GENITAL

INFECTIONS
Assoc Prof Suna KABİL KUCUR
Marmara University School of Medicine
Obstetrics and Gynecology Department
 Learning objectives

• Learn common types of v infections

• Understand pathophysiology/ effective diagnostic approach  antimicr

therapy

• Approach to the women with vaginal infections

One of the leading causes of ptx to
seek care from gynecologists!
 Vaginitis:
• General term for disorders of the vagina caused by infection, inflammation,
or changes in the N vaginal flora

• Often result of an infectious agents

 Patient presentation:
• Change in volume, color, odor of v. discharge
• Pruritis
• Burning
• İrritation
• Erythema
• Dyspareunia, dysuria
• Spotting
• Initial evaluation: history, physical examination, vaginal pH, microscopy, cx
tests for STDs

• Confirmation of a diagnosis targeted treatment

• No diagnosis/recurrent symptoms  more detailed evaluation

The physiologic vaginal discharge (mucoid endocervical
secretion+sloughing epithelial cells+vaginal transudate)

• White/ transparent, thick or thin, odorless..

• Sometimes discharge is yellowish, slightly malodorous, normal vaginal
discharge is not accompanied by pruritis, pain, burning, erythema, erosion, or
vaginal friability.
• Vaginal epithelium (nonkeratinised stratified squamous epithelium) is well
estrogenized in premenopausal women  rich in glycogen

• Glycogen lactic acid (vaginal pH 4-4.5) maintain normal vaginal flora,

inhibit growth of pathogenis organisms

• Disruption of the normal ecosytstem  vaginitis

• STD, Antibiotic use, foreign body, estrogen level, hygenic products, pregnancy,
sexual activity, contraceptive choices  disrupt ecosystem
 Pathogenesis:

• Vaginal ecosystem:
 Steps of initial evaluation:
• History & physical examination (confirmation by examination of vag
secretions, pH, whiff test)
• Discharge (quantity, color, odor, consistency)
• Burning: candidal inf and vulvodynia causes burning
• Pruritis: infection, allergy, dermatosis or malignancy
• Timing of symptoms: candidal vv in premenstrual period, Trich or BV occur during or
after period.
• Etsrogen status: atrophy
• Physical examination: inspect vulva, vagina and cx with speculum examination.
Bimanual examination for cx tenderness (PID?).
 Tests for vaginal/cx infections
• pH testing… easy
• Microscopy (wet mount)… insensitive compared to culture
• Culture (less sensitive than molecular methods and also specific, but requires 7
days)
• Rapid antigen test (immunochromotographic capillary flow enzyme immunoassay
detecting microorganism membrane proteins in 10 min)… detects antigens of m/o
from vaginal swabs
• Nucleic acid amplification tests (most sensitive tests, detect rRNA of m/o)
 Vaginal pH test
• Apply pH test stick or paper to the vaginal sidewall for afew sec. (patients
can do a self pH testing or you perform it on the patient)

• pH>4.5 suggests BV or trichomoniasis and exclude candida infection

(pH<4-4.5)
 Microscopy:
• Vaginal discharge is obtained with a cotton swab and smeared on a slide and
evaluated under a microscobe with saline (saline wet mount) and KOH
(KOH wet mount destroys cellular elements and help to identify yeasts): look
for candidal hyphae and buds, clue cells, motile trichomonads)
• İf micr is neg further evaluation for VVC and TV is needed:
• culture for candida if micr is neg but you suspect candidal infection
• NAAt test for TV
I. Bacterial vaginosis (clue cells: epithelial cells covered with adherent gramnegative rods)
II. Trichomonas vaginalis (flagellated mo)
III. Candida vulvovaginitis (hyphae)
• Cultures are rarely used: many bacterias colonize in the vagina.

• Amine test (whiff test): BV causes fishy odor after KOH apply

• Cervical tests for STI (N Gonorrhea and Chlamydia Trochomatis) should be

excluded in sexually active women with vaginitis to avoid PID.
Cervisitis: typically from sexually transmitted
infections gonorrhea, chlamydia, and mycoplasma,
can also present as nonspecific vaginal symptoms

Non infectious etiologies: vaginal atrophy, foreign body, irritants, allergens,

systemic med disorders (rheumatoid arthritis, SLE)
 What to do?

• Diagnostic testing  targeted reatment  therapeutic compliance

• NO ampiric therapy based on history and physical examination !!!

• 25-40% patients with genital symptoms will not a specific cause
identified on initial diagnostic tests
• For women in whom an etiology is not identified of symptoms recur
evaluate for less common causes, and sexual partner
 Common Types
90% cases are caused by
• Bacterial vaginosis (bacterial)

• Candida vulvovaginitis (fungal)

• Trichomoniasis (parasitic)
 Bacterial Vaginosis
(BV)
• The most common form of vaginitis
• Altered vaginal bacterial flora  loss of lactobacilli  loss of H2O2 
overgrowth of anaerobic bacteria
• Normally anaerobic bacteria are found in <1% of normal flora… Here they
are 100-1000 times higher!
• Few wbc in the vaginal discharge… B vaginosis
• 50% asymptomatic!
Diagnosis /BV (3 positive out of 4)
• 1. Thin, white/Gray vaginal homogenous discharge coatting the vaginal wall
• 2. pH>4.5
• 3. Microscopy of secretions: CLUE CELLS (superficial epithelial cells with
adherent bacteria)
• 4. positive Whiff test (add KOH to the vag secretions fishy, aminelike
odor!)
If no microscopy use pH and amine test. Culture is not specific and not
recommended.
Risk factors/ BV
Intrauterine device
Early sexual intercourse
Multiple partners
History of STD
African race
 Comorbidities of BV
• PID
• Postoperative vaginal cuff infections after hysterectomy
• Abnormal cervical cytology
• Premature rupture of membranes, preterm labour/delivery,
chorioamnionitis, postcesarean endometritis in pregnants with BV infections
Treatment/BV: (male partner treatment is
not recommended!)
• 1. Metronidazole (excellent activity against anaerobes but not lactobacilli)
• 500mg oral 2x1 for 7 days
• %0.75 gel 5mg intravaginal 1x1 for 5 days
• 2. Clindamycin
• Clindamycin ovule 100 mg intravaginally, 1x1 for 3 days
• Clindamycin cream 2%, 100 mg intravaginally in a single dose
• Clindamycin 300 mg orally 2x1 for 7 days
 Trichomonas Vaginitis
(TV)
• Sexually transmitted, flagellated parasite, Trichomonas Vaginalis.
• High transmittion rate (70%)
• İt is an anaerobe that often accompanies BV (60% of pattients)
• Frequently asymtomatic!
 Diagnosis/TV:
• 1. profuse, purulent, malodorous vaginal discharge that may be with vulvar pruritis
• 2. patchy vaginal erythema and colpitis macularis (strawberry cervix)
• 3. pH>5
• 4. microscopy: motile trichomonads and increased number of leukocytes
• 5. Clue cells may be present (association with BV)
• 6. Whiff test may be positive
• Screen for other STD (N gonorrhea, C. trochomatis), serology for syphilis
and HIV!!
 Associated morbidities/TV:

• Vaginal cuff cellulitis after hysterectomy operation

• Preterm delivery and prematüre rupture of membranes in pregnants with TV

 Treatment:
• 1. Metronidazole: single dose 2 gr oral or 500 mg 2x1 orally for 7 days
• 2. Sexual partner treatment
• 3. in refractory cases obtain cultures of parasite
 Vulvovaginal Candidiasis:
(VVK)
• Candida albicans is responsible for 85-90% of all candidal infections.
• İncreased number of m/o  symptomatic patients
• Pruritis is leading symptom
• Predisposing factors:
• Antibiotic use
• Pregnancy
• Diabetes
 Diagnosis/VVC:
• Vulvar pruritis with a vaginal discharge that resembles cottage cheese
• Watery to thick discharge
• Dyspareunia, vulvar burning, irritation, external dysuria
• Normal vaginal pH (<4.5)
• Microscopy: Fungal elements (budding yeasts, mycelia) are seen in 80% cases.
• Whiff test is negative
• İf microscopy is neg, pH is normal, but you suspect VVC based on symptoms 
fungal culture
Predisposing factors

Antibiotic use
Pregnancy
Diabetes
Combined oral contraceptive use
Obesity
stress
 Treatment/VVC:
• Azole drugs, topically.. So much effective!
• Fluconazole 150 mg orally single dose
• Complicated VVC: additional 150 mg fluconazole 72 hrs after the first dose
• Topical steroids releave irritative symptoms
Recurrent VVC (>=4 episodes in a year): fluconazole 150 mg every 3days for 3
doses and 150 mg fluconazole weekly for 6 months… (dif diag: atrophic
vulvovaginitis, atopic dermatitis)
 Inflammatory Vaginitis
• Diffuse exudative vaginitis,epithelial cell exfoliation, and a profuse prulent
vaginal discharge.
• Replacement of lactobacilli with Gr+ cocci esp. Streptococci
• Treatment:
• 2%clindamycin cream vaginally once daily for 7 days
• In case of relapse same treatment for 2 weeks
 Atrophic vaginitis:
• Dyspareunia and postcoital bleeding
• Due to estrogen deprivation
• Loss of vaginal rugae, predominance of parabasal epithelium in microscopy
• Treatment:
• use of 1 gr of conjugated estrogen cream each day for 1 to 2 weeks