Lower Genital Tract Infections

1. Lower Genital Tract Infections NazilaKaramy-MD Obstetrics and Gynecology Specialist wwww.doctorkaramy.ir

2. عفونت هاي زنانه • قارچي • باكتري • انگلي

3. Case 1 • A 25 y married woman come with little non –malodor, white discharge without burning @pruritis ,LMP:2 weeks ago ? • Suggestive DX@ T??

4. “Normal” Vaginal Discharge? • Normal increase in cervical mucous production mid-cycle (ovulation)tht helpful for fertility, White or clear(not yellow or green), non- malodorous and not accompanied by irritative symptoms

5. Case 2 • 35 y female with 2 sexual partners complains of smelly discharge. The pelvic exam reveals no vulvar or vaginal inflammation,no burning; a foamy, thin discharge with pH of 5.0; and some bleeding at the cervix. Wet prep reveals 2 clue cells and no motile organisms. Your diagnosis?

6. Case 3 • Healthy 33 y Bad –smelling,Grey colour vaginal discharge. She is sexually active with 1 male partner. This is the first time she has had these symptoms and is worried it may represent a serious health problem. • What is ur suggestive DX??? • Do u suggest tratment of her partner??

7. Bacterial Vaginosis • Most common cause of vaginitis in premenopausal women • Represents in change vaginal flora • Decrease in lactobacilli • Increase in gardnerella vaginalis, mycoplasma hominis, anaerobic G- rods, and peptostreptococci

8. Bacterial Vaginosis

9. Clinical Features • 50% are asymptomatic • Unpleasant, “fishy smelling” discharge • No Itching and inflammation

10. Amstel Criteria grayish-whitish discharge • Vaginal pH > 4.5 • Positive Whiff test • Clue cells on wet mount

11. Clue Cells

12. Complications • Increases risk for: • Preterm labor in pregnant women • Endometritis and postpartum fever • Post-hysterectomy vaginal-cuff cellulitis • Postabortal infection

13. Therapy • May resolve spontaneously • Treat if: • Symptomatic • Asymptomatic prior hysterectomy, IUD placement,Pregnant and have history of PTL • No need to treat sexual partners

14. Therapy • Metronidazole • 500mg PO BID x 7 days or metro-gel 1 applicator full qd x 5d • Single dose therapy (2gm) but has higher relapse rate

15. Therapy • Clindamycin • Topical vaginal cream • As effective as metronidazole • Can use oral but less effective • Side effect::Pseudomembranous colitis in oral taking

16. case4 • A 19 Y not married woman come with cheesy discharge .she has HX of travel ,she took antibiotic for the sinusitis. • Suggestive DX????

17. Case 5 • A 23 y woman come with watery discharge ,pruritis ,burning tht exacerbate after cuitus tht had 2 days ago . • Suggestive DX???

18. Candida Vulvovaginitis • Up to 75% of premenopausal women have at least one episode • Rare before menarche@ postmenopausal women( unless taking estrogen)

19. Predisposing factors(Candida albicans) • Antibiotics • Diabetes mellitus • OCPs • Contraceptive devices (IUD, tampon) • Pregnancy

20. Clinical Features • Vulvar/vaginal pruritis • “Burning”,Irritation, soreness, dyspareunia • White, clumpy discharge,but sth watery like

21. CANDIDIA • pH 4- 4.5 (normal)

22. Therapy • Mostly improve with therapy within 2 days • Severe infections may require up to 14 days to improve

23. Therapy – “Azole” Antifungals • Imidazoles – effective against C. albicans:Miconazole, clotrimazol, all OTC • Triazoles – effective against C. albicans, and C. glabrata and tropicalis • fluconazole, ketoconazole

24. PREVENTION THERAPY • Taking @sitting yogurt full of lactobacillus • Taking alkalotic agent NaHco3 (not acidic agent as venegar ) • Forbid of humid ,warm condition(as tight underwear),dryness after washing forward to backward

25. CASE 6 • A 37 Y married woman come with malodor green colour discharge , • external dysuria ,dysparonia since yesterday . • Suggestive DX@T?? • Do u suggest tratment of partner???

26. Trichomoniasis • 3rd most common vaginitis • Nonaerobic,active Flagellated protozoan – trichomonas vaginalis • Elevated PH • Infects vagina, urethra and paraurethral glands • always sexually transmitted

27. Clinical Features • Ranges from asymptomatic to severe, acute inflammatory disease • Purulent, malodorous, thin, frothy discharge • Dysuria (external), dyspareunia and pruritis are common • “strawberry cervix”

28. Trichomoniasis

29. Therapy • Metronidazole 500 mg Bd till 7 days,2gm single dose • If refractory to treatment • treat with partner

30. CASE 7 • A 57 Y menopause woman come with a little wattery discharge ,external dysuria,dysparonia. • Suggestive DX@T??

31. Other Causes of Vaginitis • Atrophic vaginitis • High vaginal pH, thin epithelium • Topical estrogen cream

32. CASE 8 • A 26 y married woman come with aphtus itchy ulcer ,external dysuria bilateral inguinal lymphadenopathy tht had low grade fever ,headache ,LBP, from 3 days ago . • Suggestive DX???

33. Herpes Simplex Virus • HSV – 1 • Mostly oro-labial, but increasing cause of genital herpes • HSV – 2 • Almost entirely genital • > 95% of recurrent genital lesions • Primary infections • Recurrent infections

34. Case 9 • A pregnant woman G2L1 (NVD) term ,HX:HSV 2 one month ago but no ulcers exists now . • Wht is the root of delivery?

35. Transmission • Horizontal Transmission • Intimate sexual contact (oral/genital) • Vertical Transmission • Maternal-infant via infected cervico-vaginal secretions, blood or amniotic fluid

36. Primary Herpes – Classic Symptoms • Systemic – fever, myalgia, malaise • Can have meningitis, encephalitis, or hepatitis • Local – clusters of small, painful blisters that ulcerate and crust outside of mucous membranes • Itching, dysuria, vaginal discharge,bilateral inguinal adenopathy, bleeding from cervicitis

38. Diagnosis • Viral isolation (culture) • High specificity, low sensitivity • Direct detection of virus ( PCR) • Serology • Newer tests that are specific for type of virus ( IgG detect, ELISA)

39. Management Goals • Relieve symptoms • Heal lesions • Reduce frequency of recurrency@ viral transmission • Patient support and counseling

40. Oral Antiviral Therapy Acyclovir (Zovirax) Famciclovir (Famvir)(in resistant cases)

41. SUGGESTION • Because of transmission of virus even in remmission period Barrier(condom) suggested for the partner cos of stop transmission

42. CASE 10 • A 24 y Married woman come with a plaque ,multiple gray nodules with non smooth surface on external genitalia. • DX ,T???

43. HPV • Can convert SCC,esp in CX DUE TO Hpv type 16,18 • T:cryo ,cauter ,laser,5 FUO,medical (TCC,…),Podophylin • ONLY In codyloma acuminata =>do C/S(Due to risk of larynx papiloma)

44. CASE 11 • A 22 Y Woman ,multipartner,sexually active,BC:IUD ,In mense period,come with severe lower abdominal pain ,a lot of malodor discharge ,severe tenderness in exam • DX ,TREATMENT???

45. Pelvic Inflammatory Disease A Condition Requiring Closer Attention

46. What is PID ? • Inflammation of pelvic structures • Ascending spread of infection from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, &/ or adjoining structures =>>> salpingitis endometritis, parametritis, tubo-ovarian abscess & pelvic peritonitis

47. Presentation: Acute PID • Severe pain & tenderness lower abdomen • Fever, Malaise, vomiting, tachycardia • Offensive vaginal discharge • Irregular vaginal bleeding • Bilat adnexal tenderness • Tubo-ovarian mass

48. Presentation: Chronic PID • • Chronic lower abdominal pain, Backache • • General malaise & fatigue • • Deep dyspareunia, Dysmennorhea • • Intermittent offensive vaginal discharge • • Lower abdominal/ pelvic tenderness • • Bulky, tender uterus • Infertility due to adhesion

49. Predisposing Factors • • Frequent sexual encounters, many partners • • Young age, early age at first intercourse • • Relative ill-health & poor nutritional status. • • Previously infection (STD/ PID) • • Frequent vaginal douching

50. PID: Differential Diagnosis • Ectopic Pregnancy • Torsion/ Rupture adnexal mass • Appendicitis • Endometriosis • Cystitis/ pyelonephritis