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Female Genital System infection

Female Genital System infection. Vulva Inherent resistance to infection Fungicidal Proper apposition of introitus by of labia Vagina Close apposition of vaginal wall Well developed stratified squamous epithelium Vaginal flora Vaginal acidity. Natural defenses of genital tract. Contd.

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Female Genital System infection

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  1. Female Genital System infection

  2. Vulva Inherent resistance to infection Fungicidal Proper apposition of introitus by of labia Vagina Close apposition of vaginal wall Well developed stratified squamous epithelium Vaginal flora Vaginal acidity Natural defenses of genital tract

  3. Contd.. • Cervix • Functional closure of cervix • Thick mucus plug • Immune –abundance of plasma cell in sub epithelial layer and high concentration of cytotoxic T cell • Uterus • Periodic shedding of surface endometrium during menses • Tubes • Peristalsis movement

  4. Contents • Vulvovaginal infection • Cervicitis • Pelvic inflammatory disease (PID)

  5. Vulvitis Bartholinitis/Bartholin’s cyst Trichomonas vaginitis Candidiasis Bacterial vaginosis Atrophic vaginitis Section 1 Vulvovaginal infection

  6. Lactobacilli Self-cleaning Thicken vaginal epithelium Resistance↑ Result in large quantities of glycogen in epithelial cells Kill or inhibit pathogens Produce H2O2 Lactic acid production↑ Acidenvironment(3.5-4.0) Promote growth of normal vaginal flora

  7. Bartholinitis/Bartholin’s cyst

  8. Anatomy of Bartholin’s glands • Position: the base of each bulb • Opening • Secretion: viscid, clear and stringy

  9. Etiology Infection Congenital narrowing of duct Obstruction of main duct of bartholin Retention of secretions and cystic dilatation

  10. Clinical findings • Bartholinitis • Pain • Tenderness • Dyspareunia • Surrounding tissues become edematous and inflamed • Fluctuant, tender mass • Bartholin’s cyst • No system • Fluctuant mass can be palpable

  11. Clinical findings

  12. Treatment • Drain the abscess • Marsupialization for preservation of the gland function • Antibiotics (Ampicillin) in the early stage • Excision for recurrent cases or postmenopausal patient

  13. Trichomonas vaginitis

  14. Etiology • Trichomonad • A flagellate protozoan • Best living environment • Moist • Anaerobic • pH: 5.2-6.6

  15. Pathogenesis • The trichomonad lives on glycogen and iron of the host cell • Direct contact and damage of the target cell • Arose immune reaction resulting in inflammation

  16. Transmission • Sexual contact (70% male infection, asymptomatic carrier) • Nonsexual transmission • Iatrogenic • Contact-soap

  17. Clinical findings • latent period: 4-28 days • Asymptomatic: 25-50% • Symptoms • Main: Profuse vaginal discharge thin,creamy orslightly green in colour irritating and frothy.and pruritus ,inflamation of vulva. • Occasional: odor, pain, dyspareunia, dysuria, infertility. • Signs • Multiple small putate Strawberry spot on vagina and cervix. • Tiny, punctuate hemorrhages on the mucosa

  18. Characteristics of the vaginal discharge  • Profuse • Purulent • Gray to yellow color • Malodorous • Frothy Anaerobic glycolysis

  19. Diagnosis • Microscopic identification of trichomonad (60%-70%) Precautions for the examination • Avoid • Intercourse 1-2 days before examination • Washing and medication • Lubricant • Heat preservation • Culture for suspected cases Refractory case

  20. Treatment • Systemic therapy : Oral metronidazole • 2g single dose • 400mg, twice or 3 times a day, for 7 days • Side effect • Topical application (≤50%) • Effervescent tablets of metronidazole 200mg/day, 7-10 days • Acidify vagina with 1% lactic acid or 0.5% acetic acid

  21. Treatment • Criterion for cure: Negative finding in postmenstrual examination of vaginal discharge for three times • Failure rate: 5%-10% • Poor compliance • Repeated infection • To avoid repeated infection • Sterilize underwear, towels, etc • Treat the sexual partner • Metronidazole

  22. Candidiasis

  23. Etiology • Very common • About 1/3 of vaginitis cases are caused by fungal infection • About 75% of women develop candidiasis at least once in life • The etiologic agent is Candida • Candida albicans is responsible for 80-90% of VVC.

  24. Etiology • Candida albicans is an opportunistic pathogen • Suitable environment: acid (＜4.5), warm, and moist • Can be isolated from 10-20% Nonpregnant and 30% pregnant women (asymptomatic) • Treatment is not indicated unless symptoms are present

  25. Proper environment Pathogenesis Yeast spores (Asymptomatic parasitism) Two phases of candida albicans Result in inflammatory reaction Pseudohypha (Pathogenic) Penetrate vaginal epithelium for nutrients Release proteolytic enzymes and toxins etc

  26. Predisposing factors • Pregnancy • DM • Immunosuppressant • Broad-spectrum antibiotics: suppress the vaginal normal flora (esp. lactobacillus) • Others • Restrictive synthetic underwear • Obesity • Contraceptive medication

  27. Transmission • Endogenous infection (most often) Vagina, oral cavity, intestinal tract • Sexual contact • Contact fomites

  28. Clinical findings • Vulvovaginal pruritus (main) Usually intense, coincident with menses or intercourse • Vaginal discharge↑ white, thick, curd-like discharge, forming patches adhere to vaginal walls • Vulvar erythema • Systems may worse just prior to menses

  29. Diagnosis • Microscopic identification of candida albicans • Saline: 30-50% • 10% KOH: 70-80% • Gram’s stain: 80% • Culture: higher sensitivity and drug test • Measurement of pH value • pH<4.5 simple infection • pH>4.5 combined infection

  30. Treatment • Only for symptomatic patients. • Eliminate predisposing factors • Control DM • Discontinue complicating medications • Long-term, regular, multiple topical therapy • Treatment of sexual partner • Asymptomatic: No treatment • 15% should be treated

  31. Treatment • Topical application of antifungal agents • Miconazole • 200mg/day for 7days • 400mg/day for 3 days • Clotrimazole ( cream) • 150mg/day for 7 days • 150mg, twice a day for 3 days • 500mg single dose • Nystatin: 500,000 units/day for 10-14 days

  32. Treatment • Systemic medication: for cases who can’t be treated with topical application of antifungal drugs • Fluconazole: 150mg, single use. • Itraconazole • 200mg/day for 3-5 days • 400mg for 1 day divided in two doses • Ketoconazole: 200mg, once or twice/day until culture result is negative

  33. Points of note for treating VVC • Treatment should be followed-up with a premenstrual examination of vaginal discharge • Approximately 10% of cases will not respond to initial therapy→prolong treatment up to 14 days • Identify and eliminate predisposing factors • RVVC (5%)should be treated with oral therapy followed by prophylactic doses

  34. Bacterial Vaginosis

  35. Etiology • Imbalance of normal vaginal flora • Lactobacilli is decreased • Other bacteria are increased (anaerobic bacteria—Gardnerella) • Causative factors of the imbalance are unknown • Vaginal douching • Frequent sexual relationship

  36. Clinical findings • Systems • Asymptomatic: 10-40% • Mild pruritus or burning sensation • Increased vaginal discharge and fishy odor • Signs • Discharge: fishy, gray-white, homogenous, but not sticky • No inflammation

  37. Diagnosis • Identification of clue cells *together with 2 of the following 3 items • Vaginal discharge: homogenous, thin and white • pH>4.5: in virtually all cases (5.0-5.5) • Positive Whiff test (with 10% KOH)

  38. Clinical pictures • Clue cells: Desquamated epithelial cells covered with clumps of coccobacili especially Gardnerella vaginalis→ gives the cells a speckled appearance

  39. Treatment • Antibiotics • Systemic therapy (oral) • Metronidazole: 400mg, 2-3 times a day for 7d • Clindamycin : 300mg, twice a day for 7d • Topical therapy • Effervescent tablets of metronidazole: 200mg/day, for 7-10 days • 2% Clindamycin cream, once a day for 7 days

  40. Criteria for cure • Absence of clue cells with at least 1 of the following items • Normal vaginal discharge • pH≤4.5 • Whiff test

  41. Points of note for treating BV • Systemic or topical treatment has the same cure rate (80%). • Patients who are asymptomatic, but scheduled to have a gynecologic surgical procedure should be treated. • Patients who are pregnant can be treated with oral metronidazole. • Follow-up examination should be given after the treatment (postmenstrual)

  42. Differential diagnosis of vaginitis

  43. Atrophic vaginitis

  44. Etiology • Ovarian function decreaseE • Vaginal mucosa is thin • PH of vagina is abnormal high → Normally acidogenic flora are replaced by mixed flora • Vaginal epithelium is more susceptible to infection and trauma

  45. Clinical findings • Symptoms • Vaginal discharge↑ • Vulvar itching • Dyspareunia • Signs • Vaginal mucosa is thin ,vaginal folds are few or absent • Spotting hemorrhage

  46. Treatment • Intravaginal application of E cream • 1/3 of vaginal E is systemically absorbed • Contraindication: women with a history of breast or endometrial cancer • E tablet intravaginally daily for two weeks twice per week for at least 3-6 months • Intravaginal antibiotics

  47. Cervicitis Section2

  48. General consideration • In direct contact with vagina • Common: 50% women of reproductive age • May lead to pelvic infection • Need to identify a venereal disease and differentiate from malignancies • Classification

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