Infections of the

Lower Genital Tract

Rex M. Poblete MD, FPOGS

Dept. of Obstetrics and Gynecology
DLSU-HSI
 Normal Physiology and
Bacteriology of the Vagina
Vagina : non-keratinized stratified squamous
epithelium
: influenced by estrogen & progesterone

At BIRTH : colonized by anaerobes and

aerobic bacteria
- rich in glycogen due to influence of the
placenta and maternal hormones
 low pH ( 3.7 – 6.3 )
AFTER BIRTH : Decrease Estrogen
 lack of glycogen
 epithelium becomes thin & atrophic
 increased pH ( 6-8 )
 gram (+) coccobacilli predominates

PUBERTY : Increasing ovarian function

 increasing estrogen
 glycogen increase
 Lactobacilli predominate
 breakdown of glycogen to lactic acid
 decrease in pH (3.5 – 4.5 )
Physiologic Vaginal Secretions

Cervical mucus (Major Component)

+
Fluid Exudates
( Sebaceous, sweat, Bartholin’s and Skene’s gland )
+
Transudates / Exfoliates
( Vaginal Squamous Epithelium)
+
Metabolic Products ( Microflora )
 Normal Vaginal Discharge
Thin . Odorless , and Colorless
Defense Mechanism of Vagina :
1. Continuous discharge from the cervix
 helps “wash out” harmful substances

2. Normal Vaginal Flora (Lactobacillus)

 produce lactic acid  acidic pH  prevents growth of
harmful bacteria

3. Estrogen  keeps vaginal epithelium thick

and resistant to bacterial invasion
* children and menopausal pxs 
susceptible to infection due to low
estrogen levels
A Vaginal Discharge is
Abnormal If :

It irritates ( itchy or burning )

It is foul – smelling
Affecting your sexual partner ( causing irritation ,
itching , burning or rashes )
It causes dyspareunia (painful intercourse)
It stains your underwear
You consider it heavy or profuse
 Investigation of Vaginal
Discharge

Characteristic
Color , Texture , Viscosity , Odor
Associated Clinical Symptoms
Pruritus , Pain/Tenderness , Painful LN
Evaluation
Wet Mount , KOH , gram stain , Culture
Clinical Conditions
Vaginitis
Trichomonasis
Candidiasis
Bacterial Vaginosis

Ulcerative
Herpes Genitalis
Chancroid
Lymphogranuloma Venereum
Granuloma Inguinale

Proliferative
Molluscum contagiosum
Trichomoniasis

Caused by Trichomonas vaginalis

( flagellated
protozoa )
Sexually Transmitted
Can inhabit vagina and male
urethra
25 % of infected pxs are
asymptomatic
Clinical Features :
Thin , frothy , pale greenish or grayish
vaginal discharge
Foul rancid odor
Erythema and edema of vulva/vagina
Petechiae of cervix (“strawberry cervix”)

Diagnosis : Wet mount smear or Culture

* Pear-shaped motile protozoa with a
flagella
Thin , Frothy Discharge
Strawberry Cervix
Trichomonads
Trichomonads
Recommended Treatment :

Metronidazole 2 gms orally single dose

or
500 mg BID x 7 days

* Both partners have to be treated to

prevent re-infection
Candidiasis
Caused by a yeast : Candida albicans ,
C. glabrata , C. tropicalis
High-risk factors : Pregnancy
Diabetes
Oral Contraceptives
Antibiotic abuse
Normal inhabitant of the vagina
Opportunistic infection
Clinical Features :
Whitish to yellowish , thick , “cheese-like”
or “ curd-like” discharge
Vulvar pruritus, edema , or erythema
Dysuria
Dyspareunia
Vaginal pH : ~ 4.5

Diagnosis : KOH wet mount

* Identification of pseudo-hyphae and spores
of C. albicans
Others :
Nickerson’s / Sabouraud’s medium
Latex Agglutination Test ( for non-albicans sp.)
Thick , Cheese-like Discharge
Curd-like Discharge
Pseudohyphae
Pseudohyphae
Recommended Treatment :

Oral : Fluconazole 150 mg single dose

Intravaginal Agents : creams , ointments,

vaginal tablets or suppositories

Others :
Butoconazole
Clotrimazole
Miconazole
Nystatin
Tioconazole
Terconazole
 Bacterial Vaginosis
Formerly called non-specific vaginitis or
Gardnerella vaginitis

Presence of anaerobes : Bacteroides sp.

Peptococcus spp.
Sexually Transmitted
Clinical Features :
Profuse , thin , grayish , foul-smelling
discharge
+ KOH  release of amines 
“Fishy Odor”
Profuse, Thin Homogenous Discharge
Vulvovaginal itching and irritation (~ 20 %)

Diagnosis : Wet mount

“ Clue cells “ : epithelial cells with
numerous bacilli on the surface

Recommended Treatment :
Metronidazole 500 mg BID x 7 days
or
2 gm single dose

Clindamycin 300 mg BID x 7 days

Clue Cells
Clue Cells
Clue Cells
Condyloma Acuminata
Papillomatous “ cauliflower-like ” lesions on the
perianal area, vulva , vagina , or cervix
Caused by Human Papilloma Virus ( type 6 and 11 )
Often occur with Trichomonas and Bacterial
Vaginosis
Sexually Transmitted
Diagnosis is clinical
Paps smear : koilocytosis
Management :

Podophyllin 0.5% solution BID x 3 days

may be repeated after 4 days
for 4 cycles
Imiquimod cream 5% TID at bedtime
for 16 weeks
Cryotheraphy
Trichloroacetic acid 80-90%
Surgical removal
Laser surgery
Molluscum contagiosum
Benign epithelial proliferation
 raised nodules
 pearl-like or reddish shiny papules
Caused by : Poxvirus
Causes no systemic illness
Self-limiting
Common in children (trunk & extremities)
In adults  sexually transmitted
( genital area )
Immunocompromised pxs : severe lesions
may cause disfiguring scar
 Herpes Genitalis
Venereal disease caused by :
Herpes simplex type II (90% of cases)
and type I (10% of cases)

Primary infection : s/sxs appear within 3-7

days after exposure

May be asymptomatic
Lesions :

Clear vesicles
( labia, vulva, perineal area ,vagina and ectocervix )
↓
Vesicles rupture ( within 7 days )
↓
Ulcer formation
( shallow , painful with red borders )
↓
Secondary infection ( necrosis )
Diagnosis :

Usually done clinically +

Tsanck or Paps smear : Multinucleated giant
cells with nuclear inclusions

Others :
Direct Immunoflourescence of ulcer
scrapings
Viral culture
Multinucleated Giant Cell
Multinucleated Giant Cell
Recommended Treatment :
1st episode :
Valacyclovir 1 gm PO BID x 7 days

Episodic Recurrent Episode :

Valacyclovir 500 mg PO bID x 5 days

Daily Suppresive Therapy :

Valacyclovir 500 mg OD for 1 year
 Chancroid
Caused by : Hemophilus ducreyi bacillus ,
gm (-) rod in chain
More frequent in tropical / subtropical
countries
Clinical feature :
Painful suppurative ulcers with a grayish base
and foul odor
Lymphadenopathy
Inguinal Buboes ( pus-filled lymph node
 bulge  drain thru the skin )
Soft Chancre
Inguinal Buboe
Diagnosis : Clinical
Culture of H. ducreyi

Treatment :
Azithromycin 1 gm PO single dose
or
Ceftriaxone 250 mg IM single dose
or
Ciprofloxacin 500 mg PO x 3 days
or
Erythromycin base 500 mg PO QID x 7 days
Lymphogranuloma Venereum

Caused by Chlamydia trachomatis

Sexually transmitted
Affects males 20x more than females
Clinical feature :
Painless vulvovaginal ulcer
Adenitis
Inguinal buboes
Chronic progression 
ulceration
elephantiasis
sinus tract formation
rectovaginal fistula
abscesses
rectal strictures
Groove Sign
Rectal Stricture
Elephantiasis
Diagnosis :

Clinical + lab tests :

Biopsy and Culture of
Cyclohexamide treated tissues
Complement fixation
Direct Immunoflourescence for
antibodies
Enzyme Immuno-assay
Polymerase or Ligase Chain Reaction
Recommended Treatment :

Azithromycin 1 gm PO single dose

or
Doxyxcycline 100 mg BID x 7 days

Alternative Regimens :
Erythromycin base 500 mg PO QID x 7 days
or
Erythromycin ethylsuccinate 800 mg PO QID
x 7 days
or
Ofloxacin 300 mg PO QID x 7 days
Granuloma Inguinale
Caused by Calymmatobacterium granulomatis ,
gm (-) rod with bipolar staining

More common in African-Americans

Clinical Feature :
Painless , “ beefy red “ ulcers with
irregular borders
Inguinal lymphadenopathy
Pseudo-bubo formation (inguinal inflammation
but no lymphatic involvement)
Diagnosis :
Giemsa – Wright stain
Enlarged mononuclear cells with cytoplasmic
vacoules packed with bipolar-staining bacteria
( “ Safety pin ” appearance)

DONOVAN BODIES
(Pathognomonic)
Donovan Body
Recommended Treatment :
Trimethoprim-Sulfamethoxazole
80/400 mg BID x 3 weeks
or
Doxyxycline 100 mg BID x 3 weeks

Alternative Regimens :
Ciprofloxacin 750 mg BID x 3 weeks
or
Erythromycin base 500 mg QID x 3 weeks
End of Part I