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Comprehensive Guide to Genital Tract Infections in Obstetrics & Gynecology

Understand normal vs. abnormal vaginal discharge, common causes like BV, candidiasis, trichomonas, diagnosis, treatment, and other related conditions in reproductive health.

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Comprehensive Guide to Genital Tract Infections in Obstetrics & Gynecology

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  1. King Khalid University Hospital Department of Obstetrics & Gynecology Course 481 Genital Tract Infections

  2. Normal vaginal discharge • The normal vaginal flora is predominately aerobic organisms • The most common is the H+ peroxide producing lactobacilli • The normal PH is <4.5

  3. Normal vaginal discharge Normal vaginal secretions • In reproductive aged women it consists of 1-4 mL fluid (per 24 hours), white or transparent, thick or thin, and mostly odorless. • formed by mucoid endocervical, sloughing epithelial cells, normal vaginal flora, and vaginal transudate. • ↑ in the middle of the cycle because of (physiologic leukorrhea)↑ in the amount of cervical mucus: during ovulation, pregnancy and in patient using OCP.

  4. Abnormal vaginal discharge(vaginitis) • Extremely common • signs and symptoms are generally similar • Women with vaginitis present with one or more of the following vulvovaginal signs and symptoms: -Change in the volume, color, or odor of vaginal discharge -Pruritus, burning, Irritation, erythema -Dyspareunia, dysuria -Spotting • The most common causes of vaginitis symptoms: bacterial vaginosis, candida vulvovaginitis and trichomoniasis (>90% of cases).

  5. Bacterial Vaginosis (BV) • It is caused by alteration of the normal flora, with over-growth of anaerobic bacteria • It is triggered by ↑ PH of the vagina (intercourse, douches) • Recurrences are common • May present with Fishy odor (especially after intercourse) no dyspareunia • Increases risk for: -in pregnant women (PTL, endometritis and postpartum fever) -Post-hysterectomy vaginal-cuff cellulites -Postabortal infection -Acquiring other STDs, especially HIV

  6. Bacterial Vaginosis (BV) • Diagnosis: Amstel Criteria • Homogenous, grayish-whitish discharge • Presence of clue cells • PH >4.5 • +ve whiff test(amine test) (adding KOH to the vaginal secretions will give a fishy odor) in 70-80% of cases “Clue cells are the most reliable predictor of BV”

  7. Clue Cells

  8. Bacterial Vaginosis (BV) • Treatment: • Flagyl 500mg Po Bid for one week (95% cure) • Flagyl 2g PO x1 (84% cure) • Flagyl gel PV • Clindamycin cream PV • Clindamycin PO • Treatment of the partner is not recommended

  9. Trichomonas Vaginalis • It is an anaerobic parasite, that exists only in trophozite form • 60% of patients also have BV • 70% of males will contract the disease with single exposure • Patients should be tested for other STDs (HIV, Syphilis)

  10. Trichomonas Vaginalis • Diagnosis: • Profuse, frothy ,purulent malodorous discharge • It may be accompanied by vulvar pruritis • Secretions may exudate from the vagina • If severe → patchy vaginal edema and strawberry cervix • PH >5 • Microscopy: motile trichomands and ↑ leukocytes • Clue cells may if BV is present • Whiff test may be +ve

  11. Wet Mount • Trichomonads seen only in 50 – 70% • Elevated pH • Can increase leukocytes • Paps

  12. Trichomoniasis

  13. Trichomoniasis

  14. Trichomonas Vaginalis • Treatment: • Falgyl PO (single or multi dose) • Flagyl gel is not effective • The partner should be treated

  15. Candidiasis • 75% of women will have at least once during their life • 45% of women will have two or more episodes/year • 90% of yeast infections are secondary to Candida Albican • Other species (glabrata, tropicalis) tend to be resistant to treatment

  16. Candidiasis • Predisposing factors: • Antibiotics: disrupting the normal flora by ↓ lactobacilli • Pregnancy (↓ cell-mediated immunity) • Diabetes

  17. Candidiasis • Diagnosis: • Symptoms: Vulvar pruritis and burning Vaginal soreness an dysparunea and splash dysuria • The discharge vary from watery to thick cottage cheese discharge • O/E: erythema and edema of the labia and vulva &the vagina may be erythematous with adherent whitish discharge • PH< 4.5budding yeast or mycelia on microscopy • Microscopic saline wet mount : Pseudohyphae (in about 70 percent of patients) • Culture if microscopy nondiagnostic

  18. Candidiasis

  19. Candidiasis • Treatment: • Topical Azole drugs (80-90% effective) • Fluconazole is equally effective (Diflucan 150mg PO x1), but symptoms will not disappear for 2-3 days • 1% hydrocortisone cream may be used as an adjuvant treatment for vulvar irritation • Chronic infections may need long-term treatment (6 months) with weekly Fluconazole

  20. Other Causes of Vaginitis • Atrophic vaginitis (in post mepausal women) • High vaginal pH, thin epithelium, d/c • Parabasal cells on wet mount • Topical estrogen cream • Atypical manifestations: HSV, HPV • Noninfectious vulvovaginitis • Irritants/allergens • Lichens syndromes (sclerosus, simplex chronicus, planus) • Cytolyticvaginitis

  21. 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 • Latency

  22. Transmission • Horizontal Transmission • Intimate sexual contact (oral/genital) • Aerosol and fomite transmission is rare • Vertical Transmission • Maternal-infant via infected cervico-vaginal secretions, blood or amniotic fluid at birth • Autoinoculation • From one site to another

  23. Diagnosis • Viral isolation (culture) • High specificity, low sensitivity • 50% for primary infxn • 20% for recurrent infxn • Direct detection of virus (Tzcank smears, PCR) • Serology • Newer tests that are specific for type of virus (HerpesSelect 2, herpes glycoprotein for IgG, ELISA)

  24. Oral Antiviral Therapy • Valacyclovir (Valtrex) • Famciclovir (Famvir) • Acyclovir (Zovirax)

  25. Genital Warts • Condyloma accuminata secondary to HPV infection (usually 6&11), these are non-oncogenic types • HPV Types 16 and 18 (oncogenic type) are the most commonly isolated HPV types in cervical cancer • Usually at areas affected by coitus (posterior fourchette) • 75% of partners are infected when exposed • Recurrences after treatment are secondary to reactivation of subclinical infection

  26. Genital Warts

  27. Genital Warts

  28. Cervicitis • Neisseria Gonorrhea and Chlamydia Trachomatis infect only the glandular epithelium and are responsible for mucopurulent endocervisitis (MPC) • Ectocx epithelium is continuous with the vaginal epithelium, so Trichomonas, HSV and Candida may cause ectocx inflammation

  29. Cervicitis • Tests for Gonorrhea (culture on Thayer- martin media) and Chlamydia (ELISA, direct IFA) should be performed

  30. Pelvic Inflammatory Disease (PID) • Ascending infection, ? Up to the peritoneal cavity • Organisms: Chlamydia, N Gonorrhea • Less often: H Influenza, group A Strept, Pneumococci, E-coli

  31. Fitz-Hugh-Curtis

  32. PID • Diagnosis: difficult because of wide variation of signs and symptoms • Clinical triad: fever, pelvic pain and cervical motion and adnexal tenderness • Cervical motion tenderness indicate peritoneal inflammation • Patients may or may not have mucopurulent discharge

  33. Sequelae • Infertility -In 20% of patients -infertility rate increase direct with number of episodes of acute pelvic infection • Ectopic pregnancy -increase 6-10 fold • Chronic pelvic infection -4 fold increase • TOA -10% risk -if rupture high mortality rate

  34. CDC Recommended treatment regimens for OPD of acute PID

  35. Tubo-ovarian Abscess (TOA) • End-stage PID • Causes agglutination of pelvic organs (tubes, ovaries and bowel) • 75% of patients respond to IV antibiotics • Drainage may be necessary • Surgical treatment

  36. Tubo-ovarian Abscess (TOA)

  37. Thank you

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