vulvitis, candidiasis, trichomoniasis, sexually transmitted infections, bartholinitis, normal vaginal flora

1. LOWER GENITAL TRACT
INFECTIONS
BY DR. PREKSHA JAIN

2. I. Due to specific infections
II. Due to sensitive reaction
III. Due to vg discharge or urinary contamination
 BACTERIAL:
1. Pyogenic (non gonoccocal)
2. STD: gonorrhea, syphilis, chancroid, LGV, granuloma
inguinale
3. Tubercular
VULVAL INFECTIONS

3. VIRAL: condyloma acuminata, H. genitalis, H. zoster,
molluscum
FUNGAL: moniliasis, ringworm
PARASITIC: pediculosis, scabies, threadworm
Bartholinitis- gonococcal, junction of ant 2/3rd post 1/3rd ,
painful swelling, dyspareunia, t/t by marsupialization.

4.  NORMAL VAGINA:
 Composed of secretions from skene, bartholin, sweat glands, vulva,
endometrium, cervix (alkaline), squamous cells, micro organisms m/c
lactobacilli.
 Vaginal epithelial cells: superficial (estrogen responsive), intermediate
(progesterone), parabasal (E & P absence)
 Vaginal flora: E stimulated epithelial cells are rich in glycogen broken
down by epithelial cells to monosacharrides & by lactobacilli
producing lactic acid (ph <4.5)
 Normal secretions: floccular, white, located in post fx, leucorrhea-
pregnancy, early puerperium, ovulation, before menstruation
 Moderate increase: freq change of under garments
 Excessive: use of pad
VAGINAL INFECTIONS

5.  Structure: superficial, middle & deep (basal and parabasal)
layer. Cornification index for E activity.
 Acidity: Newborn- 5.7, children- 6-8, puberty-4, childbearing
period-4.5, pregnancy-4, menopause-7.
 Defence: stratified sq epi, no glands, low ph
 VAGINITIS: vulvovaginitis in childhood, trichomoniasis,
moniliasis, vaginitis by chlamydia, atrophic vaginitis,
nonspecific vaginitis, TSS, bacterial vaginosis.

6. BACTERIAL VAGINOSIS
 Alteration in flora. Lactobacilli, ph, h2o2, gardnerella(m/c),
mobilincus, H. vaginalis, M. hominis.
 c/o white discharge without itching.
 Characteristics:
1. Gray, thinly coat vg wall.
2. Fishy odour (whiff test)
3. Ph >4.5
4. Clue cells. Advanced cases >20%
 Complications: PID, cuff cellulitis, miscarriage, PROM, Preterm,
endometritis
 Dx: A) Amsel’s criteria: homogenous vg discharge, ph>4.5, whiff
test+(10% KOH), clue cells(cells covered with coccobacilli appear as
stippled/ granular)>20%. B) Gram stain
 T/t: Metronidazole 500mg BD 7 days po or 0.75% gel OD intravg 5 days,
clindamycin 2% cream or 300mg OD 7 days, Lacteal gel LA

7. VULVOVAGINITIS IN CHILDHOOD
 Due to lack of E
 CAUSES: non specific, foreign body, intestinal
infestation, candida, gonococcus.
 C/F: pruritus, discharge, painful micturation
 I/v: gram stain, culture, vaginoscopy
 T/t: hygiene, E cream.

8.  2nd m/c
 CAUSED BY: trichomonas vaginalis (protozoa)
 MODE: sexual contact
 PATHO: thrive when defence is gone
 C/F:
1. Profuse, thin, greenish, creamy, irritating, frothy, offensive discharge
2. Angry looking vg, strawberry vg, punctate h’agic spots, pruritus
3. Urinary symp, abd pain, dyspareunia.
 Dx :
1. Wet mount prep/ hanging drop
2. Culture with added antibiotics
 T/t: Metronidazole 200mg TID 7day, vinegar douching or betadine gel in
pregnancy, recurrent inf by tinidazole & vg pessary, use of condom
TRICHOMONAS VAGINITIS

9.  M/C BY: candida albicans (gram +ve fungus)
 PREDISPOSED BY: immunosupp, broad antibiotics, ocp, (acid
medium) diabetes, pregnancy
 C/F:
1. Pruritus out of proportion to discharge. Red swollen vulva
2. Thick, curdy, white, flaky, cottage cheese discharge.
3. Congestion of vg wall
 Dx: Wet smear with 10% KOH (remove debris) mycelia & hyphae,
Gram stain, Culture.
 T/t: vg pessary of azole grp, nystatin pessar, fluconazole Sd
MONILIASIS (CANDIDAL VAGINITIS)

10.  Postmenopausal women E deficiency atrophy, impaired
defence
 C/F:
1. Dry vg, dyspareunia,
2. Purulent blood stained discharge
3. Vg tender, inflamed
4. Urinary symptoms
 Complication : senile endometritis, pyometra
 Ca cervix , ca endometrium may coexist, D&C should be done.
 T/T: Vg cream, Oral Ethinylestradiol 0.01 mg 3weeks
SENILE VAGINITIS

11.  Barrier contraceptives (sponge, diaphragm), Menstruating women using
tampons.
 Patho: Exotoxin by Staph aureus with bradykinin release (blood cultures –ve )
 C/F:
1. Fever >38.9° F
2. Diffuse macular rash, myalgia
3. GI: vomit, diarrhea
4. CVS & RS: hypotension, ARDS
5. RFT: BUN
6. LFT: deranged enzymes
7. Platelets < 1 lac/ cumm
8. Mucous memb hyperemia
 T/t: IV fluids, dopamine infusion, corticosteroids, β lactamase resistant
penicillin(clinda, cloxa, oxacillin)
 Multi organ failure can occur. Mortality in 6-10%
TOXIC SHOCK SYNDROME

12.  Infection of endocervix gland & stroma.
 ACUTE:
• following delivery, abortion, operation on cx
• Chlamydia, trichomonas, mycoplasma, gardnerella, HPV,
Gonococcus
• C/F: mucopurulent discharge, tender, congested,
edematous
• Prognosis: resolve, spread, chronic
• T/t: antibiotics
CERVICITIS

13.  CHRONIC CERVICITIS:
• Mucosa, deeper tissues congested, fibrosed, infiltrated
with leukocytes, plasma cells.
• Glands hypertrophied increased secretory activity.
• If fibrosed lead to retention cyst formation nabothian
follicles.
• Chronic endocervicitis
• a/w ectropion
• C/F: excessive mucopurulent discharge
• T/t: cervical scrape cytology
electro/ diathermy laser / cryosurgery

14. STI
Disease Agent
Gonorrhoe
BACTERIAL
Neisseria gonorrheae
Non –gonococcal urethritis Chlamydia trachomatis(D-K serotype)
Syphilis Treponema pallidum
L.G.V. Chlamydia trachomatis (L serotypes)
Chancroid Hemophilus ducreyi
Granuloma inguinale Donovania granulomatis
Non-specific vaginitis Hemophilus vaginalis
Mycoplasma infection Mycoplasma vaginalis

15. VIRAL
AIDS HIV1/2
Genital herpes HSV 2
Condyloma acuminata HPV
Molluscum contagiosum HPV-16,18 OR 31
Viral hepatitis Pox virus
CIN Hep B, C

16. PROTOZOAL
Bacterial vaginosis Gardnerella vaginalis
Trichomonas vaginitis Trichomonas vaginalis
FUNGAL
Monilial vaginitis Candida albicans
ECTOPARASITES
Scabies Sarcoptes scabiei
Pediculosis pubis Phthirus pubis

17. GONORRHEA
 N. gonorrhea G –ve diplococcus
 Genitourinary epithelium. Resistant to squamous epithelium
 S/S: dysuria, discharge, Bartholinitis, proctitis, intermenstrual
bleeding
 DISTANT: Perihepatitis, septicemia, acute PID
 COMPLICATION: PID, infertility, ectopic preg, dyspareunia, CPP,
TO mass.
 DIAGNOSIS: NAAT, culture
 T/T: Preventive – t/t male partner, use condom
Curative – ceftriaxone, ciproflox, oflox, levoflox Single dose
 Syphilis, chlamydia t/t
 F/U: culture sent after 7 days, repeat every 3 mth, if –ve declared
cured

18.  Anaerobic spirochete Treponema pallidum
 C/F: papule, ulcer (punched out, rolled out, painless) inguinal lymph
nodes enlarged
 Primary chancre heals spontaneously 1-8 wks
 2° syphilis: 6wk to 6mth condyloma lata. Coarse, flat necrotic.
Maculoppular rash. LAP
 Latent : 2 to 20 yrs. Quiescent phase
 3° syphilis: CNS, CVS, musculoskeletal system. 3,6,7,8 nerves, tabes
dorsalis, hemiplegia, aortic aneurysm, gummas of skin & bone.
Endarteritis & Periarteritis of small & med arteries.
serpiginous outline
 Congenital syphilis
SYPHILIS