Lower genital tract infection

By Int. Sarisa Supawimon

Lower genital tract infection

Vaginal Infections Cervicitis Genital Ulcer Disease

The Normal Vagina

Vaginal secretions
Sebaceous, sweat, Bartholin Skene glands Exfoliated vaginal and cervical cells Cervical mucus Endometrial and oviductal fluid Micro-organisms & their metabolic products

The Normal Vagina

Normal vaginal secretions
Floccular in consistency White in color Usually located in the dependent portion of the vagina (posterior fornix)

Normal flora is mostly aerobic The most common : hydrogen peroxide producing lactobacilli pH is lower than 4.5 which is maintained by the production of lactic acid

Vaginal Infections
Bacterial Vaginosis Trichomonas Vaginitis Vulvovaginal Candidiasis

Bacterial Vaginosis
Nonspecific vaginitis Gardnella vaginitis Most common form of vaginitis in the United States Alteration of normal vaginal bacterial flora (hydrogen peroxideproducing lactobacilli overgrowth anaerobic bacteria) mechanism by which change takes place is unclear Concentration of anaerobes, is 100-1,000 times higher than in normal women

Bacterial Vaginosis

Adverse sequelae
Increased risk for pelvic inflammatory disease Postabortal PID Postoperative cuff 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
Fishy odor (particularly noticeable following coitus) Vaginal discharge
Gray Thinly coat the vaginal walls

pH of these secretions is higher than 4.5 (usually 4.7-5.7) Microscopy : increased number of clue cells and leukocytes are conspicuously absent. The addition of KOH to the vaginal secretions (the whiff test) fishy, aminelike odor.

Clue Cells

Treatment
Metronidazole
500 mg 1x2 for 7 days
(Patients should be advised to avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter.)

Metronidazole gel,
0.75%, (5 g) intravaginally once or twice daily for 5 days

Treatment
Clindamycin in the following regimens :
Clindamycin, 300 mg, 1x2 for 7 days Clindamycin ovules, 100 mg, intravaginally once at bedtime for 3 days Clindamycin cream : 2%, one applicator full (5g) intravaginally at bedtime for 7 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 (not recommended)

Trichomonas Vaginitis
Caused by the sexually transmitted, flagellated parasite, Trichomonas vaginalis Transmission rate is high : 70% It often accompanies BV : 60% Symptoms and signs may be much milder in patients with a small inocula of trichomonads Trichomonas vaginitis often is asymptomatic

Diagnosis
Profuse, purulent, malodorous vaginal discharge that may be accompanied by vulvar pruritus. In patients with high concentrations of organisms, a patchy vaginal erythema and colpitis macularis (strawberry cervix) may be observed. pH of the vaginal secretions is usually higher than 5.0 Microscopy : 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

Trichomonas vaginalis

Treatment
Metronidazole is the drug of choice
a single-dose (2 g orally) a multidose (500 mg 1x2 for 7 days)

Women who do not respond to initial therapy should be treated again with metronidazole, 500 mg 1x2 for 7 days. If repeated treatment is not effective,
metronidazole 2 g once daily for 5 days tinidazole, 2 g, in a single dose for 5 days.

The sexual partner should also be treated.

Vulvovaginal Candidiasis
75 % of women experience at least one episode of vulvovaginal candidiasis Candida albicans is responsible for 85% to 90% of vaginal yeast infections. Patients with symptomatic disease usually have an increased concentration of Micro-organisms (>104/mL) compared with asymptomatic patients (<103/mL) Rare before menarche, but 50% will have it by age 25 Less common in postmenopausal women, unless taking estrogen

Predispose factors
Antibiotic use Pregnancy Diabetes Immunocompromised host OCPs Contraceptive devices (IUD, sponge)

Diagnosis
Symptoms
vulvar pruritus vaginal discharge (typically resembles cottage cheese). Vaginal soreness, dyspareunia, vulvar burning, irritation External dysuria (splash dysuria) may occur when micturition leads to exposure of the inflamed vulvar and vestibular epithelium to urine.

PV : Erythema and edema of the labia and vulvar skin. The vagina erythematous with an adherent, whitish discharge. The cervix appears normal.

Diagnosis
pH is usually normal < 4.5 Fungal elements, either budding yeast forms or mycelia, appear in as many as 80% of cases. A presumptive diagnosis can be made in the absence of fungal elements confirmed if the pH and the saline preparation evaluations are normal and the patient has increased erythema based on examination of the vagina or vulva.

Vulvovaginal Candidiasis

Classification of Vulvovaginal Candidiasis

Treatment
Topically applied azole drugs
Relief of symptoms and negative cultures in 80%90% Symptoms resolve in 2-3days.

oral antifungal agent : fluconazole, used in a single 150 mg dose, has been approved for the treatment of VVC. Patients should be advised that their symptoms will persist for 2-3 days so they will not expect additional treatment.

Complicated Vulvovaginal Candidiasis

Women with complicated VVC benefit from an additional 150 mg dose of fluconazole given 72 hours after the first dose. Patients with complications also can be treated with a more prolonged topical regimen lasting 10 to 14 days. Adjunctive treatment with a weak topical steroid, such as 1% hydrocortisone cream, may be helpful in relieving some of the external irritative symptoms.

Recurrent Vulvovaginal Candidiasis

fluconazole :150 mg every 3 days for 3 doses Maintained fluconazole 150 mg weekly for 6 months. 90% of women with RVVC will remain in remission.

Cervicitis
Cervix : two different types of epithelial cells: squamous epithelium & glandular epithelium. Ectocervical epithelium can become inflamed by the same micro-organisms that are responsible for vaginitis. Trichomonas, candida, and HSV can cause inflammation of the ectocervix. Conversely, N. gonorrhoeae and C. trachomatis infect only the glandular epithelium

Diagnosis
Based on the finding of a purulent endocervical discharge, generally yellow or green in color and referred to as mucopus Intracellular gram-negative diplococci, leading to the presumptive diagnosis of gonococcal endocervicitis. If the Gram stain results are negative for gonococci, the presumptive diagnosis is chlamydial cervicitis.

Treatment

all sexual partners be treated with a similar antibiotic regimen

Genital Ulcer Disease

Most common : genital HSV or syphilis Chancroid is the next most common Followed by the rare occurrence of lymphogranuloma venereum (LGV) and granuloma inguinale (donovanosis). (These diseases are associated with an increased risk for HIV infection.)

Evaluation
Evaluation of a patient with a genital ulcer should include
darkfield examination or direct immunofluorescence testing for Treponema pallidum culture or antigen testing for HSV, culture for Haemophilus ducreyi

Even after complete testing, the diagnosis remains unconfirmed in one fourth of patients with genital ulcers.

Diagnosis
A diagnosis based on history and physical examination alone often is inaccurate. Therefore, all women with genital ulcers should undergo a serologic test for syphilis

Syphilis
A painless and minimally tender ulcer, is likely to be syphilis, especially if the ulcer is indurated. Lab to diagnose syphilis
nontreponemal rapid plasma reagin (RPR) test, venereal disease research laboratory (VDRL) test, confirmatory treponemal testfluorescent treponemal antibody absorption (FTA ABS) microhemagglutininT. pallidum (MHA TP),

Treatment
penicillin G is the preferred treatment of all stages of syphilis.
Benzathine penicillin G, 2.4 million units intramuscularly in a single dose, is the recommended treatment for adults with primary, secondary, or early latent syphilis. The Jarisch-Herxheimer reactionan acute febrile response accompanied by headache, myalgia, and other symptomsmay occur within the first 24 hours after any therapy for syphilis; patients should be advised of this possible adverse reaction.

Treatment
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 should be treated with intramuscularly each, at 1 week intervals. All patients with latent syphilis should be evaluated clinically for evidence of tertiary disease (e.g., aortitis, neurosyphilis, gumma, and iritis). Quantitative nontreponemal serologic tests should be repeated at 6 months and again at 12 months.

Genital herpes
Grouped vesicles mixed with small ulcers, particularly with a history of such lesions, are almost always pathognomonic of genital herpes. Nevertheless, laboratory confirmation of the findings is recommended.
Culture is the most sensitive and specific test; sensitivity 100% in the vesicle stage 89% in the pustular stage 33% in patients with ulcers.

Because false-negative results are common with HSV cultures, type-specific glycoprotein G-based antibody assays are useful in confirming a clinical diagnosis of genital herpes.

Treatment
Herpes A first episode of genital herpes should be treated with
acyclovir,400 mg orally 3 times a day; or famciclovir, 250mg orally three times a day; or valacyclovir, 1 orally twice a day for 7-10 days or until clinical resolution is attained.

Although these agents provide partial control of the symptoms and signs of clinical herpes. Daily suppressive therapy
acyclovir, 400 mg orally twice daily or famciclovir, 250 mg twice daily; or valacyclovir, 1 g orally once a day

reduces the frequency of HSV recurrences by at least 75% among patients with six or more recurrences of HSV per year.

Chancroid
One to three extremely painful ulcers, accompanied by tender inguinal lymphadenopathy. The adenopathy is fluctuant. An inguinal bubo accompanied by one or several ulcers is most likely chancroid. If no ulcer is present, the most likely diagnosis is LGV.

Treatment
Chancroid Recommended regimens
azithromycin 1 g orally in a single dose ceftriaxone, 250 mg intramuscularly in a single dose; ciprofloxacin, 500 mg orally twice a day for 3 days; erythromycin base, 500 mg orally 4 times daily for 7 days.

Patients should be reexamined 3-7 days after initiation of therapy to ensure the gradual resolution of the genital ulcer, which can be expected to heal within 2 weeks unless it is unusually large.

granuloma inguinale (donovanosis). lymphogranuloma venereum

Genital Warts
Human papillomavirus (HPV) infection Occur in areas most directly affected by coitus : the posterior fourchette and lateral areas on the vulva. Minor trauma associated with coitus can cause breaks in the vulvar skin, allowing direct contact between the viral particles from an infected man and the basal layer of the epidermis of his susceptible sexual partner. Infection may be latent or may cause a wart. External genital warts are highly contagious; more than 75% of sexual partners develop when exposed.

Treatment
The goal of treatment is removal of the warts; it is not possible to eradicate the viral infection. Most successful : small warts & present for less than 1 year. Recurrences more often from reactivation of subclinical infection than reinfection by a sex partner.

Treatment
Selection of a specific treatment regimen depends on the
anatomic site size number of warts efficacy convenience potential adverse effects