Leukorrhea, STDs, HIV infection

Rujira Manorompattarasan,MD
13/3/2561
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Scope
 Normal Vagina
 Vagina infection
 STDs
 HIV infection

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Normal Vagina
 Vaginal secretion
- Vulva secretion
- Vaginal wall transudate
- Exfoliated vagina and cervical cell
- Cervical mucus
- Endometrial and oviductal ducts

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Normal Vagina
 Vaginal secretion
 type and amount depend on cycle
 Increase in the middle of cycle because of increase
of cervical mucus

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Vaginal secretion

 Gross
- Color : Clear to White
- Consistency : Milky to clumpy
- Odor : non-existent to mild
- Located at posterior fornix
Vaginal secretion

 Microscope
 Many superficial epithelial cell
 Few WBC (<1 per epithelium)
 Few clue cell: superficial vaginal epithelial cell with
adherent bacteria
 Normal vaginal flora
Normal vagina
 Normal vaginal flora
 mostly aerobic
 6 species of bacteria ;most common :
lactobacilli (gram-positive rod)
 PH <4.5 (production of lactic acid)

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Vaginal infection

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Vaginal Infection

 Bacterial vaginosis

 Trichomonas vaginitis

 Vulvovaginal candidiasis

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Bacterial
vaginosis

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Bacterial vaginosis (BV)
 Most common : leukorrhea problem
(33%)

 PATHOGENESIS
 Environment of vaginal flora was altered

 Decreased population of lactobacilli

 So overgrowth of anaerobes and Gardnerella

vaginalis ( ~ 80% )

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Bacterial vaginosis
 Anaerobic bacteria
 G.vaginalis
 Nonencapsulated, non motile, gram -ve
 Mycoplasma hominis

 Increase vaginal discharge

 Grey or whitish homogenous discharge
 Fishy odor
 Amine producing  ↑ pH
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Bacterial vaginosis

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Bacterial vaginosis

 Diagnosis criteria (Amsel criteria)

 Grey or whitish homogenous vaginal
discharge
 pH > 4.5
 Whiff test +ve (amine +10%KOH)
 Clue cell > 20%

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INVESTIGATION

 Vaginal PH > 4.5

 10% KOH ……fishy odor

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INVESTIGATION

 Wet smear : clue cell

 Clue cells are epithelial cells of the vagina that get their
distinctive stippled appearance by being covered with bacteria.

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Treatment : BV
 Recommended Regimens
 Metronidazole 500 mg oral bid for 7 days
(THAI มีขนาด 200mg and 400mg)

 Alternative regimens
 Clindamycin 300 mg oral bid for 7 days

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Oral Metronidazole use
 Avoid alcohol at least 72 hours
 Disulfiram-like reaction
 Nausea, vomiting
 Flushing of skin
 Tachycardia
 Shortness of breath

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Trichomonas
vaginitis

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Trichomonas vaginitis
 Trichomonas vaginalis
 Protozoa
 3 species
 Trichomonas vaginalis
 Trichomonas tenax
 Trichomonas hominis

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Trichomonas vaginitis
 10x20 um
 ใหญ่ กว่า WBC เล็กน้ อย
 Flagella
 มีการเคลื่อนไหวแบบกระตุก เป็ นจังหวะตลอดเวลา
 ชอบสภาวะ anaerobic
 pH ด่ าง (5.8 – 7.0)

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Trichomonas vaginalis

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Trichomonas vaginalis
 STDs
 70% men contract the disease after a
single exposure to an infected woman
 Co-incident with BV (60%)

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Diagnosis
 Often is asymptomatic

 Profuse, purulent, malodorous vaginal discharge

 pH > 5.0
 Strawberry-like cervix
 Wet smear : motile trichomonas , increased WBC
 Clue cell may be presents
 Whiff test may be positive

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Trichomonas vaginitis

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Strawberry cervix

Pathy vaginal erythyma and colpitis macularis

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Investigation
 Vaginal discharge
– hanging drop with
saline (wet smear)

 Pap smear –
Trichomonas
vaginalis

 Culture
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Treatment : trichomonas vaginitis

 Recommended regimen
 Metronidazole 2 g oral single dose

 Alternative regimen
 Metronidazole 500 mg oral bid for 7 days

Sexual partner should

be treated

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Vulvovaginal
candidiasis

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Vulvovaginal candidiasis
 Candida albicans (85%)
 Other : C.glabrata, C.tropicalis
 75% of women : at least one episode
during lifetimes

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Vulvovaginal candidiasis
 Risk factor
 Pregnancy
 Oral pills
 Antibiotics use
 Corticosteroid
 Immunosupressive drugs
 Diabetes mellitus

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Vulvovaginal candidiasis
 Symptoms

 Itching
 Vaginal soreness
 Dyspareunia
 Dysuria
 Curd like leukorrhea
 No foul smell

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Diagnosis
 Valvar pruritus
 Vaginal discharge : vary form watery
to homogenously thick (cottage
cheese curd like)

 PH is usually normal (<4.5)

 Whiff test is negative

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Vulvovaginal candidiasis

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Vulvovaginal candidiasis

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Investigation
 10% KOH: hyphae or pseudohyphae
with budding yeast cell
 Pap smear

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Vaginal candidiasis
 Treatment
 Clotrimazole 100 mg vg x 6
 Clotrimazole 500 mg vg, single dose

 Ketoconazole 200 mg P.O. bid x 5d

 Itraconazole 100 mg P.O. bid
 Fluconazole 150 mg P.O., single dose

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Uncomplicated vs complicated

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Recurrent VVC
 Defined as >= 4 / years
 May be co-incident with chronic atopic
dermatitis or atrophic vulvovaginitis

 Treatment :
 Fluconazole 150mg x 3 dose, every3days
 Maintenance : Fluconazole 150mg weekly
for 6 months

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Complicated VVC
 Treatment
 Additional fluconazole 150mg x 2,q72 hrs

 Duration : 10-14 days

 Adjunctive treatment : weak topical steroid

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THE END

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Rujira Manorompattarasan 42
STDs (sexually transmitted diseases)
 Genital ulcers disease
 Syphilis
 Chancroid
 Genital herpes

 Non-genital ulcers
 Gonorrhea
 Nongonococcal urethritis
 LGV (lymphogranuloma venereum)
 Condyloma acuminate
 Molluscum contagiosum

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Genital ulcers disease

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Syphilis

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Syphilis
 Treponema pallidum
 Lab : dark field microscope ->
spirochete  definite diagnosis

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TRANSMISSION

 Sexual contact
 Tran placenta ( congenital )

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CLASSIFICATION
 Congenital syphilis : early and late

 Acquired syphilis
1. Primary
2. secondary
3. latent :early and late
4. late or tertiary

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Signs and symptoms
:Acquired syphilis
1. Primary
2. Secondary
3. latent :early and late
4. late or tertiary

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Syphilis : 1.primary syphilis

 Primary Syphilis : Hard Chancre

- painless
- Firm border, smooth and red base
- no lymphadenopathy

 Resolve spontaneous 2-8 weeks

 Incubation period 21 day (10-90 d)
 Lab : RPR, VDRL (positive 75%)

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1.Primary Syphilis : Hard chancre

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1.Primary Syphilis : Hard chancre

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1.Primary Syphilis : Hard chancre

At tongue At lip

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2.Secondary Syphilis
 Affect multiple organ
 Occur 4-10 weeks after hard chancre
 Skin lesion (90%)
 Diffuse macular rash, plantar and palmar
 Target lesion
 Pathy alopecia
 Mucous patches
 Constitutional symptoms : fever, malaise,arthralgia
 Aseptic meningitis 1-2%
 Hepatitis, nephropathy, ocular changes

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2.Secondary syphilis
 Spirochetemia
 High population of spirochete at
lymphnode
 High titer VDRL
 Most contagious stage

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Rash

Diffuse maculopapular rash

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Target lesions

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Alopecia areata

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3.Latent syphilis (asymptomatic)

 Develops when primary or secondary

syphilis is not treated

 Lab : reactive serological testing but no

symptoms

 Types
3.1 Early latent syphilis : within 12 months
3.2 Late latent syphilis : more than 12 months
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4.Tertiary or late syphilis
 Slowly progressive disease
 Affect any organ
 Rarely seen in reproductive-aged
 Cardiovascular syphilis
 Neurosyphilis

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Diagnosis

All women with genital ulcers should

test for syphilis

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Serologic test for syphilis

Non specific Specific

screening treponemal
test test
– RPR (rapid plasma – FTA-ABS ( fluorescent
reagin test ) treponemal antibody
absortion test )

– VDRL (venereal – TPHA ( treponema

diseased research pallidum
laboratory) hemagglutination test )
Nonspecific test : RPR, VRDL

 Use to screen and follow up

 Must confirm by specific treponemal test

 Titer below 1: 8 may have biological false

positive

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Biological false positive STS
 Pregnancy
 Viral hepatitis
 LGV
 Leptospirosis
 Leprosy
 Advanced T.B.
 SLE , autoimmune disease
 Anemia
 malaria

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CLASSIFICATION
 Acquired syphilis
1. Primary
2. secondary
Same drug regimen
3. Latent Benzathine peniclillin G 2.4
1. Early latent mil.U IM x 1 dose

2. Late latent Same drug regimen

4. late or tertiary Benzathine peniclillin G 2.4
mil.U IM x 3 dose ,q1wk

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Syphilis : Treatment
 Early syphilis
 Benzathine peniclillin G 2.4 mil.U IM x 1 dose

 Late latent syphilis

 Benzathine peniclillin G 2.4 mil.U IM x 3 dose ,q1wk

 Neurosyphilis
 Aqueous crystalline penicillin G 3-4 mil.U IV q 4hr
 10-14 d

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Jarisch-Herxheimer reaction

 Acute febrile response with headache,

myalgia
 may occur within the first 24 hrs. after
treatment syphilis

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Follow up
 Repeat nontreponemal test
 At 6, 12 months

 Diagnosis of treatment failure

 4 fold rising  abnormal
 4 fold decline  response to treatment
(1:16 to 1:4, 1:32 to 1:8) [6-12 months in
early] [12-24 months in latent]

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Chancroid

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STDs : Chancroid
 Hemophilus ducreyi
 Incubation period 3-5 days

 Chancroid (soft chancre)

- extremely painful ulcers
- dirty necrotic exudate
- non-indurated
- tender inguinal
lymphadenopathy(fluctuant)
- inguinal bubo + one or
several ulcers
( without ulcer = LGV)

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Chancroid

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Investigation
 Gram stain
 Culture is difficult

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 Chancroid

 Treatment
 Azithromycin 1g. Oral single dose
 Ceftriaxone 250 mg IM single dose
 Ciprofloxacin 500mg 1x2 / 3 d
 Erythromycin 500 mg 1 x4 /7 d

 Follow up 3-7 days after treatment

 expected to heal within 2 weeks

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Genital Herpes

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STDs : Genital Herpes
 Genital Herpes
 Pathogen : Herpes simplex virus type 2 (HSV2)
 Group vesicles mixed with small ulcers

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Genital herpes : Symptoms
 Numbness, tingling, or burning in the
genital region

 A burning sensation while urinating or

having intercourse

 Painful urination, difficulty urinating,

or a frequent need to urinate

 Watery blisters in the genital area

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Genital Herpes

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Genital Herpes

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Diagnosis of genital herpes

 Clinical diagnosis

 Virology test
 PCR is test of choice : specific 99%
 Viral culture : Sensitive 100% in vesicle stage, 89% in
pustular stage, 33% in ulcers
 Cytology (Tzanck test) : insensitive, no virus type (CMV,
HSV, zoster etc.)

 Serology testing : use only glycoprotein G

based assays

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Tzanck test : Multinucleated giant cell

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Treatment
 First episode =Acyclovir 400mg 1x3,
7-10 days
 Suppressive therapy
 400 mg 1x2 ( >=6 /years)
 reduce recurrences at least 75%
 decrease symptomatic and
asymptomatic viral shedding

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Counseling patient
 Signs and symptoms
( recurrent disease , not cure )
 Transmission
 Risk for neonatal infection

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Chancroid Herpes Syphillis

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Non-Genital ulcers
disease
Gonorrhea
Nongonococcal urethritis
LGV (lymphogranuloma venereum)
Condyloma acuminate
Molluscum contagiosum

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Gonorrhea

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Gonorrhea
 Neisseria gonorrhea
 Men : urethritis
 Women : 70% asymptomatic until
complication (PID)

 MSM : extra-genital infections (pharynx

and rectum)

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Risk factors
 Not use condom in multiple partners
 Previous STDs

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 Neisseria gonorrhea

Gram-negative intracellular diplococci

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Transmission
 Sexual contact

 Mother to child

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PATHOGENESIS
 Incubation period 2-10 days

 Site of penetration : columnar epithelial of

Para urethral gland , cervical gland , Bartholin
gland , rectal mucosa

 Spreading along endothelial gland to deeper

and upper genital organ or spreading via
venous , lymphatic to other organ

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Signs and
symptoms

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Gonorrhea

Purulent urethral
Cervicitis discharge

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Gonorrhea

Bartholin abscess Epididymo-orchitis

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Perihepatic adhesion

Fit-Hugh-Curtis Syndrome

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Gonococcal
pharyngotonsilitis

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G.C. conjunctivitis

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UNCOMPLICATED vs COMPLICATED G.C.

 Urethritis  Pelvic inflammatory disease

 Vaginitis  Epididymo-orchitis
 Para urethral abscess
 cervicitis
 G.C. pharyngitis , tonsillitis
 Conjuntivitis neonatorum

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DIAGNOSIS

 History taking
 Signs and symptoms
 Physical examination
 Swab pus gram stain culture

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Gonorrhea
 Male urethral gram stain sensitivity and specificity >
95%

 Male homosexual gram stain from rectum and pharynx

sensitivity and specificity ~ 50-60% suggestion

 Sensitivity , specificity from female urethra and cervix

~ 60-70%

 >40% asymptomatic so every women at risk should

be culture (NAAT)

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TREATMENT OF UNCOMPLICATE G.C.

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TREATMENT OF COMPLICATE G.C.

 Same drug as uncomplicated G.C

 Duration : At least 2 days and until

improve

 Bartholin abscess  I and D

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Nongonococcal
urethritis

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Nongonococcal urethritis
(หนองในเทียม)
 Symptomatic men with urethral
secretions without gram negative
diplococci

 Chlamydial urethritis
 Azithromycin = doxycycline

 M.genitalium
 Azithromycin > doxycycline
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Nongonococcal urethritis
(หนองในเทียม)

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LYMPHOGRANULOMA
VENEREUM (LGV)

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LYMPHOGRANULOMA
VENEREUM

 PATHOGEN

 Chamydia trachomatis serotype

1,2,3
 incubation period 3-30 days

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Signs and symptoms

 Dysuria
 Urethral discharge
 Leucorrhoea
 Enlarge groin node ,
inflammation, abscess ( bubo )

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LGV

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Treatment

 Never I/D if tense abscess permit aspiration to

avoid fistula and stricture

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Anogenital warts
(Condyloma acuminata)

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Anogenital warts (Condyloma
acuminata)
 HPV types 6,11
 Usually asymptomatic depend on
 SIZE
 LOCATION : posterior fourchette,
vulva,vagina,cervix

 Painful or pruritic
 Flat,popular or peduculated growths on
the genital mucosa
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Anogenital warts (Condyloma
acuminata)
 Diagnosis : visual inspection

 Biopsy
 Uncertain
 Not respond to standard therapy
 Worsens during therapy

 HPV testing : not recommended

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Anogenital warts (Condyloma
acuminata)

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Anogenital warts (Condyloma
acuminata)

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Anogenital warts (Condyloma
acuminata)
 Goal of treatment
 Removal of the warts
 Not possible to eradicate the viral infection

 Recurrences more often result from

reactivation of subclinical infection than
reinfection by a sex partner
 Examination of sex partners is not absolutely
necessary

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Anogenital warts (Condyloma
acuminata)
 Treatment
 Podophyllin 25%
Avoid in pregnancy
 Imiquimod 5%

 Trichloroacetic acid (TCA) 80-100%

Use in pregnancy

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Anogenital warts (Condyloma
acuminata)
 Treatment : Surgical
 Cryotherapy
 Laser
 surgical excision
 Electric surgery

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Molluscum
contagiosum

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Molluscum contagiosum
 Pox virus

 Skin lesion
 Single or multiple, rounded
 Dome-shaped
 Pink, waxy popular 2-5 mm Central umblilication
 Papules are umbilicated and contain a
caseous plug

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Treatment
 Medications
 Podophyllin 10-25% 2-3 times/wks
 Imiquimod cream 3 times/wks

 Surgery
 Sterile needle (สะกิดที่ตุ่ม บีบเนื้อหูดสี ขาวออกให้หมด)
 Electrosurgery
 Cryotherapy
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HIV infection in GYN

Rujira Manorompattarasan

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Gynecological problems of HIV/AIDS

 80% of female HIV patient  at least one

gynecological problem in 5 years

 Gynecological infections are the most common

reason to seek care for the first time in HIV
infected women

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Gynecological problems of HIV/AIDS

 Frequent problems in HIV-positive women

 Sexually transmitted infections (STI)

 PID
 Tuberculosis
 Cervical cancer
 Other HIV-related malignancies
 Menstrual disorders
 Miscarriages
 Family planning, infertility

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Diagnosis

 HIV antibody testing

 Screening
 TB
 STIs
 Intraepithelial neoplasia
 Cervical cancer

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Treatment

 Start antiretroviral therapy

 All women with any CD4 count

 Consult medicine

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THANK YOU

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