LOWER GENITAL TRACT INFECTIONS

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GYNAECOLOGICAL INFECTIONS

• By Dr. M. Chiduo
• HKMU
• Department of OBGY
• 2023

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TYPES

• Lower Genital Tract Infections
• - Vulvovaginitis
• - Bartholinitis
• - Bartholin Abscess
• - Cervicitis

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Upper Genital Tract Infection

• - Endometritis
• - Salphingitis
• - Oophoritis
• - Pelviperitonitis
• - Pelvic Abscess

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Defense Mechanisms

• Vaginal acidity
• Thick layer of squamous epithelium
• Closure of the introitus - Hymen
• Glandular secretions Cervical and and Bartholin
  glands secretions

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LOWER GENITAL TRACT INFECTIONS

• DEFENCE MECHANISMS
• Vaginal Acidity pH of 3-4 inhibits most of
  microorganisms causing infection. Glycogen
  produced by vaginal epithelium under the
  influence of Estrogens is converted to Lactic
  Acid by Doderleins bacillus

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Defence

• 2. The thick layer of Vaginal wall- Squamous
  Epithelium is a considerable barrier to
  infection. Continuous desquamation glycogen
  production combat bacterias.

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Defense.

1. Closure of the introitus especially in
   children and Virgins the vaginal
   opening(introitus) is kept closed by the
   surrounding muscles and the Hymen. This is
   altered and has little importance during sexual
   activity and after delivery.

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Defense

• 4. Glandular secretions A physiological vaginal
  discharge consists of Cervical, vaginal
  secretions as well as epithelial cells and
  bacterial flora.
• This physiological discharge is usually whitish
  odorless, without itching nor burning sensation
• Secretions from the cervix and Bartholins
  glands lubricates the vagina and helps to clear
  vaginal canal debris.

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VULVOVAGINITIS

• Candiasis
• Bacterial Vaginosis (Gardnerella , Bacteroides,
  Mycoplasma hominis)
• Trichomoniasis

• Chlamydia trachomatis
• Herpes Simplex
• Condyloma acuminata (HPV)
• Pediculosis pubis (louse)
• Scabies

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CANDIDIASIS

• Fungal infection by Candida albicans
• Normal vaginal inhabitant in up to 25 of women
• Risk factors Immunosupression(HIV), Diabetes
  mellitus, Pregnancy, Antibiotics, Obesity,
  Anaemia
• Thick whitish, curd-like secretions, itching,
  dysuria.

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Candidiasis.

• Clotrimazole /Nystatin / Miconazole pessaries
• Clotrimazole cream
• Fluconazole tabs
• Boilable underwears

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TRICHOMONIASIS

• A sexually transmitted infection by Trichomonas
  vaginalis
• Thin, frothy, yellow copious offensive discharge,
• Severe vaginal itching, pain and tenderness
• Inflamed vagina with red patches (strawberry)
• Dysuria and dyspareunia
• Wet smear-Trichomonas
• Treatment- Metronidazole 2g stat/400mg tds x7
  days. Treat sexual partner.

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BACTERIAL VAGINOSIS

• Commonly caused by Gardnerella vaginalis,
• Thin, gray adherent, foul smelling discharge,
  fishy smell, gray with KOH
• Vaginal smear- Clue cells
• Metronidazole tabs 2g stat/400mg tds x7 days.
• Treat sexual partner.

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Gardnerella
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GENITAL HERPES

• Sexually transmitted infection by Herpes simplex
  virus- HSV- 1 and 2
• Fever, malaise, paresthesia of the vulva,
  multiple vesicles, shalow painful ulcers.
• Enlarged inguinal lymph nodes
• Self limiting and heal without scar formation
• Tends to be recurrent

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Herpes.

• Confirm diagnosis by ELISA/ Tissue culture
• During pregnancy deliver by Caesarean section.
  Infection may be fatal to the baby.
• Treat by Acyclovir tabs and cream, long term

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Genital Herpes
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Herpes
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CONDYLOMA
ACUMINATA(Genital warts)

• Caused by Human Papilloma Virus(HPV)
• HPV types 6 and 11 cause condyloma
• HPV types 16,18,31,33 and 35 cause carcinoma
• Lesion on vulva, vagina or cervix

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Warts.

• High risk factors Pregnancy, Diabetes mellitus,
  Immunosupression.
• Diagnosis by colposcopy, biopsy
• Treatment Surgical excision/ Local
  cytodestructive agents

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Condyloma acuminata (Warts)
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Condyloma acuminata.
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WartsTreatment

• Podophyllin 1025 in compound tincture of
  benzoin, applied carefully to the warts, avoiding
  normal tissue.
• External genital and perianal warts should be
  washed
• thoroughly 46 hourly after the application of
  podophyllin

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Treatment..

• Podophyllin applied to warts on vaginal or anal
  epithelial surfaces should be allowed to dry
  before removing the speculum
• Treatment should be repeated at weekly intervals.

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Other treatment approaches

• Cryotherapy with liquid nitrogen, solid carbon
  dioxide, or a cryoprobe. Repeat applications
  every 1-2 weeks
• OR
• Electrosurgery
• OR
• Surgical removal
• For Cervical Warts
• Treatment should not be started until the results
  from a cervical smear test are known(negative)

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VULVOVAGINITIS IN CHILDREN

• This is a less common condition and arises only
  in certain circumstances, for example
• Sexual Abuse.
• Insertion of foreign bodies
• Worm infestation

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Sexual Abuse

• The changes will be those of physical damage to
  the tissues (lacerations, cuts etc.) Infection
  will depend to some extent on whether the person
  guilty of the offence is a carrier of a specific
  STI
• Foreign bodies
• Infection may arise from bowel commensals.

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FOREIGN BODIES

• Vaginitis due to foreign bodies is also seen in
  adults. Tampons, contraceptive devices and
  supportive pessaries used for prolapse may be
  left, forgotten, in situ.
• These give rise to an offensive purulent
  discharge.
• Bacteriological investigation will give an
  indication of the type of infection and
  appropriate treatment following removal of the
  offending body.

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Threadworm infestation

• Also known as pinworms, are tiny parasitic worms
  that infect the large intestine of humans.
  Threadworms are a common type of worm infection,
  particularly in children under the age of 10. The
  worms look like small pieces of thread

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BARTHOLINITIS

• Inflammation of the Bartholin gland
• Cystic dilatation and abscess formation
• Painful swelling on vulva area.
• Antibiotics
• Marsupialisation for the cyst and abscess.

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Bartholin Cyst/Abscess
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CERVICITIS

• An infection of the cervix.
• Common microorganism Chlamydia trachomatis and
  Neisseria gonorrhoeae.
• Herpes simplex , HPV in few cases
• Asymptomatic in most cases
• Common symptoms yellow-green/Muco-purulent
  discharge, post-coital/contact bleeding

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Chlamydia Cervicitis
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Cervicitis

• Diagnosis by Gram stain Gonococci
• Colposcopy, Cell culture
• Antibiotics Azythromycin/ Doxycycline/Metronidazo
  le
• Ciprofloxacin

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CERVICAL ECTOPY(Ectropion)

• Differential diagnosis for Cervicitis
• An overgrowth of the columnar epithelium
  replacing the squamous epithelium around the
  cervical os giving a raw appearance
• It is physiological, occurring at Puberty, after
  Delivery, Contraceptive pill use.

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Investigations

• Wet preparation
• Gram stain
• Culture and Sensitivity
• Fluorescent Microscopy
• Pap test (Papanicolau test)
• ELISA
• Quantitative or qualitative PCR
• NB starts simple to complex investigations

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• Management of STIs/RTIs using Syndromic Approach
• Recommended if the HF is not able to conduct
  appropriate Laboratory Investigation(s)
• Syndromic management of STIs/RTIs is based on the
  diagnosis of defined symptoms and easily
  recognizable clinical signs. Each syndrome can be
  caused by several different causative agents. For
  each syndrome, a well-defined standard treatment
  which has been proven to be effective against
  most endemic causative agents for the syndrome
  are used.
• Syndromic approach of managing STIs/RTIs entails
  the service provider to follow laid down steps
  in the flow chart

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Vaginal Discharge syndrome

• 1. Non curdled Discharge(Gonorrhea, Chlamydia,
  Bacterial vaginosis Trichomoniasis)
• Tab. Cefixime 400 mg stat
• Tab. Azythromycin 1 gm stat
• Metronidazole 400 mg 8 hrly x 7/7
• If no Improvement
• Clotrimazole pessaries 100 mg od x 6/7
• Inj. Ceftriaxone 1 gm IM stat
• Caps. Doxycycline 100 mg 12 hrly x 7/7
• Metronidazole 400 mg 8 hrly x 7/7

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Vaginal Discharge syndrome.

• 2. Curdled Discharge
• Clotrimazole pessaries 100 mg od x 6/7
• If no Improvement
• Clotrimazole pessaries 100 mg od x 6/7
• Tab. Cefixime 400 mg stat
• Caps. Doxycycline 100 mg 12 hrly x 7/7
• Tab. Metronidazole 2 gm stat
• NB Do not use Metronidazole in 1st Trimester
  pregnancy Do not use Doxycycline in pregnant and
  lactating mothers

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References

• A. Monga S. Dobbs. Gynaecology by Ten Teachers
  19th Ed. Chapter 6 . Page 49-61
• E. Malcom Symonds Ian M. Symonds Essential
  Obstetrics and Gynaecology 3rd Ed. 1998 Pg
  243-248
• Standard Treatment Guidelines and National
  Essential Medicines list for Tanzania Mainland
  6th Ed. 2021 Pg. 245, 249 257

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THANK YOU

• FOR YOUR ATTENTION!