Lower Gt Infxn

Infections of the Lower Genital Tract Rex M. Poblete MD, FPOGS Dept. of Obstetrics and Gynecology DLSU-HSI

Normal Physiology and Bacteriology of the Vagina Vagina : non-keratinized stratified squamous epithelium : influenced by estrogen & progesterone At BIRTH : colonized by anaerobes and aerobic bacteria - rich in glycogen due to influence of the placenta and maternal hormones  low pH ( 3.7 – 6.3 )

AFTER BIRTH :

Decrease Estrogen

 lack of glycogen  epithelium becomes thin & atrophic  increased pH ( 6-8 )  gram (+) coccobacilli predominates PUBERTY : Increasing ovarian function  increasing estrogen  glycogen increase  Lactobacilli predominate  breakdown of glycogen to lactic acid  decrease in pH (3.5 – 4.5 )

Physiologic Vaginal Secretions Cervical mucus (Major Component) + Fluid Exudates ( Sebaceous, sweat, Bartholin’s and Skene’s gland ) + Transudates / Exfoliates ( Vaginal Squamous Epithelium) + Metabolic Products ( Microflora )

Normal Vaginal Discharge Thin . Odorless , and Colorless Defense Mechanism of Vagina : 1. Continuous discharge from the cervix  helps “wash out” harmful substances 2. Normal Vaginal Flora (Lactobacillus)  produce lactic acid  acidic pH  prevents growth of harmful bacteria 3. Estrogen  keeps vaginal epithelium thick and resistant to bacterial invasion * children and menopausal pxs  susceptible to infection due to low estrogen levels

A Vaginal Discharge is Abnormal If : It irritates ( itchy or burning ) It is foul – smelling Affecting your sexual partner ( causing irritation , itching , burning or rashes ) It causes dyspareunia (painful intercourse) It stains your underwear You consider it heavy or profuse

Investigation of Vaginal Discharge Characteristic Color , Texture , Viscosity , Odor Associated Clinical Symptoms Pruritus , Pain/Tenderness , Painful LN Evaluation Wet Mount , KOH , gram stain , Culture

Clinical Conditions Vaginitis Trichomonasis Candidiasis Bacterial Vaginosis Ulcerative Herpes Genitalis Chancroid Lymphogranuloma Venereum Granuloma Inguinale Proliferative Molluscum contagiosum

Trichomoniasis Caused by Trichomonas vaginalis ( flagellated protozoa ) Sexually Transmitted Can inhabit vagina and male urethra 25 % of infected pxs are asymptomatic

Clinical Features : Thin , frothy , pale greenish or grayish vaginal discharge Foul rancid odor Erythema and edema of vulva/vagina Petechiae of cervix (“strawberry cervix”) Diagnosis : Wet mount smear or Culture * Pear-shaped motile protozoa with a flagella

Thin , Frothy Discharge

Strawberry Cervix

Trichomonads

Trichomonads

Recommended Treatment : Metronidazole 2 gms orally single dose or 500 mg BID x 7 days * Both partners have to be treated to prevent re-infection

Candidiasis Caused by a yeast : Candida albicans , C. glabrata , C. tropicalis High-risk factors : Pregnancy Diabetes Oral Contraceptives Antibiotic abuse Normal inhabitant of the vagina Opportunistic infection

Clinical Features : Whitish to yellowish , thick , “cheese-like” or “ curd-like” discharge Vulvar pruritus, edema , or erythema Dysuria Dyspareunia Vaginal pH : ~ 4.5 Diagnosis : KOH wet mount * Identification of pseudo-hyphae and spores of C. albicans Others : Nickerson’s / Sabouraud’s medium Latex Agglutination Test ( for non-albicans sp.)

Thick , Cheese-like Discharge

Curd-like Discharge

Pseudohyphae

Pseudohyphae

Recommended Treatment : Oral : Fluconazole 150 mg single dose Intravaginal Agents : creams , ointments, vaginal tablets or suppositories Others : Butoconazole Clotrimazole Miconazole Nystatin Tioconazole Terconazole

Bacterial Vaginosis Formerly called non-specific vaginitis or Gardnerella vaginitis Presence of anaerobes : Bacteroides sp. Peptococcus spp. Sexually Transmitted Clinical Features : Profuse , thin , grayish , foul-smelling discharge + KOH  release of amines  “Fishy Odor”

Profuse, Thin Homogenous Discharge

Vulvovaginal itching and irritation (~ 20 %) Diagnosis : Wet mount “ Clue cells “ : epithelial cells with numerous bacilli on the surface Recommended Treatment : Metronidazole 500 mg BID x 7 days or 2 gm single dose Clindamycin 300 mg BID x 7 days

Clue Cells

Clue Cells

Clue Cells

Condyloma Acuminata Papillomatous “ cauliflower-like ” lesions on the perianal area, vulva , vagina , or cervix Caused by Human Papilloma Virus ( type 6 and 11 ) Often occur with Trichomonas and Bacterial Vaginosis Sexually Transmitted Diagnosis is clinical Paps smear : koilocytosis

Management : Podophyllin 0.5% solution BID x 3 days may be repeated after 4 days for 4 cycles Imiquimod cream 5% TID at bedtime for 16 weeks Cryotheraphy Trichloroacetic acid 80-90% Surgical removal Laser surgery

Molluscum contagiosum Benign epithelial proliferation  raised nodules  pearl-like or reddish shiny papules Caused by : Poxvirus Causes no systemic illness Self-limiting

Common in children (trunk & extremities) In adults  sexually transmitted ( genital area ) Immunocompromised pxs : severe lesions may cause disfiguring scar

Herpes Genitalis Venereal disease caused by : Herpes simplex type II (90% of cases) and type I (10% of cases) Primary infection : s/sxs appear within 3-7 days after exposure May be asymptomatic

Lesions : Clear vesicles ( labia, vulva, perineal area ,vagina and ectocervix ) ↓ Vesicles rupture ( within 7 days ) ↓ Ulcer formation ( shallow , painful with red borders ) ↓ Secondary infection ( necrosis )

Diagnosis : Usually done clinically + Tsanck or Paps smear : Multinucleated giant cells with nuclear inclusions Others : Direct Immunoflourescence of ulcer scrapings Viral culture

Multinucleated Giant Cell

Multinucleated Giant Cell

Recommended Treatment : 1st episode : Valacyclovir 1 gm PO BID x 7 days Episodic Recurrent Episode : Valacyclovir 500 mg PO bID x 5 days Daily Suppresive Therapy : Valacyclovir 500 mg OD for 1 year

Chancroid Caused by : Hemophilus ducreyi bacillus , gm (-) rod in chain More frequent in tropical / subtropical countries Clinical feature : Painful suppurative ulcers with a grayish base and foul odor Lymphadenopathy Inguinal Buboes ( pus-filled lymph node  bulge  drain thru the skin )

Soft Chancre

Inguinal Buboe

Diagnosis :

Clinical Culture of H. ducreyi

Treatment : Azithromycin 1 gm PO single dose or Ceftriaxone 250 mg IM single dose or Ciprofloxacin 500 mg PO x 3 days or Erythromycin base 500 mg PO QID x 7 days

Lymphogranuloma Venereum Caused by Chlamydia trachomatis Sexually transmitted Affects males 20x more than females Clinical feature : Painless vulvovaginal ulcer Adenitis Inguinal buboes

Chronic progression  ulceration elephantiasis sinus tract formation rectovaginal fistula abscesses rectal strictures

Groove Sign

Rectal Stricture

Elephantiasis

Diagnosis : Clinical + lab tests : Biopsy and Culture of Cyclohexamide treated tissues Complement fixation Direct Immunoflourescence for antibodies Enzyme Immuno-assay Polymerase or Ligase Chain Reaction

Recommended Treatment : Azithromycin 1 gm PO single dose or Doxyxcycline 100 mg BID x 7 days Alternative Regimens : Erythromycin base 500 mg PO QID x 7 days or Erythromycin ethylsuccinate 800 mg PO QID x 7 days or Ofloxacin 300 mg PO QID x 7 days

Granuloma Inguinale Caused by Calymmatobacterium granulomatis , gm (-) rod with bipolar staining More common in African-Americans Clinical Feature : Painless , “ beefy red “ ulcers with irregular borders Inguinal lymphadenopathy Pseudo-bubo formation (inguinal inflammation but no lymphatic involvement)

Diagnosis : Giemsa – Wright stain Enlarged mononuclear cells with cytoplasmic vacoules packed with bipolar-staining bacteria ( “ Safety pin ” appearance) ↓ DONOVAN BODIES (Pathognomonic)

Donovan Body

Recommended Treatment : Trimethoprim-Sulfamethoxazole 80/400 mg BID x 3 weeks or Doxyxycline 100 mg BID x 3 weeks

Alternative Regimens : Ciprofloxacin 750 mg BID x 3 weeks or Erythromycin base 500 mg QID x 3 weeks

End of Part I