LOWER FEMALE

GENITAL
TRACT
INFECTIONS
Defence Mechanism Against Ascent of
Infection (Natural Barrier)
 Vulva:
 Apocrine glands: modified sweat glands → fungicidal
acid
 Apposition of labia closes introitus
 Vagina:
 Apposition of anterior and posterior walls
 Stratified squamous epithelium resistant to infection
 Vaginal acidity
 Flora: the G+ve Doderlein’s bacilli splits glycogen into
lactic acid
 Cervix: closed by bacteriolytic cervical mucus
 Uterus: Periodic endometrial shedding during
menstruation eliminates any infection
 Variations in The Efficacy
of Defence Mechanism
 With Age:
During childhood and after the menopause
 Estrogen deficiency →  glycogen and Doderlein
bacilli → absent vaginal acidity.
 Endometrium poorly developed or atrophic and
does not undergo cyclic shedding.
 With menstruation:
 Absent cervical mucus plug
 Lowered vaginal acidity by alkaline menstruation.
 Variations in The Efficacy
of Defence Mechanism
 During the puerperium:
 Uterus, cervix & vagina widely opened
 Vaginal acidity neutralized by alkaline lochia

 Raw placental site

 Lacerations

 Low general resistance

 VAGINITIS
PRIMARY VAGINITIS
 During childhood: Vulvovaginitis of children

 During the reproductive period:

 Trichomonas infection
 Monilia infection
 Bacterial vaginosis
 Puerperal infection
 Others; Gonococcal, T.B. syphilis, bilharziasis
 Post menopausal: Senile vaginitis
 VAGINITIS
SECONDARY VAGINITIS
 Spread from

 Urinary conditions: Vesico-vaginal fistula

 Rectal conditions: Recto-vaginal fistula

and complete perineal tear
 Mechanical irritation (pessary or tampon)

 Chemical irritation (drugs and douches)

 BACTERIAL VAGINOSIS
(Non-specific Vaginitis, Gardnerella Vaginitis)
 Incidence:
 The most common cause of vaginitis

 12-25%

 32-64% of women in clinics for

STDs.
 Organism:
 Alternation of normal flora; decrease
lactobacilli and increase Gardnerella
and anaerobes.
 Mode of infection:
 Sexual transmission
Clinical Picture:
 Symptoms:
 50% may be asymptomatic

 Discharge: thin excessive greyish

frothy malodorous
 Pruritis
 Signs:
 Characteristic discharge and
vulvovaginitis
Investigations:
 Fresh drop:
 Clue cells; vaginal epithelium with
obscured borders due to attachment
of the organism
 Culture:
 Casman’s agar
 Blood agar at 10% CO2
 Gram stain:
 gram -ve rods, absent lactobacilli
 Whiff test:
 Discharge + 10% KOH → fishy
odour
Diagnosis:

 Amsel’s criteria: (3 of the following criteria)

 Thin homogeneous discharge on examination.
 pH of discharge > 4.5.
 Whiff test: vaginal discharge + 10% KOH → "amine-
like" or "fishy" odor.
 Clue cells on microscopy,
 Gram-stained vaginal smear
 Culture of vaginal secretions has no place in the
diagnosis of BV.
Treatment:
 A) Intravaginal preparations;
Clindamycin cream 2% at bed time for 7 days
Metronidazole once daily for 5 days
 B) Oral regimens:

Metronidazole as a single 2 gm dose

Clindamycin 300 mg twice daily for 7 days
 C) Sexual partner should be treated if infection is recurrent

 D) During pregnancy;
Clindamycin may be used throughout pregnancy
Metronidazole may be used after the first trimester
Trichomonas Vaginitis
 the 3rd most common cause for
vaginitis
 Organism: Trichomonas vaginalis,
 ovoid, motile, flagellated protozoon,

 4 anterior flagellae and an axostyle,

 20mm in length and 10mm in width

 flourishes in weak acid medium pH

5.5-6.5.
Trichomonas Vaginitis
 Sites of infection:
 Vagina, urethra, Skene’s tubules, bladder and
cervix
 Mode of infection:
 Sexual intercourse
 Contaminated towels and instruments
Trichomonas Vaginitis
 Clinical picture: Incubation period 3-28 days
 Symptoms:
 Often manifests after menstruation; vaginal pH is raised
 Profuse yellowish, frothy malodorous vaginal discharge
 Pruritis vulvae
 Vaginal soreness
 Dysparunia and dysuria
 Signs:
 Vulvitis (redness, hotness, oedema)
 Vagina: red, oedematous, tender with punctate
haemorrhage (strawberry vagina)
 Cervix: Strawberry like, sometimes eccentric erosion
 The characteristic discharge (forthy, yellowish,
maloderous…….. etc)
Trichomonas Vaginitis
 Investigations:
 Fresh smear: Shows the organism and
leucocytes
 Stained film: Giemsa stain

 Culture on Finberg-Whittington media

Trichomonas Vaginitis
 Treatment:
 Metronidazole tablets (Flagyl):
500 mg/12 h for 10 days OR
2 gm single dose
 Protozole and Tinedazole:
2 gm single dose
 Clotrimazole, vaginal pessaries used during
pregnancy and lactation in stead of
metronidazole.
 The husband should be treated at the same
time
Monilia Vaginitis (Candidiasis)
 Organism:
 Candida albicans causes 90% of cases.
 C. tropicalis and C. glabrata cause 10% of cases.
 Flourishes in acidic media.
 Incidence:
 The second most common cause of vaginitis.
 Mode of infections:
 May be present in the vagina and flourish
 with predisposing factors  vaginal acidity
 or suppression of other vaginal flora.
 Sexual intercourse.
Predisposing factors:
 Antibiotics →  the lactobacilli that  Candida
growth
 Oral contraceptives → glycogen
 Pregnancy high oestrogen level → glycogen
 Steroids and immunosuppressives lower
immunity
 Male partner infection
 Diabetes → glycogen deposition and low
immunity
 Lack of proper hygiene
Clinical Picture:
 Symptoms:
 Discharge: thick, scanty, white, curd-like, adherent
 Burning sensation in the vaginal
 Itching and scratching sensation on the vulva.
 Dyspareunia and dysuria
 Signs:
 Vulvitis: redness, oedema, itching marks
 Vaginitis: red, tender vaginal, with adherent plaques
 Characteristic discharge
Investigations:
 Fresh drop with added 10% KOH
 G+ve spores and long pseudohyphae on wet
preparation microscopic examination.
 Stained film with methylene blue
 Culture of Feinberg-Whittington media
Treatment:
 Vaginal Antifungal preparations
 Vaginal suppositories or intravaginal creams with special
applicator available as either a single dose, a 3-day course,
or a 7-day course
 Agents include clotrimazole, miconazole, and tioconazole
preparations

 Oral antifungal treatment

 Fluconazole; Single oral dose 150 mg, for treatment of
uncomplicated cases
 Ketoconazole; 200 mg twice a day for 5 days, for recurrent cases.
Treatment can be repeated on special schedules along a period of 3
-6 months, for chronic cases.
Vulvovaginitis of Children
 Microorganism:
 E. coli, Strept, Staph, gonococci, Candida, Trichomonas
 Predisposing factors:
 Foreign body (oxyuris)
 Decreased vaginal acidity
 Poor hygiene
 Mode of infection: Infected towels
 Clinical picture:
 Symptoms:
 Purulent, sometimes bloody, vaginal discharge,
 Itching, pain, sometimes dysuria
 Signs:
 Foul discharge, vulvitis, vaginitis
Vulvovaginitis of Children
 Investigations:
 U.S. ± X-ray to detect foreign body
 Investigations to detect oxyuris, culture and sensitivity of
discharge
 Treatment:
 Treatment of oxyuris,
 Removal of foreign body
 Systemic antibiotics
 Local cleanliness with diluted antiseptics
 Estrogen: Ethinyl estradiol 10 g/12 hours for 2 weeks,
followed by 10 g/day for another 2 weeks
Senile Vaginitis
 Organisms:
 Various cocci and gram-negative bacilli
 Clinical Picture:
 Symptoms:
 Purulent vaginal discharge sometimes spotting
 Pruritis: Dyspareunia
 Signs:
 Atrophy of vulva and vagina with areas of vaginal ulcerations
 Purulent (sometimes bloody) discharge
 Investigations:
 Exclude genital malignancy by Pap smear and fractional current
 Culture and sensitivity of the discharge
 Treatment:
 Antibiotics; ampicillin, cephalosporines,…… etc
 Topical estrogen cream and hormone replacement therapy
 Lactic acid 1% vaginal douches
Acute Cervicitis
 Acute inflammation of the endocervical
glands and underlying tissues.
 Cause:
 Gonococcal
 Chlamydial

 Puerperal

 Post-abortive

 Post-operative infection, after instrumentation or

cervical dilatations, cauterization or
trachelorraphy (i.e. repair of a lacerated cervix)
Clinical Picture:
 Symptoms:
 Mucopurulent discharge
 Mild fever
 Dyspareunia and backache
 Signs:
 The cervix is red swollen with mucopurulent discharge
 Marked tenderness on moving the cervix
 Investigations:
 Culture and sensitivity of the discharge
Acute Cervicitis
 Treatment:
 Antibiotics , according to organism (broad spectrum)

 Complications:
 Commonly turns chronic infection due to the
racemose nature of the cervical glands
 Secondary vaginitis

 Spread to:

upper genital tract

parametrium
urinary tract
Chronic Cervicitis
CLINICAL PICTURE:
 Symptoms
 Mucopurulent discharge

 Congestive dysmenorrhea and menorrhagia (pelvic

congestion)
 Backache (spread of infection along the uterosacral
ligament)
 Contact bleeding (cervical erosion)

 Dyspareunia (parametritis)

 Infertility (hostile cervical discharge)

 Frequency of micturition (cystitis)

 Manifestations of septic focus

Chronic Cervicitis
CLINICAL PICTURE:
 Signs by Speculum examination →
 Mucopurulent discharge coming out from the cervix
(Endocervicitis)
 Cervical erosion

 Mucous polypi: reddish pedunculated small (hyperplasia of

endocervical epithelium)
 Nabothian follicles: small blue or yellowish cysts projecting
on the portiovaginalis (distended blocked cervical glands)
 Swollen, hyperaemic cervix (Chronic hypertrophic
cervicitis)
 Ectropion: the anterior and posterior lips of the cervix are
everted due to bilateral cervical tears.
 Signs by Speculum examination →
 Mucopurulent discharge

 Mucous polypi:

 Nabothian follicles:

 Swollen, hyperaemic cervix

 Ectropion:
Chronic Cervicitis
 Investigations:
 Exclusion of malignancy
 Culture and sensitivity of the discharge.

 Treatment:
 Oral or vaginal Antibiotics
 Cervical Cauterization

 Trachelorraphy: to treat cervical tears

 Conization in suspicious lesions

Cervical Erosion (Ectopy)
 A bright red area around the external os due to
replacement of the stratified squamous epithelium of the
ectocervix with endocervical columnar epithelium, which
is thin and shows the underlying blood vessels.
 Etiology
 Chronic Cervicitis:
 Infected discharge produces denuded area around external os.
 Columnar epithelium grows from the cervical canal to cover the
denuded area
 Congenital erosion:
 Persistence of the intra-uterine condition where the columnar
epithelium covers an area on the ectocervix.
 Hormonal erosion:
 Excess estrogen causes the columnar epithelium to grow and
replace the stratified squamous epithelium
Clinical Picture:
 Symptoms:
 Mucous discharge
 Contact bleeding
 Symptoms of chronic cervicitis if present
 Signs:
 Vaginal examination: Velvety sensation and occasional contact
bleeding
 Speculum examination:
 Flat erosion: red area.
 Papillary erosion; raised folds.
 Follicular erosion; glandular distension
 Investigations: Vaginal and cervical smears exclude
malignancy
Treatment:
 Hormonal erosion: NO ttt except if the
case persists for more than three months.
 Antibiotics to treat associated infection.
 Cauterisation:
 The main line of treatment
 It opens and drains the infected glands and
coagulates the superficial epithelium over the
erosion
Methods Of Cauterisation
 Electrocautery
 Cryocautery (freezing)
 Laser Cauterisation
 Endcoagulation: Semm’s coagulator
 Chemical Cautery
Electrocautery
 No anaesthesia
 Cervix is exposed and cleaned by sodium
carbonate
 Using a red-hot electrode, 3 linear burns are
made on the anterior and posterior lips of the
cervix extending from the internal as to the edge
of the erosion.
 The depth of cauterisation is 2 mm.
 Vaginal discharge will increase for 10 days
 Squamous epithelium takes 4-6 weeks to cover
the cauterised area.
Electrocautery
Complications:
 Secondary haemorrhage:
 Due to sloughing
 About the 10th day

 Treated by packing, antibiotics

 Ascending infection and parametritis

 Cervical stenosis
Cryocautery (freezing):
 Using CO2 or nitrogen cylinder; a cone
shaped probe is applied on the external
os extending in the lower part of the
cervical canal.
 Application of the probe for 2 minutes to
-60˚C freezes the tissues to a depth of 2
mm leading to necrosis and separation
of these tissues.
 The healing after cryocautery is much
better than electrocautery; and the
complications are less.
Laser Cauterization
 Controlled destruction of the superficial
thin layer of tissues by vaporization of
cells.
 It gives excellent results but the instrument
is expensive and requires training.
Endcoagulation: Semm’s coagulator

 The probe is heated to 100°C causing

coagulation without excessive necrosis the
results are excellent but the instrument is
expensive.
Chemical Cautery:

 Using silver nitrate 20% (after protecting

the vagina with Ferguson speculum).
 It is an old method but can be used for
mild residual lesions