IRENE MARIA ELENA

DEPARTEMEN KEBIDANAN & KANDUNGAN

FK UKRIDA

VAGINITIS

A syndrome of unknown cause characterized

by the decrease in the concentration of
lactobacilli and overgrowth of an anaerobic
organism associated with loss of vaginal
acidity

Gardnerella vaginalis 90 %
Gram negative rods 50-70%
Peptostreptococcus 30-60%
Mycoplasma hominis 60-75%
Mobiluncus sp 50%

SCHEMATIC
REPRESEENTATION
OF MICROBIAL
SHIFTS IN BV
Normal vaginal
secretions

Bacterial vaginosis

pH 4.0-4.4
104 CFU/ml
Lactobacilli
predominate

pH 4.7
Up to 1011 CFU/ml
Few lactobacilli
Abundant anaerobs
G.Vaginalis and
genital mycoplasmas

There are 2 approaches by which BV is

diagnosed :
1. Amsal criteria
2. Identification of the predominant
bacterial morphotypes on Grams stain (gold
standart)

Homogenous, milky or cream discharge

Presence of clue cells on microscopic
examination
pH secretion above 4.5
Fishy or amine odor without addition of 10%
KOH

(presence of the 3 of the following 4 criteria is

necessary for diagnosis)

Multiple sex partners

Woman having sex with woman
Lower socioeconomic status
IUD use
Uncircumcised sex partners
Smoking
Increased parity

Salpingitis
PID
Abortion
Prematurity
PROM
Chorioamnionitis
Postpartum and postoperative morbidity

Metronidazole 500mg orally 2x/day for 7 days

Metronidazole gel 0.75%, one full applicator
(5g) intravaginally, once a day for 5 days
Clindamycin cream, 2 %, one full applicator
(5g) intravaginally at bedtime for 7 days

Clindamycin 300mg orally 2x/day for 7 days

Clindamycin ovules 100g intravaginally once
at bedtime for 3 days
Tinidazole 2g orally once daily for 2 days
Tinidazole 1g orally once daily for 5 days

 Routine

treatment of
sex partners is not
recommended

Metronidazole 500mg orally 2x/day for 7 days

Metronidazole 250mg orally 3x/day for 7 days
Clindamycin 300mg orally 2x/day for 7 days

More than 100 candida species exits,

majority of which are dimorphic fungal
pathogen for humans
Risk factors : pregnancy, diabetes, antibiotic
or immunosuppressive therapy, oral
contraceptives

Candida
Candida
Candida
Candida
Candida

albicans 85%
glabrata
tropicalis
parapsilosis
krusie

Pruritus
Erythema
Edema
Excoriation
Tenderness
Discharge is thick, white, curdy and attached
on the vaginal walls
Vaginal pH is acidic (<4.5)

+ result wet mount with 10% KOH or normal

saline reveals the presence of mycelial phase
or pseudohyphae dx of fungla infection
Grams stain shoe pseudohyphae
Pap smear of cervical and vaginal secretions
- result wet mount vaginal cultures for
candida should be considered (in the absence
of symptoms or signs is not and indication for
treatment, because 10-20% of woman harbor
Candida sp)

Intravaginal agents:
Butoconazole 2% cr 5g for 3 days
Butoconazole 2% cr 5g (butoconazole1sustained release), single intravaginal
application
Clotrimazole 1% cr 5g for 7-14 days
Clotrimazole 2% cr 5g for 3 days

Miconazole 2% cr 5g for 7 days

Miconazole 4% cr 5g for 3 days
Miconazole 100mg vaginal supp, 1 supp for 7
days
Miconazole 200mg vaginal supp, 1 supp for 3
days
Miconazole 1200mg vaginal supp, 1 supp for 1
day

Nystatin 100,000 unit vaginal tablet, 1 tab

for 14 day
Tioconazole 6.5% ointment 5g in a single
application
Terconazole 0.4% cr 5g for 7 days
Terconazole 0.8% cr 5g for 3 days
Terconazole 80mg vaginal supp, 1 supp for 3
days

Oral agent:
Fluconazole 150mg oral tablet, one tablet in
single dose
Drugs with clinically important interactions
with oral fluconazole :
Astemizole, Ca channel antagonist, cisalpine,
warfarin, oral hypoglycemic agents,
phonation, protease inhibitors, tacrolimus,
terfenadine, theophylline, trimetrexate,
rifampicin

1st line is oral floconazole (100mg, 150mg,

200mg) weekly for 6 months
Alternative regimen is topical clotrimazole
200mg 2x/week, Clotrimazole (500mg dose
vaginal supp once weekly

STEP 1 : Eradication regimen

Fluconazole 150mg po on day 1,4, and 8 OR
intravaginal azoles for 10-14 days
STEP 2 : Prevention regimen for 3-6 months
Fluconazole 150mg po weekly OR
clotrimazole 200mg vaginally 2x/week OR
Clotrimazole 200mg vaginally 2x/week OR
Clotrimazole 500mg vaginally weekly

VVC is not sexually transmitted

Treatment of sex partner is not
recommended
Unless male sex partners manifest with
symptoms of balanitis treatment with
antifungal agents

 Only

topical azole
therapies, applied for
7 days

Trichomonas vaginalis is an anaerobic protozoan

parasites (fusiform in shape)caused of this
Hardy organism that can survive for up to 24
hours on a wet towel and up to 6 hours on a
moist surface
Resides in paraurethral glands
Incubation period : 4-28 days
The organism prefers an alkaline pH as max
growth and metabolic function occur at pH 6
It proliferates during menstruation and
frequently associated with leukocytosis
Trichomoniasis is a STI
Patients should be evaluated for other STI :
gonorrhea, chlamydial infection, syphilis, HIV

Frothy yellow copious discharge

Vaginal erythema
Strawberry cervix

Microscopic wet mount of vaginal secretions

obtained from anterior fornix
Pap smear
Culture (considered the best method)
modified Diamonds feinberg-whittington or
kupferberg
OSOM Trichomonas rapid test, an
immunochromatographic capillary flow
dipstick technology, Affirm VP III (a nucleic
acid probe test that evaluates for T.vaginalis,
G.vaginalis, C.albicans)

Recommended regimens
Metronidazole 2g orally in a single dose
Tinidazole 2g orally in a single dose
Alternative regimen
Metronidazole 500mg orally 2x/day for 7 days

Sex partner of patients should be treated and

instructed to avoid sex until both of them
are cure (when therapy has completed and
patient and partner(s) are asymptomatic)

Treatment might relieve symptoms of vaginal

discharge and might prevent respiratory or
genital infection of the newborn and further
sexual transmission
2g of metronidazole in a single dose

MUCOPURULENT
CERVICITIS

Caused by Neisseria gonorrhea which is a

gram-negative diplococcus
Non-pregnant : urethritis, cervicitis, PID
Infection during pregnancy is primary
concern Gonorrheal ophthalmia
neonatorum
Amniotic infection, PROM, chorioamnionitis,
prematurity, IUGR, neonatal sepsis,
postpartum endometritis

A short incubation time 3-5 days

Often asymptomatic
Most woman develop symptoms within 10
days of infection
Primary site of infections is : endocervix,
bartholins, skenes, periurethral, rectum,
and the pharynx may be involved

This characterized by a purulent or

mucopurulent endocervical exudation,
cervical bleeding, friability and ectopy,
increased in the number of leukocytes on
endocervical grams satin
Patients tested +GO should be screened for
chlamydia, syphilis, and HIV

Majority pregnant woman with infection are

asymptomatic; if symptomatic vaginal
discharge and dysuria are the two most
common presentation

The most common systemic complication of

GO is disseminated gonococcal infection
(DGI)
EARLY STAGE : migratory arthritis,
tenosynovitis, dermatitis
LATE STAGE : arthritis, perihepatitis,
endocarditis, meningitis, pericarditis,
osteomyelitis

Gram stain
Culture Thayer-martin medium (standard
means of diagnosis)
Nucleic acid hybridization test
Nucleic acid amplification test (NAAT)

CERVIX, URETHRA, AND RECTUM

Recommended regimen :
Ceftriaxone 250mg IM in a single dose
Cefixime 400mg in a single dose
Single injectable cephalosporin regimen
PLUS
Azithromycin 1g orally single dose
Doxycycline 100mg orally 2x/day for 7 days

Alternative regimen :
Spectinomycin 2g in a single dose IM
Cefpodoxime 400mg single dose
Cefuroxime axetil 1g single dose
PLUS
Treatment for chlamydia infection is not
ruled out

PHARYNGITIS
Recommended regimen :
Ceftriaxone 250mg IM in a single dose
PLUS
Azithromycine 1g orally in single dose
Doxycycline 100mg orally 2x/day for 7 days

DGI
Recommended regimen :
Ceftriaxone 1g IM or IV every 24h
Alternative regimen :
Ceftriaxone 1g IM every 8h
Cefotaxime 1g every 8h
Treatment should be continued for 24-48h after
improvement begins, and therapy may be
switched to Cefixime 400mg orally 2x/day to
complete 1 week of therapy

Sex partners whose last sex contact falls

within 60 days before onset of
symptoms/diagnosis should be evaluated and
treated for N.gonorrhoeae and C.trachomatis
infections
Sex partners whose last sex contact falls
beyond 60 days before onset of
symptoms/diagnosis should be treated
Avoid sexual intercourse until therapy is
completed and symptoms have resolved

Treated with cephalosporins

Woman who cannot tolerate cephalosporin :
Spectinomycin 2g IM single dose, if not
available Azithromycin 2g orally can be
considered

Chlamydia trachomatis
Incubation periods are relatively long (1-3
weeks)
It is an obligatory intracellular organism,
exits in 2 forms :
1. elemantary body infectious particle
2. reticulate body metabolically active
and reproductive form
15 serotypes
Is a major cause of mucopurulent cervicitis
(MPC)

Age sexually active adolesent most

important risk factor
Previous infection
Recent change partner, more than one
partner
Failure to use barrier contraceptives
Low socio economic status
History of other STD

Can be made by demonstrating the presence:

1. yellow or green mucus on a swab positive
swab test
2. >10 PMN leukocytes per oil immersion
field of gram stain of the endocervix
3. friability, erythema, or edema within zone
of cervical atopy; 30 PMNs per x 1,000 field
best correlates with chlamydial cervicitis

Cytology
Serology (anti-chlamydial antibody)
Culture
Antigen detection method (enzyme
immunoassay)
DNA probe (hybridization without
amplification)
Nucleic acid amplification tests (NAATs)
Hybridization with amplification of detection
signal

Relatively poor sensitivity compared to NAATs

even in very experienced lab
Cold-chain transport of specimen required
Expensive
Delay obtaining the result (3-7days)
Need for substantial technical experties

PID
Tubal factor infertility
Ectopic pregnancy
Chronic pelvic pain
Adverse pregnancy outcome
High risk for HIV infection
Neonatal infection

Recommended regimen :
Azithromycin 1g orally in SD
Doxycycline 100mg orally 2x/day for 7 days
Alternative regimen :
Erythromycin base 500mg orally 4x/day for 7
days
Erythromycin ethylsuccinate 800mg orally 4x/day
for 7 days
Ofloxacin 300mg orally 2x/day for 7 days
Levofloxacin 500mg orally once daily for 7 days

Recommended regimen :
Azithromycin 1g orally in SD
Amoxicillin 500mg orally 3x/day for 7 days
Alternatives regimen :
Erythromycin base 500mg orally 4x/day for 7
days
Erythromycin base 250mg orally 4x/day for 14
days
Erythromycin ethylsuccinate 800mg orally 4x/day
for 7 days
Erythromycin ethylsuccinate 400mg orally 4x/day
for 14 days

GENITAL ULCERS

 Chronic

infection usually involved the

mucous membrane
Treponema pallidum
Anaerobic,

elongated tightly woung spirochete

Dark field microscopy
Penetrate either the skin of mucous membrane
early

syphilis is a cofactor in the transmission

and acquisition of HIV
Incubation: 10 to 90 days, replicate every 30
to 36 hours
Contagious during primary, secondary and
probably the 1st year of the latent phase

 DIAGNOSIS
Serologic

test generally become positive 4 to 6

weeks after exposure
Nonspecific nontreponemal test: screening test
and index of response to treatment
VDRL
RPR

Specific
TPI

nontreponemal test

(Treponema immobilization test)

FTA-ABS (Fluorescent-labeled Treponema antibody
absorption)
MHA-TP (Microhemagglutination assay for antibodies
to T. pallidum)

PRIMARY SYPHILIS

Painless papule appear at the site of inoculation ulcerate

(CHANCRE) heal spontaneously within 3 to 8 weeks

SECONDARY SYPHILIS
Develops between 6 weeks after chancre
The cutaneous and mucousmembrane manisfestations :
macular, maculopapular, scaly lesions involving face,
torso&flexor aspect of extremities
Classic rash: red macules and papules over the palms of the
hands and soles of the feet
Systemic manifestations include generalized
lymphadenopathy, hepatitis, nephrosis, optic neuritis, uveitis,
meningitis, alopecia, periostitis
Genital lesions are called mucous patches and condyloma
latum, both of witch are moist and highly infectious and
easily diagnosed by darkfield exam
Serologic test positive
Heal spontaneously within 2-6weeks

 LATENT
After

SYPHILIS

2-3weeks
Diagnosis is made only by a reactive serologic
test
Early and late latent syphilis (WHO early lesst
than 2yr)
Late latent stage, patient has agreater risk
progressing to tertiary or neurosyphilis
This stage is not infectious by sexual
transmission, however the spirochetes may still
be transplacentally transmitted to the fetus at
any AOG

LATE or TERTIARY SYPHILIS

Characterized by the presence of gumma,
aortitis, meningovascular disease, paresis, optic
neuritis, argyll-robertson pupil and tabes dorsalis

NEUROSYPHILIS
No

single testing technique has been able to diagnose

All adults with latent syphilis be evaluated clinically
for aortitis, neurosyphilis, gumma, iritis (CDC
recommended)
Lumbar puncture for cerebrospinal fluid analysis
should be done in any patient with latent syphilis of
unknown or greater than 1 yr durationin specific
situatuons

CSF include cell count, quantitative protein

determination and VDRL test
CSF leukocyte count is elevated and greater
than 5 WBC/mm3
The WBC is also a sensitive measure of the
effectiveness of treatment

Darkfield microscopy and direct fluorescent

antibody tests (methods of choice for
diagnosing primary and secondary syphilis)
Nonspecific antibody (nontreponemal) can be
measured by the RPR & VDRL for screening
and following up on the response to therapy
Specific antibody (treponemal), MHA-TP and
FTA-ABS to confirm the infection following
a reactive RPR or VDRL

 TREATMENT
Primary,

Secondary and Early latent syphilis :

Benzathine Penicillin 2.4 million units IM SD or
Tetracycline 500mg 4x/day for 14 days or
Doxycycline 100mg twice a day for 14 days
Late latentand Tertiary syphilis : Benzathine
Penicillin G 2.4 million units IM weekly for 3
doses
NEUROSYPHILIS: 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
Alternative regimen : Procaine penicillin 2.4
million units IM once daily + Probenacid 500mg
orally 4x/day, both for 10-14 days

 Recurrent

and incurable
Transmission during asymptomatic shedding (2-3
weeks after vulvar lesions appear)
HSV-1
infect the epithelium above the waist
May cause lower genital tract infections

HSV

Infect the epithelium below the

Offer some protection to HSV-1

Occur

waist

in women aged 15-25

Incubation: 3 to 7 days
Resides in the dorsal root ganglia of S2, S3 and S4

Symptoms:
paresthesia

of the vulvar skin before skin papules

and vesicle formation
Multiple vesicles that became shallow ( 2-6
weeks) coalesce and heals spontaneously
without scarring
Vulvar pain, tenderness and inguinal adenopathy
Last approximately to 14 days

DIAGNOSIS
By

clinical inspection
Herpesvirus cultures ( 80% sensitivity; less useful
in recurrent episodes)
PCR (most accurate and sensitive technique)
Western blot assay (most specific method for
diagnosing recurrent herpes

TREATMENT
Primary episodes:
Duration

and severity of the symptoms is

lessened and shedding is shortened

Episodic episodes:
Shorten

the duration if started within 24 hours of

prodromal symptoms or lesion appearance

Daily suppression:
Recommended

when patient has 6 or more

episodes a year

VALACYCLOVIR

ACYCLOVIR

FAMCICLOVIR

Primary episodes

1000mg BID x 710 days

200mg 5x day or
400 mg TID for 710 days

250 mg TID for 710days

Recurrent
episodes

1000mg OD or
500mg BID for 5
days or 3 days

400mg TID for 5

125 mg BID for 5
days or 800mg BID days or 100mg BID
for 5 days or
for 1 day
800mg TID for 3
days

Daily suppressive
therapy

500mg OD (8
recurrences/yr)
or 1000mg OD or
250 BID (9
recurrences/yr)

400mg BID

250mg BID

Recurrence:
Less

severe symptoms than the primary infection

First recurrence happened 50% within 6 months
of the initial infection
On the average, women will have four
recurrences within 1 year

 Chronic

ulcerative, bacterial infection of the skin

and subcutaneous tissue of the vulva, rarely the
vagina and cervix
Calymmatobacterium granulomatis
Spread both sexual and nonsexual contact;
autoinoculation
Incubation: 1 to 12 weeks
Asymptomatic nodule skin over the nodules
ulcerate beefy-red ulcer with fresh
granulation tissue
Painless ulcers
No adenopathy except with infections
Vulvar edema due to lymphatic obstruction

DIAGNOSIS:
Donovan

bodies in smears which was taken from

the deep aspects of the ulcer crater and fresh
edge of expanding lesion
DONOVAN BODIES clusters of dark-staining
bacteria with bipolar (safety pin) appearance
found in cytoplasm of large mononuclear cells

TREATMENT
Doxycycline

100mg BID PO for a minimum of 3

weeks
Alternative: Azithromycin 1g PO per week for 3
weeks, Ciprofloxacin 750mg BID PO for a
minimum of 3 weeks
Or Erythromycin 500mg or TMP-SMZ one double
strenght tablet BID PO for a minimum of 3 weeks
Sexual partners should be examined if they had
sexual contact during the 60 days preceding the
onset of symptoms

Sexually transmitted acute ulcerative disease of the

vulva
Soft chancre is always painful and tender
Hemophilus ducreyi

Highly

contagious, small gram negative rod; non motile

facultative anaerobe; streptobacillary chains school of
fish
Tissue trauma and excoriation of the skin must precede
to penetrate and invade the normal skin

Incubation: 3 to 6 days
Small papule pustules (48 to 72 hours) ulcerates
Ulcers have dirty, gray necrotic, foul-smelling
exudate with no induration at the base
Bubo may develop

DIAGNOSIS:
Gram

stain
Culture of purulent material or by aspiration of
tender lymph nodes

TREATMENT
Azithromycin

1gm PO
OR Ceftriaxone 250mg IM
OR Ciprofloxacin 500mg BID for 3 days

Chlamydia trachomatis
Ratio to males to female (5:1)
Vulva is the most common site but the
cervix, urethra , rectum may also be
involved
Incubation: 3 to 30 days

PHASES

Primary

infection: shallow painless ulcer of the

vestibule or labia ulcers heals rapidly without
therapy
Secondary phase: begins 1 to 4 weeks after; Painful
adenopathy in the inguinal and perirectal areas
increasingly tender, enlarged, matted together
forming bubos
Groove sign: classic clinical sign; depression between
the groups of inflamed nodes
Tertiary Phase: within 7 to 15 days the bubo will
rupture spontaneously multiple draining sinuses
and fistulas

DIAGNOSIS:
Culture

of pus or aspirate from the tender lymph

node

TREATMENT:
Doxycycline

100mg BID for atleast 21 days

Alternative: Azithromycin 1gm PO once per week
for 3 weeks, Ciprofloxacin 750mg BID PO for
atleast 3 weeks
OR Erythromycin 500mg QID PO for 21 days
Fluctuant nodes should be aspirated to prevent
sinus formation

VIRAL INFECTION

Asymptomatic viral disease primarily of the

vulvar skin in adults
May present over the entire body in children
Common generalized skin disease in adults with
immunodeficiency especially HIV infection
Etiology: Poxvirus
Spread by close contact
Incubation period: several weeks to many
months
Many of the skin lesions result from
autoinoculation

Clinical presentation:
Small

nodules or domed papules, usually 1-5 mm

in diameter
water wart
Umbilicated center
(+) intracytoplasmic molluscum bodies with
Wrights or Giemsa stain
Major complication: bacterial superinfection

Treatment:
Self-limiting

infection
Treatment will decrease transmission and
autoinoculation of the virus
Caseous material is evacuated and nodule
excised with a sharp dermal curet
Base of the papule is subsequently chemically
treated with either ferric subsulfate (Monsels
solution) or 85% trichloroacetic acid OR
treated cryosurgery or electrocautery

Sexually transmitted disease of the vulva,

vagina and cervix
Etiologic agent: Human papillomavirus
Frequently discovered in women
concurrently with other sexually
transmitted disease
A.k.a. genital, venereal or anogenital
wart
Clinically recognizable macroscopic lesion
in 30% and subclinical in 70%

High risk: HPV 16 and 18

Benign: HPV 6 and 11
Incubation period: 1-8 months (M=3 months)
Incidence: between ages 15-25 y/o

Clinical presentation:
Occur

on moist skin
Pedunculated warts are friable and tend to
bleed following minor trauma
Initial lesions are pedunculated, soft papules
approx 2-3mm in diameter and 10-20mm long
May occur as a single papule or in clusters
Progresses by autoinoculation
Lesions vary from pinhead-sized papules to
large cauliflower-like masses

Clinical presentation:
Condylomata

in the cervix tend to be flat and

sometimes bleed on contact- discovered by
colposcopy
Subclinical HPV infection: discovered by
applying 3-5% acetic acid to the epithelium

HPV infected cells appear shiny white in color with the

area of infection having irregular borders and
sometimes satellite lesions

Clinical presentation:

Subclinical HPV
infection: discovered
by routine cytology

Koilocytosis( cells with

perinuclear halos)

Predisposition:
immunosuppression,
pregnancy, DM and local
trauma; vulvovaginitis

Management:
Topical

podophyllin resin as a 10-25% solution

with benzoic in alcohol- painted directly on the
lesion at weekly intervals for 4-6 weeks

Produce neuropathy, bone marrow

depression and fetal death when
absorbed systematically

Podofilox

0.5% solution- less caustic

Trichloroacetic acid- preferable for small vaginal
lesions

Management:
5-fluorouracil

Drawback: local irritation of the skin and vaginal

mucosa

Cryotherapy, electrocautery

lesions larger than 2-3 cm

or laser therapy- for

ECTOPARASITIC
INFECTIONS

Infestation by the crab louse, Phthirus

pubis
Generally confined to the hairy areas of the
vulva
MOT: direct sexual contact
Louse moves slowly
incubation period: 30 days

predominant clinical symptom is constant

itching in the pubic area, which is secondary
to allergic sensitization
3 stages in the louses life cycle:
Egg (nit)
Nymph
Adult- approximately 1mm long

Diagnosis:
Demonstration of eggs and adults lice in hair
shaft- pepper grain feces
Microscopy- miniature crab with 6 legs that
have claws
Treatment:
Permethrin cream 1%
Lindane

Parasitic infection of the itch mite,

Sarcoptes scabiei
MOT: direct sexual contact
Is a widespread infection over the body
without predilection for hairy areas,
involving the hand, wrists, breasts, vulva and
buttocks being most commonly involved

Adult itch mite is usually less than 0.5mm

long
Travels rapidly over the skin
Predominant clinical symptom is severe but
intermittent itching.
May present as papules, vesicles, or burrows
Pathognomonic sign: burrow in the skin

Diagnosis:
Visual inspection- papule, burrow in the
skin
Microscopy- mites lack legs but have 2
anterior triangular hairy buds
Treatment:
Permethrin cream 5%
Lindane 1%
antihistamines

THANK YOU