05 Infections of The Lower Genital Tract and TB

Infections of the Lower Genital Tract
shock syndrome. It is a small protein with a molecular weight of

22,000. Its primary effects are the production of increased vascular
permeability and profuse leaking of fluid from the intravascular
space to the extravascular space.
KEY TERMS AND DEFINITIONS

Bubo
Calymmatobacterium
Calymmatobacterium
granulomatis.
Clue Cells
An enlarged and inflamed lymph node, particularly in the axilla or

groin, caused by infections such as plague, syphilis, gonorrhea,
lymphogranuloma venereum, or tuberculosis.
Epithelial cells with clusters of bacteria adherent to their external

surfaces, obscuring their normal, fine border. They have a granular
or stippled appearance and are associated with bacterial vaginosis.
A sexually transmitted viral disease of the vulva, vagina, cervix, and
rectum caused by the human papillomavirus.
Condyloma Latum
The nonpainful large, raised, flattened, grayish white lesions of

secondary syphilis, most often found on the vulva.
DarkDark-Field Microscopy
A technique used to identify the spirochetes of syphilis, Treponema

pallidum.
Donovan Bodies
The pathognomonic clusters of dark-staining bacteria (bipolar in

appearance) found in the cytoplasm of large mononuclear cells in
patients with granuloma inguinale.
Groove Sign
A depression between groups of inflamed nodes producing a double

genitocrural fold in patients with lymphogranuloma venereum.
Gumma
An infectious granuloma characteristic of late or tertiary syphilis.
Mucopurulent
Cervicitis
This inflammatory condition is diagnosed by gross visualization of

yellow mucopurulent material or the presence of 10 or more
polymorphonucleocytes per high-powered field on Gram stain of
the endocervix.
Nit
The egg of the crab louse.
Podophyllin
A topical resin mixed with benzoin and alcohol used to treat the
lesions of condyloma acuminatum.
Prozone Phenomenon
A false-negative VDRL or RPR caused by an excess of

anticardiolipin antibody in the serum.
Sexually Transmitted A term used to describe an infection acquired primarily through

sexual contact; venereal disease.
Disease (STD)
Page | 1
Word Catheter
A short catheter with an inflatable Foley balloon used to help

develop a fistulous tract from a Bartholin duct to the vestibule.
The gram-negative, nonmotile rod that causes granuloma

inguinale.
Condyloma
Acuminatum
Toxin 1
Whiff Test
A test used clinically. The smell of vaginal discharge after the

addition of 10% potassium hydroxide. A positive sample associated
with either bacterial vaginosis or Trichomonas infections will give
off a fishy or aminelike smell.
Infection of the Vulva

Composed of a stratified squamous epithelium containing hair follicles and
sebaceous, sweat, and apocrine glands
Subcutaneous tissue contains specialized structures such as the Bartholin glands
Subject to both primary and secondary infections
Three most prevalent primary viral infections of the vulva are herpes genitalis,
condyloma acuminatum, and molluscum contagiosum
Secondary infections of the vulva caused by organisms that produce vulvovaginitis
are among the most common of all gynecologic conditions
Vulvar itching or burning of acute onset and short duration suggests infection or
contact dermatitis
The signs of erythema, edema, and superficial skin ulcers of the vulva also suggest
infection
Skin fissures and excoriation may be signs of primary infection, may be caused by
the patient's scratching as a result of irritation from a vaginal discharge, or may be
the manifestation of a primary dermatologic disease.
I. Acute Bacterial Cystitis
Risk Factors:
adult women experience symptoms of dysuria and urinary frequency
An individual woman's lifetime risk of developing at least one urinary tract
infection (UTI) is approximately 50%
The highest incidence of acute bacterial cystitis is found in women during their
early 20s.
Reproductive-age women are prone to ascending infections because of the
shortness of the female urethra and the fact that the distal one third of the urethra
is often colonized by bacteria from the vulvar vestibule
Independent risk factors for the development of acute bacterial cystitis include
sexual intercourse, use of a vaginal diaphragm or spermicide in premenopausal
women, previous UTI, and recent exposure to antibiotics.
The toxin involved in producing the signs and symptoms of toxic
COMPREHENSIVE GYNECOLOGY
Infections of the Lower

Lower Genital Tract
In postmenopausal women followed prospectively for 2 years, a history of six or

more prior UTIs and insulin-treated diabetes were independent risk factors for
cystitis, but sexual activity was not.
In postmenopausal women, the lack of estrogenic effect on urovaginal epithelium
and sometimes the presence of residual urine after voiding predisposes them to
infection.
Basic science studies have demonstrated that vaginal and uroepithelial cells have an
increased susceptibility to adherence by Escherichia coli in some women.
Clinical Features:
Acute bacterial cystitis is characterized by multiple symptoms:
Dysuria
Urgency
Frequent voiding
Abrupt in onset
Suprapubic tenderness specific sign for acute bacterial cystitis
Table 2222-1 -- Major Infectious Causes of Acute Dysuria
Dysuria in Women
Condition Pathogen
Cystitis
Pyuria
Urine
Culture[*] Symptoms,
Hematuria (cfu/mL) Factors
Signs,
and
Escherichia coli, Usually Sometimes 102 to Abrupt

onset,
severe
Staphylococcus
105
symptoms,
multiple
symptoms
(dysuria,
saprophyticus,
sp.,
increased frequency and
Proteus
Klebsiella sp.
urgency), suprapubic or
low back pain; suprapubic
tenderness on examination
Urethritis Chlamydia
Usually Rarely
<102
Gradual
onset,
mild
symptoms,
vaginal
discharge or bleeding (due
to concomitant cervicitis),
lower abdominal pain,
new
sexual
partner;
cervicitis or vulvovaginal
herpetic
lesions
on
examination
<102
Vaginal discharge or odor,

pruritus,
dyspareunia,
external
dysuria,
no
increased frequency or
urgency; vulvovaginitis on
examination
trachomatis,
Neisseria
gonorrhoeae,
herpes
virus
Vaginitis
simplex
Candida
Trichomonas
vaginalis
Page | 2
sp., Rarely
Rarely
Vulvovaginitis may be associated with external dysuria in contrast to a deeper

internal dysuria associated with cystitis
With urethritis have more chronic symptoms, with a gradual onset and less
urgency, than do women with acute bacterial cystitis.
Etiologic Agent:
Most common pathogens causing acute urethritis are C. trachomatis and N.
gonorrhoeae.
Postmenopausal women may experience urethral symptoms related to estrogen
deficiency without significant bacterial colonization of the bladder
Most common cause of acute bacterial cystitis is ascending infection from the
introitus and distal urethra
The pathogens most frequently involved in uncomplicated lower
lower UTIs are E. coli
(approximately 80%) and Staphylococcus saprophyticus (approximately 5% to
15%).
Diagnostic Procedure and Work Up:
Certain bacterial virulence factors provide a selective advantage to strains
possessing them with regard to colonization and infection. There is increasing
resistance of urinary tract pathogens with up to one third of bacterial isolates
resistant to sulfanilamides, ampicillin, and first-generation cephalosporins. These
agents should not be used for empiric therapy.
Varying diagnostic steps in the laboratory workup of classic symptoms of acute
cystitis:
First step is to demonstrate pyuria by microscopic examination of the urine
*Pyuria is demonstrated in the vast majority of episodes of acute bacterial cystitis and gross
hematuria identified in approximately 20%
*Women with classic symptoms and confirmation of pyuria, it is not necessary to perform a
urine culture
*For urine cultures include patients with a complicated history (e.g., recent catheterization),
UTI within the past month, urinary symptomatology that has been present more than 7 days,
cystitis in a woman older than 65, preg-nancy, or intercurrent diseases such as diabetes
mellitus or immunosuppression.
Obtain accurate estimates of the number of bacteria per milliliter, it is important to
culture the urine within 2 hours or to refrigerate the specimen until it is sent to the
laboratory.
Gold standard of more than 105 uropathogens per milliliter had been the criterion
used to make the diagnosis of signifi-cant bacteriuria in asymptomatic women.
However, bacterial concentrations of as few as 102 per milliliter are accepted as
bacteriologic confirmation of cystitis in symptomatic women.
Management:
First episode of acute, uncomplicated cystitis the current treatment of choice is 3
days of oral therapy with TMP-SMX, trimethoprim alone, or one of the quinolones
such as ciprofloxacin or norfloxacin

Lower Genital Tract
Compared with the traditional 7 to 14 days of therapy, the advantages of 3-day

therapy are simplicity, better patient compliance, lower cost, and reduction of side
effects such as diarrhea and vaginitis
With appropriate antibiotic therapy it takes approximately 24 hours for the
symptoms of acute bacterial cystitis to resolve
In a community where resistance to trimethoprim is greater than 25%, treatment
with a quinolone such as 250 mg twice daily of ciprofloxacin is appropriate
Obviously standard empiric regimens for acute bacterial cystitis should be
reassessed periodically because of changing patterns of resistance to antibiotics.
When resistance of E. coli to a therapeutic agent (e.g., TMP-SMX) reaches 20%,
that agent should no longer be used for empiric therapy
Women with chronic infections, systemic manifestations of infection, renal disease,
anatomic abnormalities of the urinary tract, pregnancy, or diabetes mellitus should
be given more prolonged oral therapy for a minimum of 7 to 14 days.
Failure to respond necessitates quantitative culture of the urine for bacteria and
also culture of the endocervix and urethra for chlamydia and gonorrhea organisms.
In the past, single-dose therapy was a popular regimen because of the convenience
and simplicity. However, the rates of recurrence and failure with single-dose
therapy were found to be unacceptable.
Table 2222-2 -- Recommended ThreeThree-Day Regimens for Acute Uncomplicated Cystitis in
Young Women
Drug

Possible modifications in lifestyle include discontinuing use of a diaphragm for

contraception, increasing oral fluid intake, voiding frequently, voiding immediately
after intercourse, double voiding
type of prophylaxis depends on the individual patient's history whether broadspectrum antibiotics are prescribed continuously, postcoitally, or when the patient
believes she is developing an infection.
The broad-spectrum antibiotics that are most commonly chosen for low-dose
antibiotic prophylaxis are trimethoprim, TMP-SMX, nitrofurantoin, or a
cephalosporin
Prophylaxis may be given for months without significant emergence of antibioticresistant bacteria.
Complicated lower UTIs are those caused by antibiotic-resistant bacteria and those
infections that occur in women with anatomic or functional abnormalities of the
urinary tract.
Many different organisms can be cultured in complicated cystitis, including E. coli,
Enterococcus faecalis, Proteus mirabilis, Staphylococcus epidermidis, S. aureus,

Klebsiella, Pseudomonas, Enterobacter, and Serratia.
The quinolones currently are the drugs of choice for empiric therapy of
complicated cystitis, primarily because of their broad antibacterial spectrum.
Dosage
Trimethoprim/sulfamethoxazole 160/180 mg q12h

Trimethoprim
100 mg q12h
Quinolones
Ciprofloxacin
250 mg q12h
Enoxacin
400 mg q12h
Lomefloxacin 4
400 mg q12h
Norfloxacin
400 mg q12h
Ofloxacin
200 mg q12h
Management of Recurrent Cystitis:

Persistent or recurrent cystitis following the initial infection presents in
approximately 20% of women
It is important to differentiate whether the infection is a relapse or a reinfection.
More than 90% of recurrences in young women are exogenous reinfection with
new isolates arising from local flora.
Behavioral modification has become popular for preventing recurrent acute cystitis
Page | 3
II. Infections of Bartholins Gland

Normally are two rounded, pea-sized glands deep in the perineum.
At the entrance of the vagina at 5 o'clock and 7 o'clock.
normal Bartholin's gland cannot be palpated

Lower Genital Tract
Bartholin's ducts are approximately 2 cm in length, and they open in a groove

between the hymen and labia minora in the posterior lateral wall of the vagina
Most common dilation is cystic dilation of Bartholin's duct
Mucinous secretions from Bartholin's glands do provide moisture for the
epithelium of the vestibule but are not important for vaginal lubrication.
Pathogenesis:
Cause of a Bartholin's duct cyst is obstruction of the duct secondary to nonspecific
inflammation or trauma
Histologically, Bartholin's ducts are lined by transitional epithelium, these ducts are
easily obstructed, usually near the distal orifice
Positive cultures from Bartholin's gland abscesses are often polymicrobial and
contain a wide range of bacteria similar to the normal flora of the vagina.
Differential Diagnosis:
Mesonephric cysts - generally more anterior and cephalad in the vagina
Epithelial inclusion cysts - more superficial
Rarely:
Lipoma
Fibroma
Hernia
Vulvar varicosity
Hydrocele may be confused with a Bartholin's duct cyst. Bartholin's duct cysts are
found in the labia majora, and the duct orifices are at the base of the labia minora
just distal to the hymen.
Clinical Features:
Most women with Bartholin's duct cysts are asymptomatic
Cysts may vary from 1 to 8 cm in diameter, and they are usually unilateral, tense,
and nonpainful.
Majority of cysts are unilocular. However, occasionally in chronic or recurrent
cysts there are multiple compartments.
Abscess of a Bartholin's gland tends to develop rapidly over 2 to 4 days.
Symptoms include acute vulvar pain, dyspareunia, and pain during walking. Local
symptoms of acute pain and tenderness are secondary to rapid enlargement,
hemorrhage, or secondary infection.
Signs are those of a classic abscess: erythema, acute tenderness, edema, and
occasionally cellulitis of the surrounding subcutaneous tissue. Without therapy,
most abscesses tend to rupture spontaneously by the third or fourth day.
Diagnostic Procedure:
Biopsy for gland enlargement in women older than 40 is performed to exclude
adenocarcinoma of Bartholin's gland
Excision of a Bartholin duct and gland is indicated for persistent deep infection or
multiple recurrences of abscesses and may be performed for enlargement of the
gland in women older than 40.
Treatment:
Depends on their symptomatology
Page | 4
Asymptomatic cysts in women younger than 40 do not need treatment.

Therapy for acute adenitis without abscess formation is broad-spectrum antibiotics
and frequent hot sitz baths
Treatment of choice for a symptomatic cyst or abscess is the development of a
fistulous tract from the dilated duct to the vestibule
Simple incision and drainage of a Bartholin gland abscess are complicated by a
tendency for the abscess to recur.
The classic surgical treatment is to develop a fistulous tract to marsupialize the
duct. After an elliptical wedge of tissue has been removed, the remaining edges of
the duct or abscess are everted and sutured to the surrounding skin with
interrupted sutures. This forms an epithelialized pouch that provides drainage for
the gland
Alternative surgical approach is to insert a Word catheter (a short catheter with an
inflatable Foley balloon) through a stab incision into the abscess and leave it in
place for 4 to 6 weeks. During this period a tract of epithelium will form. All of the
previously mentioned operations may be performed with local anesthesia.
Antibiotics are not necessary unless there is an associated cellulitis surrounding the
Bartholin gland abscess.
Removal of a Bartholin gland for recurrent infection should be performed when
the infection is quiescent. Because of the richness of the vascular supply to the
region, including the vestibular bulbs directly below Bartholin's gland, excision is a
more formidable task than one would expect. It is best to have either regional block
or general anesthesia for excision.
Removal of a Bartholin gland is often accompanied by morbidity, including
intraoperative hemorrhage, hematoma formation, fenestration of the labia,
postoperative scarring, and associated dyspareunia. Bartholin's gland secretions are
not important for providing lubrication during sexual intercourse.
III. Pediculosis Pubis
Skin of the vulva is a frequent site of infestation by animal parasites, the two most
common being the crab louse and the itch mite. Ideally, early diagnosis and
treatment are of the utmost importance in controlling parasitic infection.
Etiology:
An infestation by the crab louse, Phthirus pubis.
Crab louse is also called the pubic louse and is a different species from the body or
head louse
Transmitted usually by close contact
May be acquired from towels or bedding.
Lice in the pubic hair are the most contagious of all sexually transmitted diseases
Phthirus pubis is generally confined to the hairy areas of the vulva. It may
occasionally be found in other areas such as the eyelids.
The major nourishment of the louse is human blood
Body lice predominately infect schoolchildren and, secondarily, their mothers, by
direct contact.
Schools and playgrounds are the major reservoir.


Lower Genital Tract
Pubic lice are typically transmitted by direct sexual contact. However, nonsexual
transmission of pubic lice has been documented.
Louse's life cycle has three stages: egg (nit), nymph, and adult.
The entire life cycle is spent on the host. Eggs are de-posited at the base of hair
follicles. The adult parasite is approximately 1 mm long and dark gray when its
alimentary tract is not filled with blood
Clinical Feature:
Predominant clinical symptom of louse infestation is constant itching in the pubic
area, which is secondary to allergic sensitization
It is estimated that it takes a minimum of 5 days following initial infection to
develop allergic sensitization. Usually, initial sensitization takes several weeks to
develop.
Incubation period for pediculosis is approximately 30 days.
Pruritus may occur within 24 hours after a reinfection.
Examination of the vulvar area without magnification demonstrates eggs and adult
lice and pepper grain feces adjacent to the hair shafts
The tiny rough spots visualized with the naked eye are the alimentary tracts of lice
filled with human blood.
The vulvar skin may become secondarily irritated or infected by constant
scratching.
For definitive diagnosis one can make a microscopic slide by scratching the skin
papule with a needle and placing the crust under a drop of mineral oil. The louse's
body looks like that of a miniature crab with six legs that have claws on them.
Treatment for Pediculosis Pubis
Treatment of pediculosis pubis or scabies involves an agent that kills both the adult
parasite and the eggs
Pediculosis pubis involves the use of permethrin (Nix Creme), lindane (Kwell), or
pyrethrins with piperonyl butoxide
Permethrin is available as a 1% cream rinse, applied to affected areas and washed
off after 10 minutes. Lindane 1% is recommended as a shampoo.
Should be applied for 4 minutes to the affected area and subsequently thoroughly
washed off.
An alternative is pyrethrin with piperonyl butoxide applied to the affected area and
washed off in 10 minutes. None of the regimens should be applied to the eyelids
Permethrin is more expensive than lindane, and it has less potential for toxicity in
the event of inappropriate use.
Seizures have been reported when lindane was applied immediately after a bath or
in women with extensive dermatitis.
Lindane is not recommended for pregnant or lactating women, or for children
younger than age 2. Women should be reevaluated after 7 days if symptoms persist.
Retreatment may be necessary if lice are found or if eggs are observed at the hair
skin junction.
Page | 5
CDC recommendation for scabies is permethrin cream 5% applied to all areas of the
body from the neck down and washed off after 8 to 14 hours or ivermectin 0.2
mg/kg orally, repeated in 2 weeks, if necessary.
Alternative regimens include lindane 1% 1 oz of lotion or 30 g of cream applied
thinly to all areas of the body from the neck down and thoroughly washed off after
8 hours
IV. Scabies
Parasitic infection of the itch mite, Sarcoptes scabiei.
Epidemic outbreaks of scabies tend to occur approximately every 20 to 30 years.
Similar to the crab louse, it is transmitted by close contact.
Unlike louse infestation, scabies is an infection that is widespread over the body
without a predilection for hairy areas.
The adult female itch mite digs a burrow just beneath the skin. She lays eggs in this
home during her life span of approximately 1 month.
Adult itch mite is usually less than 0.5 mm long, approximately the size of a grain
of sand. Unlike the crab louse, an itch mite travels rapidly over skin and may move
up to 2.5 cm in 1 minute.
Mites are able to survive for only a few hours away from the warmth of skin.
Clinical Features:
Predominant clinical symptom of scabies is severe but intermittent itching
More intense pruritus occurs at night when the skin is warmer and the mites are
more active.
Initial symptoms usually present approximately 3 weeks after primary infestation
Scabies may present as papules, vesicles, or burrows.
Pathognomonic sign of scabies infection is the burrow in the skin
Burrow usually has the appear-ance of a twisted line on the skin surface, with a
small vesicle at one end.
Any area of the skin may be infected, with the hands, wrists, breasts, vulva, and
buttocks being most commonly involved.
A handheld magnifying lens is helpful for examining suspicious areas. Microscopic
slides may be made by use of mineral oil and a scratch technique
Mites lack lateral claw legs but have two anterior triangular hairy buds. Scabies has
been termed the great dermatologic imitator, and the differential diagnosis includes
virtually all dermatologic diseases that cause pruritus.
Treatment for Scabies:
Patients with scabies have intense pruritus that may persist for many days
following effective therapy
An antihistamine will help to alleviate this symptom. Similar to pediculosis pubis,
women should be examined 1 week following initial therapy and retreated with an
alternative regimen if live mites are observed.
Avoid reinfection by either pediculosis pubis or scabies, treatment should be
prescribed for sexual contacts within the previous 6 weeks and other close
household contacts.

Lower Genital Tract
Those individuals with close physical contact should be treated at the same time as
the infected woman whether or not they have symptoms.
Clothing and bedding should be decontaminated. Importantly, women and
physicians alike should not confuse the 1% cream rinse of permethrin dosage
recommended for pubic lice with the permethrin cream 5% being recommended
for scabies.
V. Molluscum Contagiosum
Etiology:
Is a pox virus that causes a chronic localized infection, consisting of flesh-colored,
dome-shaped papules with an umbilicated center.
Molluscum is spread by direct skin to skin contact
Incubation time is 2 to 7 weeks. In children, molluscum contagiosum may present
over the entire body.
It is primarily an asymptomatic disease of the vulvar skin and unlike most sexually
transmitted diseases, it is only mildly contagious. However, lesions can be spread
by autoinoculation, during contact sports, or by fomites on bath sponges or towels.
Replicates in cytoplasm of cells
Widespread infection in adults is most closely related to underlying cellular
immunodeficiency, such as during an HIV infection. It can also occur in the setting
of chemotherapy or corticosteroid administration.
Made by the characteristic appearance of the lesions
nodules or domed papules of molluscum contagiosum are usually 1 to 5 mm in
diameter
Close inspection reveals that many of the more mature nodules have an
umbilicated center.
Characteristically, an infected woman will have 1 to 20 solitary lesions randomly
distributed over the vulvar skin. A crop of new nodules will persist from several
months to years. If the diagnosis cannot be made by simple inspection, the white,
waxy material from inside the nodule should be expressed on a microscopic slide.
The finding of intracytoplasmic molluscum bodies with Wright or Giemsa stain
confirms the diagnosis.
The major complication of molluscum contagiosum is bacterial superinfection.
The umbilicated papules may resemble furuncles when secondarily infected.
Molluscum contagiosum is usually a self-limiting infection and spontaneously
reduces after a few months in immunocompetent individuals.
Treatment:
Treatment of individual papules will decrease sexual transmission and
autoinoculation of the virus.
Of individual papules is initiated with injec-tion of a local anesthetic with a small
subdermal wheal of 1% lidocaine (Xylocaine).
Caseous material is then evacuated and the nodule excised with a sharp dermal
curette.
Page | 6
Base of the papule is subsequently chemically treated with either ferric subsulfate
(Monsel solution) or 85% trichloroacetic acid.
An alternative method is canthardin, a chemical blistering agent. In one
retrospective study, 90% of 300 children had clearance of lesions with an average of
two visits.
In immunocompromised individuals, treatment is more difficult. In the HIVinfected patient, there have been multiple reports of recalcitrant molluscum lesions
resolving only after initiating highly active antiretroviral therapy.
VI. Condyloma Acuminatum
Etiology:
Most common viral sexually transmitted disease of the vulva, vagina, rectum, and
cervix caused by the human papillomavirus (HPV).
Synonyms for vulvar condylomata acuminata include genital, venereal, or
anogenital warts
DNA testing demonstrates that the majority of HPV infections are subclinical. Thus
the prevalence of the disease depends on the sophistication of the technique used to
diagnose subclinical infection, such as cytology, colposcopy, or molecular probes of
biopsy material.
Most common HPV subtypes, numbers 16 and 18 are high risk to be associated
with aneuploid, premalignant, or malignant lesions of the female genital tract.
Sexual intercourse is the usual method of transmitting genital HPV infection.
The average incubation period is 3 months, with a wide range of 1 to 8 months. As
with other sexually transmitted diseases, peak incidence occurs between the ages of
15 and 25 years.
Diagnostic Procedures:
made by direct inspection
Condyloma acuminata-type warts tend to occur primarily on moist surfaces.
Indications to perform a biopsy include the rare situations when lesions do not
respond to standard therapy; the condition accelerates during therapy
the woman is immunocompro-mised; or when growths are pigmented, indurated,
fixed, or ulcerated
Type-specific HPV nucleic acid tests are not indi-cated, nor are they of benefit in
the diagnosis or management of visible genital warts.
Clinical Features:
Pedunculated warts are friable and tend to bleed following minor trauma
Initial infections usually begin in the vestibule and adjacent areas of the labia.
However, adjacent, moist epithelium may be involved with condyloma, including
the vagina, cervix, urethra, bladder, and rectum
Initial lesions are pedunculated, soft papules approximately 2 to 3 mm in diameter
and 10 to 20 mm long.
They may occur as a single papule or in clusters. The infection progresses by means
of autoinoculation. As adjacent lesions coalesce, many different presentations may
evolve

Lower Genital Tract

Lesions vary from pinhead-sized papules to large cauliflower-like masses that may
grow to several centimeters in diameter.
Uncomplicated condylomata acuminata are usually asymptomatic. Depending on
size and location, some warts are symptomatic, producing pain, itching, tendency
to bleed when friable, and an odor when secondarily infected.
Condylomata in the cervix tend to be flat and sometimes bleed on contact.
The presence of condylomata of the cervix, especially subclinical disease, is
generally discovered by colposcopic examination.
Subclinical HPV infection of the cervix, vagina, or vulva may be discovered by
applying 3% to 5% acetic acid to the epithelium. However, application of acetic
acid is not a specific test for HPV infection
HPV-infected cells appear shiny white in color, with the area of infection having
irregular borders and sometimes satellite lesions.
Common benign skin lesions to consider in the differential diagnosis of condyloma
acuminata are micropapillomatosis labialis, seborrheic keratosis, nevi, and other
STDs such as condyloma lata and molluscum contagiosum and neoplasms such as
giant condyloma or bowenoid papulosis or squamous cell carcinoma.
Several conditions are known to predispose women to infection with HPV and
include immunosuppression, diabetes, pregnancy, and local trauma.
Table 2222-3 -- Genital HPV Types

Morphology
6, 11
Genital warts, LSIL, RRP Low (negligible)
16, 18, 31, 33, 35, 39
LSIL
45, 51, 52, 56, 58, 59
HSIL
68, 73, 82
Cancer
61, 62, 67, 69, 70

Potential for Cancer

Low (negligible)

High
There is a wide range of therapeutic choices, including chemical, cautery, and

immunologic therapy.
The CDC-recommended treatments for external genital warts are subdivided into
patient-applied therapies and provider-administrated therapies
None of the various treatment regimens is more effective than other acceptable
treatments.
However, warts located on moist surfaces and in intertriginous areas respond faster
to topical treatment than do warts on drier surfaces.
Another
chemical
alternative
treatment
is
topical
5fluorouracil/epinephrine/bovine collagen gel. The preparation is injected directly
into the base of the wart. This therapy requires frequent visits and the lack of
superior efficacy makes it difficult to justify its routine use.
Lesions larger than 2 to 3 cm are best treated by cryotherapy, electrocautery, or
laser therapy
It is sometimes best to surgically shave the condyloma and then apply thermal
injury to the virus in the base of the lesion.
The woman should be advised that changes in skin pigmentation are common
following ablative therapy.
interferons, when given parenterally, may result in severe systemic symptoms
similar to a viral illness in some women.
Interferon treatment of HPV has been accomplished by topical creams and direct
injection into the condylomata. Local application exerts antiviral activity by
stimulating a focal immune response.
Recurrences usually present within 3 months of successful treatment of the initial
treatment.
A quadrivalent HPV vaccine is now available against types 16, 18, 6, and 11.
In females nave to HPV virus initial administration of the vaccine followed by
repeat inoculation at 2 and 6 months can prevent 90% of genital warts.
Treatment of Warts: PatientPatient-Administered

Podafilox 0.5% Solution or
Gel (Condylox)
Imiquimod 5% Cream (Aldera)
Uncertain
Treatment:
Vulvovaginitis should be treated as part of the therapeutic plan for condyloma
acuminatum.
Management of the individual woman depends on the location, size, and extent of
the condyloma and whether the woman is pregnant.
Most clinicians attempt to treat the patient until the macroscopic lesions disappear.
Most important priority is to remove symptomatic growths.
No present therapy of HPV eliminates subclinical infection from the surrounding
epithelium
Almost all low-risk HPV infections and two thirds of high-risk HPV infections are
eradicated over a 24-month period.
Page | 7
HPV Type
40, 42, 53, 54, 57, 66, 84 LSIL
Dose
Mode
action
Bid for 3 days, 4 days off up Daily and qhs, 3 times/week up to 16

to 4 cycles
weeks, wash 610 min after Rx
of Antimitotic
Immune enhancer
Side effects
Mild to moderate pain, local Mild to moderate local inflammation

irritation
Pregnancy
NO
NO
MMWR 55(RR-11), 2006.

Lower Genital Tract
Treatment of Warts: ProviderProvider-Administered

Podophyllin
Resin
Cytotherapy
Weekly every 12 weeks (no Weekly

cryoprobe in vagina)
Dose
Mode
action
of Thermal-induced cytolysis
Trichloroacetic
(TCA)
Acid
Chemical coagulation of
proteins
Side effects
Pain, necrosis + blistering
Local
irritation
Pain, adjacent
[use soap, soda]
Pregnancy
OK
NO
OK
damage
MMWR 55(RR-11), 2006.
Herpes
Chancroid
Lymphogranulo
ma Venereum
Donovanosis
3 days6 weeks
Incubation
period
24 weeks 27 days
(112
weeks)
114 days
Primary lesion
Papule
Vesicle
Papule or Papule, pustule, Papule

pustule
or vesicle
Multiple,
may
coalesce
Usually
multiple,
may
coalesce
Usually one
Variable
12
220
210
Variable
Number
lesions
of Usually
one
14 weeks (up
to 6 months)
Diameter (mm)
515
Edges
Sharply
Erythemato Undermine Elevated, round Elevated,
demarcate us
d, ragged, or oval irregular irregular
d Elevated,
irregular
round or
oval
Depth
Superficial Superficial
or deep
Excavated
Superficial
deep
Base
Smooth,
Serous,
nonpurule erythemato
nt
us
Purulent
Variable
Page | 8
Chancroid
Induration
Firm
None
Soft
Pain
Unusual
Common
Usually
Variable
very tender
Lymphadenopat Firm,
Firm,
hy
nontender, tender,
bilateral
often
bilateral
Tender,
may
suppurate,
usually
unilateral
Occasionally
firm
or Elevated
Red and rough
(beefy)
Firm
Uncommon
Tender,
may Pseudoadenopat
suppurate,
hy
loculated,
usually
unilateral
Herpes, granuloma inguinale (donovanosis), lymphogranuloma venereum,

chancroid, and syphilis may all present as ulcerations in the genital area.
recurrent and incurable and is among the most frequently encountered STDs.
It is frequently transmitted by asymptomatic shedding; approximately 80% of the
individuals are unaware they are infected.
Recent evidence suggests that viral shedding from asymptomatic individuals may
occur as frequently as 1 in 5 days.
some infectious disease specialists consider herpes a persistent rather than a
intermittent disease.
It is important that the woman understand the natural history of disease with
emphasis on probability of recurrent attacks, the effect of antiviral agents, and the
risks of neonatal infection.
Recurrent genital herpes is not a debilitating physical disease, yet it may present an
overwhelming psychological burden.
the individual patient there is an immense sense of social isolation and a reluctance
to initiate a sexual relationship. This can result in a decrease in self-esteem,
depression, and, most important, a feeling of loss of control due to the inability to
predict the time of the next recurrence.
There are two distinct types of herpes simplex virus: type 1 (HSV-1) and type 2
(HSV-2).
HSV-I tends to infect epithelium above the waist
HSV-2 tends to cause ulceration below the waist.
HSV-1 is the most commonly acquired genital herpes in women younger than 25.
HSV-1 does not protect against HSV-2, but HSV-2 does offer some protection
against HSV-1.
Primary infection by herpes is both a local and a systemic disease. The majority of
initial genital infections occur in women between the ages of 15 and 35.
The incubation period is between 3 and 7 days, with an average of 6 days.
Clinical Features:
VII. Genital Ulcers

Etiology:
Table 2222-6 -- Clinical Features of Genital Ulcers
Syphilis
Herpes
Weekly, frosting
Antimitotic
Lymphogranulo
ma Venereum
Donovanosis
Syphilis

Lower Genital Tract
Often the patient experiences paresthesias of the vulvar skin before papules and
subsequent vesicle formation.
Usually there are multiple vesicles that become shallow, superficial ulcers over a
large area of the vulva.
There is often simultaneous involvement of the vagina and cervix
Patients experience multiple crops of ulcers for 2 to 6 weeks. Often the ulcers
coalesce; however, the ulcers heal spontaneously without scarring
Viral shedding may occur for 2 to 3 weeks after vulvar lesions appear.
The majority of symptomatic women have severe vulvar pain, tenderness, and
inguinal adenopathy.
Subclinical primary herpes infection is common. Regional lymphadenopathy
usually develops during primary genital infections.
Primary infections of the urethra and bladder may result in acute urinary retention,
necessitating catheterization
Symptoms of vulvar pain, pruritus, and discharge peak between days 7 and 11 of
the primary infection. The average woman experiences severe symptoms for
approximately 14 days.
Recurrent genital herpes is a local disease, and the symptoms are much less severe
than the primary outbreak
If a woman's initial genital infection was with HSV-2, she has an approximately
80% chance of having a recurrence within 12 months.
Women whose primary HSV-2 infection was severe have recurrences
approximately twice as often, with a shorter time to recurrence intervals compared
with women with milder initial episodes of the disease
On the average a woman will have four recurrences during the first year. In
contrast, if the initial pelvic infection was with HSV-1, there is a 55% chance of a
recurrence within 1 year, with the average rate of recurrence slightly less than one
episode.
There is a general clinical opinion that recurrences are frequently related to the
onset of a men-strual period or emotional stress.
Most clinical manifestations of recurrent infection are half as severe as those of
primary infections. That is, vulvar involvement is usually unilateral, recurrent
attacks last an average of 7 days, and viral shedding occurs for approximately 5
days.
A common feature of recurrence is a prodromal phase of sacroneuralgia, vulvar
burning, tenderness, and pruritus for a few hours to 5 days before vesicle
formation.
The probability and frequency of recurrence of herpes is related to the HSV
serotype.
Extragenital sites of recurrent infection are common. The herpesvirus resides in a
latent phase in the dorsal root ganglia of S2, S3, and S4.
Often made by simple clinical inspection
Women come to the physician when they develop symptoms from vulvar ulcers.
Page | 9
Herpetic ulcers are painful when touched with a cotton-tipped applicator, whereas
the ulcers of syphilis are painless
As stated earlier, viral cultures are useful in confirming the diagnosis in primary
episodes when culture sensitivity is 80%, but less useful in recurrent episodes.
Most herpesvirus cultures will become positive within 2 to 4 days of inoculation.
most accurate and sensitive technique for identifying herpesvirus is the polymerase
chain reaction (PCR) test. Serologic tests are helpful in determining whether a
patient has been infected in the past with herpesvirus.
Western blot assay for antibodies to herpes is the most specific method for
diagnosing recurrent herpes, as well as unrecognized or subclinical infection.
However Western blot tests are not widely available and difficult to perform
ELISA and immunoblot tests are available for both HSV-1 and HSV-2.
Rapid serologic point-of-care tests are now available for HSV-2 antibodies.
Appropriate screening tests for other STDs should be obtained, as they may coexist
with herpes
Treatment:
Treatment of HSV-1 or HSV-2 may be used for three different clinical scenarios:
1. Primary Episode
duration and severity of symptoms is lessened and shedding is shortened with
antiviral therapy
Antiviral therapy is recommended for use in all patients with primary episodes.
2. Recurrent Episode
Shorten duration of outbreak if started within 24 hours of prodromal symptoms or
lesion appearance.
Due to the necessity of starting antiviral therapy immediately after recognizing
symptoms, it is impor-tant that the patient with HSV be given a prescription for
antiviral therapy to have at home.
Patient-initiated therapy has been found to be superior to therapy ordered by a
physician because patients initiate therapy earlier in the course of a recurrence
antiviral medication should be started as early as possible during the prodrome and
definitely within 24 hours of the appearance of lesions.
3. Daily Suppression
recommended when the patient has six or more episodes a year or for psychological
distress. It is important for patients to be aware that asymptomatic viral shedding
can occur even when on daily suppressive therapy.
Regular use of condoms in serodiscordant couples also decreases transmission, but
is not 100% protective.
HSV seronegative women are three times as likely to acquire HSV infection from
seropositive male partners compared with seronegative males acquiring HSV from
infected female partners
Acyclovir is a drug with relatively minimal toxicity, and recent reports have
documented daily use for as long as 6 years helping to establish the long-term
safety of the drug.

Lower Genital Tract
CDC recommends that acyclovir or other suppressive drug should be discontinued

after 12 months of suppressive therapy to determine the subsequent rate of
recurrence for each individual woman. Even if herpes is not treated over time,
clinical recurrences tend to dramatically decrease in number.
Antiviral Treatment for HSVHSV-Nonpregnant Patient

Patient
Indication
Valacyclovir
Acyclovir
First clinical 1000 mg bid for 710 days

episode
Famciclovir
200 mg five times a 250 mg tid for 7

day or 400 mg tid for 10 days
710 days
Recurrent
episodes
1000 mg daily or 500 mg bid 400 mg tid for 5 days 125 mg bid for 5
for 5 days (or 3 days)
or 800 mg bid for 5 days 1000 mg bid
days or 800 mg tid for 1 day
for 3 days
Daily
suppressive
therapy
500 mg daily (8 recurrences

per year) or 1000 mg/day or
250
mg
bid
(>9
recurrences/year)
VIII. Granuloma Inguinale (Donovanosis)

Etiology:
A chronic, ulcerative, bacterial infection of the skin and subcutaneous tissue of the
vulva.
Rarely the vagina and cervix are involved in advanced, untreated cases.
This chronic disease is caused by an intracellular gram-negative, nonmotile,
encapsulated rodCalymmatobacterium granulomatis
Bacterium shares common antigens with Klebsiella and E. coli.
It is very difficult to culture on standard media but has recently been isolated in
cell culture.
Serologic tests are nonspecific
This disease can be spread both sexually through close, nonsexual contact.
However, it is not highly contagious, and chronic exposure is usually necessary to
contract the disease.
The incubation period is extremely variablefrom 1 to 12 weeks.
It is also found in young children and elderly women, who are not sexually active.
Thus some experts hypothesize that the disease may be secondary to
autoinoculation following trauma to the infected area.
Clinical Features:
Page | 10
initial growth of granuloma inguinale is an asympto-matic nodule. The skin over

the nodule ulcerates, and the characteristic lesion is a beefy-red ulcer with fresh
granulation tissue.
Area around the lesions is highly vascular, thus the ulcers bleed easily when
touched. Usually there are multiple nodules and, subsequently, multiple ulcers of
the vulva.
Adjacent areas of ulceration grow and coalesce and, if untreated, will eventually
destroy the normal vulvar architecture.
The ulcers are painless unless secondarily infected.
Adenopathy is not a prominent feature unless there is a superimposed infection
Vulvar edema, especially of the labia, is a common feature of the disease. If
untreated, the chronic form of the disease is characterized by scarring and
lymphatic obstruction, which produces marked enlargement of the vulva.
Diagnosis is established by identifying Donovan bodies in smears and specimens
taken from the ulcers
Both the deep aspects of the ulcer crater and the fresh edge of an expanding lesion
should be sampled.
The pathognomonic Donovan bodies are clusters of dark-staining bacteria with a
bipolar (safety pin) appearance found in the cytoplasm of large mononuclear cells.
Special silver stains highlight the Donovan bodies. However, even a brief period of
previous antibiotic therapy may result in an absence of Donovan bodies in women
who have granuloma inguinale.
Differential diagnosis includes lymphogranuloma venereum, vulvar carcinoma,
syphilis, chancroid, genital herpes, amebiasis, and other granulomatous diseases
Treatment:
CDC recommends doxycycline 100 mg orally twice a day for a minimum of 3
weeks
Alterna-tive antibiotic regimens are azithromycin 1 g orally per week for 3 weeks,
ciprofloxacin 750 mg orally twice a day for a minimum of 3 weeks, or
erythromycin base 500 mg or TMP-SMZ one double-strength tablet orally twice a
day for a minimum of 3 weeks orally four times a day for a minimum of 3 weeks.
Tetracycline is no longer recommended because many strains of the bacteria have
developed resistance.
The initial response to antibiotic therapy should be apparent within the first 7 days.
However, optimal clinical response usually takes 3 to 5 weeks to ensure that the
lesions have healed completely.
It is best to continue antibiotics until a complete clinical response is noted with
healing of the ulcerative lesions.
Alternative antibiotic therapy such as an aminoglycoside has been used in
refractory cases. Rarely, medical therapy fails and surgical excision is required.
Coinfection with another sexually transmitted patho-gen is a distinct possibility.
Sex partners of women who have granuloma inguinale should be examined if they
have had sexual contact during the 60 days preceding the onset of symptoms.

Lower Genital Tract
IX. Lymphogranuloma Venereum

Etiology:
Chronic infection of lymphatic tissue produced by Chlamydia trachomatis. It is
found most commonly in the tropics.
Majority of cases are reported to occur in men. In most series the ratio of males to
females with the disease is approximately 5:1.
The vulva is the most frequent site of infection in women, but the urethra, rectum,
and cervix may also be involved. Subclinical infection is common.
This STD is produced by serotypes L1, L2, and L3 of C. trachomatis. These serotypes
are similar to the serotypes that produce trachoma. The incubation period is
between 3 and 30 days.
three distinct phases of vulvar and perirectal LGV:
primary infection
is a shallow, painless ulcer of the vestibule or labia.
Occasionally this ulcer is near the urethra or rectum.
The ulcer heals rapidly without therapy.
secondary infection
The patient usually consults a physician during the secondary phase of the disease,
which begins 1 to 4 weeks after the primary infection
secondary phase is marked by painful adenopathy in the inguinal and perirectal
areas.
Two thirds of women have unilateral adenopathy, and half have systemic
symptoms, includ-ing general malaise and fever.
When the disease is untreated, the infected nodes become increasingly tender,
enlarged, matted together, and adherent to overlying skin, forming bubos (tender
lymph nodes).
A classic clinical sign of LGV is the double genitocrural fold, or groove sign a
depression between groups of inflamed nodes.
The groove sign develops in approximately 20% of women with LGV. Within 7 to
15 days the bubo will rupture spontaneously and form multiple draining sinuses
and fistulas. These are classic signs of the tertiary phase of the infection.
tertiary infection
Extensive tissue destruction of the external genitalia and anorectal region may
occur during the tertiary phase. This tissue destruction and secondary extensive
scarring and fibrosis may result in elephantiasis, multiple fistulas, and stricture
formation of the anal canal and rectum.
established by culture of pus or aspirate from a tender lymph node. With the recent
development of mono-clonal antibodies for Chlamydia, the diagnosis may be
confirmed with this technique using fluid aspirated from an infected node
The complement fixation antibody titer is the most frequently used serum method
for diagnosis.
Page | 11
Antibody titers greater than 1:64 are indicative of active infection. The antibody
test will cross-react with other Chlamydia infections. However, mucosal
Chlamydia infections usually are associated with low titers
The differential diagnosis of LGV includes syphilis, chancroid, granuloma
inguinale, bacterial lymphadenitis, vulvar carcinoma, genital herpes, and Hodgkin's
disease
Treatment:
CDC recommends doxycycline 100 mg twice daily for at least 21 days as the
preferred treatment. Alternative choices for therapy include azithromycin 1 gm
orally once per week for 3 weeks, ciprofloxacin 750 mg orally twice daily for at
least 3 weeks, or erythromycin base 500 mg four times daily orally for 21 days.
Antibiotic therapy cures the bacterial infection and prevents further tissue
destruction. However, fluctuant nodes should be aspirated to prevent sinus
formation. Rarely incision and drainage of infected nodes is necessary to alleviate
inguinal pain. The late sequelae of the destructive tertiary phase of LGV often
require extensive surgical reconstruction. It is important to administer antibiotics
during the perioperative period.
X. Chancroid
Etiology
a sexually transmitted, acute, ulcerative disease of the vulva
soft chancre of chancroid is always painful and tender. In comparison, the hard
chancre of syphilis is usually asymptomatic.
clinical importance of chancroid is enhanced by recent reports that the genital
ulcers of chancroid facilitate the transmission of HIV infection. Chancroid is a
common disease in developing countries
Caused by Haemophilus ducreyi, a highly contagious, small, gram-negative rod. H.
ducreyi is a nonmotile, facultative anaerobe.
This bacterium on Gram stain exhibits a classic appearance of streptobacillary
chains, or what has been described as an extracellular school of fish. The
incubation period is shortusually 3 to 6 days.
Tissue trauma and excoriation of the skin must precede initial infection because H.
ducreyi is unable to penetrate and invade normal skin.
Clinical Features:
Women with chancroid who consult a physician have solitary or multiple ulcers,
most commonly of the vulvar vestibule and rarely of the vagina or cervix.
The initial lesion is a small papule. Within 48 to 72 hours the papule evolves into a
pustule and subsequently ulcerates. Multiple papules and ulcers may be in different
phases of maturation secondary to autoinoculation.
The extremely painful ulcers are shallow with a characteristic ragged edge
The ulcers have a dirty, gray, necrotic, foul-smelling exudate, and there is an
absence of induration at the base (the soft chancre).

Lower Genital Tract
Approximately 50% of women develop acutely tender inguinal adenopathy, a bubo,

usually within the first 2 weeks of an untreated infection. In most cases the
inguinal adenopathy is unilateral, on the same side of the vulva as the
preponderance of infection.
Nodes that are fluctuant should be treated by needle aspiration to prevent rupture
of the abscess or, if greater than 5 cm in diameter, treated by incision and drainage
diagnosis is made by Gram stain and culture of purulent material or by aspiration of
tender lymph nodes.
The sensitivity of Gram stain for this organism is poor and culture requires special
media and growth conditions.
PCR may not be a practical diagnostic tool for most STD clinics. Sometimes the
clinical diagnosis is made in a woman with painful vulvar ulcers after the
differential diagnosis of the other common STDs that produce vulvar ulcers,
including genital herpes, syphilis, lymphogranuloma venereum, and donovanosis
has been excluded
Treatment:
Because of antibiotic resistance to tetracyclines and sulfonamides, the CDC
recommends azithromycin 1 g orally in a single dose or ceftriaxone 250 mg
intramuscularly in a single dose, or ciprofloxacin 500 mg orally twice for 3 days
All four regimens are effective for treatment of chancroid in HIV-infected women,
although such patients may be at higher risk for treatment failures.
Large ulcers may require 2 to 3 weeks to heal with clinical resolution of
lymphadenopathy slower than that of ulcers. Sexual partners should be treated in a
similar fashion. H. ducreyi is very sensitive to quinolones, but they are
contraindicated in pregnancy.
Successful antibiotic therapy results in both symptomatic and objective
improvement within 5 to 7 days of initiating therapy.
Following therapy, symptomatic improvement in ulcers occurs within 3 days.
Objective improvement occurs within 7 days.
Bubos respond at a slower rate than do skin ulcers. Approximately 10% of women
whose ulcers initially heal have a recurrence at the same site. Women with HIV
infection have an increased rate of failure to the standard treatments for chancroid
and therefore often require more prolonged therapy.
XI. Syphilis
Etiology
a chronic, complex systemic disease produced by the spirochete Treponema
pallidum.

The increase is mainly among men who have sex with men.
Syphilis remains a devastating disease. Early syphilis is a cofactor in the
transmission and acquisition of HIV.
Syphilis should be included in the differential diagnosis of all genital ulcers and
cutaneous rashes of unknown origin, and all diagnosed with syphilis should be
screened for HIV
Page | 12
T. pallidum is an anaerobic, elongated, tightly wound spirochete. Because of its

extreme thinness, it is difficult to detect by light microscopy. Therefore, the
presence of spirochetes is diagnosed by use of specially adapted techniquesdarkfield microscopy or direct fluorescent antibody tests
The incubation period is between 10 and 90 days, with the average being 3 weeks.
They replicate every 30 to 36 hours, which accounts for the comparatively long
incubation period.
Patients are contagious during primary, secondary, and probably the first year of
latent syphilis.
Syphilis can be spread by kissing or touching a person who has an active lesion on
the lips, oral cavity, breast or genitals. Case transmission can occur with oral
genital contact.
Diagnosis of syphilis is complicated by the fact that the organism cannot be
cultivated in vitro. Hence, serologic tests have been the foundation of screening
programs to detect early syphilis
There are two types of serologic tests: the nonspecific, nontreponemal and the
specific, antitreponemal antibody tests
The nonspecific tests such as the VDRL (Venereal Disease Research Laboratories)
slide test and the RPR (rapid plasma reagin) card test are inexpensive and easy to
perform. They are used as screening tests for the disease and also as an index of
response to treatment.
Many conditions produce biologic false-positive results, including a recent febrile
illness, pregnancy, immunization, chronic active hepatitis, malaria, sarcoidosis,
intravenous drug use, HIV infection, advancing age, acute herpes simplex, and
autoimmune diseases such as lupus erythematosus or rheumatoid arthritis.
Biologic false-positive serum tests usually are associated with extremely low titers
(<1:8). A false-negative result is a possibility, occurring in approximately 1% to 2%
of tests. This negative reaction occurs in women in whom there is an excess of
anticardiolipin antibody in the serumtermed the prozone phenomenon.
Table 2222-7 -- Potential

Potential Causes of Biologic FalseFalse-Positive Results in Syphilis Serology
Acute BFP Reactions
Chronic BFP Reaction
Physiologic
Pregnancy
Advanced
age
transfusions
Infections
Varicella
HIV
Vaccinia
Tropical spastic paraparesis
Measles
Leprosy[*]
Mumps
Tuberculosis
Infectious mononucleosis
Malaria[*]

Lower Genital Tract
Multiple
blood
Acute BFP Reactions
Acute BFP Reactions
Herpes simplex
Lymphogranuloma venereum
Hashimoto's thyroiditis
Viral hepatitis
Trypanosomiasis[*]
Mixed connective tissue disease
HIV seroconversion illness
Kala-azar[*]
Primary biliary cirrhosis
Cytomegalovirus
Chronic liver disease
Pneumococcal pneumonia
Idiopathic thrombocytopenic purpura
Mycoplasma pneumonia
Other
Intravenous drug use
Chancroid
Advanced malignancy
Lymphogranuloma
venereum
Hypergammaglobulinemia
Lymphoproliferative disease
Psittacosis
Bacterial endocarditis
Scarlet fever
Rickettsial infections
Toxoplasmosis
Lyme disease
Leptospirosis
Relapsing fever
Rat-bite fever
Vaccinations
Smallpox
Typhoid
Yellow fever
Autoimmune
disease
Systemic lupus erythematosus

Discoid lupus
Drug-induced lupus
Autoimmune hemolytic anemia
Polyarteritis nodosa
Rheumatoid arthritis
Sjgren's syndrome
Page | 13
Clinical Features:
syphilis is divided into primary, secondary, and tertiary stages:
primary syphilis
a papule, which is usually painless, appears at the site of inoculation 2 to 3 weeks
after exposure.
This soon ulcerates to produce the classic finding of primary syphilis, a chancre.
The chancre is a painless ulcer, 1 to 2 cm, with a raised indurated margin and a
nonexudative base. Most often the chancre is solitary, painless, and found on the
vulva, vagina, or cervix
During the first week of clinical disease, the woman develops regional adenopathy
that is nontender and firm. An increase in extragenital primary lesions has been
reported, including lesions of the mouth, anal canal, and nipple of the breast
The painless ulcer heals spontaneously within 2 to 6 weeks without treatment.
Hence, many do not seek treatment, a feature that enhances transmission
likelihood.
Confirmation that the ulcer is primary or secondary syphilis depends on
identification of T. pallidum by dark-field microscopy from wet smears of the ulcer.
Special preparations must be made to obtain suitable smears. It is important to
clean and abrade the ulcer with gauze before obtaining the serum for the slides.
Syphilis is not frequently diagnosed in the primary stage in women.
Serologic tests for syphilis generally become positive 4 to 6 weeks after exposure
thus 1 to 2 weeks after development of the chancre
At the time of dark-field identification of T. pallidum from a primary chancre,
approximately 70% of women will have a positive serologic test. If the serologic
test result remains negative for 3 months, it is unlikely that the ulcer was syphilis.
Secondary syphilis
result of hematogenous dissemination of the spirochetes and is a systemic disease

Lower Genital Tract
If primary syphilis is untreated, weeks to a few months later approximately 25% of

individuals develop a systemic illness that represents secondary syphilis.
Secondary syphilis develops between 6 weeks and 6 months (with an average of 9
weeks) after the primary chancre
During an attack of secondary syphilis, which if untreated will last 2 to 6 weeks, a
multitude of systemic symptoms may occur depending on the major organs
involved
The classic rash of secondary syphilis is red macules and papules over the palms of
the hands and the soles of the feet.
Vulvar lesions include mucous patches and condyloma latum associated with
painless lymphadenopathy. The vulvar lesions of condyloma latum are large, raised,
flattened, grayish-white areas. On wet surfaces of the vulva, soft papules often
coalesce to form ulcers.
These ulcers are larger than herpetic ulcers and are not tender unless secondarily
infected. A woman with syphilis is most infectious during the first 1 to 2 years of
her disease with decreasing infectivity thereafter.
Latent phase
latent stage of syphilis follows the secondary stage and varies in duration from 2 to
20 years.
During the latency period, a woman has a positive serology without symptoms or
signs of her disease. The majority of women who are diagnosed as having syphilis
are discovered by positive blood tests during the latent stage of the disease.
Early latent syphilis is an infection of 1 year or less. All other cases are referred to a
late latent or latent syphilis of unknown duration. All women who have been
sexually active with latent syphilis should have a pelvic exam to discover potential
lesions involving the vagina or cervix.
Women with latent syphilis should have quantitative nontreponemal serologic tests
6, 12, and 24 months following therapy
During the first 3 to 4 years of the latent phase an individual may experience
relapses of secondary syphilis. Women with syphilis in the primary or secondary
stages and during the first year of latent syphilis are believed to be infectious.
tertiary phase of syphilis is devastating in its potentially destructive effects on the
central nervous, cardiovascular, and musculoskeletal systems.
The manifestations of late syphilis include optic atrophy, tabes dorsalis, generalized
paresis, aortic aneurysm, and gummas of the skin and bones.
A gumma is similar to a cold abscess with a necrotic center and the obliteration of
small vessels by endarteritis.
Treatment:
Parenteral penicillin G is the drug of choice for syphilis. T. pallidum is exquisitely
sensitive to penicillin. However, because of the slow replication time of the
spirochete, blood levels must be maintained for 7 to 14 days.
The CDC recommends 2.4 million units of benzathine penicillin G intramuscularly
in one dose for early syphilis (primary and early latent secondary syphilis). Patients
Page | 14

who are allergic to penicillin should receive oral tetracycline 500 mg every 6 hours
for 14 days or doxycycline 100 mg orally twice a day for 2 weeks.
All women with early syphilis should be reexamined clini-cally and serologically at
6 months and 12 months following therapy. With successful therapy in early
syphilis, the titer should decline fourfold in 6 months and become negative within
12 months.
Women who have a sustained fourfold increase in nontreponemal test titers have
failed treatment or have become reinfected
They should be retreated and evaluated for concurrent HIV infection. When
women are retreated the recommendation is three weekly injections of benzathine
penicillin G 2.4 million units IM.
For long-term follow-up the same serologic tests should be ordered. Optimally, the
test should be obtained from the same laboratory. The VDRL and RPR are equally
valid, but RPR titers tend to be slightly higher than VDRL titers.
With successful treatment the VDRL titer will become nonreactive or at most be
reactive with a lower titer within 1 year.
are con-sidered therapeutic failures. They should be treated once again
Patients with syphilis lasting longer than 1 year should have quantitative VDRL
titers for 2 years following therapy because their titers will decline more slowly.
In sum-mary, all women with a first attack of primary syphilis should have a
negative nonspecific serology within 1 year, and women treated for secondary
syphilis should have a negative serology within 2 years. If they are not, treatment
failure, reinfection, and concurrent HIV infection should be investigated
For the treatment for neurosyphilis, the CDC recommends aqueous crystalline
penicillin G 18 to 24 million units a day, administered as 3 to 4 million units IV
every 4 hours for 10 to 14 days.
An alternative regimen is procaine penicillin 2.4 million units IM a day, plus
probenecid 500 mg orally four times a day, for 10 to 14 days.
The duration of both of these regimens for neurosyphilis are shorter than that of
the regimen used for late syphilis in the absence of neurosyphilis. Therefore, some
experts administer benzathine penicillin, 2.4 million units IM, after completion of
either regimen to provide comparable total duration of therapy.
CDC's recommendation for treating early syphilis is the same for women whether
or not they are concurrently infected with HIV. Following penicillin treatment for
syphilis, women with HIV should be followed with quantitative titers at more
frequent intervals, for example 3, 6, 9, 12, and 24 months following therapy.
Centers for Disease Control

Control Recommended Treatment of Syphilis (2006)
Early Syphilis (primary, secondary, and early latent syphilis of less than 1 year's duration)
Recommended Regimen: benzathine penicillin G, 2.4 million units intramuscularly, one
dose
Alternative Regimen (Penicillin-Allergic Nonpregnant Patients): Doxycycline 100 mg
orally 2 times a day for 2 weeks

Lower Genital Tract
or tetracycline 500 mg orally 4 times a day for 2 weeks

Late Latent Syphilis (of more than 1 year's duration, gummas, and cardiovascular syphilis)
Recommended Regimen: benzathine penicillin G, 7.2 million units total, administered as 3
doses of 2.4 million units intramuscularly at 1-week intervals
Alternative Regimen (penicillin-allergic nonpregnant patients): doxycycline 100 mg orally
2 times a day for 2 weeks if < 1 year; otherwise, for 4 weeks
or tetracycline 500 mg orally 4 times a day for 2 weeks if < 1 year; otherwise, for 4 weeks
Neurosyphilis
Recommended Regimen: aqueous crystalline penicillin G, 1824 million units daily,
administered as 34 million units IV every 4 hours, for 1014 days
Alternative Regimen: Procaine penicillin 2.4 million units IM daily, for 1014 days plus
probenecid 500 mg PO 4 times a day for 1014 days
Syphilis in Pregnancy
Recommended Regimen: Penicillin regimen appropriate for stage of syphilis. Some experts
recommended additional therapy (e.g., a second dose of benzathine penicillin 2.4 million
units intramuscularly) 1 week after the initial dose, for those who have primary,
secondary, or early latent syphilis.
Alternative Regimen (penicillin allergy): Pregnant women with a history of penicillin
allergy should be skin tested and desensitized
Syphilis Among HIVHIV-Infected Patients
Primary and Secondary Syphilis: Recommended benzathine penicillin G 2.4 million units
IM. Some experts recommended additional treatments, such as 3 weekly doses of
benzathine penicillin G, as in late syphilis. Penicillin-allergic patients should be
desensitized and treated with penicillin.
Latent Syphilis (normal CSF examination): Benzathine penicillin G 7.2 million units as 3
weekly doses of 2.4 million units each

Most often serologic titers are higher than expected. However, false-negative
serologic tests or delayed appearance of seroreactivity has been reported.
Sexual partners of women with syphilis in any stage should be evaluated both
clinically and serologically
The time intervals used to identify an at-risk sex partner are 3 months plus duration of symptoms for primary syphilis, 3 months plus dura-tion of symptoms for
secondary syphilis, and 1 year for early latent syphilis.
Individuals who are exposed within the 90 days preceding the diagnosis of primary,
secondary, or early latent syphilis in their sexual partners should be treated
presumptively because they may be infected even if seronegative
Infections of the Vagina

Vagina

normal pH: 4.0

normal flora: Lactobacillus vaginalis
normal secretions: white, floccular or curdy, and odorless
Table 2222-8 -- Bacterial Vaginal Flora among Asymptomatic Women Without Vaginitis
Organism
Range of Recovery (%)
Facultative Organisms
Gram-positive rods
Lactobacilli
5075
Diphtheroids
40
Gram-positive cocci
Syphilis often involves the CNS. The diagnosis is complicated, and there is no
established diagnostic test that is a gold standard for neurosyphilis. All women with
suspected neurosyphilis should be tested for HIV infection.
The diagnosis of neurosyphilis is made on a combination of clinical findings,
reactive serologic tests, and abnormalities of cerebrospinal fluid, serology, cell
count, or protein. Infection of the CNS by spirochetes may occur during any stage
of syphilis
Women should undergo a cerebral spinal fluid examination if they develop
neurologic or ophthalmologic signs or symptoms, evidence of active tertiary
syphilis, treatment failures, and HIV infection with late latent syphilis or syphilis of
an unknown duration
It is important for all women with syphilis to be tested for HIV infection.
Simultaneous syphilis and HIV infection alters the natural history of syphilis, with
earlier involvement of the CNS.
Page | 15
Staphylococcus epidemidis
4055
Staphylococcus aureus
05
Beta-hemolytic streptococci 20
Group D streptococci
3555
Gram-negative organisms
Escherichia coli
1030
Klebsiella sp.
10
Other organisms
210
Anaerobic
Anaerobic Organisms
Peptococcus sp.
565

Lower Genital Tract
Organism
Range of Recovery (%)
Peptostreptococcus spp.
2535
Bacteroides spp
2040
Bacteroides fragilis
515
Fusobacterium sp.
525
Clostridium sp.
520
Eubacterium sp.
535
Veillonella sp.
1030
Vaginitis
vaginal discharge is the most common symptom in gynecology
associated symptoms of vaginal infection include:
superficial dyspareunia
dysuria
odor
vulvar burning and pruritus
three common infections of the vagina are produced by:
1. fungus (candidiasis)
2. protozoon (Trichomonas)
3. synergistic bacterial infection (bacterial vaginosis)
Histology
there is an absence of inflammation in bi-opsies of the vagina, thus the term
vaginosis rather than vaginitis
Clinical Features
associated with upper tract infections, including endometritis, pelvic inflammatory
disease, postoperative vaginal cuff cellulitis, and multiple complications of infection
during pregnancy, such as preterm rupture of the membranes and
endomyometritis, and decreased success with in vitro fertilization and increased
pregnancy loss of less than 20 weeks' gestation
most frequent symptom is an unpleasant vaginal odor, which patients describe as
musty or fishy
the odor is often sensed following intercourse, when the alkaline semen results in a
release of aromatic amines
vaginal discharge: thin, frothy and gray-white
the consistency of the discharge is similar to a thin paste made from flour
examination reveals that the discharge is mildly adherent to the vaginal walls
Diagnosis
classic findings on wet smear are clumps of bacteria and clue cells, which are
vaginal epithelial cells with clusters of bacteria adherent to their external surfaces
leukocytes are not nearly as frequent as epithelial cells underneath the microscope
four criteria for the diagnosis of bacterial vaginosis:
1.
2.
3.
I. Bacterial Vaginosis
bacterial vaginosis reflects a shift in vaginal flora from lactobacilli-dominant to
mixed flora, including genital microplasmas, G. vaginalis, and anaerobes, such as
peptostreptococci, and Prevotella and Mobiluncus species
most prevalent cause of symptomatic vaginitis
Etiology
no causative agent has been identified
because of the inability to find a transmissible agent, bacterial vaginosis has not
been classified as an STD
risk factors for bacterial vaginosis include new or multiple sexual partners
also prevalent in women who have sex with women
other risk factors:
douching (at least monthly or within 7 days)
social stressors
lack of hydrogen peroxide-producing lactobacilli is also a recognized risk factor for
bacterial vaginosis
Page | 16
homogeneous vaginal discharge is present

vaginal discharge has a pH equal to or greater than 4.5
vaginal discharge has an aminelike odor when mixed with potassium
hydroxide - whiff tests
4.
wet smear of the vaginal discharge demonstrates clue cells greater in

number than 20% of the number of the vaginal epithelial cells
three of the four criteria is sufficient for a presumptive diagnosis

Gram stain of vaginal secretion is an excellent diagnostic method

a colorimetric test that detects proline iminopepti-dase has been developed for
office use
enzyme levels in vaginal fluid are elevated in women with bacterial vaginosis
positive test may be obtained with either bacterial vaginosis or
Trichomonas infection
it is usually more prominent with bacterial infections because of the
amount of anaerobic metabolism
the common aromatic amines are cadaverine and putrescine, both of
which result from anaerobic metabolism
vaginal bacterial culture has no role in the evaluation of bacterial vaginosis

Lower Genital Tract
Treatment
there are no effective means of replacing lactobacilli
treatment for bacterial vaginosis is to decrease anaerobes with antibiotic therapy
and hope the patient will then regenerate her own lactobacilli
Clindamycin is the only single-does therapeutic agent with equivalent efficacy to
multiple-dose regimens
recurrent bacterial vaginosis (three or more episodes in the previous year) is a
common clinical problem
concurrent treatment of the male partner is not recommended at this time
II. Trichomonas Vaginalis Infection
Etiology
Trichomonas vaginalis is a unicellular intracellular parasite that is sexually
transmitted and inhabits the vagina and lower urinary tract, especially Skene's
ducts in the female
Trichomonas vaginal infection is the cause of acute vaginitis
T. vaginalis infection is a highly contagious STD
the incubation period for Trichomonas infection is 4 to 28 days
Trichomonas is a hardy organism and will survive for up to 24 hours on a wet towel
and up to 6 hours on a moist surface
Trichomoniasis is caused by the anaerobic, flagellated protozoon, Trichomonas

vaginalis
T. vaginalis is a unicellular protozoon that is normally fusiform in shape
this organism exists only in the trophozoite form or vegetative cell
it is slightly larger than a white blood cell
three to five flagella extend from one end of the organism
the flagella provide the active movement of the protozoon, with the direction of
motion usually toward the end with the flagella
Trichomonas organism assumes a spherical shape in an acidic environment
motion is then restricted to waves of the undulating membrane of the protozoon
Clinical features
vaginitis from Trichomonas is a disease primarily of women in the reproductive
years
Trichomonas in their vaginal secretions are free of symptoms
the normal highly acidic vaginal environment is resistant to Trichomonas infection
Trichomonas produces a wide variety of patterns of vaginal infection
the primary symptom of Trichomonas vaginal infection is profuse vaginal discharge
the volume of discharge associated with symptomatic Trichomonas infection is the
most abundant of common vaginal infections
the discharge may be white, gray, yellow, or green
the classic discharge of Trichomonas infection has been termed frothy (with
bubbles) and often has an unpleasant odor
Page | 17

discharge is not diagnostic, because it may be seen also with bacterial vaginosis
associated with the acute vaginal discharge are erythema and edema of the vulva
and vagina
classic sign of a strawberry appearance of the upper vagina and cervix is RARE
skin involvement is limited to the vestibule and labia minora, which helps to
distinguish it from the more extensive vulvar involvement of Candida vulvovaginitis
often women with chronic infection have a malodorous discharge as their only
complaint
dysuria is a symptom in approximately one out of five women with symptomatic
Trichomonas infection
T. vaginalis is associated with upper genital tract infections, including infections
after delivery, surgery, abortion, pelvic inflammatory disease, preterm delivery,
infertility, and cervical dysplasia
Diagnosis
diagnosis is confirmed by examination of vaginal fluid mixed with physiologic
saline under the microscope
to optimally visualize Trichomonas organisms, it is best to use high power and
dampen the condenser to produce the greatest contrast
Trichomonads are best discovered in an area of the wet smear with relatively few
white blood cells
if the wet smear is fresh and warm, the organisms will exhibit forward motion
if the slide is cold, if the organisms are surrounded by white blood cells, or if the
saline is too hypertonic, the Trichomonas organisms will assume an ovoid
configuration and exhibit minimal motion
the wet smear usually contains a large number of inflammatory cells and many
vaginal epithelial cells
atrophic vaginitis the only other vaginitis with an abundance of white blood cells
the epithelial cells are normal in appearance and have distinct edges
culture for Trichomonas is rarely indicated
the vaginal pH associated with T. vaginalis is between 5.0 and 7.0
Treatment
the major side effects of metronidazole therapy to treat trichomoniasis include
nausea, vomiting, a metallic taste, and secondary Candida infections
nausea is the most frequent complication
metronidazole is safe in all trimesters of pregnancy
patients should be warned that metronidazole inhibits ethanol metabolism.
Therefore, they may experience a disulfiram-like reaction if the two drugs are used
concurrently
tinidazole has a longer half-life, advise patients to abstain from alcohol for 72 hours
the asymptomatic female who has Trichomonas identified in the lower genital
urinary tract definitely should be treated

Lower Genital Tract

extended follow-up studies have shown that one out of three asymptomatic females
will become symptomatic within 3 months
HIV acquisition is increased in women with Trichomonas infection
women with recurrence in most cases have either been reinfected or complied
poorly with therapy
treatment of the patient's partner is important and increases cure rates
oral metronidazole therapy is recommended for treatment of Trichomonas vaginitis
a single dose (2 g) of metronidazole or tinidazole oral therapy is recommended
Tinidazole is a second-generation nitroimidazole and has a longer half life of 24
hours
topical therapy for Trichomonas vaginitis is not recommended because it does not
eliminate disease reservoirs in Bartholin's and Skene's glands
III. Candida Vaginitis

Etiology
Candida vaginitis is produced by a ubiquitous, airborne, gram-positive fungus (
Candida albicans)
Candida species are part of the normal flora, being a commensal saprophytic
organism on the mucosal surface of the vagina
its prevalence in the rectum is three to four times greater and in the mouth two
times greater than in the vagina
Lactobacilli inhibit the growth of fungi in the vagina
following the traditional regimen of 10 to 14 days of oral broad-spectrum
antibiotics, the percentage of women who have vaginal colonization with Candida
increases threefold
C. albicans is responsible for most cases of vaginal fungal infections
Histology
organisms develop both filamentous (hyphae and pseudohyphae) and ovoid forms,
termed conidia, buds, or spores
C. glabrata does not produce filamentous forms
the filamentous forms of C. albicans have the ability to penetrate the mucosal
surface and become intertwined with the host cells
results in secondary hyperemia and limited lysis of tissue near the site of infection
Causes of overgrow of Candida
Hormonal factors
hormonal changes associated with both pregnancy and menstruation favor growth
of the fungus
the prevalence of Candida vaginitis increases throughout pregnancy, probably as a
result of the high estrogen levels
Depressed Cell mediated Immunity
women who take exogenous corticosteroids and women with AIDS often
experience recurrent Candida vulvovaginitis
Page | 18

altered local immune responses, such as hyper-IgE-mediated response to a small

amount of Candida antigen, may occur in women with recurrent vulvovaginal
candidians
some women with recurrent vulvovaginal candidians have tissue infiltration with
polymorphonuclear (PMN) leukocytes
this high density of PMNs correlates with symptomatology but does not result in
clearance of Candida
Antibiotic Use
broad-spectrum antibiotics, especially those that destroy lactobacilli (penicillin,
tetracycline, cephalosporins), are notorious for precipitating acute episodes of C.
albicans vaginitis
Other Predisposing Factors
women with diabetes mellitus, or even a low renal threshold for sugar, have a
higher incidence of vaginal and vulvar candidiasis
obesity and debilitating disease
Clinical features
predominant symptom is pruritus
depending on the degree of vulvar skin involvement, pruritus may be accompanied
by vulvar burning, external dysuria, and dyspareunia
the vaginal discharge is white or whitish gray, highly viscous, and described as
granular or floccular
it does not have an odor
the amount of discharge is highly variable
the vulvar signs include erythema, edema, and excoriation
with extensive skin involvement, pustules may extend beyond the line of erythema
during speculum examination a cottage cheese-type discharge is often visualized
with adherent clumps and plaques (thrush patches) attached to the walls of the
vagina
these clumps or raised plaques are usually white or yellow
the pH of the vagina associated with this infection is below 4.5. (in contrast to
bacterial vaginosis and Trichomonas vaginitis, which are associated with elevated
pH)
Diagnosis
diagnosis is established by obtaining a wet smear of vaginal secretion and mixing
this with 10% to 20% potassium hydroxide
the alkali rapidly lysis both red blood cells and inflammatory cells
active disease associated with filamentous forms, mycelia, or pseudohyphae, rather
than spores
a negative smear does not exclude Candida vulvovaginitis

Lower Genital Tract

the diagnosis can be established by culture with either Nickerson or Sabouraud

medium
these cultures will become positive in 24 to 72 hours
vaginal culture for Candida is particularly useful when a wet mount is negative for
hyphae, but the patients have symptoms and discharge or other signs suggestive of
vulvovaginal candidiasis on examination
fungal culture may also be useful in cases of women who have recently treated
themselves with an antifungal agents
a specimen should be cultured from women with recurrent vulvovaginal
candidians to ensure it is C. albicans because non-albicans Candida are often azoleresistant
Treatment
for treatment of vulvovaginal candidiasis, the CDC recommends placing the patient
into uncomplicated or complicated category to guide treatment.
multiple azole vaginal preparations are available for treatment, and a single oral
agent, fluconazole, is approved for treatment
in uncomplicated vulvovaginal candidiasis, topical antifungal agents are typically
used for 1 to 3 days, or a single oral dose of fluconazole
guides in choosing therapy
patient preference
response to prior therapy
cost

in complicated vaginitis, topical azoles are recommended for 7 to 14 days

in cases of recurrent vulvovaginitis, a vaginal fungal culture to determine species
and sensitivities is needed
Table 2222-9 -- Typical Features of Vaginitis

Condition
Bacterial
vaginosis[]
Findings on
Examination[*]
Increased
discharge
(white,
thin)
Thin, whitish
>4.5 Clue cells
gray
(>20%) shift in
homogeneous
flora
discharge,
sometimes frothy
Candidiasis
Page | 19
Increased
pH
Wet Mount
Amine odor
after adding
potassium
hydroxide to
wet mount
Thick, curdy
<4.5 Hyphae or
Comment
Greatly
decreased
lactobacilli
Greatly
increased cocci,
bacilli small
curved rods
Can be mixed
Symptoms
and Signs[*]
Findings on
Examination[*]
discharge
(white,
thick)[]
discharge
Pruritus
Vaginal
erythema
Dysuria
pH
Wet Mount
Comment
spores
infection with
bacterial
vaginosis, T.
vaginalis, or
both, and have
higher pH
Burning
Trichomoniasis[] Increased
discharge
(yellow,
frothy)
Yellow, frothy
>4.5 Motile
discharge with or
trichomonads
without vaginal
or cervical
erythema
Increased
odor
More symptoms
at higher
vaginal pH
Increased white
cells
Pruritus
Dysuria
Table 2222-10 -- Diagnostic Tests Available for Vaginitis
Test
Sensitivity Specificity
(%)
(%)
Comment
Bacterial Vaginosis
pH > 4.5
Symptoms
and Signs[*]
Increased
odor
Condition
Amsel's criteria
97
64
92
77
Nugent criteria
Pap smear
Must meet 3 of 4 clinical criteria (pH > 4.5,

thin watery discharge, >20% clue cells, positive
whiff test), but similar results achieved if 2 of
4 criteria met
Gram's stain morphology score (110) based on
lactobacilli and other morphotypes; a score of
13 indicates normal flora, and score of 710
bacterial vaginosis; high interobserver
reproducibility
49
93
Point-of-care
tests

Lower Genital Tract
Sensitivity Specificity
(%)
(%)
Comment
Test
QuickVue
Advance pH +
amines
89
96
Positive if pH >4.7
QuickVue
Advance G.
91
>95
Tests for proline iminopeptidase activity in

vaginal fluid; if used when pH >4.5, sensitivity
is 95% and specificity is 99%
90
<95
Tests for vaginal sialidase activity
Overall
50
97
Growth of 3
4+ on culture
85
Growth of 1+
on culture
23
vaginalis*
OSOM BV blue*
Candida
Wet mount
pH 4.5
C. albicans a commensal agent in 1520% of

women
Usual
Pap smear
25
72
4560
95
If symptoms present, pH may be elevated if

mixed infection with bacterial vaginosis or T.
vaginalis present
Trichomonas Vaginalis
Wet mount
8590
>95
pH > 4.5
56
50
Pap smear
92
61
83
98.8
Increased visibility of microorganisms with a

higher burden of infection
False positive rate of 8% for standard Pap test

and of 4% for liquid-based cytologic test
Point-of-care
tests
Cervicitis
an inflammatory process in the cervical epithelium and stroma
associated with trauma, inflammatory systemic disease, neoplasia, and infection
cervical infection can be ectocervicitis or endocervicitis
ectocervicitis can be viral (HSV) or from a severe vaginitis (e.g., strawberry cervix
associated with T. vaginalis infection) or C. albicans
the cervix is a potential reservoir for Neisseria gonorrhoeae, Chlamydia
trachomatis, herpes simplex virus, human papillomavirus, and Mycoplasma species
often, the patient is asymptomatic, even though the cervix is colonized with either
gonorrheal or chlamydial organisms
bacterial infection of the endocervix becomes a major reservoir for sexual and
perinatal transmission of pathogenic microorganisms
primary cervical infection may result in secondary ascending infections including
pelvic inflammatory disease and perinatal infections of the membranes, amniotic
fluid, and parametria
endocervicitis may be secondary to bacterial infection with either C. trachomatis or
Histopathology
characterized by a severe inflammatory reaction in the mucosa and submucosa
tissues are infiltrated with a large number of PMNs and monocytes, and
occasionally there is associated epithelial necrosis
Mucopurulent Cervicitis
the diagnosis of cervicitis continues to rely on symptoms, examination, and
microscopic evaluation
two simple, definitive, objective criteria to establish mucopurulent cervicitis:
1.
10 min required to perform tests for T.

vaginalis antigens
gross visualization of yellow mucopurulent material on a white cotton

swab
2.
Infections of the Cervix
Page | 20
acts as a barrier between the abundant bacterial flora of the vagina and the
bacteriologically sterile endometrial cavity and oviducts
cervical mucus exerts a definite bacteriostatic effect
it may act as a competitive inhibitor with bacteria for receptors on the
endocervical epithelial cells
contains antibodies and inflammatory cells that are active against various
sexually transmitted organisms
N. gonorrhoeae
Culture
OSOM
Cervix
presence of 10 or more PMN leukocytes per microscopic field

(magnification 1000) on Gram-stained smears obtained from the
endocervix
clinical criteria
1. erythema and edema in an area of cervical ectopy
2. bleeding secondary to endocervical ulceration

Lower Genital Tract
3.

friability when the endocervical smear is obtained
women may also report increased vaginal discharge and intermenstrual vaginal
bleeding
symptoms that suggest cervical infection include:
vaginal discharge
deep dyspareunia
postcoital bleeding
physical sign of cervical infection:
hyperthrphy
edema
C. trachomatis is the cause of cervical infection in many women with
mucopurulent cervicitis
depending on geographic region, gonorrhea is also an important cause of
mucopurulent cervicitis
the presence of active herpes infection is correlated with ulceration of the
exocervix but not with mucopus
Treatment
when mucopurulent cervicitis is clinically diagnosed, empiric therapy for C.
trachomatis is recommended in women at increased risk of this common STD
(young age 25 years, new or multiple sex partners, unprotected sex)
concomitant trichomoniasis should also be treated if detected, as should bacterial
vaginosis
recommended regimens for for presumptive cervicitis therapy include
azithromycin 1 g orally in a single dose or doxycycline 100 mg orally twice daily
for 7 days
women treated for chlamydia should be instructed to abstain from sexual
intercourse for 7 days after single-dose therapy or until completion of the 7-day
regimen
Detection of Pathogenic Cervical Bacteria

screening of high-risk individuals is the primary way to control the disease

Gonorrheal NAAT are over 95% sensitive and specific
Recommended Regimens for Treatment of Chlamydial Infection
Recommended Regimens
Azithromycin 1 g PO in a single dose,
or
Doxycycline 100 mg PO bid for 7 days.
Alternative Regimens
Erythromycin base 500 mg PO qid for 7 days,
or
Erythromycin ethylsuccinate 800 mg PO qid for 7 days,
or
Ofloxacin 300 mg PO bid for 7 days.
From CDC 2006 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR
55:11.
Centers for Disease Control Recommended Treatment of Uncomplicated Gonococcal
Infections of the Cervix, Urethra, and Rectum in Adults (1997)
Recommended Regimens
Neisseria gonorrhoeae

Nucleic acid amplification testing (NAAT) of the urine or cervix is the most
sensitive and specific diagnostic tool for identifying gonorrheal infections
urine tests should be first void (either the first void in morning, or at least one
hour since last void)
to allow sensitive detection of DNA particles originating either from
either the urethra, or from the endocervix (which fall into the vaginal
pool and vestibule)
majority of colonized patients are asymptomatic
it is important to routinely screen women at high risk for gonorrheal
infection
Page | 21
Cefixime 400 mg PO in a single dose

or
Cefriaxone 125 mg IM in a single dose
or

Lower Genital Tract
Ciprofloxacin 500 mg PO in a single dose,

or
Ofloxacin 400 mg PO in a single dose or levofloxacin 250 mg PO in a single dose
plus
ofloxacin
if the woman is asymptomatic, follow-up testing is no longer recommended

women with positive cultures for gonorrhea should have a serologic test for syphilis
in 4 to 6 weeks, even though patients with incubating syphilis are usually cured by
antibiotic combinations of ceftriaxone and tetracycline. Similarly, patients should
be offered informed consent and testing for HIV infection.
It is important to remember . gonorrhoeae attaches to columnar epithelium, so a
vaginal cuff swab in women with prior hysterectomies is not recommended
Azithromycin 1 g PO in a single dose,
Chlamydia trachomatis
or
Doxycycline 100 mg PO bid for 7 days
unless C. trachomatis is ruled out

Alternative Regimens
1.
Spectinomycin 2 g IM in a single dose
2.
Injectable cephalosporins such as ceftizoxime 500 mg IM, cefotaxime 500 mg IM,

cefoxitin 2 g IM with probenecid 1 g PO, all as a single dose.
Cefpodoxime 400 mg PO
3.
Other quinolones such as gafifloxin 400 mg PO, lomefloxacin 400 mg PO, or

norfloxacin 800 mg PO, all as a single dose

From 2006 CDC treatment guidelines.

it is important to know quinolone resistance patterns in one's geographic region

these changes are based on the increasing trends of the development of antibioticresistant N. gonorrhoeae, including fluoroquinolones-resistant N. gonorrhoeae, and
strains with chromosomally mediated resistance to multiple antibiotics, including
penicillin and spectinomycin
two considerations in choosing an antibiotic:
single-dose efficacy
simultaneously treating coexisting chlamydial infection.
C. trachomatis has been frequently found to simultaneously colonize women with
gonorrhea
The present recommended parenteral regimen is ceftriaxone, 125 mg IM one time
other drugs:
cefixime
cefpodoxime
ciprofloxacin
Page | 22
the gold standard of techniques used to identify C. trachomatis infection is NAAT.

C. trachomatis also attaches to columnar epithelium
vaginal specimens should not be collected in a women who had a hysterectomy
because C. trachomatis is an obligatory intracellular organism
if a culture is used for diagnosis, it is mandatory to obtain epithelial cells to
maximize the percentage of positive cultures
a Dacron, rayon, or calcium alginate swab is placed in the endocervical canal
it is rotated for 15 to 20 seconds to gently abrade the columnar epithelium
C. trachomatis infection is frequently asymptomatic
CDC recommends annual screening of all sexually active women 25 years of age or
younger, and screening of older women with risk factors (e.g., those who have a
new sex partner or multiple partners).
For all women with either chlamydial or gonorrheal infections, partners should be
treated
patients should be instructed to refer all sex partners of the last 60 days for
evaluation and treatment and to avoid sexual intercourse until therapy is completed
and they and their partners have resolution of symptoms
if a patient is unsure if her partner will get treated, delivery of antibiotic therapy
(either by prescription or medication) is an option
TOXIC SHOCK SYNDROME

is an acute, febrile illness produced by a bacterial exotoxin, with a fulminating
downhill course involving dysfunction of multiple organ systems
cardinal features: abrupt onset and the rapidity with which the clinical signs and
symptoms may present and progress
it is not unusual for the syndrome to develop from a site of bacterial colonization
rather than from an infection
a woman with TSS may develop rapid onset of hypotension associated with multiorgan system failure
agent: Staphylococcus aureus
TSS may be a sequela of focal staphylococcal infection of the skin and subcutaneous
tissue, often following a surgical procedure

Lower Genital Tract

TSS related to a surgical wound occurs early in the postoperative course, usually
within the first 48 hours
three requirements for the development of classical TSS:
1. must be colonized or infected with S. aureus
2. the bacteria must produce TSS toxin-1 (TSST-1) or related toxins
3. the toxins must have a route of entry into the systemic circulation
if an individual woman signs and symptoms of TSS are produced by the exotoxin
named toxin-1
it is simple protein with a molecular weight of 22,000
accepted as the underlying cause of the disease
toxins act as superantigens
molecules that activate up to 20% of T cells at once, resulting in massive
cytokine production
superantigens do not require processing by antigen-presenting cells
the primary primary effects of toxin-1 are to produce increased vascular
permeability and thus profuse leaking of fluid (capillary leak) from the
intravascular compartment into the interstitial space and associated profound loss
of vasomotor tone, resulting in decreased peripheral resistance
because of the severity of the disease, gynecologists should have a high index of
suspicion for TSS in a woman who has an unexplained fever and a rash during or
immediately following her menstrual period
the syndrome has a wide range of symptoms
the varying degree of severity of both symptoms and signs depends on the
magnitude of involvement of individual organs
most women experience a prodromal flulike illness for the first 24 hours
between days 2 and 4 of the menstrual period, the patient experiences an abrupt
onset of a high temperature associated with headache, myalgia, sore throat,
vomiting, diarrhea, a generalized skin rash, and often hypotension
it is important to consider that not all women with TSS experience the full-blown
manifestations of the disease
skin changes is the most characteristic manifestations of TSS
during the first 48 hours the skin rash appears similar to an intense
sunburn
during the next few days the erythema will become more macular and
look like a drug-related rash
from days 12 to 15 of the illness, there is a fine, flaky, desquamation of
skin over the face and trunk with sloughing of the entire skin thickness of
the palms and soles
the vaginal mucosa is hyperemic during the initial phase of the syndrome
during pelvic examination, patients complain of tenderness of the
external genitalia and vagina
myalgia, vomiting, and diarrhea are experienced by more than 90% of women with
TSS (see the following box on case definition of toxic shock syndrome)
Page | 23
differential diagnosis include:

Rocky Mountain spotted fever
streptococcal scarlet fever
leptospirosis.
management of a classic case of severe TSS demands an intensive care unit and the
skills of an expert in critical care medicine
the first priority is to eliminate the hypotension produced by the exotoxin
copious amounts of intravenous fluids are given while pressure and
volume dynamics are monitored with a pulmonary artery catheter
mechanical ventilation is required for women who develop adult
respiratory distress syndrome
Case Definition of Toxic Shock Syndrome
1.
Fever (temperature 38.9C, 102F)
2.
Rash characterized by diffuse macular erythroderma
3.
Desquamation occurring 12 weeks after onset of illness (in survivors)
4.
Hypotension (systolic blood pressure 90 mm Hg in adults) or orthostatic

syncope
5.
Involvement of three or more of the following organ systems:

a.
Gastrointestinal (vomiting or diarrhea at onset of illness)
b.
Muscular (myalgia or creatine phosphokinase level twice normal)
c.
Mucous membrane (vaginal, oropharyngeal, or conjunctival

hyperemia)
d.
Renal (BUN or creatinine level twice normal or 5 WBC/HPF in

absence of UTI)
e.
Hepatic (total bilirubin, SGOT, or SGPT twice normal level)
f.
Hematologic (platelets 100,000/mm3)
g.
Central nervous system (disorientation or alterations in consciousness

without focal neurologic signs when fever and hypotension absent)
h.
Cardiopulmonary (adult respiratory distress syndrome, pulmonary

edema, new onset of second- or third-degree heart block, myocarditis)
6.
Negative throat and cerebrospinal fluid cultures (a positive blood culture for
staphylococcus aureus does not exclude a case)
7.
Negative serologic tests for Rocky Mountain spotted fever, leptospirosis, rubeola

Lower Genital Tract

when the patient is initially admitted to the hospital, it is important to obtain

cervical, vaginal, and blood cultures for S. aureus
although there is no controlled series documenting its efficacy, it is prudent to
wash out the vagina with saline or dilute iodine solution to diminish the amount of
exotoxin that may be absorbed into the systemic circulation.
Women with TSS should be treated with clindamycin 600 mg IV every 8 hours
plus nafcillin or oxacillin 2 g IV every 4 hours, and most experts recommend a 1- to
2-week course of therapy with an antistaphyloccocal agent such as clindamycin or
dicloxacillin even in the absence of positive S. aureus culture. If the diagnosis is
questionable, it is best to include the use of an aminoglycoside to obtain coverage
for possible gram-negative sepsis
antibiotic therapy probably has little effect on the course of an individual episode
of TSS
however, if the underlying cause of toxic shock syndrome is a skin
infection, the infected site should be drained and dbrided
Prothrombin time > 12 seconds

Present in > 70% of patients
Platelet count < 150,000/mm3
Pyuria > 5 WBCs/HPF
Proteinuria 2
(BUN) > 20 mg/dL
Aspartate aminotransferase (formerly SGOT) > 41 U/L
the treatment of TSS depends on the severity of involvement of individual organ

systems
not all patients develop a temperature of greater than 38.9 C and hypotension
Laboratory Abnormalities in Early Toxic Shock Syndrome[*]
Present in > 85% of patients

Coagulase-positive staphylococci in cervix or vagina
Immature and mature polymorphonuclear cells > 90% of WBCs
Total lymphocyte count < 650/mm3
Total serum protein level < 5.6 mg/dL
Serum albumin level < 3.1 g/dL

it is possible to decrease the incidence of TSS by a change in use of catamenial

products
women should encouraged to change tampons every 4 to 6 hours
the intermittent use of external pads is also good preventive medicine
Other causes of TSS:

there are cases of streptococcal toxic shocklike syndrome that are secondary to lifethreatening infections with group A streptococcus (Streptococcus pyogenes)
M-type 1 and 3 are the two most common serotypes of exotoxin found in group A
Streptocoocus
in gynecology, the majority of these cases involve massive subcutaneous
postoperative infections
one of the most distinguishing characteristics of a necrotizing skin infection is the
intense localized pain in the involved area
elderly women and women who are diabetic or immunocompromised are at much
greater risk to develop invasive streptococcal infection and streptococcal toxic
shocklike syndrome
mortality rate is approximately 30% when TSS is secondary to group A
streptococcal infections
Serum calcium level < 7.8 mg/dL

KEY POINTS
Serum creatinine clearance > 1.0 mg/dL
The three most prevalent primary viral infections of the skin of the vulva are
genital herpes, condyloma acuminatum, and molluscum contagiosum.
Acute bacterial cystitis is characterized by abrupt onset and multiple symptoms,

including dysuria, urgency, and frequent voiding. Suprapubic tenderness is a
specific sign for acute bacterial cystitis; however, it is not present in the majority
Serum bilirubin value > 1.5 mg/dL

Serum cholesterol level 120 mg/dL
Page | 24

Lower Genital Tract
of patients.
The differential diagnosis of dysuria in adult women includes acute cystitis, acute
urethritis, or vulvovaginitis.
Condyloma acuminatum presents as a clinically recog-nizable macroscopic lesion

in 30% of infected women and as a subclinical infection in 70% of women.
The most frequent pathogens involved in uncomplicated lower UTI are

Escherichia coli (approximately 80%) and Staphylococcus saprophyticus
(approximately 5% to 15%).
Condyloma acuminatum is an STD spread by skin-to-skin contact. It is caused by

the human papillomavirus (HPV). Autoinoculation also occurs. It is a highly
contagious disease.
Vaginal condylomata are identified in approximately one of three women with

vulvar disease.
No present therapy of HPV eliminates subclinical infection from the surrounding

epithelium.
For the first episode of acute, uncomplicated cystitis the current treatment of
choice is 3 days of oral therapy with TMP-SMZ, trimethoprim alone, or one of the
quinolones such as ciprofloxacin or norfloxacin.
More than 90% of recurrences in young women are exogenous reinfection with
new isolates arising from local flora.
HPV vaccine against types 6 and 11 can prevent 90% of condylomata when
administered to HPV-nave females
A normal Bartholin's gland cannot be palpated. Approximately 2% of adult

women develop enlargement of both Bartholin's glands.
Genital herpes is a recurrent, incurable STD. Approximately 80% of the

individuals are unaware they are infected.
The treatment of choice for a symptomatic Bartholin's cyst or abscess is the

development of a fistulous tract from the dilated Bartholin's duct to the vestibule.
Excision of Bartholin's duct and gland is indicated for persistent deep infection,
multiple recurrences of abscesses, or enlargement of the gland in a woman older
than 40. Removal of a Bartholin's gland for recurrent infection should be
performed when the infection is quiescent.
Genital herpes is most frequently transmitted by individuals who are

asymptomatic and unaware that they have the infection at the time of
transmission.
From a clinical standpoint the important difference be-tween HSV-1 and HSV-2
is that the frequency of recurrence is four times greater following a primary
infection with HSV-2 than with HSV-1.
The primary infection by herpes is both a local and a systemic disease. The
majority of symptomatic women have severe vulvar pain, tenderness, and
inguinal adenopathy. However, subclinical primary herpes infection is common.
Oral medication effective against HSV has been shown to be beneficial in

reducing the duration of herpetic ulcerative lesions and in reducing the time that
the virus can be isolated from these lesions.
Patients with frequent episodes of recurrent genital herpes may be successfully

treated with prophylactic oral medication. The primary goals of continuous
suppressive therapy are to limit the severity and number of occurrences as well as
to give the woman a sense of control over her disease. In discordant couples
suppressive therapy also decreases acquisition of HSV in the seronegative partner.
Granuloma inguinale, also known as donovanosis, is a chronic, ulcerative,

bacterial infection of the skin and subcutaneous tissue of the vulva.
Granuloma inguinale may be managed by a wide range of oral broad-spectrum

antibiotics.
Lymphogranuloma venereum (LGV) is an STD produced by serotypes L1, L2, and

L3 of C. trachomatis.
Pediculosis pubis, an infestation by the crab louse Phthirus pubis, is characterized

by constant itching, predominantly vulvar involvement, and the finding of eggs
and lice by visual inspection. It may be treated by topical application of 1%
permethrin cream rinse (Nix) or 1% lindane shampoo (Kwell).
Scabies, an infection by the itch mite Sarcoptes scabiei, is characterized by

intermittent pruritus, most commonly in the hands, wrists, breasts, vulva, and
buttocks. It is diagnosed by a scraping of the papules, vesicles, or burrows in
which the mites live and inspection under the microscope. It may be treated by
topical application of 5% permethrin cream (Nix) or 1% lindane lotion or 30 g of
cream.
Permethrin is more expensive than lindane, and permethrin has less potential for
toxicity in the event of inappropriate use. Seizures have been reported when
lindane was applied immediately after a bath or in women with extensive
dermatitis. Lindane is not recommended during pregnancy or for lactating women
or children younger than 2.
Molluscum contagiosum in adults is an asymptomatic viral disease primarily of
the vulvar skin. It is a common generalized skin disease in adults with
immunodeficiency, especially HIV infection.
Page | 25

Lower Genital Tract
The treatment for LGV is oral doxycycline, 100 mg twice a day for 3 weeks. An
alternative regimen is erythromycin base 500 mg every 6 hours for 3 weeks.
Chancroid is a sexually transmitted, acute, ulcerative dis-ease of the vulva. The

soft chancre of chancroid is always painful and tender. In comparison, the hard
chancre of syphilis is usually asymptomatic.
represent approximately 25% each.
The normal vaginal environment is a dynamic and delicate ecosystem, with a pH

of approximately 4.0 in premenopausal women.
A vaginal pH of greater than 5.0 indicates atrophic vaginitis, bacterial vaginosis,

or Trichomonas infection, whereas a vaginal pH of less than 4.5 in a symptomatic
woman is characteristic of either a physiologic discharge or fungal infection.
Bacterial vaginosis results when high concentrations of anaerobic bacteria replace

the normal H2O2-producing Lactobacillus species in the vagina. Histologically,
there is an absence of inflammation in biopsies of the vagina.
The classic criteria for the diagnosis of bacterial vaginosis are (1) a homogeneous
vaginal discharge is present; (2) the vaginal discharge has a pH equal to or greater
than 4.5; (3) the vaginal discharge has an aminelike odor when mixed with
potassium hydroxide; and (4) a wet smear of the vaginal discharge demonstrates
clue cells greater in number than 20% of the number of the vaginal epithelial
cells.
Ironically, 50% of women who have three of the four clinical criteria for bacterial
vaginosis are asymptomatic.
HIV acquisition is increased in women with bacterial vaginosis and Trachomatis

vaginalis infection.
Trichomonas vaginal infection is the most prevalent non-viral, nonchlamydial

STD of women. Trichomonas is the causal factor for approximately one in four
Syphilis is a chronic complex systemic disease produced by the spirochete
Treponema pallidum.
Early syphilis is a cofactor in the transmission and acquisition of HIV.
Dark-field microscopy rather than normal light microscopy is used for detection
of syphilis because of the extreme thinness of the spirochete Treponema pallidum.
Quantitative nontreponemal antibody titers usually correlate with the activity of

syphilis.
Nonspecific tests for syphilis, the VDRL and RPR, have a 1% false-positive rate.
Many conditions produce biologic false-positive results, including a recent febrile
illness, pregnancy, immunization, chronic active hepatitis, malaria, sarcoidosis,
intravenous drug use, and autoimmune diseases such as lupus erythematosus or
rheumatoid arthritis. Therefore, specific tests such as the TPI, FTA-ABS, and
MHA-TP must be employed when a positive nonspecific test result is
encountered.
A woman with a positive reactive treponemal test usually will have this positive
reaction for her lifetime regardless of treatment or the activity of the disease.
The characteristic chancre of primary syphilis is a red, round ulcer with firm,
well-formed, raised edges, with a nonpurulent clean base and yellow-gray
exudate. During the first week of clinical disease, the woman develops regional
adenopathy that is nontender and firm.
episodes of infectious vaginitis.
T. vaginalis infection is a highly contagious STD. Following a single sexual

contact, at least two thirds of both male and female sexual partners become
infected.
A woman with syphilis is most infectious during the first 1 to 2 years of her
disease with decreasing infectivity thereafter.
Dysuria is a symptom in approximately one of five women with symptomatic

Trichomonas infection.
Tertiary syphilis develops in approximately 33% of patients who are not

appropriately treated during the primary, secondary, or latent phases of the
disease.
Concurrent HIV infection should be considered in patients with syphilis. It is

optimal for all women with syphilis to be tested for HIV infection.
The asymptomatic female who has Trichomonas identified in the lower female
genital urinary tract definitely should be treated. Extended follow-up studies have
shown that one in three asymptomatic females will become symptomatic within 3
months.
Candida vaginitis is produced by a ubiquitous, airborne, gram-positive fungus.

The vast majority of cases are caused by Candida albicans, with 5% to 20% of
vaginal fungal infections produced by C. glabrata or C. tropicalis.
Candida species are part of the normal flora of approxi-mately 25% of women,
being a commensal saprophytic organism on the mucosal surface of the vagina.
When the ecosystem of the vagina is disturbed, Candida becomes an opportunistic
Sexual partners of women with syphilis in any stage should be evaluated both
clinically and serologically.
In women in the reproductive age range, bacterial vaginosis represents

approximately 50% of vaginitis, and candidiasis and Trichomonas infection
Page | 26

Lower Genital Tract
pathogen.
Recurrent vulvovaginal candidiasis is defined as four or more episodes of

symptomatic lower tract infection within 12 months.
Toxic shock syndrome (TSS) is an acute, febrile illness, produced by a bacterial

exotoxin with a fulminating downhill course involving dysfunction of multiple
organ systems.
Menstrual associated TSS is decreasing. Severe postopera-tive infections by

Streptococcus pyogenes may produce a similar TSS.
Because of the severity of the disease, gynecologists should have a high index of
suspicion for TSS in a woman who has an unexplained fever and a rash during or
immediately following her menstrual period.
The initial rash of TSS over the first 48 hours is similar in appearance to an
intense sunburn. Over the next several days it evolves into a macular rash with
fine, flaky desquamation over the face and trunk, and sloughing of the entire skin
thickness over the palms and soles.
The differential diagnosis of TSS includes Rocky Mountain spotted fever,

streptococcal scarlet fever, and leptospirosis.
Bacterial infection of the endocervix becomes a major reservoir for sexual and
perinatal transmission of pathogenic microorganisms.
The most common site of Chlamydia infection in the female reproductive tract is
the columnar cells of the endocervix.
Symptoms that suggest cervical infection include vaginal discharge, deep

dyspareunia, and postcoital bleeding. Chlamydia trachomatis is the major
infective agent in women with mucopurulent cervicitis.
The majority of women who have lower reproductive tract infections by C.

trachomatis or N. gonorrhoeae do not have mucopurulent cervicitis. The corollary
is the majority of women who have mucopurulent cervicitis are not infected by C.
trachomatis or N. gonorrhoeae.
Routine dual therapy for gonococcal and chlamydial infections is indicated if the
woman has chlamydia and comes from a population in which the prevalence of
gonococcal infections is greater than 5%.
Many women harboring sexually transmitted pathogens in the cervix are

asymptomatic.
Nucleic acid amplification testing is the standard detection method for C.

trachomatis and N. gonorrhoeae. Urine testing requires a first void specimen.
Page | 27
N. gonorrhoeae Gram stain smears are positive for only 50% of women with
positive cultures. Culture of a second consecutive endocervical cotton swab will
increase detection of N. gonorrhoeae by approximately 7% to 10%.
If the woman is asymptomatic, follow-up cultures are no longer recommended by

the CDC as a test of cure for lower tract infections (uncomplicated gonorrhea).
mitsiko 05.26.10
edited by: Mike
3A

Lower Genital Tract

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Infections of the Lower Genital Tract

shock syndrome. It is a small protein with a molecular weight of

KEY TERMS AND DEFINITIONS

An enlarged and inflamed lymph node, particularly in the axilla or

Epithelial cells with clusters of bacteria adherent to their external

The nonpainful large, raised, flattened, grayish white lesions of

A technique used to identify the spirochetes of syphilis, Treponema

The pathognomonic clusters of dark-staining bacteria (bipolar in

A depression between groups of inflamed nodes producing a double

An infectious granuloma characteristic of late or tertiary syphilis.

This inflammatory condition is diagnosed by gross visualization of

The egg of the crab louse.

A false-negative VDRL or RPR caused by an excess of

Sexually Transmitted A term used to describe an infection acquired primarily through

A short catheter with an inflatable Foley balloon used to help

The gram-negative, nonmotile rod that causes granuloma

A test used clinically. The smell of vaginal discharge after the

Infection of the Vulva

The toxin involved in producing the signs and symptoms of toxic

Infections of the Lower

In postmenopausal women followed prospectively for 2 years, a history of six or

Escherichia coli, Usually Sometimes 102 to Abrupt

Vaginal discharge or odor,

Vulvovaginitis may be associated with external dysuria in contrast to a deeper

Infections of the Lower

Compared with the traditional 7 to 14 days of therapy, the advantages of 3-day

Possible modifications in lifestyle include discontinuing use of a diaphragm for

Enterococcus faecalis, Proteus mirabilis, Staphylococcus epidermidis, S. aureus,

Trimethoprim/sulfamethoxazole 160/180 mg q12h

Management of Recurrent Cystitis:

II. Infections of Bartholins Gland

Infections of the Lower

Bartholin's ducts are approximately 2 cm in length, and they open in a groove

Asymptomatic cysts in women younger than 40 do not need treatment.

Infections of the Lower

Infections of the Lower

Infections of the Lower

Table 2222-3 -- Genital HPV Types

Genital warts, LSIL, RRP Low (negligible)

16, 18, 31, 33, 35, 39

45, 51, 52, 56, 58, 59

61, 62, 67, 69, 70

Potential for Cancer

There is a wide range of therapeutic choices, including chemical, cautery, and

Treatment of Warts: PatientPatient-Administered

40, 42, 53, 54, 57, 66, 84 LSIL

Bid for 3 days, 4 days off up Daily and qhs, 3 times/week up to 16

Mild to moderate pain, local Mild to moderate local inflammation

MMWR 55(RR-11), 2006.

Infections of the Lower

Treatment of Warts: ProviderProvider-Administered

Weekly every 12 weeks (no Weekly

Pain, necrosis + blistering

MMWR 55(RR-11), 2006.

Papule or Papule, pustule, Papule

Herpes, granuloma inguinale (donovanosis), lymphogranuloma venereum,

VII. Genital Ulcers

Infections of the Lower

Infections of the Lower

CDC recommends that acyclovir or other suppressive drug should be discontinued

Antiviral Treatment for HSVHSV-Nonpregnant Patient

First clinical 1000 mg bid for 710 days