Review of

Gynecologic
Infections
CDC 2015

Maria Julieta V. Germar ,M.D., FPOGS, FSGOP, FPSCPC

Section of Gynecologic Oncology
UP College of Medicine

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Gynecologic Infections

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Bartholin’s Cyst
Most common large cyst of the vulva
Etio- Cystic enlargement of the Bartholin
pathogenesis duct due to plugging results in swelling
of the vulva

Symptoms asymptomatic, painful

PE unilateral swelling
4 or 8 o clock position of
labia minora

Diagnosis Visual inspection

Management Surgery- Marsupialization

Excision is indicated for persistent deep

infection, multiple recurrences or
enlargement after the age of 40
Condyloma acuminata
Most common sexually
transmitted infection
Etio- Human Papilloma Virus 6, 11
pathogenesis

Symptoms asymptomatic

PE skin-colored or pink, range from smooth

flattened papules to a verrucous,
papilliform appearance

Diagnosis Visual inspection

Biopsy

Management chemical
podophyllin, Trichloroacetic acid
physical destruction
Excision, electrocautery
immunologic therapy
imiquimod,
Molluscum contagiosum
Poxvirus infection
Etio- spread by direct skin-to-skin contact
pathogenesis When it occurs in the genital region , it
is classified as a sexually transmitted
disease.

Symptoms located only in the anogenital area,

mons pubis, and inner thighs of young
adults
PE located only in the anogenital area,
mons pubis, and inner thighs of young
adults
lesions have a central umbilication with
a white core (molluscum body)

Diagnosis Shave biopsy

Management TCA
Cryotherapy or Electrocautery
 STDs of Concern

“Sores” (ulcers)
◦ Syphilis
◦ Genital herpes (HSV-2, HSV-1)
◦ Others uncommon in the Philippines
– Lymphogranuloma venereum
– Chancroid
– Granuloma inguinale

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 STDs of Concern (continued)

“Drips” (discharges)
◦ Gonorrhea
◦ Chlamydia
◦ Nongonococcal urethritis / mucopurulent cervicitis
◦ Trichomonas vaginitis / urethritis
◦ Candidiasis (vulvovaginal, less problems in men)

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 “Sores”
Syphilis
Genital Herpes (HSV-2, HSV-1)

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 Genital Ulcer Diseases – Sores
Does It Hurt?

Painful Painless
◦ Genital herpes ◦ Syphilis
simplex ◦ Lymphogranulom
◦ Chancroid a venereum
◦ Granuloma
inguinale

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Genital Ulcer Diseases – Sores
Does It Hurt?

Painless
◦ Syphilis
◦ Lymphogranulom
a venereum
◦ Granuloma
inguinale

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 The ulcer of
The syphilis ulcer has a The genital herpes ulcer is
chancroid has irregular
smooth, indurated border and superficial and inflamed
margins and is deep with
a smooth base.
undermined edges.
 Syphilis (SY)

— Caused by Treponema pallidum

— Primary SY: occur ~ 3 weeks after infection
◦ painless chancre (a single, clean-based ulcer usually on
labia/vaginal wall/ cervix) & painless lymphadenopathy
— Secondary SY: Systemic disease results from
hematogenous dissemination 6–8 weeks after
infection.
◦ maculopapular rash on the palms & soles, condyloma latum (moist,
grayish papules-like warts), malaise, fever, arthralgias, pharyngitis, &
generalized lymphadenopathy.

— Tertiary SY: 3–10 yrs after initial infection.

◦ gummas (noninfectious granulomatous lesions found in skin and bones),
cardiovascular syphilis (aortitis or an aortic aneurysm), and
neurosyphilis (general paresis, tabes dorsalis, or an Argyll-Robertson
pupil)
 Syphilis SY
Diagnosis Dark field microscopy (gold standard) showing
spirochetes
§Serological tests:
§Nonspecific: Venereal Disease Research Laboratory (VDRL) and
rapid plasma reagin (RPR)
§Specific: Fluorescent treponemal antibody absorption (FTA-
ABS), microhemagglutination assay (MHA-TP),

Treatment Parenteral administration of penicillin G is the preferred

treatment of all stages of syphilis
•Benzathine penicillin G, 2.4 million units IM in a single
dose

All sexual partners should be treated

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Lymphogranuloma Venereum (LGV)
— Caused by Chlamydia trachomatis
— Occurs in three stages and involves
infection of the lymphatic tissue in the
genital region
◦ Stage 1: small, painless papules/shallow ulcerations
typically on the vaginal wall
◦ Stage 2: painful unilateral inguinal lymphadenopathy;
bubo (matted nodes that adhere to the overlying
skin); systemic symptoms; groove sign (enlargement
of the nodes above and below the inguinal ligament)
◦ Stage 3: rupture of the bubo -> genitoanorectal
syndrome (strictures and fistulas in the anogenital
tract); constitutional symptoms; proctocolitis;
abscesses
 LGV
Diagnosis • Complement fixation tests
• Serologic tests for IgG antibodies
• Immunofluorescence on aspirates
from bubo for the presence of
inclusion bodies
• PCR for C. trachomatis or DNA
swab from lesion
• Genital or lymph node specimen
tested by culture
Treatment •Oral doxycycline 100 mg BID or
erythromycin 500 mg QID for 3 weeks
All sexual partners should be treated
 Granuloma Inguinale (Donovanosis)

Caused by Klebsiella granulomatis (previously known as Calymmatobacterium

granulomatis)
Large, painless, and spreading ulcers in the vulvar area; with friable bases
with raised, rolled margins that bleed easily. Typically beefy red in appearance
and exude a malodorous discharge.
Inguinal lymphadenopathy is rare
Typical feature: Donovan bodies (intracytoplasmic safety pin shaped
organisms seen after Giemsa or Wright staining of tissue specimens)
Treatment: Azithromycin 500 mg or 1 gram
SD weekly x 3 weeks OR Doxycycline 100 mg BID x 3 weeks
 Genital Ulcer Diseases – Sores
Does It Hurt?

Painful
◦ Genital herpes
simplex
◦ Chancroid

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 Genital Herpes Simplex (HSV )
Clinical Vesicles ⇒ painful ulcerations ⇒ crusting
presentation Grouped vesicles, uniform in size, around
the vulva, perineum, and perianal area are
pathognomonic

fever, malaise, and bilateral inguinal

lymphadenopathy

Diagnosis Viral Culture (Gold Standard )

PCR Assay Serology
(Western blot)
Tzanck smears -Insensitive

Treatment Oral acyclovir (200 mg 5x/day or 400 mg 3x/day

for 7-10 days) ;
Valacyclovir 1 gram BID x7-10 days
All sexual partners should be evaluated for
infection. Treated if symptomatic. 18
 Chancroid

An acute, curable, STI caused by H. ducreyi

1-3 extremely painful ulcers around the perilabial area that are
deep, purulent, and have ragged edges. associated with
unilateral, suppurative, painful swollen inguinal lymph nodes
that, in 25% of cases, will rupture, releasing a heavy, foul
discharge that is contagious (suppurative adenopathy = bubo)
Systemic symptoms (fevers, myalgias) are typically not present
 Chancroid

Diagnosis Culture on selective media for H ducreyi,

GS from the ulcer base or bubo aspirate:
gram-negative rods in a chain – school of
fish pattern; PCR
HSV culture negative
Treatment Azithromycin (oral) 1 g single dose or ceftriaxone
(IM) 250 mg in a single dose or
Ciprofloxacin 500 mg BID x 3 days
All sexual partners should be evaluated for
infection and treated
 “Drips”

Gonorrhea
Nongonococcal urethritis
Chlamydia
Mucopurulent cervicitis
Trichomonas vaginitis and urethritis
Candidiasis

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 Normal Vaginal Secretions

Without subjective symptoms

Normal volume of white or clear curdy vaginal secretion
pH of 3.8-4.2
No unusual odor
Dominant flora of acidific rods, lactobacilli or
diphtheroids
 Symptoms
C. trachomatis Mucoid discharge; may have subclinical infection in some

N. gonorrhoea purulent endocervical discharge, generally yellow or green

in color and referred to as mucopus
Trichomonas profuse, purulent, malodorous frothy vaginal discharge
vaginitis that may be accompanied by vulvar pruritus; patchy vaginal
erythema and colpitis macularis ( strawberry cervix)

Bacterial vaginosis fishy vaginal odor, which is particularly noticeable following

coitus, & vaginal discharge; pH of secretions is > 4.5 (usually 4.7
to 5.7)
Candidiasis Intense pruritus vulvae, dyspareunia, cottage cheese-like
discharge
 Diagnostic Tests
C. trachomatis Nucleic Acid Amplification Test (NAAT) of urine or cervical
swab
N. gonorrhoea Nucleic Acid Amplification Test (NAAT) of urine or cervical
swab
Trichomonas visualization of motile trichomonads on wet mount
vaginitis pH of the vaginal secretions > 5.0
Bacterial vaginosis Microscopy -- ↑ number of clue cells, & leukocytes are absent; whiff
test
pH of the vaginal secretions 4.5

Candidiasis Microscopy of a wet saline or KOH prep of vaginal fluid shows

hyphae, pseudohyphae, or budding yeast ( spaghetti and meatballs )
fungal culture to confirm the diagnosis ;
pH - 4.0-4.5
 Treatment
C. Trachomatis Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days

N. Gonorrhoea Ceftriaxone 250 mg IM single dose * OR

***Cefixime, 400 mg orally (single dose) plus
Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days
Trichomonas vaginitis Oral metronidazole 500 mg BID, both patient & partner

Bacterial vaginosis Metronidazole 500 mg PO BID for 7 days, OR

Clindamycin 300 mg PO BID for 7 days
Candidiasis Fluconazole PO (single dose 150 mg in nonpregnant women) or topical or
intravaginal antifungal drugs [clotrimazole, miconazole, nystatin] (3–7
days)
 Treatment
C. Trachomatis Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days

N. Gonorrhoea Ceftriaxone 250 mg IM single dose * OR

***Cefixime, 400 mg orally (single dose) plus
Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days
Trichomonas
CDC novaginitis Oral metronidazole
longer recommends cefixime500
at mg
anyBID,
doseboth
aspatient & partner
a first-line regimen for
treatment of gonococcal infections. If cefixime is used as an alternative agent, then
Bacterial vaginosis Metronidazole 500 mg PO BID for 7 days, OR
the patient should return in 1 week
Clindamycin forPOa BID
300 mg test-of-cure
for 7 days at the site of infection.
Candidiasis Fluconazole PO (single dose 150 mg in nonpregnant women) or topical
or intravaginal antifungal drugs [clotrimazole, miconazole, nystatin] (3–7
days)
Recent sex partners (i.e., persons having sexual contact
with the infected patient within the 60 days preceding onset
of symptoms or gonorrhea diagnosis) should be referred for
evaluation, testing, and presumptive dual treatment.

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 Treatment
C. Trachomatis Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days

N. Gonorrhoea Ceftriaxone 250 mg IM single dose * OR

***Cefixime, 400 mg orally (single dose) plus
Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days
Trichomonas vaginitis Oral metronidazole 2 grams orally OR 500 mg BID, both patient & partner

Bacterial vaginosis Metronidazole 500 mg PO BID for 7 days, OR

Clindamycin 300 mg PO BID for 7 days
Candidiasis Fluconazole PO (single dose 150 mg in nonpregnant women) or topical or
intravaginal antifungal drugs [clotrimazole, miconazole, nystatin] (3–7 days)
 Treatment of Sexual Partners
C. Trachomatis Recent sex partners (i.e., persons having sexual contact with the infected
patient within the 60 days preceding onset of symptoms or chlamydia
gonorrhea diagnosis) should be referred for
N. Gonorrhoea evaluation, testing, and presumptive dual treatment.

Trichomonas vaginitis Oral metronidazole 500 mg BID, both patient & partner

Bacterial vaginosis Not recommended

Candidiasis Uncomplicated VVC is not usually acquired through sexual intercourse; thus,
data do not support treatment of sex partners.
 Pelvic Inflammatory Disease

Germar CDC 2019

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 Pelvic Inflammatory Disease

— Spectrum of inflammatory diseases of upper

genital tract caused by micro-organisms
colonizing the endocervix ascending to the
endometrium and fallopian tubes
— Commonly caused by N. gonorrhoeae and C.
trachomatis
— Abdominal or pelvic pain with one or
more Minimum criteria: can start treatment
◦ cervical motion tenderness OR uterine
tenderness OR adnexal tenderness.
 PID:Additional Criteria

— Oral temperature >101°F (>38.3°C)

— Abnormal cervical or vaginal mucopurulent discharge
— Abundant number of WBC on saline microscopy of vaginal
secretions
— Elevated erythrocyte sedimentation rate (ESR)
— Elevated C-reactive protein (CRP)
— Laboratory documentation of cervical infection with N.
gonorrhoeae or C. trachomatis
 PID: Specific Criteria

— Endometrial biopsy - histopathologic

evidence of endometritis
— Transvaginal sonography or MRI showing
thickened, fluid-filled tubes with or without
free pelvic fluid or tubo-ovarian complex,
or Doppler studies suggesting pelvic
infection
— Laparoscopic abnormalities consistent with
PID
 PID: Criteria for Hospitalization

— Surgical emergencies (e.g., appendicitis) cannot be excluded

— Patient is pregnant
— No clinical response to oral antimicrobial therapy
— Unable to follow or tolerate an outpatient treatment regimen
— Severe illness, nausea and vomiting, or high fever
— Tubo-ovarian abscess
 PID: Parenteral Treatment

— Cefotetan 2 g IV every 12 hours, OR

A — Cefoxitin 2 g IV every 6 hours, PLUS
— Doxycycline 100 mg orally or IV every 12 hours

— Clindamycin 900 mg IV every 8 hours

B — Gentamicin loading dose IV or IM (2 mg/KBW)
followed by a maintenance dose (1.5 mg/kg) every 8
hours
 PID: Parenteral: Alternative Tx

— Ampicillin-Sulbactam 3
g IV every 6 hours, PLUS
— Doxycycline 100 mg orally or IV every 12 hours
 IM/Oral Treatment
Updated recommended treatment regimens for gonococcal infections
and associated conditions
Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg PO
BID for 14 days WITH OR WITHOUT
Metronidazole 500 mg PO BID for 14 days
OR
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO single dose
PLUS
Doxycycline 100 mg PO BID for 14 days WITH OR WITHOUT
Metronidazole 500 mg PO BID for 14 days
 Pelvic Inflammatory Disease

Fitz Hugh Curtis syndrome - perihepatic inflammation in PID.

Treatment is the same as in PID
Adnexal abscess occurs in around 10% of women
Surgery is indicated for life-threatening infections, ruptured
abscesses, cul-de-sac abscess, persistent masses in patients with
completed families and persistence of symptoms.
 Review of
Gynecologic
Infections
CDC 2015

Maria Julieta V. Germar ,M.D., FPOGS, FSGOP, FPSCPC

Section of Gynecologic Oncology
UP College of Medicine

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