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
peroxide–producing 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 Bubbly discharge due to bacterial

symptoms is liquid discharge that gives vaginosis in a 28 years old patient
the patient the sensation of wetness 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&redi
 Trigger? Postulat??
 repeated alkalinization of the vagina, which
occurs with frequent sexual intercourse or use
of douches, plays a role.

 After normal hydrogen peroxide–producing

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, 1 st 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 µm.

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-bacterial-
vaginosis-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-vaginal-
candidiasis/
 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=false
 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 Atropic vaginitis in a 47 years old
after topical estrogen aplication patient with petechiae bleeding

http://books.google.co.id/books?
id=sw_6Lozgd8QC&pg=PA128&dq=atlas+atrophic+vaginitis&hl=en&sa=X&ei=XDY9UbuFGM3jr
AersYHQDA&ved=0CDYQ6AEwAA#v=onepage&q=atlas%20atrophic%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 micro-
organisms 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 38°C
 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 test—fluorescent
• treponemal antibody absorption (FTA ABS)
• microhemagglutinin—T. 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
Cryotherapy 63–88 21–39
Imiquimod 5% creama 33–72 13–19
Podophyllin 10%–25% 32–79 27–65
Podofilox 0.5% 45–88 33–60
Trichloroacetic acid 80%–90% 81 36
Electrodesiccation or cautery 94 22
Laser 43–93 29–95
Interferon 44–61 0–67
 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