Gynaecological

Infections

Dr. Abdel-Fattah Salem

M.B.B.Ch., D.G.O., M.R.C.O.G., F.R.C.O.G.
 Outline of Lecture

1. Physiological vaginal discharge

2. Pathological vaginal discharge

3. Sexually transmitted diseases (STD)

4. Genital ulcers

5. Bartholinitis and abcess

6. Pelvic Inflammatory Disease (PID)

Physiological Vaginal Discharge
 Normal vaginal discharge
• Vaginal fluid is a transudate through the epithelium

• Vaginal discharge consists of;

- desquamated cells - Polymorphs
- lactobacilli

• Vaginal fluid is highly acidic due to lactic acid from lactobacilli

and glycogen from desquamated cells

• Contributions to the fluid come from;

- Cervical mucus - Skene’s glands
- Bartholin’s glands
Pathological Vaginal Discharge
Causes of pathological discharge
Candidiasis (Moniliasis)
Organisms
Candida albicans (90%)
Candida tropicalis (5%)
Candida globrata (5%)
Predisposing factors
• Immnuosuppresed host
- DM
- AIDS
- Corticosteroids
- Immunosuppressive medications

• Pregnancy

• Prolonged broad-spectrum antibiotic usage

Vaginal discharge
Whitish cottage cheese
discharge
pH ≤ 4.5
 Additional symptoms
• 20% asymptomatic

• Intense pruritus

• Swollen, inflamed genitals

• Vulval burring, dysuria, dyspareunia

Saline wetmount
KOH wetmount reveals hyphae
and spores
Treatment
- Suppositories and creams for 1, 3 or 7 day
treatments
- Symptomatic relief with douching, yogurt,
acidophilus
- Treatment in pregnancy is usually topical
- Fluconazol 150 mg PO in single dose
Bacterial vaginosis
Organisms
Gardenella vaginalis
Mycoplasma hominis
Others
Vaginal Discharge
Gray, thin, diffuse
Fishy odour
Absence of vaginal irritation
pH > 4.5
Saline wetmount
- Clue cells (sqamous epithelial cells dotted with
coccobacilli)
- Paucity of WBC
- Paucity of lactobacilli
- Positive whiff test (fishy odour with addition of
KOH to slide due to formation of amines
 Possible complications during
pregnancy

• Recurrent preterm labour

• Postpartum endometritis
Treatment
- Metronidazol 500mg PO BID × 7 days
OR metronidazol gel 0.75% × 5 days OD
- Routine treatment of partners is not
recommended
- Metronidazol can be used in pregnancy
Trichomoniasis
Organism
Trichomonas vaginalis, a flagellated
protozoan
Vaginal discharge
- Yellow-green
- Malodorous
- Diffuse
- pH > 4.5
- Petechiae on vagina and cervix
- Irritated tender vulva
- Dysuria, urinary frequency
Wetmount
- Motile flagellated
organisms
- Many WBC
- Inflammatory cells
Treatment
- 2 g PO single dose
OR 500 mg BID × 7 days
- Treat partners
- Symptomatic pregnant women
should be treated with 2 g once
Sexually transmitted diseases (STDs)
Microorganisms that can be
transmitted sexually
• Bacteria Chlamydia trachomatis
Neisseria gonorrhoeae
Gardnerella vaginalis
Treponema pallidum
Group B hemolytic streptococci
Haemophilus ducreyi
Calymmatobacterium granulomatis
Mycoplasma hominis
Ureaplasma urealyticum

• Parasites Sarcoptes scabiei

Phthirus pubis
Microorganisms that can be
transmitted sexually (continued)
• Viruses Herpes simplex
Papillomavirus
Molluscum contagiosum
Hepatitis B
Cytomegalovirus
HIV

• Protozoa Giardia lamblia

Trichomonas vaginalis

• Fungi Candida albicans

Chlamydia
Chlamydia trachomatis
- Most common bacterial STD in
North America
- Often associated with N.
Gonorrhaea
Predisposing factors
• Sexually active youth

• Multiple sexual partners

• Not using barrier contraception

• Contact with infected person

• History of previous STD

Clinical Features
• Asymptomatic (70%)

• Muco-purlent endocervical discharge

• Urethral syndrome ( dysuria, frequency, pyuria,

no bacteria)

• Pelvic pain

• Post-coital bleeding or intramenstrual bleeding

Investigations
- Cervical culture
- Nucleic acid amplification
- Obligate intracellular parasite-
tissue culture is the definitive
standard
Treatment
- Doxycycline 100 mg BID for 7 days
OR Azithromycin 1 g orally in a single dose
- Treat partners
- Screen;
- high risk groups
- during pregnancy
Complications
Gonorrhoea
Nisseria gonorrheae
Symptoms and risk factors same as with
chlamydia
Investigations
• Gram stain shows gram-negative intracellular
diplococci

• Cervical, rectal, and throat culture

OR OR
Treatment (continued)
• Add doxycyclin or azithromycin to treat for
concomitant chlamydial infection

• Treat partners

• If pregnant; use cephalosporin regimen or 2 g

spectinomycin IM (avoid quinolones)
AIDS
HIV
HIV is carried in body fluids such as;
- Semen
- Blood
- Vaginal fluid
Methods of spread
• Vaginal sexual intercourse
• Anal intercourse
• Sharing intravenous hypodermic needles with an
infected person
• Transfusions of infected blood
• Other activities that allow semen, blood, or
vaginal fluid to enter the mouth, anus, or vagina
or to touch an open cut or sore
• Vertical transmission
• HIV is not spread by kissing, shaking hands, or
sharing food, clothing, or toilets
CD4 and AIDS
• CD4 (cluster of differentiation 4) is a glycoprotein
expressed on the surface of T- helper cells, regulatory
T cells, monocytes, macrophages and dendritic cells

• CD4 is a primary receptor used by HIV-1 to gain entry

into host T cells

• CD4 tests measure the number of T cells containing

the CD4 receptor

• Patients often undergo treatments when the CD4

count reaches a low point, around 200 cells per
microliter
Genital ulcers
EPIDEMIOLOGY OF GENITAL ULCERS;

HSV 70-80%

Primary syphilis 5%

Chancroid < 5%
Herpes Simplex of the Vulva
Herpes simplex
- Herpes simplex virus type II
(genital) 90%
- Herpes simplex virus type I
(oral) 10%
Presents 2-21 days following contact
- Multiple, painful, shallow ulcerations with
small vesicles
- Lesions are infectious
- Appear 7-10 days after initial infection
- Inguinal lymphadenopathy
- Fever
- Dysuria and urinary retention if urethral
mucosa affected
- Maybe asymptomatic
Investigations
Viral culture
- Preferred in patients with ulcer
- Sensitivity decreases as ulcers
heal
Cytological smear
- Multinucleated giant cells
- Acidophilic intranuclear inclusion
bodies
HSV DNA PCR
Treatment
- First episode
Acyclovir 400 mg PO TID for 6-10 days
- Recurrent episodes
Acyclovir 400 mg PO TID for 5 days
- Daily suppressive therapy
Consider if 6-8 attacks per year
Acyclovir 400 mg PO BID
- Severe disease
Consider IV thearpy 5-10 mg/ kg/ IV q8h × 5-7 days
- Avoid contact from prodrome until lesions have
cleared
- Use barrier contraception
Syphilis
Treponema pallidum
Primary syphilis
- Painless chancre on vulva, vagina or
cervix
- Painless inguinal lymphadenopathy
- 3-4 weeks after exposure
- Serological tests usually negative
Secondary syphilis
- 2-6 months after initial exposure
- Can resolve spontaneously
- Generalized maculopapular rash on palms,
soles, trunk, limbs
- Nonspecific symptoms: headaches, diffuse
lymphadenopathy, anorexia
- Condylomata lata (anogenital, broad-based
fleshy gray lesions)
- Serological tests usually positive
Tertiary syphilis
- May involve any organ
- Neurological: tabes dorsalis, general
paresis
- Cardiovascular: aortic aneurysm, dilated
aortic root
- Gumma of the vulva: rare nodule that
enlarges, ulcerates and becomes necrotic
Congenital syphilis
May cause fetal anomalies, stillbirths or
neonatal death
Investigations
- Darkfield microscopy: most sensitive and
specific diagnostic test for syphilis
- Non-treponemal tests (VDRL, RPR)
screening tests: nonreactive after treatment
- Specific anti-treponemal antibody tests
(FTA-ABS, MHA-TP, TP-PA): confirmatory
tests, remain reactive for life (even after
treatment)
 Treatment
Treatment of primary, secondary,
latent syphilis of < 1 year
duration
- Bezathine penicillin G 2.4 million
units IM
- Treat partners
Treatment of latent syphilis > 1
year duration
- Bezathine penicillin G 2.4 million
units IM once per week × 3 weeks
Treatment of neurosyphillis
- IV aqueous penicillin
Chancroid
Aetiology: Haemophilus ducreyi

Clinical features: painful soft ulcer with or without

ulcer
tender regional lymphadenopathy

Investigations: gram-stain shows gram-negative

bacilli in rows

Treatment: erythromycin 500 mg qid for 7 days

Granuloma Inguinale (Donovanosis)
Aetiology: Calymmatobacterium granulomatis

Clinical features: - painless progressive ulcerative lesions

- regional lymphadenopathy

Investigations: Donovan bodies with Giemsa stain from

tissue biopsy

Treatment: Doxycycline 100 mg BID for 3 weeks

Lymphogranuloma venereum
Aetiology: Chlamydia trachomatis serotypes L-1, L-
2, L-3

Clinical features: - painless vulvovaginal ulcer

- rectal ulceration
- regional lymphadenopathy
Investigations: Frei test for antibodies to
chlamydia
Treatment: doxycycline 100 mg BID for 21 days
Bartholinitis and abcess
Aetiology
Often polymicrobial
Clinical features
• Swelling and pain in lower lateral opening of
vagina

• Sitting and walking may become difficult

Treatment
• Sitz bath
• Antibiotics and heat (rarely helpful)
• Incision and drainage with placement of latex
catheter for 2-3 weeks
• Marsupialisation is the more definitive
treatment
• Removing the gland is rarely indicated
Pelvic Inflammatory Disease (PID)
Introduction
• Definition: Inflamation of the upper genital
tract (above cervix) including endometrium,
fallopian tubes, pelvic peritoneum and
contagious structures

• Constitutes up to 20% of all gynaecological

hospital admissions
Aetiology
• Causitive orginisms in order of frequency;
- C.trachomatis
- N.gonorrhoea
- Endogenous flora (E.coli, staph, strep)
often associated with instrumentation
- Actinomyces israelii (gram positive, non
acid-fast anaerobe)
- Others (TB, gram-negative organisms,
CMV)
Risk factors
• Age < 30

• Risk factors of chlamydia

• Vaginal douching

• IUCD (especially first 10 days after insertion)

• Invasive gynaecological procedures (D&C,

endometrial biopsy)
Clinical features
• Asymptomatic
• Fever > 38.3 ⁰
• Lower abdominal pain and tenderness
• Abnormal vaginal discharge

• Chronic disease;
- constant pelvic pain
- dyspareunia
- palpable mass
Investigations
Bloodwork
- βhCG to rule out ectopic pregnancy
- CBC
- Blood culture id septicaemia is
suspected
Speculum examination
- Vaginal swab
- Gram stain
- Cervical culture for N.gonorrhoea,
C.trachimatis
- Endometrial biopsy
Ultrasound
- May be normal
- Fluid in cul-de-sac
- Pelvic or tubo-ovarian abcess
- Hydrosalpinx
Laparoscopy (gold standard)
Diagnosis
• Must have;
- lower abdominal pain
- cervical motion tenderness
- adnexal tenderness

• Plus one or more of the following;

- temperature > 38 ⁰
- leukocytosis
- cervical discharge
- elevated ESR or CRP
- positive culture
 Treatment
Inpatient if;
• Atypical infection
• Adnexal mass or abcess
• Moderate to severe illness
• Unable to tolerate oral AB
• Failed oral therapy
• Immunocompromised
• Pregnant
• PID is secondary to
instumentation
Outpatient if;
• Typical findings
• Mild to moderate illness
• Oral antibiotics tolerated
• Compliance ensured
• Follow-up within 72 hours
(to ensure symptoms are
not worsening)
Inpatient therapy
• Cefoxitin 2 g IV q6h + doxycycline 100mg IV q12h
• Continue IV antibiotics for at least 48 hours after
symptoms have resolved
• Percutanous drainage of abscess under U/S
guidance
• When no response to treatment; laparoscopic
drainage
• If failure; treatment is surgical (salpingectomy,
TAHBSO)
Outpatient therapy
• Ceftriaxone 250 mg IM OR ofloxacin 400 mg
BID for 14 days + doxycycline 100 mg PO BID
for 14 days ± metronidazol 500 mg BID for 14
days if abcess is suspected

• Remove IUCD after a minimum of 24 hours of

treatment

• Treat sexual partner

Complications of untreated PID
• Chronic pelvic pain
• Abscess, peritonitis
• Adhesion formation
• Ectopic pregnancy
• Infertility
• Bacteraemia
• Septic arthritis
• Endocarditis
Gardnerella vaginalis
A. Is a gram positive bacillus
B. Is associated with clue cells which are
bacteria attached to vaginal epithelial cells
C. Is associated with a vaginal pH between 3.8-
4.2
D. Can be cultured using stuart’s media
E. Provides a fishy odour when two drops of 5-
10% potassium hydroxide are added
Gardnerella vaginalis
Thank you