dr.

Maringan DLT, SpOG

Divided to : - Low infection
- High infection
Marked of ostium uteri internum.
Low Infection
Vulvitis, vaginitis dan cervisitis caused by
bacterial, parasite, viral, mycosis.
The most common symptom is leucorrhea
(Fluor albus).
High Infection
Endometritis, salphingitis, and adnexitis.
Gynecological Infection
LEUCORRHEA

Fisiologic : clear, no itch, no odor, not colouring
underwear.
Caused by vaginal transudat, the secretions of
cervix, Bartholin and Skene glands.

Etiology :
Corpus alienum.
Bacterial infection ex : G. Vaginalis,
N.Gonorrhoeae, Chlamydia, M.Hominis,etc
Viral infection ex : DNA viral.
Others :

Candida infection.
Trichomonas infection.
Cervicitis.
Atrophy vaginitis.
Others ex neoplasma, Enterobius
vermikularis, vaginal ulcus, etc.
Symptoms :
Increased number of secretion.
Odor, itch and colouring underwear.
Spesific secretion :
Milky secretion usually from vagina
Mucopurulent secretion usually from cervix.
Purulent secretion usually caused by gonococcus.
Foamy secretion usually caused by trichomonas.
Cheese like secretion usually with pruritic
caused by Candida.
Bloody secretion usually caused by neoplasma,
senilis endometrytis
Diagnosis :

1. Sign and symptom.
2. Ph test of vaginal secretion.
3. Wet preparation ( Sodium Chloride ).
4. Swiff test ( KOH).

Complication:
Pruritic, eczema,condyloma acuminata.

Treatment :
Depends on location
1. VULVITIS

Inflammation of labia mucous.
Sign :
Disuria.
Lecorrheae with vulvar pruritus.
Coitus disturbance.
Erythema of labia and introitus vagina.


Etiology :

Less of hygiene.
Gonococcal infection.
Candida infection.
Trichomonas infection.
Oxyuris infection.
Pedunculus pubis infection.
Diabetic.
Secondary to leucorrhoeae and genital
tract fistel.
Vulva ulcer :
Tuberculosum ulcer.
Acutum vulva ulcer.
Syphiliticum ulcer.
Chancroid ulcer.
Varicosum ulcer.

Vulvitis complication :
Bartholinitis.
Edema of major labium.
Condyloma acuminata.

Treatment :
Causative therapy.
BARTHOLINITIS AND ABSCESS :

Sign and symptom :
Sign of inflammation such edema, erythema,
pain, etc.

Treatment :
Antibiotic.
Drainage if needed.
II.VAGINAL INFECTION / VAGINITIS

A. Bacterial vaginosis :
Referred as nonspesific vaginitis or Gardnerella
vaginitis.
An alteration of normal vaginal bacterial flora.

Diagnosis :
Fishy vaginal odor.
Gray and thinly coat vaginal secretions.
Ph of the secretion higher than 4.5
Increased number of clue cells of vaginal secretion.
The addition of KOH to vaginal secretion releases a
fishy amine-like odor.
Treatment :

Metronidazole : 500 mg twice a day orally for
7 days or 2 g oral single dose.
Metronidazole gel 0,75% , 5 g intravaginally
twice a day for 5 days.
Clindamycin cr 2 %, 5 g intravaginally at
bedtime for 7 days.
Clindamycin, 300 mg orally twice daily for 7
days.
B.Trichomonas Vaginitis
Caused by the STD, flagellated parasite, Trichomonas
Vaginalis.
Often companies bacterial vaginosis.

Diagnosis :
Local immune factors and inoculum size influence the
appearance of symptoms.
Profuse, purulent, malodorous vaginal discharge that may
be accompanied by vulvar pruritus.
Vaginal secretion may exude from the vagina.
Vaginal erythema and colpitis macularis (strawberry
cervix).
Ph of the vaginal secretions usually higher than 5.0.
Increased number of leucocytes and motile trichomonads in
microscopy of the secretions.
The whiff test may also be positive.
Treatment :
Metronidazole 2 g single dose orally or 500 mg
twice a day orally for 7 days.
Sexual partner should also be treated.
Women who do not respond to initial therapy should
be treated again with metronidazole 500 mg, twice
daily for 7 days.
If repeated treatment is not effective, therapy
must be followed with sigle 2 g-dose metronidazole
for 3-5 days.
Patients who do not responds to repeated
treatment should be referred for expert
consultations.
C.Vulvovaginal Candidiasis.
During their lifetimes, 75 % of women
experience one episode of VVC and 45 %
experience two or more
Caused by Candida albicans, 85 90 %
Predispose factors :
1. Antibiotic use
2. Pregnancy
3. Diabetes.

Diagnosis :
Symptoms : 1. Vulvar pruritus
2. Vaginal discharge
-Sign : 1. The Discharge, vary from watery to
homogeneously thick.
2. Vaginal soreness
3. Dispareunia
4. Vulvar Burning
5. Irritation

- Laboratory finding :
1. The Whiff tes is negative
2. Fungal elements : budding yeast forms
or mycelia
3. The saline preparation is normal.
4. The pH of the vagina is usually normal
Treatment :

1. Topically azole drugs
2. Fluconazole 150 mg, single dose
3. Topical steroid as adjunctive treatment
III. CERVISITIS

The cervix have two different type of epithelial
cells
- squamous epithelium.
- glandular epithelium.
The cause of cervical inflammation depends on the
epithelium affected.
Trichomonas, Candida, and Herpes Simplex virus can
cause inflammation of the ectocervix. N. GO and C.
Trachomatis infect only glandular epithelium and
make mucopurulent endocervicitis ( MPC ).
Diagnosis :
Purulent endocervical discharge,generally yellow
or green in color and referred to as mucopus.
Erotio portionis.
Secondary vaginitis or vulvitis.
Nabothi ovula in the chronic case.

Etiology :
Gonococcal infection.
Contraseption device.
Intrauterine instrumentation.
Portio ulcer :

Carsinomatosum ulcer.
Syphiliticum ulcer.
Tuberculosum ulcer.

Treatment :
Antibiotic regimen recommended for the
treatment of uncomplicated lower genital tract
infection.
IV. Pelvic Inflammatory Disease (PID)

PID is caused by microorganisms colonizing the
endocervix ascending to the endometrium and
fallopian tubes spread from hematogenous,
limfogenous or direct extension
Most cases caused by sexually transmitted
microorganisms,
Neiserria gonorrhoeae and Chlamydia trachomatis
and less Frequently H. influenza.
Diagnosis :

Based on a triad of symptoms and signs :
pelvic pain
cervical motion
adnexal tenderness
and the presence of fever.

Treatment :
Provide empiric, broad spectrum antibiotics.
ACUTE ENDOMETRITIS
Particularly post partum or post abortum.
Sign :
febrile.
Odor lochia sometimes purulent endocervical
discharge.
Bloody lochia untill metrorragia.
Pain if spread to parametrium or perimetrium.

Treatment :
Uterotonic.
Bed rest in Fowler position.
Antibiotic.
Curretage if needed.
CHRONIC ENDOMETRITIS

Sign :
Discharge from ostium.
Metrorrhagia or menorrhagia.
Treatment :
Curretage.

MYOMETRITIS
Usually secondary from endometritis. Sign and
symptom like endometritis. Diagnosis made by
histopatologic.
Usually related with N. Gonorrhoea invasion.
Sign :
Lower abdominal pain or pelvic, usually bilateral.
Pain can spread to medial upper leg.
Purulent discharge.
Nausea, vomitus, headache.
Sometimes febrile.

Symptom :
Abdominal pain particularly lower kwadran abomen.
Abdominal distension if there is pelvic peritonitis.
Cervical motion tenderness.
ACUTE SALPHYNGITIS PERITONITIS
Laboratory finding :
Leucocytosis.
Clouded peritoneal fluid if we didi kuldocentesis.
Mycroscopic found bacterial and leucocyt.
Radiology :
Abdominal plain foto give an ileus image, but
nonspesific.
Laparotomy needed if there is a sign of tubo-ovarial
abscess or pelvic abscess.
Differential diagnosis :
Acute appendicitis.
Ectopic pregnancy.
Ruptured of corpus luteal cyst.
Diverticulitis.
Septic abortion.
Adnexa mass torsio.
Leiomioma.
Endometriosis.
Urynary tract infection.
Regional enteritis.
Ulserative colitis.
Complication :
Pelvic peritonitis or general peritonitis.
Paralytic ileus.
Pelvic celulitis with trombophlebitis.
Abscess of salphing, tuboovarial, or Douglas cave.

Preventive care :
Early diagnosis and eliminated of STD.
Treatment :
A. Hospitality needed for severe case, unclear diagnosed case,
pregnancy women, suspect pelvic abscess, patient who can
not eat oral antibiotic or unsuccessful ambulatory
treatment.
Totally Bed rest
Food limited orally.
Intravenous fluid to correct acidosis and dehydration.
Abdomen decompresi if there any abdominal distension
or ileus.
Antibiotic :
Doxcyciclin 100 mg twice a day i.v or orally with cefoxitin
2 g four times a daily for 10 days.
Clindamycin 900 mg three times a day i.v with
gentamycin 2 mg / kg i.v followed 1,5 kg i.v three times a
day followed with doxycicline 100 mg twice a day or
clyndamycin 400 mg four times a day for 14 days.
B. Ambulatory treatment :
Cefoxitin 2 g i.m with probenecide 1 g orally
followed with doxyciclin 100 mg twice daily orally
for 14 days or tetracyclin 500 mg four times orally
for 10 days.
Cefiaxone 250 mg i.m or cephalosporin equivalen
i.m with probenecide 1 gr orally, followed with
doxyciclin 100 mg orally twice a day for 10 days.
Ofloxacin 400 mg twice a day orally for 14 days
with clindamycin 450 mg four times a day or
metronidazole 500 mg twice a day orally for 14
days
Doxyciclin 100 mg twice a day for 10 days.
Complication :
Infertility.
RECURRENT OR CHRONIC PELVIC INFECTION
Primary like other pelvic infection which recurrent and
made severe disturbance like sticky peritoneum,
hydrosalphyng.
Diagnosis :
History of acute salphyngitis, pelvic infection, post
partum infection or pos abortum infection.
Recurrent episode or acute reinfection or recurrent sign
before 6 weeks after treatment.
Chronic infection usually asymptomatic, sometimes
dispareunia or chronic pelvic pain.
Pelvic pain usually found on clinical finding.
Adnexa thicknes with or no hydrosalphynx.
History of infertility.
Laboratory finding :
Leucocytosis.
Bacterial culture from cervical discharge.

Differential diagnosis :
Ectopic pregnancy.
Endometriosis.
Appendicitis
Diverticulitis.
Regional enteritis.
Ulserative colitis.
Cysto-uretritis.

Complication :
Hydrosalphyng, pyosalphyng, tubo-ovarial abscess,
infertility, ectopic pregnancy, chronic pelvic pain
Treatment :
A. Recurrent case
Treatment like acute salphyngitis.
B. Chronic case
Antibiotic : Tetracycline, Ampicillin, or
cephalosporine 500 mg four times a day
orally for 3 weeks.
Analgetics : Acetaminophen or aspirin.

PELVIC ABSCESS :
Un common complication to chronic or recurrent pelvic
inflamation. Abscess development usually related with
gonococcal infection but most common caused by
anaerobic bacterial.
Sign :
Acute or chronic pelvic inflamation with cystic mass
filled
Douglass cave and spread to rectovaginal septum.
Painful defecation or pain of rectum.
Severe degree sign related with the measure of
abscess.

Treatment :
1. Broad sectrum antibiotic for aerob and anaerob.
2. Observation for peritonitis.
3. Abscess drainage.
4. Exploration laparatomy if needed.
Tubo-Ovarian Abscess :

An end-stage process of acute PID.
TOA can related with IUD or granulamatous
infection like TBC and actimycosis.
Diagnosed :
History of pelvic infection.
Lower abdominal and pelvic pain.
Nausea, vomitus, febrile, tachicardia.
A pelvic mass that is palpable during
bimanual examination.
Paralitic ileus.
Laboratory finding :
Leucopenia until leucocytosis


Radiology finding :
Plain photo needed if there a suspicious of
abscess ruptured or paralitic ileus.

USG finding :
Can help clinical changes such as progresivity,
regretion, etc.S
Differential diagonosis :
Ovarium cyst or mass.
Undisturbed ectopic pregnancy.
Periappendix abscess.
Myoma uteri.
Hydrosalphyng.
Appendix perforation.
Diverticulum perforation or abscess.

Complication :
Septicaemia, ruptured, reinfection, infertility and
ectopic pregnancy.
Rupturred TOA can make septic shock,
intraabdominal abscess, septic emboly, etc.
Treatment :
A. Unrupturred TOA and asymptomatic.
Treatment is the same with chronic salphyngitis
used antibiotic for long time and observation.
Drainage if there is no change in 15-21 days.
HTSOB if needed.

B. Unrupturred symptomatic TOA.
Hospitality.
Bed rest in semi fowler position.
Observation for vital sign and urine production.
Broad spectrum antibiotic for aerob and anaerob.
Laparotomy if needed.
C. Rupturred TOA :
- This is an emergency case and laparotomy
should be done.
- Life saving care.

D.Treatment of TOA involves an antibiotic
regimen administerd in a hospital. Failure of
medical therapy suggests the need for surgical
exploration and the drainage of the abscess.
V.Other Major Infections

Genital ulcer disease.
Caused by Herpes Simplex Virus (HSV), syphilis,
chancroid.
Diagnosis : based on history, physical examination, and
laboratory test for STD.
Treatment :
Chancroid : - Azithromycin 1 g single dose orally
Ceftriaxone 250 mg single dose i.m
Erythromycin base 500 mg four times
daily orally for 7 days.
Herpes : - Acyclovir 200 mg orally 5 times daily
for 7-10 days.
Syphillis : - Parenteral Penicillin G is the preferred drug
for all stages of syphillis.

Genital warts
Condyloma acuminata are manifestation of HPV infection
Treatment : removal of the warts.

Human Immunodeficiency Virus (HIV)
At least 20-25% of persons with HIV are women.
Although i.v drugs use remains the most common risk
behavior for women with AIDS (50%), heterosexual
transmision is increasing,now constituting 36% of AIDS
cases in women.
Infection with HIV produces a spectrum of disease that
progresses from an asymptomatic state to full-blown
AIDS.
Diagnosis :

Diagnosed by HIV 1 ab-test such ELISA and
confirmed by
WESTERN- blot or other suplemental testing.

Treatment :

-Zidovudine (ZDV)
GENITAL HERPES :
Caused by Herpes Simplex Viral (HSV) infection
in adult who has active sexual intercourse.
About 85 % type 2 herpetic viral.

Sign :
About 2 7 days incubation period.
Prodormal sign is pruritic followed by vesicle.
Vesicle growth to pain ulcer.
Disuria untill urine retention.
Febrile, malaise and edema of inguinal lymphe gld.
Thinly leucorrhoea.
Laboratory findings :

1. Papanicolau smear.
2. Serologic test.

Treatment :
Usually self limiting disease.
Symptomatic therapy for pruritic and pain.
HERPES ZOSTER :
The infection sign with pain vesicle along one or
more nerve dermatome. Usually unilateral.
Treatment : symptomatic therapy.

MOLOSCUM CONTAGIOSUM :
The infection sign with very infectious papula on
vulvar surface.
Laboratory finding : molloscum bodies.
Treatment : operative therapy.
PELVIC TUBERCULOSIS
The most common organ onvolved is tuba ( 90 %) and
endometrium ( 70 %).

Diagnosis :
Infertility.
Active Pulmonal TB or in recovery.
Diagnosis finding with HSG, Hysteroscopy or
laparoscopy.
Bacterial M. TBC finding in menstrual fluid or biopsy
specimen.
Laboratory finding :
Finding the bacterial from menstrual blood,curretage
or biopsy with direct preparation or cultur
Radiology finding :
Thorax photo.
Hysterosalphyngonococusgrafi.

Differential diagnosis :
Schistosimiasis.
Enterobiasis.
Carcinoma.
Fungal infection.

Complication :
Infertility.
Generalisata tuberculous peritonitis.S
Treatment :
A. Medicine.
Initial therapy with INH, Rifampicyn,
Pirazinamide,Streptomycin or Ethambutol.
Treatment should be done for 24 36 months.

B. Operative
Before operative, the patient should give anti-
microbial for 12 18 months.
Indication operative treatment :
1. Unsuccessful medical treatment.
2. Resistent or reactivation case.
3. Persistent menstrual circle disturbance.
4. Fistula development.S
TOXIC SHOCK SYNDROME

First report case in child ,1978.
Etiology : Staphylococcus aureus toxin.
Diagnosis :
Febrile more than 38,9 C.
Red spot on the skin.
Deskuamation ( usually after 1-2 weeks ).
Hypotension.
3 or more organ involved ( GIT, muscle,
mucous membran, renal, hepar, hematologic,
or central nerve system ).A
Laboratory finding :
Direct bacterial test and culture from blood
specimen, throat secretion and cerebrospinal
fluid.
Sometimes vaginal culture can found S. Aureus.

Differential Diagnose :
Other systemic desease with the same sign.

Treatment :
Agresive support therapy such electrolite and
fluid resucitation, mechanical ventilation,
hemodialisys.
Corticosteroid therapy if needed.S
Complication :

Three most common death caused is :
1.Respiratory distress syndrome.
2.Unrecovery hypotension.
3.Secondary bleeding caused by intravasculer
bleeding disseminata.