulent endocervical discharge, generally yellow or green in color and referred to as mucopus Increased number of neutrophils (30 per high power field) Gram negative diplococci gonococcal endocervotis Gram negative gonococci chlamydial cervicitis

Treatment of Neisseria gonorrhoeae endocervicitis


Cefixime, 2 x 100 mg orally for 7 days, Ceftriaxone, 125 mg intramuscularly (single dose), or Ciprofloxacin, 500 mg orally (single dose)a, or Ofloxacin, 400 mg orally (single dose)a, or Levofloxacin 250 mg orally (single dose)

Treatment of Chlamydia trachomatis endocervicitis


Azithromycin, 1 g orally (single dose), or Doxycycline, 100 mg orally twice daily for 7 days, or Ofloxacin, 300 mg orally twice daily for 7 days, or Levofloxacin, 500 mg orally for 7 days

Pelvic Inflamatory
caused by micro-organisms colonizing the endocervix ascending to the disease endometrium and fallopian tubes. includes endometritis, salpingitis, and peritonitis caused by the sexually transmitted microorganisms N. gonorrhoeae and C. trachomatis BV micro-organisms, also often are isolated from the upper genital tract of women with PID.

Diagnosis
on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal tenderness, and the presence of fever. increased number of polymorphonuclear leukocyte, mucopurulent discharge Elevated C-reactive protein or erythrocyte sedimentation rate Temperature higher than 38C Positive test for gonorrhea or chlamydia Endometrial biopsy Ultrasound, radiologig test laparoscopy

Treatment
Broadspectrum Regimen A
Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or Ceftriaxone, 250 mg intramuscularly, or Equivalent cephalosporin

Plus: _Doxycycline, 100 mg orally 2 times daily for 14 days With or without: _Metronidazole, 500 mg orally 2 times daily for 14 day

Treatment
Regimen B Ofloxacin, 400 mg orally 2 times daily for 14 days, or Levofloxacin, 500 mg orally once daily for 14 days With or without: Metronidazole, 500 mg orally 2 times daily for 14 daysa

Hospitalzation
only when the diagnosis is uncertain, pelvic abscess is suspected, clinical disease is severe, or compliance with an outpatient regimen is in question

Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea

Tubo ovarian Abcess


End stage process of acute PID Pelvic mass that is palpable during bimanual examination ovarian abscess can result from the entrance of micro-organisms through an ovulatory site. 75% of women witt TOA respond to antimicrobial therapy alone. drainage ot the abcess

Genital Ulcer Disease


HSV or Syphilis Chancroid Lymphogranuloma Venereum granuloma inguinale (donovanosis)

Diagnosis
based on history and physical examination alone often is inaccurate

serologic test for syphilis Darkfield examination or direct immunofluorescence testing for Treponema pallidum, culture or antigen testing for HSV, and culture for Haemophilus ducreyi.

Diagnosis
nontreponemal rapid plasma reagin (RPR) test venereal disease research laboratory (VDRL) test, confirmatory treponemal testfluorescent treponemal antibody absorption (FTA ABS) microhemagglutininT. pallidum (MHA TP), should be used to

diagnose syphilis presumptively. treponemal EIA tests, the results of which should to be confirmed with nontreponemal tests.

Treatment for Chancroid


azithromycin,1 g orally in a single dose ceftriaxone, 250 mg i.m in a single dose; ciprofloxacin, 500 mg oral 2x for 3 days; erythromycin base, 500 mg oral 4x for 7 days

reexamined 3 to 7 days after initiation of therapy

Treatment for Herpes A


acyclovir, 400 mg oral 3x a day; famciclovir, 250 mg oral 3x a day;

for 7 to 10 days or until clinical resolution attained.

Treatment Syphilis
Benzathine penicillin G, 2.4 million units i.m in a single dose Latent syphilis is defined as those periods after infection with T. pallidum when patients are seroreactive but show no other evidence of disease. Patients with latent syphilis of longer than 1 year's duration or of unknown duration

benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units

Genital Wart
Manifestation of human papiloma virus (HPV) types 6 and 11 occur in areas most directly affected by coitus, namely the posterior fourchette and lateral areas on the vulva warts can be found throughout the vulva, in the vagina, and on the cervix. Minor trauma?

Treatment
specific treatment regimen depends on the anatomic site, size, and number of warts most successful in patients with small warts that have been present for less than 1 year. reduces transmission of HPV. examination of sex partners is not absolutely necessary. Recurrences more often result from reactivation of subclinical infection than reinfection by a sex partner

Modality

Efficacy (%)

Recurrence Risk
2139 1319 2765 3360 81 36 22 2995 067

Cryotherapy 6388 Imiquimod 5% creama 3372 Podophyllin 10%25% 3279 Podofilox 0.5% 4588 Trichloroacetic acid 80%90% Electrodesiccation or cautery 94 Laser 4393 Interferon 4461

Human Immunodeficiency Virus


40% to 50% of individuals with HIV are women Intravenous drug use and heterosexual transmission median time between infection with HIV and the development of AIDS is 10 years, with a range from a few months to more than 12 years.

Diagnosis
ELISA or a rapid assay + Western blot

a positive antibody test result confirms that a person is infected with HIV and is capable of transmitting the virus to others. Women at risk for STD, such as those with multiple sexual partners or whose partners have multiple sexual partners, should be offered HIV testing.
HPV infection and has been found to occur in high frequency in women with both HPVand HIV.

Treatment
Antiretroviral therapy guided by monitoring the laboratory parametersof HIV RNA (viral load) and CD4-cell count.

suppression of viral load, restoration or preservation of immunologic function, improvement of quality of life reduction of HIV-related morbidityand mortality patients with less than 200 CD4 T cells/ L should receive prophylaxis against opportunistic infections, such as trimethoprim-sulfamethoxazole or aerosol pentamidine for the prevention of PCP pneumonia

Acute Cystitis
Dysuria, frequency, and urgency Pyuria, hematuria Lowback pain Suprapubic tenderness

Risk
sexual intercourse, the use of a diaphragm and a spermicide, delayed postcoital micturition, and a history of a recent urinary tract infection

Diagnosis
80% Esherichia coli 5 15% Staphylococcus saprophyticus
Colonization on vagina and uretra antimicrobial agent. Trimethoprim and floroquinolone

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