GUYS, REMINDER LANG!!!
(Di ako galeeet) ○ cysts vary in size and can be up to 8 cm in
PAG IPAPASA NA TONG REFLECTION
- I-edit niyo into format na hindi tayo pare pareho
- ALISIN NIYO RIN YUNG MGA NAMES BAKA
MAKALIMUTAN NIYO HAHA
- Wag sabay sabay magpasa
- Yung iba kung gusto niyo lagyan ng pictures na
wala dito okay lang para hindi obvious na
parepareho tayo HAHAHAHAHAH
Camille - DONE
Cherry - DONE
Ellen - DONE
Janine - DONE
Jessa - DONE
Judith - DONE
KC - DONE
Mariella - DONE
Olive - DONE
Suzanne - DONE
GENITAL TRACT INFECTIONS
Vulva, Vagina, Cervix, Toxic Shock Syndrome,
Endometritis, and Salpingitis
● One must keep in mind that infectious agents that
colonize and involve one organ often infect adjacent
organs to understand the pathophysiology and
natural history of infectious diseases of the genital
tract
● Most common conditions seen by gynecologists are
symptoms caused by infections of the lower genital
tract
● Most devastating pathologic processes from these
diseases occur in sites other than the genital tract
● they often obtain entry into the body through the
vulvar, rectal, vaginal, or cervical epithelium
● STIs often coexist—for example, Chlamydia
trachomatis and Neisseria gonorrhoeae
○ When one disease is suspected,
appropriate diagnostic methods must be
used to detect other infections.
INFECTIONS OF THE VULVA
● vulvar area is subject to primary and secondary
bacterial, viral, parasitic, or fungal infections and is
sensitive to hormonal and allergic influences.
● Vulvar skin is composed of a stratified squamous
epithelium
○ Contains hair follicles and sebaceous,
sweat, and apocrine glands
○ Subcutaneous tissue of the vulva contains
the bartholin glands
● Vulvar pruritus - 10% of outpatient gynecology visits
○ Short-duration- causes include infection or
contact dermatitis.
○ Long-duration - causes infection or contact
dermatitis and vulvar dystrophies
INFECTIONS OF BARTHOLIN GLANDS
● Its mucinous secretions provide moisture for the
epithelium of the vestibule & open the vagina at 5
and 7 o’clock (between hymen & labia minora)
● 2% of adult women develop enlargements of one or
both glands because of narrow ducts for drainage
approximately 2cm
● most common cause is cystic dilation of the
Bartholin duct
○ caused by distal obstruction secondary
to nonspecific inflammation or trauma
with subsequent continued glandular
fluid secretion resulting in the cystic
dilation
● Bartholin duct cyst
○ Most are asymptomatic
diameter
● Abscess of a Bartholin gland
○ often polymicrobial, reflecting the normal
flora of the vagina, and rarely are caused
by an STI
○ tends to develop rapidly over 2 to 4 days
○ With significant acute pain and tenderness
with signs of a classic abscess:
■ erythema, acute tenderness,
edema, and, occasionally,
cellulitis of the surrounding
subcutaneous tissue.
○ Without therapy, most abscesses tend to
rupture spontaneously by the third or
fourth day
● Treatment:
○ Asymptomatic cysts in women younger
than 40 years do not need treatment.
○ Treatment of choice: Marsupialization
■ to develop a fistulous tract from
the dilated duct to the vestibule
○ Alternative: Word catheter
○ Excision of a Bartholin duct and gland
■ for persistent deep infection,
multiple recurrences of
abscesses, or recurrent
enlargement of the gland in
women older than 40 years.
■ should be performed when the
infection is quiescent
■ Drainage and biopsy may be
sufficient.
● Differential diagnosis:
○ mesonephric cysts of the vagina
○ epithelial inclusion cysts
○ Rarely, a lipoma, fibroma, hernia, vulvar
varicosity, or hydrocele may be confused
with a Bartholin duct cyst
PEDICULOSIS PUBIS AND SCABIES
● Vulvar pruritis may be caused by animal parasites
○ Most common: crab louse and the itch mite
● Pediculosis pubis
○ infestation by the crab louse, Phthirus
pubis
○ Lice in the pubic hair are the most
contagious of all STIs, with more than
90% of sexual partners becoming
infected after a single exposure
○ Transmitted via close contact, towels &
beddings
○ Incubation period: approximately 30 days
○ constant pubic pruritus caused by
allergic sensitization - predominant
symptom
○ Examination of the vulvar area without
magnification demonstrates eggs and
adult lice and pepper grain feces
adjacent to the hair shafts
○ Definitive diagnosis: make a microscopic
slide by scratching the skin papule with a
needle and placing the crust under a drop
of mineral oil.

● Scabies
○ Caused by itch mite, Sarcoptes scabiei,
also transmitted by close contact
○ spreads over the body, without a
predilection for hairy areas (hands,
wrists, breasts, vulva, and buttocks are
the most common)
○ itch mite travels rapidly over skin: 2.5 cm
in 1 minute
○ Predominant clinical symptom is severe
but intermittent itching
○ intense pruritus occurs at night
○ Initial symptoms usually present
approximately 3 weeks after primary
infestation.
○ may present as papules, vesicles
○ DDx: includes almost all dermatologic
diseases that cause pruritus (great
dermatologic imitator)
● Treatment
○ involves an agent that kills both the adult
parasite and the eggs
○ pediculosis pubis involves the use of
permethrin 1% cream rinse, or pyrethrins,
with piperonyl butoxide applied to the
affected area and washed off after 10
minutes.
○ For scabies, permethrin 5% cream
applied to all areas of the body from the
neck down and washed off after 8 to 14
hours or ivermectin, 200 mg/kg orally,
repeated in 2 weeks, if necessary
○ Alternative: Lindane, but
recommended as first-line therapy
because of toxicity
○ women should be examined 1 week after
initial therapy
To avoid reinfection pediculosis pubis or scabies:
● Treatment prescribed for sexual contacts within the
previous 6 weeks and other close household
contacts
● Bedding and clothing should be decontaminated
● Fumigation of living areas is NOT necessary.
● women and physicians should not confuse the 1%
cream rinse of permethrin dosage recommended for
pubic lice with the 5% permethrin cream
recommended for scabies.
MOLLUSCUM CONTAGIOSUM
● poxvirus spread by direct skin-to-skin contact
● flesh-colored, dome-shaped papules with an
umbilicated center.
● Mode of transmission:
○ autoinoculation
○ during contact sports
○ fomites on bath sponges or towels
● Incubation period
○ 2-7 weeks
● Manifestation
○ ADULTS:
■ asymptomatic disease of the
vulvar skin; mildly contagious
■ If widespread infection; closely
related to underlying HIV
infection, chemotherapy or
corticosteroid use
● Diagnosis:
○ characteristic appearance of the lesions:
■ small nodules or domed papules
■ 1 to 5 mm in diameter
■ more mature nodules have an
umbilicated center
○ To confirm diagnosis:
■ white waxy material from inside
the nodule may be expressed on
a microscopic slide
■ intracytoplasmic molluscum
bodies with Wright or Giemsa
stain
● Major complication:
○ bacterial superinfection
● Molluscum contagiosum is usually a self-limiting
infection and spontaneously resolves after a few
months in immunocompetent individuals
● Treatment
○ Inject local anesthesia
○ Evacuate caseous material
○ Excise nodule with a sharp dermal curette
○ Base of papule is chemically treated with
■ ferric subsulfate (Monsel solution)
not or 85% trichloroacetic acid.
○ Alternative: cantharidin - chemical
blistering agent
○ Imiquimod
○ Cryotherapy
○ In HIV: Highly active antiretroviral therapy
(HAART)
 ○ involvement of the vagina and cervix are
common
● Systemic symptoms:
○ 70% of women: general malaise and
fever
○ Primary infections of the urethra and
bladder may result in acute urinary
retention
■ necessitating catheterization
○ Symptoms of vulvar pain, pruritus, and
discharge
■ Peak: Day 7 and 11 of primary
infection
○ Severe symptoms in approx. 14 days
● Recurrent genital herpes:
○ less severe symptoms
○ typically with unilateral involvement
○ Last ave. of 7 DAYS

HSV-2
● 80% of women experience a recurrence in the 1st
yr of infection
● Common feature of recurrence:
○ PRODROMAL PHASE [few hrs to 5 days
before vesicle formation]
■ Sacroneuralgia
■ vulvar burning
■ Tenderness
■ pruritus
○ LATENT PHASE
■ dorsal root ganglia of S2, S3, and
GENITAL ULCERS S4.
● present as ulcerations in the genital area ● Extragenital sites of recurrent infection are
○ Herpes common.
○ granuloma inguinale (donovanosis)
○ Lymphogranuloma venereum
○ Chancroid
○ Syphilis

GENITAL HERPES
● recurrent viral infection
● Incurable and highly contagious
● 75% of sexual partners of infected individuals
contracts the disease
● 80% of infected individuals are unaware that they
are infected
● Asymptomatic shedding that leads to transmission
may occur as frequently as once in 5 days

2 Distinct types:
● herpes simplex virus type 1 (HSV-1)
● herpes simplex virus type 2 (HSV-2)

Genital HSV-1
● Transmitted from orolabial lesions to the vulva
during
○ oral-genital contact
○ genital to genital to contact
● most commonly acquired genital herpes in
women younger than 25 years
● Local Effects:
○ vulvar skin paresthesia preceding eruption
of multiple PAINFUL vesicles→ progress to
shallow, superficial ulcers over a large area of
the vulva
○ heal without scarring
○ Viral shedding:
■ 2 to 3 weeks
■ positive cultures for HSV may be
obtained from lesions in 80% of
women
○ Severe vulvar pain, tenderness, and
inguinal adenopathy
DIAGNOSIS OF GENITAL HERPES
● Often made clinically by simple inspection
● Viral cultures are useful in primary episodes, when
culture sensitivity is 80%, but less useful in
recurrent episodes
● Polymerase chain reaction (PCR) assay the
most accurate and sensitive technique for
identifying herpesvirus
● Serologic tests determine whether a woman was
infected with herpes virus in the past
● Western blot assay for antibodies to herpes is the
most specific method but is not widely available and
is difficult to perform
● Screening for HSV-1 or HSV-2 in the general
population is not indicated

TREATMENT
● Treatment of HSV-1 or HSV-2 may be used for
three different clinical scenarios
○ Primary episode
○ Recurrent episode
○ Daily suppression
● Daily suppressive therapy is recommended when
the woman has six or more episodes annually or for
psychological distress
● Patients must be aware that asymptomatic viral
shedding can occur even when on daily
suppressive therapy.
● Acyclovir or other suppressive drugs are
discontinued after 12 months to determine the
subsequent rate of recurrence for each individual
woman (CDC)
● Acyclovir is a drug with minimal toxicity and safe
● Vaccine would be the logical approach for optimum
prevention of herpes (research is ongoing)

GRANULOMA INGUINALE
● Also known as donovanosis
● Chronic, ulcerative, bacterial infection of the skin
and subcutaneous tissue of the vulva
● Common in tropical climates
● Spread through both sexual and close nonsexual
contact, not highly contagious, and chronic
exposure is usually necessary with a variable
incubation period from 1 to 12 weeks
● Caused by an intracellular, gram-negative,
nonmotile, encapsulated rod, Klebsiella
granulomatis, which is difficult to culture on
standard media
● Thera is no FDA approved molecular tests for the
detection of K. granulomatis DNA and serologic
tests are nonspecific.
● The disease course is as follows:
○ Initial nodule progresses into a painless,
slowly progressing ulcer surrounded by
granulation tissue
○ Ulcer has a beefy red appearance, bleeds
easily when touched, and is painless and
without regional adenopathy
 ○ Multiple nodules are typically present, ➔ 1 to 4 weeks later — Painful inguinal and
resulting in ulcers that grow and coalesce perirectal adenopathy is present
○ Chronic disease eventually destroys the ➔ 50% of patients develop systemic
normal vulvar architecture with scarring symptoms — including general malaise
and lymphatic obstruction, producing and fever
marked enlargement of the vulva ➔ Without treatment: infected nodes become
increasingly tender, matted together and
DIAGNOSIS adherent to overlying skin — forming a
● Clinically diagnosed in endemic areas bubo or tender lymph node
● Identifying Donovan bodies in smears and ➔ Groove sign: double genitocrural fold — a
specimens taken from the ulcers depression between groups inflamed
● Donovan bodies appear as clusters of dark-staining nodes — classic sign of LGV.
bacteria with a bipolar (safety pin) appearance
found in the cytoplasm of large mononuclear cells
● The differential diagnosis includes:
○ lymphogranuloma venereum
○ Vulvar carcinoma
○ Syphilis
○ Chancroid
○ Genital herpes
○ Amebiasis
○ Other granulomatous diseases.

3. Tertiary phase
➔ Extensive tissue destruction of the external
genitalia and ano rectal region
➔ Tissue destruction and secondary
extensive scarring and fibrosis may result
in:
◆ Elephantiasis
◆ Multiple fistulas
◆ Stricture formation of the anal
canal and rectum
Diagnosis:
● Established by detecting C. trachomatis by:
○ Culture
○ Direct immunofluorescence
○ Nucleic acid detection from the pus or
TREATMENT aspirate from a tender lymph node
● A wide range of oral broad-spectrum antibiotics ● Chlamydia serologic testing — complement fixation
may be used to manage granuloma inguinale titers: > 1:64 — can support the diagnosis
● Azithromycin 1 g orally once a week or 500 mg ● Absence of specific LGV diagnostic testing — treat
daily for 3 weeks and until all lesions have healed patients based on the clinical presentation —
● If medical therapy fails: surgical excision is required including proctocolitis or genital ulcer disease with
● Coinfection with another sexually transmitted lymphadenopathy.
pathogen is a distinct possibility Differential Diagnosis:
● Sex partners of women who havegranuloma ● Syphilis
inguinale should be examined if they have had ● Chancroid
sexual contact during the 60 days preceding the ● Granuloma inguinale
onset of symptoms ● Bacterial lymphadenitis
● Vulvar carcinoma
● Genital herpes
● Hodgkin disease
LYMPHOGRANULOMA VENEREUM Treatment:
● LGV is a chronic infection of lymphatic tissue ● Preferred treatment according to CDC —
produced by Chlamydia trachomatis. doxycycline 100 mg twice daily for at least 21 days
● Found most commonly in tropics and most common ● Incision and drainage of infected nodes — to
in men alleviate inguinal pain
● Vulva is the most common site of infection in ● Extensive surgical reconstruction — for late
women sequelae of the destructive tertiary phase of LGV
○ Other sites may be affected include: ○ Administration of antibiotics during the
urethra, rectum, and cervix perioperative period is important.
● Etiology: L1, L2, and L3 strains of C. trachomatis
○ Incubation period: between 3 and 30 days CHANCROID
3 Distinct Phases of Vulvar and Perirectal LGV
1. Primary Infection ● It is a sexually transmitted, acute, ulcerative
➔ A shallow, painless ulcer is present that disease of the vulva.
heals rapidly without therapy typically ● Common in developing countries but infrequent in
located on the vestibule or labia but the US
occasionally in the periurethral or ● Etiology: H. ducreyi
perirectal region. ○ A highly contagious, small, non motile,
2. Secondary phase gram- negative rod
 ● The clinical importance of chancroid has been
enhanced by reports that the genital ulcers of
chancroid facilitate the transmission of HIV infection
● Incubation period: short; usually 3 to 6 days
● Tissue trauma and excoriation of the skin must
precede initial infection because H. ducreyi is
unable to penetrate and invade normal skin.
Clinical Manifestations:
● Initial lesion: small papule, always painful and
tender
● Within 48 to 72 hours: papule evolves into a pustule
and subsequently ulcerate
○ Ulcers are usually in the vestibule:
■ Shallow
■ Extremely painful
■ A characteristic ragged edge
■ Have a dirty, gray, necrotic, foul-
smelling exudate
■ Lack induration at the base —
soft chancre
● Within 2 weeks: Untreated infection
○ 50% of women develop acutely tender
inguinal adenopathy — a unilateral bubo
Definitive diagnosis:
● Identification of H. ducreyi on special culture media
— not widely available
● PCR test
● Chancroid can be diagnosed clinically in a woman
with painful vulvar ulcers after excluding other
common STIs that produce vulvar ulcers, including
genital herpes, syphilis, LGV, and donovanosis.
Treatment: CDC recommends the following:
● Azithromycin 1 g PO once daily
● Ceftriaxone 250 mg IM in a single dose
● Ciprofloxacin 500 mg orally twice daily for 3 days
● Erythromycin base 500 mg orally three times daily
for 7 days
➔ Treat sexual partners in a similar fashion
➔ Approx. 10% of women whose ulcers initially heal
have recurrence at the same site
➔ HIV infected patients require more prolonged
therapy because of an increased rate of failure of
the standard treatments for chancroid
Note: Coinfection with another ulcer causing an STI should
be considered, especially in women lacking an appropriate
response to treatment.
SYPHILIS
● It is a chronic, complex systemic disease that is
commonly underreported
● Remains one of the most important STIs in the US
● Early syphilis is a cofactor in the transmission and
acquisition of HIV, and 25% of new syphilis cases
occur in persons coinfected with HIV.
● Etiologic agent: Treponema pallidum — penetrates
skin or mucous membrane
● Detection: noncultivable; Can be diagnosed via
dark-field microscopy, direct fluorescent antibody
test
● Incubation period: 10 to 90 days — average of 3
weeks
● Moderately contagious:
○ 3 to 10% of patients contract the disease
from a single sexual encounter with an
infected partner
○ 30% of individuals become infected during
a 1-month exposure to a sexual partner
with primary or secondary syphilis.
○ Patients are contagious during primary
and secondary stages and probably for the
first year of latent syphilis.
● Transmission:
○ via kissing or touching a person who has
an ac- tive lesion on the lips, oral cavity,
breast, or genitals.
○ Case transmission can occur with oral-
genital contact.
Diagnosis:
● Presumptive and screening of syphilis rely on 2
types of serologic tests:
○ Nonspecific nontreponemal tests
○ Specific antitreponemal antibody tests
● Nontreponemal tests such as: VDRL slide test and
RPR card test
○ Inexpensive and easy to perform
○ Positive 4 to 6 weeks after exposure
○ useful index of treatment response
because quantitative nontreponemal
antibody titers usually correlate with the
activity of the disease
○ False positive results in:
■ Recent febrile illness
■ Pregnancy
■ Immunization
■ Chronic active hepatitis
■ Malaria
■ Sarcoidosis
■ IV drug use
■ HIV infection
■ Advancing age
■ Acute herpes simplex
■ Autoimmune diseases such as
SLE and RA
○ False negative result in approx. 1% to 2%
■ occurs in women in whom there is
an excess of anticardiolipin
antibody in the serum — the
prozone phenomenon
■ Immunocompromised women
● A nonspecific positive test result is confirmed by a
specific antitreponemal test, which is more sensitive
but may produce false-positive results, especially in
women with lupus erythematosus.
● Standard for antitreponemal tests include:
○ Fluorescent-labeled Treponema antibody
absorption (FTA-ABS) test
○ Microhemmaglutinin assay for antibodies
to T. pallidum (MHA-TP)
Note: Woman with a positive reactive treponemal test usually
will have this positive reaction for her lifetime, regardless of
treatment or activity of the disease.
CLINICAL STAGES OF SYPHILIS
PRIMARY SYPHILIS
● Approximately 2 to 3 weeks after exposure painless
papule appears at inoculation site and soon
ulcerates to produce the classic chancre: a
painless ulcer, 1 to 2 cm, with a raised indurated
margin and a nonexudative base
● Chancre is typically solitary, painless, and found on
the vulva, vagina, or cervix, with non tender and
 firm regional adenopathy during the first week of
clinical disease
● Within 2 to 6 weeks, the painless ulcer heals
spontaneously; hence, many women do not seek
treatment, a feature that enhances the likelihood of
transmission
● Syphilis is not often diagnosed in the primary
stage in women
SECONDARY SYPHILIS
● Hematogenous dissemination of the spirochetes
leads to systemic disease
● Develops in approximately 25% of patients between
6 weeks and 6 months (average, 9 weeks) after the
primary chancre if primary syphilis is untreated
● Untreated attack of secondary syphilis lasts 2 to 6
weeks and produces a multitude of systemic
symptoms:
○ Rash
○ Fever
○ Headache
○ Malaise
○ Lymphadenopathy
○ Anorexia
● Classic rash: red macules and papules over the
palms of the hands and the soles of the feet
● Vulvar lesions of condyloma latum: large, raised,
flattened, grayish white areas
● On wet surfaces of the vulva, soft papules often
coalesce to form ulcers that are larger than herpetic
ulcers and are not tender unless secondarily
infected
● Women with syphilis are most infectious during
the first 1 to 2 years of disease, with decreasing
infectivity thereafter
LATENT STAGE SYPHILIS
● Positive serologic testing without symptoms or
signs of disease follows the secondary stage and
varies in duration from 2 to20 years
● When most women are diagnosed with syphilis,
which is detected via positive blood tests
● Early latent syphilis is an infection of 1 year or less
and women are infectious during the first year of
latent syphilis
● All other cases are referred to as late latent or
latent syphilis of unknown duration
● Women with latent syphilis who have been sexually
active should have a pelvic examination to discover
potential lesions involving the vagina or cervix
TERTIARY SYPHILIS
● develops in ~33% of patients who are not
appropriately treated during the primary, secondary,
or latent phases of the disease and is devastating in
its potentially destructive effects on the central
nervous, cardiovascular, and musculoskeletal
systems.
● manifestations of late syphilis:
○ optic atrophy, tabes dorsalis, generalized
paresis, aortic aneurysm, and gummas of
the skin and bones.
○ gumma is similar to a cold abscess, with a
necrotic center and the obliteration of
small vessels by endarteritis.
Treatment
● parenteral penicillin G is the drug of choice for
syphilis
● Because of the slow replication time of the
spirochete, blood levels must be maintained for 7-
14 days.
● Jarisch-Herxheimer reaction
○ ~60% of women develop an acute febrile
reaction associated with flu-like symptoms
such as headache and myalgia within the
first 24 hours after parenteral penicillin
therapy for early syphilis.
Follow-up
Following are guidelines for follow-up:
● Early syphilis:
○ reexamine clinically and serologically at 6
and 12 months after therapy; titer should
decline fourfold in 6 months and become
negative within 12 months.
● Latent syphilis:
○ quantitative nontreponemal serologic tests
6, 12, and 24 months after therapy.
○ With successful treatment, the VDRL titer
will become nonreactive or at most be
reactive, with a lower titer within 1 year.
● Therapeutic failure
○ There is a 1-2% chance that the woman
will not exhibit a fourfold titer decline
○ Women who have a sustained fourfold
increase in nontreponemal test titers have
experience treatment failure or become
reinfected
○ should be retreated with 3 weekly
injections of benzathine penicillin G, 2.4
million units IM, and evaluated for
concurrent HIV infection.
 ● Patients with syphilis lasting longer than 1 year
should have quantitative VDRL titers for 2 years
after therapy because their titers will decline more
slowly.
● A specific test for syphilis, such as the FTA-ABS,
remains reactive indefinitely.
● After penicillin treatment for syphilis, women with
HIV should be followed with quantitative titers at
more frequent intervals—for example, at 3, 6, 9, 12,
and 24 months after therapy.
Partner treatment:
● Evaluate all partners clinically and serologically.
● Identify an at-risk sex partner: 3 months plus
duration of symptoms for primary or secondary
syphilis, and 1 year for early latent syphilis.
● Those exposed within the 90 days preceding the
diagnosis of a partner with primary, secondary, or
early latent syphilis should be treated presumptively
because they may be infected, even if seronegative.

VAGINITIS
● Vaginal discharge is the most common
symptom in gynecology;
● dyspareunia, dysuria, odor, and vulvar burning, and
pruritus are other symptoms associated with vaginal
infection.
● 3 common causes of vaginitis are:
1. fungus (candidiasis)
2. protozoon (Trichomonas)
3. disruption of the vaginal bacterial
ecosystem leading to bacterial vaginosis.
● The relative prevalence of vaginitis differs
depending on the population studied.
○ In a group of mid–socioeconomic class
women in the reproductive range, bacterial
vaginosis represents approximately 50% of
cases, whereas candidiasis and
Trichomonas infection each constitute
approximately 25% of cases.
● Vaginal environment is a dynamic ecosystem.
○ Normal pH ~4.0 in premenopausal
women (maintained by a complex
interplay of hormonal, microbiologic and
other unknown factors)
Summary:
○ Lactobacillus is the regulator of normal
● All women with a first attack of primary syphilis
vaginal flora
should have a negative nonspecific serologic
● Vaginal discharge characteristics, especially the
test within 1 year, and women treated for
amount of discharge, are insensitive and
secondary syphilis should have a negative serologic
nonspecific diagnostic criteria for vaginitis
test within 2 years.
● Vaginal acidity measured with pH indicator paper
● If they do not, treatment failure, reinfection, and
is one of the most helpful diagnostic aids in the
concurrent HIV infection should be investigated.
differential diagnosis of vaginitis
● Syphilis often involves the CNS and this may occur
during any stage of syphilis.
● Diagnosis is based on a combination of clinical
findings, reactive serologic tests, and abnormalities
of cerebrospinal fluid, serology, cell count, or
protein.
● Women should undergo a CSF examination if they
develop neurologic or ophthalmologic signs or
symptoms, evidence of active tertiary syphilis,
treatment failures, and HIV infection with late latent
syphilis or syphilis of an unknown duration.
● It is important for all women with syphilis to be
tested for HIV infection.
● Simultaneous syphilis and HIV infections alter the
natural history of syphilis, with earlier involvement
of the CNS.
● Women with HIV infection may have a slightly
increased rate of treatment failure with currently
recommended regimens.
● Similarly, they may exhibit unusual serologic
responses.
● Usually, serologic titers are higher than expected;
however, false-negative serologic tests or delayed
appearance of seroreactivity has been reported.
● Nevertheless, the CDC’s recommendation for
treating early syphilis in women is the same
whether or not they are concurrently infected with
HIV.
 infection is termed frothy (with bubbles) and often
has an unpleasant odor.
● Diagnosed through nucleic acid amplification tests
(NAATs)
● Treatment: Nitroimidazoles
- Primary regimen is a single oral dose (2 g)
of metronidazole or tinidazole
- An alternate regimen is metronidazole, 500
mg orally, twice daily for 7 day
- Topical therapy for Trichomonas vaginitis
is not recommended because it does not
eliminate disease reservoirs in Bartholin
and Skene glands

KC - 529-531
● Asymptomatic women with Trichomonas identified
in the lower genitourinary tract should be treated
(one of three asymptomatic women will become
symptomatic within 3 months).
● HIV acquisition is increased in women with
Trichomonas infection.
○ In women with HIV infection, 500 mg twice
daily for 7 days for trichomoniasis is more
effective.
● low-level metronidazole resistance in T. vaginalis -
prolonged treatment with higher doses of
metronidazole and tinidazole
● Because T. vaginalis is sexually transmitted,
treatment of the woman’s partner is important
and increases cure rates.
● Patients should be rescreened with a NAAT in 3
months because of high reinfection rates.

BACTERIAL VAGINOSIS
● Most prevalent cause of symptomatic vaginitis: 15%
to 50% of vaginitis
● “musty or fishy” odor
● Represents a shift in vaginal flora—marked
decrease in lactobacilli-dominant flor
● Clinically diagnosed. Three of these four criteria are
sufficient for a presumptive diagnosis:
- 1.)a homogeneous vaginal discharge—thin
and graywhite
- 2.) discharge has a pH of 4.5 or higher
- 3.)discharge has an amine-like odor when
mixed with potassium hydroxide, the whiff
test
- 4.)a wet smear of the vaginal discharge
demonstrates clue cells
● Risk factors include new or multiple sexual partners
and women who have sex with women
● Concurrent treatment of the male partner is not
recommended at this time. Alternative therapies
such as the use of oral or vaginal Lactobacillus are
not efficacious.

Trichomonas Vaginal Infection

● Caused by the anaerobic flagellated protozoon
Trichomonas vaginalis
● The most prevalent nonviral, nonchlamydial STI of
women with 5 million new cases of trichomoniasis
annually in the United States
● Highly contagious STI
● Incubation period is 4 to 28 days
● Primary symptom is profuse vaginal discharge
● On physical examination a woman with T. vaginalis
may have erythema and edema of the vulva and Candida Vaginitis
vagina ● Candida vaginalis is produced by a ubiquitous,
● The discharge color may be white, gray, yellow, airborne, gram-positive fungus.
or green, and the classic discharge of Trichomonas
● more than 90% of cases are caused by Candida
albicans (Fig. 23.18), with 5% to 10% of vaginal
fungal infections produced by Candida glabrata or
Candida tropicalis.
● Candida spp. are part of the normal flora of
approximately 25% of women, being a commensal
saprophytic organism on the mucosal surface of the
vagina.
● Candida prevalence in the rectum is three to four
times greater and in the mouth two times greater
than in the vagina.
● Candida organisms develop filamentous (hyphae
and pseudohyphae) and ovoid forms, termed
conidia, buds, or spores.
○ The filamentous forms of C. albicans
have the ability to penetrate the mucosal
surface and become intertwined with the
host cells (Fig. 23.19). This results in
secondary hyperemia and limited lysis of
tissue near the site of infection.
○ C. glabrata does not produce
filamentous forms.
● Some women with recurrent vulvovaginal Fungal Vulvovaginitis
candidiasis have tissue infiltration with ● Primarily a disease of the childbearing years.
polymorphonuclear (PMN) leukocytes. ● Common: three of four women will have at least
○ high density of PMNs correlates with one episode.
symptoms but does not result in clearance ● Approximately 3% to 5% of women experience
of Candida recurrent vulvovaginal candidiasis (RVVC),
● Risk factors for C. albicans which is defined as four or more documented
○ Hormonal factors (pregnancy, immediately episodes in 1 year.
preceding and after menses) ● Pruritus is the predominant symptom; may have
○ Depressed cell-mediated immunity (e.g., vulvar burning, external dysuria, and dyspareunia.
corticosteroid users, HIV) ● Vaginal signs:
○ Antibiotic use, especially those that ○ vaginal pH associated with this infection is
destroy lactobacilli (e.g., penicillin, less than 4.5;
tetracycline, cephalosporins) ○ discharge is variable in amount, white or
○ Obesity and debilitating disease whitish gray, highly viscous, granular or
floccular, with no odor
● With speculum, a cottage cheese–type discharge
is often visualized, with adherent clumps and
plaques (thrush patches) (Fig. 23.20, A).
● Vulvar signs include erythema, edema, and
fissuring (Fig. 23.20, B).

● For diagnosis:
○ wet smear mixed with potassium
hydroxide;
○ a negative smear does not exclude
Candida vulvovaginitis.
● Vaginal fungal culture is particularly useful when a
wet mount is negative for hyphae but the patient
has symptoms and discharge or other signs
suggestive of vulvovaginal candidiasis on
examination, or for women who have recently
treated themselves with an antifungal agent
 ○ up to 90% have a negative culture within
1 week after treatment.
● Over-the-counter (OTC) availability of vaginal
antifungal therapy makes self-treatment an option
for many women, though the nonspecific symptoms
of fungal infections may reflect an alternative
diagnosis; hence, if a woman chooses self-
treatment, she should be advised to come in for
examination if the symptoms are not eliminated with
a single course of OTC therapy.
● Also consider noninfectious conditions such as
allergic reactions, contact dermatitis, chemical
irritants, and rare diseases such as lichen planus.
● For treatment of vulvovaginal candidiasis, the CDC
recommends placing the woman into an
uncomplicated or complicated category to guide
treatment (Box 23.2).
● Uncomplicated vulvovaginal candidiasis:
○ topical antifungal agents for 1 to 3 days, or
a single oral dose of fluconazole.
● Complicated vaginitis:
○ topical azoles for 7 to 14 days or for oral
therapy;
○ a second fluconazole dose (150 mg) given
72 hours after the first dose.
● If RVVC:
○ longer duration of therapy;
○ 7 to 14 days of topical therapy or 3 doses
of oral fluconazole 3 days apart (e.g., days
1, 4, and 7) are options.
○ Then maintenance therapy such as oral
fluconazole (e.g., 100-, 150-, or 200-mg
dose) weekly for 6 months or topical
treatments used intermittently as a
maintenance regimen may be considered.
● Women with recurrent vulvovaginitis should
receive a vaginal fungal culture to determine
species and sensitivities.
● Infections with Candida spp. other than C.
albicans are often azole resistant;
● Vaginal boric acid capsules (600 mg in 0 gelatin
capsules) for a minimum of 14 days resulted in
a symptomatic cure rate of 70% for women with
non–C. albicans infection.
● Boric acid inhibits fungal cell wall growth. It may
also be used for suppression in women with RVVC.
● After 10 days of therapy, one 600-mg capsule
intravaginally twice weekly for 4 to 6 months
decreases symptomatic recurrences.
TOXIC SHOCK SYNDROME
● acute febrile illness produced by a bacterial
exotoxin, with a fulminating downhill course
involving dysfunction of multiple organ systems.
● Cardinal features:
○ Abrupt onset and rapidity with which the
clinical signs and symptoms may present
and progress.
● It is not unusual for the syndrome to develop from a
site of bacterial colonization rather than from an
infection.
3 requirements for the development of classic TSS:
1. The woman must be colonized or infected with S.
aureus
2. The bacteria must produce TSS toxin 1 (TSST-1)
or related toxins
3. toxins must have a route of entry into the
systemic circulation.
● Tampon use remains a risk factor for TSS
○ women should be encouraged to change
tampons every 4-6 hours.
○ intermittent use of external pads is also
good prevention for TSS.
● Nonmenstrual TSS (~50% of cases) may be a
sequela of focal staphylococcal infection of the skin
and subcutaneous tissue, often after a surgical
procedure.
● Signs and symptoms of TSS are produced by the
exotoxin named toxin 1→ acts as a superantigen,
activating up to 20% of T cells at once, resulting in
massive cytokine production.
● Primary effects of toxin 1: produce increased
vascular permeability
○ resulting in profuse leaking of fluid
(capillary leak) from the intravascular
compartment into the interstitial space and
an associated profound loss of vasomotor
tone, causing decreased peripheral
resistance.
● should have a high index of suspicion for TSS in a
woman who has an unexplained fever and a rash
during or immediately after her menstrual period.
● Management of a classic case of severe TSS
demands an intensive care unit and the skills of an
expert in critical care medicine
CERVIX
● acts as a barrier between the abundant bacterial
flora of the vagina and the bacteriologically sterile
endometrial cavity and oviducts.
● Cervical mucus exerts a bacteriostatic effect,
contains antibodies and inflammatory cells that are
active against various sexually transmitted
organisms, and also may act as a competitive
inhibitor with bacteria for receptors on the
endocervical epithelial cells.
CERVICITIS
● inflammatory process in the cervical epithelium and
stroma
● can be associated with trauma, inflammatory
systemic disease, neoplasia, and infection.
● Cervical infection can be ectocervicitis or
endocervicitis.
Ectocervicitis
● can be viral: HSV; parasitic: severe vaginitis e.g.,
strawberry cervix associated with T. vaginalis infection;
or fungal: C. albicans
Endocervicitis
 ● may be secondary to infection with C. trachomatis or N.
gonorrhoeae.
● Bacterial vaginosis and Mycoplasma genitalium have
also been associated
● Primary endocervical infection may result in secondary
ascending infections, including pelvic inflammatory
disease and perinatal infections of the membranes,
amniotic fluid, and parametria.
● Chronic cervicitis, when found on a cervical biopsy as a
histologic diagnosis, is so prevalent that it should be
considered the norm for parous women of reproductive
age and does not merit empiric therapy.
Mucopurulent Cervicitis (MPC)
● diagnosed clinically with any of the following PE
manifestations:
○ Yellow mucopurulent cervical discharge and/or
the presence of ≥10 PMN
leukocytes/microscopic field (magnification, x
1000) on endocervical Gram-stained smears
○ Hypertrophy or edema or increased
erythema in cervical ectropion
○ Bleeding secondary to endocervical
ulceration
○ Friability when the endocervical smear is
obtained
○ Symptoms of MPC include the following:
○ Increased vaginal discharge
○ Intermenstrual or postcoital vaginal
bleeding
○ Deep dyspareunia
PREVALENCE
● ~30-40% of women attending clinics for STIs
● 8-10% of women in university student health clinics
have the condition.
● >60% of women with this disease are
asymptomatic.
ETIOLOGY
● present in ~40-60% of women in whom no cervical
pathogen can be identified.
● C. trachomatis or N. gonorrhoeae are important
causes;
● however, most women who have cervical infections
caused by C. trachomatis or N. gonorrhoeae do not
have MPC, and most women who have
mucopurulent cervicitis are not infected by C.
trachomatis or N. gonorrhoeae.
● Mycoplasma genitalium - noncultivable, has been
associated with mucopurulent cervicitis by DNA
testing.
● FDA-approved NAATs are now available for testing.
● Treatment is with moxifloxacin or azithromycin.
● Resistance has been found, so in women with
persistent cervicitis with a positive NAAT for M.
genitalium after moxifloxacin and azithromycin
treatment, consider consulting a specialist.
● Bacterial vaginosis has also been associated with
mucopurulent cervicitis; cervicitis resolved with
bacterial vaginosis treatment.
TREATMENT
● When clinically diagnosed, empirical therapy for C.
trachomatis
● recommended for women at increased risk of this
common STI (age younger than 25 years, new or
multiple sex partners, unprotected sex)
● Concurrent therapy for N. gonorrhoeae is indicated
if the prevalence of N. gonorrhoeae is >5% in the
population.
● Concomitant trichomoniasis should also be treated
if detected, as should bacterial vaginosis.
● If presumptive treatment is deferred, the use of a
sensitive nucleic acid test for C. trachomatis and N.
gonorrhoeae is needed with consideration of adding
a NAAT for Trichomonas.
● Recommended regimens for presumptive
cervicitis therapy:
○ azithromycin, 1 g orally in a single dose
○ Or, doxycycline, 100 mg orally twice daily
for 7 days
○ adding gonococcal treatment if the
prevalence is >5% in the population
assessed.
● Women treated for cervicitis should be instructed to
abstain from sexual intercourse for 7 days after
single dose therapy or until completion of the 7-day
regimen.
DETECTION OF CERVICAL BACTERIA
Neisseria Gonorrhoeae
● NAAT of the urine or vaginal secretions are over
95% sensitive and specific and are the most
sensitive and specific diagnostic tool for identifying
gonorrheal infections.
● Urine tests should be first void (either the first void
in morning or at least 1 hour since last void).
● Most women who are colonized with N.
gonorrhoeae are asymptomatic.
● Screening of high-risk individuals is the primary
modality to control the disease.
● Antibiotic-resistant gonorrhea (GC) is problematic.
● The CDC STD Treatment Guidelines (2015)
recommend dual therapy with ceftriaxone 500 mg
once IM as solo therapy for all GC infections

● With N. gonorrhoeae or C. trachomatis infection,
● Women with endometritis found on EMB should be
PELVIC INFLAMMATORY DISEASE
● infection in the upper genital tract not associated with
● Thus it may include infection of any or all of the following
● CDC no longer recommends follow-up test of
cure, but because of a high rate of reinfection,
frequent rescreening is prudent.
● Women with positive test for gonorrhea should have
a serologic test for syphilis in 4 to 6 weeks
● attached to the columnar epithelium hence, vaginal cuff
specimens from women who have had a hysterectomy
are not appropriate.
Chlamydia Trachomatis
● NAAT - gold standard test
● C. trachomatis attaches to the columnar epithelium;
hence, vaginal cuff specimens from women who have
had a hysterectomy are not appropriate (same with N.
gono)
● often asymptomatic
● CDC recommends annual screening of all sexually
active women 25 years of age or younger and screening
of older women with risk factors (e.g., those who have a
new sex partner or multiple partners).
● For all women with a chlamydial or gonorrheal infection,
partners should be treated.
● Instruct patients to refer all sex partners of the past 60
days for evaluation and treatment and to avoid sexual
intercourse until therapy is completed and they and their
partner have resolution of symptoms.
● All women with C. trachomatis, N. gonorrhoeae, or
mucopurulent cervicitis of unknown origin need
evaluation to rule out pelvic inflammatory disease.
● The preferred CDC treatment for C. trachomatis is
azithromycin, 1 g orally, single dose
ETIOLOGY
ENDOMETRITIS
● upper genital tract infection of the uterine lining and
occurs once an infection ascends through the cervix into
the endometrium or into the salpinx
● Distinct clinical syndrome with distinct risk factors:
○ douching in past 30 days
○ current intrauterine device in place
○ douching in days 1-7 of the menstrual
cycle
● Endometrial biopsy (EMB) - diagnostic gold standard
for endometritis with a histopathologic criterion of at
least one plasma cell per 120 field of endometrial
stroma combined with five or more neutrophils in the
superficial endometrial epithelium per X400 field.
● associated with young age (20-22 years old in most
studies), abnormal uterine bleeding (menorrhagia or
metrorrhagia or mid-cycle spotting), menstrual cycle day
less than 14, douching in the past 30 days, and a history
of prior PID.
● ● This robust inflammatory response causes cell death
● Lower genital tract infections with C. trachomatis, N.
gonorrhoeae, bacterial vaginosis, M. genitalium, and T.
vaginalis and mucopurulent cervicitis are associated
with histologic endometritis with an odds ratio (OR) of
1.5 to 3.0, depending on the study.
endometritis was apparent in 43% of those with a history
of prior PID and 23% of those without prior PID. This is
suggestive of possible immunologic memory.
treated using one of the CDC recommended treatment
regimens for PID.p
pregnancy or intraperitoneal pelvic operations.
anatomic locations:
○ endometrium (endometritis)
○ Oviducts (salpingitis)
○ ovary (oophoritis)
○ uterine wall (myometritis)
○ Uterine serosa and broad ligaments
(parametritis)
○ pelvic peritoneum
● Many authors prefer the term salpingitis because
infection of the oviducts is the most characteristic and
common component of PID.
● Importantly, most long-term sequelae of PID result from
destruction of the tubal architecture by the infection.
● >99% of acute PID results from ascending infection
from the bacterial flora of the vagina and cervix; it is
rare in the woman without menstrual periods, such as
the pregnant, premenarcheal, or postmenopausal
woman.
● <1% of cases results from transperitoneal spread of
infectious material from a perforated appendix or
intraabdominal abscess.
● Annually, acute PID occurs in 1% to 2% of all young,
sexually active women.
● ACUTE PID - most common serious infection of
women ages 16 to 25 years.
● Primary prevention of PID: prevent exposure and
acquisition of STIs such as safe sex practices and
promoting the use of condoms
● Secondary prevention: universal screening of women
at high risk for chlamydia and gonorrhea, screening for
active cervicitis, increasing use of sensitive tests to
diagnose lower genital infection, treatment of sexual
partners, and education to prevent recurrent infection.
●
● 2 classic sexually transmitted organisms associated
with PID:
○ N. gonorrhoeae and C. trachomatis
● ~15% of women with cervical infection by N.
gonorrhoeae subsequently develop acute PID.
● The virulence of the strain or colony type of N.
gonorrhoeae helps predict the incidence of upper
genital tract infection.
● Antibodies against the outer membrane protein of the
gonococcus develop in ~70% of women after severe
pelvic infection.
● The lack of significant antibody titers may help explain
why teenagers are more likely to develop upper genital
tract disease than women in their late 20s.
● The gonococcus ascends to the fallopian tube, and
damage occurs to the ciliated cells, most likely because
of an acute complement-mediated inflammatory
response with the migration of PMN leukocytes,
vasodilation, and transudation of plasma into the
tissues
and tissue damage.
 ● The process of repair with removal of dead cells and Diagnosis
fibroblast presence results in scarring and tubal ● The differential diagnosis of acute PID includes:
adhesions. ○ lower genital tract pelvic infection
● N. gonorrhoeae remains in the fallopian tubes for at ○ ectopic pregnancy,
most a few days in untreated patients. ○ Torsion or rupture of an adnexal mass,
● Upper tract chlamydial infection increases the risk of an ○ acute appendicitis
ectopic pregnancy by 3-6x compared with women ○ Gastroenteritis and
without chlamydial infection. ○ endometriosis
● Chlamydia may remain in the fallopian tubes for
months after initial colonization of the upper genital
tract.
● Cell-mediated immune mechanisms appear to be
important in tissue destruction associated with C.
trachomatis infection.
● Because chlamydial 57-kDa protein and human 60-kDa
heat shock protein have homologous regions, repeated
exposures to Chlamydia, such as may occur in
asymptomatic untreated C. trachomatis cervical
infection, may lead to an autoimmune response that
causes severe tubal damage, even if C. trachomatis is
no longer present.

Olive - 536-538

● The most common symptom of acute PID is

new-onset lower abdominal and pelvic pain.
● On pelvic examination, bilateral tenderness of the
parametria and adnexa is present and may be
exacerbated with movement of the uterus or cervix.
● M. genitalium, which is noncultivable and identified ● If the pain has been present for longer than 3
by PCR, has been associated with cervicitis, weeks, it is unlikely that the woman has acute
endometritis, and tubal factor infertility. PID.
● Endogenous aerobic and anaerobic flora of the ● Approximately 75% of patients with acute PID have
vagina often ascend to colonize and infect the an associated endocervical infection or
upper reproductive tract. coexistent purulent vaginal discharge.
● Regardless of the initiating event, the ● Abnormal uterine bleeding, especially spotting
microbiology of PID should be treated as mixed. or menorrhagia, is noted in approximately 40% of
● 85% of infections patients.
○ are spontaneous in sexually active ● Acute pelvic infection secondary to N. gonorrhoeae
females. is of rapid onset, and the pelvic pain usually
begins a few days after the start of a menstrual
● 15% of infections period.
○ develop after procedures that break the ● Acute pelvic infection caused by C. trachomatis
cervical mucus barrier, such as alone often may have an indolent course with slow
endometrial biopsy, curettage, IUD onset, less pain, and less fever.
insertion, hysterosalpingography, and ● 5% to 10% of women with acute PID develop
hysteroscopy. symptoms of perihepatic inflammation, Fitz-
Sequelae Hugh– Curtis syndrome, with right upper quadrant
● One in four women with acute PID experiences pain, pleuritic pain, and tenderness in the right
medical sequelae. upper quadrant when the liver is palpated. The pain
may radiate to the shoulder or into the back. Liver
transaminase levels may be elevated.
● It is important to remember that up to 50% of
women with tubal damage never experience any
symptoms consistent with PID.
●
● In practice, most women with acute PID do not
undergo laparoscopy because of the invasiveness
and expense of this technique. Endometrial
biopsy is more readily available as a diagnostic
tool
 ● Other factors that improve the likelihood of
diagnosis but are insensitive and nonspecific
include:
○ elevated temperature
○ elevated white blood cell (WBC) count,
○ and elevated erythrocyte sedimentation
rate.
● The presence of an increased number of vaginal
WBCs is the most sensitive laboratory indicator
of acute PID.
● Ultrasonography is of limited value for patients with
mild or moderate PID because of its low sensitivity,
but vaginal ultrasonography is helpful in
documenting an adnexal mass
● If the cervical discharge appears normal and no
WBCs are found on the wet preparation of vaginal
fluid, the diagnosis of PID is unlikely
● Multiple sexual partners = fivefold increase of
acquiring acute PID
● Condom use prevents the deposition and
transmission of infected organisms
● Women with frequent vaginal douching = threefold
to fourfold increased relative risk (compared with
women who douche less frequently than once a
month)
● Increased PID with IUD use occurs only at time of
inser- tion
● Social factors: involvement with a child protective
agency, prior suicide attempt, and alcohol use
before intercourse are also risk factors for PID
● frequency of intercourse with a monogamous
partner is not a risk factor
● Acute salpingitis occurring in a woman with a
previous tubal ligation is extremely rare and, when it
does occur, the symptoms of the infection are less
severe
● incidence of upper genital tract infection associated
with first-trimester terminations: 1 in 20 cases
● use of prophylactic antibiotics - to decrease the
incidence of associated acute PID
● concurrent bacterial vaginosis - higher risk for
postabortal infection; should be treated with oral
antibiotics with anaerobic coverage
● Women with HIV and PID have a higher incidence
of adnexal masses but respond to antibiotic therapy
in a similar fashion to that in women who are not
infected with HIV

TREATMENT

two most important goals

● resolution of symptoms
● preservation of tubal function
Timely initiation of antibiotic therapy as soon STI screening
results have been obtained and the diagnosis has been
suggested:
a. If not treated in the first 72 hours after the onset of
symptoms are three times as likely to develop tubal
infertility or ectopic pregnancy
b. Determining the need for hospitalization, patient
education, treatment of sexual partners, and careful
follow-up are key issues
Treatment and education of the male partner for the
prevention of the disease: use of proper contraceptives -
help reduce the rate of upper genital tract infection.
Most cases of PID are polymicrobial - broad-spectrum
antibiotic coverage is indicated
Outpatient treatment is appropriate if the patient can tolerate
oral therapy

The CDC has published recommendations for the outpatient

treatment of PID
● Ceftriaxone, 250 mg IM once, or cefoxitin, 2 g IM,
Risk Factors plus probenecid, 1 g orally in a single dose,
● gross indicators of the frequency of exposure to concurrently once, or another parenteral third-
STIs and PID. generation cephalosporin such as ceftizoxime or
○ age at first intercourse cefotaxime together with doxycycline, 100 mg orally
○ marital status, and twice daily for 14 days, is the recommended
○ number of sexual partners outpatient regimen
● optimal cephalosporin choice is not known
● The age distribution of uncomplicated STI is usually ● if the woman has BV - prolonged coverage with
the same as that for acute PID. It is a condition of metronidazole, 500 mg orally twice daily for 14 days
young women, with 75% of cases occurring in ● Other regimens with short-term effectiveness:
women younger than 25 years. amoxicillin-clavulanic acid and doxycycline;
azithromycin combined with ceftriaxone, 250 mg IM
single dose, with azithromycin, 1 g orally once
Suzanne - 539-541 weekly for 2 weeks
● Risk of a sexually active adolescent female: 1 in 8 ● Quinolone-containing regimens - no longer routinely
(decreases to 1 in 80 for women older than 25 recommended because of gonorrhea resistance
years) ● if parenteral cephalosporin therapy is not feasible -
use fluoroquinolones (levofloxacin, 500 mg orally
 once daily, or ofloxacin, 400 mg twice daily for 14
days), with or without metronidazole
● Reexamine within 48 to 72 hours of initiating
outpatient therapy to evaluate the response of the
disease to oral antibiotics
● If a patient develops PID with an IUD in place -
outpatient therapy leaving the IUD in situ may be
attempted if close follow-up of the woman is
possible. If the pelvic infection worsens or does not
improve - the IUD should be removed
CDC criteria for hospitalization:
● unsure diagnosis
● being too ill to tolerate oral therapy
● no improvement with oral therapy, and
● presence of a tubo-ovarian abscess or pregnancy
➔ The protocols stress the polymicrobial origin of acute
pelvic infection, increasing importance of C. trachomatis,
and emergence of penicillin-resistant N. gonorrhoeae
➔ CDC recommends that IV antibiotics be continued for at
least 24 hours after substantial improvement in the
patient
➔ If with mass - add ampicillin to clindamycin and
gentamicin;
➔ For patients without a mass - switch to oral antibiotics
when the symptoms have diminished and the woman has
been afebrile for 24 hours
➔ In both regimens, doxycycline is continued for a total of
14 days
Regimen A
● combination of doxycycline and IV cefoxitin
● excellent for community-acquired infection
● provide excellent coverage for N. gonorrhoeae, C.
trachomatis, and penicillinase-producing N.
gonorrhoeae
● Cefoxitin - excellent antibiotic against Peptococcus
and Peptostreptococcus spp. and E. coli
● disadvantage: the two drugs are less than ideal for
a pelvic abscess or anaerobic infections
● cefotetan has been found to be as effective as
cefoxitin
● no clinically significant difference in the
bioavailability of doxycycline whether it is given by
the oral or IV route
● doxycycline should be administered orally whenever
possible because of the marked superficial phlebitis
produced by IV infusion
● Doxycycline should be included in the regimen of
follow-up oral therapy; prolonged therapeutic levels
of the antichlamydial antibiotic are imperative.
Regimen B
● combination of clindamycin and an aminoglycoside
(gentamicin)
● advantage of providing excellent coverage for
anaerobic infections and facultative gram-negative
rods
● preferred for patients with an abscess, IUD-related
infection, and pelvic infection after a diagnostic or
operative procedure
● high IV levels of clindamycin, such as 900 mg every
8 hours, provide activity against 90% of bacterial
strains of Chlamydia
● Most infectious disease experts recommend the use
of a single daily dose of gentamicin rather than a
dose given every 8 hours
● initial once-daily aminoglycoside dosage is based
on nomograms that take body weight into
consideration
● advantages of a once-daily aminoglycoside
program are decreased toxicity, increased efficacy,
and decreased cost and no serum drug levels must
be measured
● Parenteral antibiotic therapy may be discontinued
when the woman has been afebrile for 24 hours,
and oral therapy with doxycycline (100 mg twice
daily) should continue to complete 14 days of
therapy
● Alternative inpatient regimens: ampicillin-sulbactam
plus doxycycline (because they have excellent
anaerobic coverage; good choice for women with a
tubo-ovarian complex)
➢ In summary, no regimen is uniformly effective for all
patients
➢ To date, there is insufficient clinical data to suggest
the superiority of one regimen over another with
respect to initial response or subsequent fertility.
Operative treatment are restricted to:
● life threatening infections,
● ruptured tubo-ovarian abscesses,
● laparoscopic drainage of a pelvic abscess,
● persistent masses in some older women for whom
future childbearing is not a consideration, and
● removal of a persistent symptomatic mass
➔ unilateral removal of a tubo-ovarian complex or an
abscess - common conservative procedure
drainage of a cul-de-sac abscess (via percutaneous
drainage or colpotomy incision) results in
preservation of the reproductive organs

Abscess Treatment
Tubo-ovarian complex
● collection of pus within an anatomic space created
by the adherence of adjacent organs
● contain a mixture of anaerobes and facultative or
aerobic organisms
Clindamycin
● penetrates the human neutrophil - this property
facilitates the level of clindamycin within the
abscess
● also stable in the abscess environment, which is not
true of many other antibiotics
● combination with an aminoglycoside is considered
the standard for treatment - this does not treat
Enterococcus, and ampicillin should be added if
there is suspicion that this organism is involved
● metronidazole alone is an effective alternative to
clindamycin for anaerobic infections but does not
provide gram-negative coverage
➔ If abscesses do not respond to parenteral broad-
spectrum antibiotics, drainage is imperative. Trans-
vaginal or transabdominal percutaneous aspiration
or drainage of pelvic abscesses may be
accomplished under ultrasonic or computed
tomography (CT) guidance
ACTINOMYCES INFECTION
Actinomyces
● a rare cause of upper genital tract infection
● most cases have been in women chronically
wearing an IUD for an average of 8 years
➔ Actinomyces israelii - part of a polymicrobial infection;
whether its role is primary or secondary in the infectious
process is unknown
➔ there is controversy about the significance of
discovering actinomycetes on a Pap smear of women
wearing an IUD
➔ Unless there are associated symptoms, such as fever,
abdominal pain, or abnormal uterine bleeding, the
identification of the organism in any cervical smear
should not prompt antibiotic therapy or IUD removal
TUBERCULOSIS
TB of the upper genital tract
● primarily chronic salpingitis and chronic
endometritis
● most gynecologists may never encounter a single
case
➔ a common cause of chronic PID and infertility in
other parts of the world
➔ should be suspected in patients who are immigrants
➔ usually found in premenopausal women also occurs
in postmenopausal women (10%)
➔ diagnosis is established by performing an
endometrial biopsy late in the secretory phase
➔ portion of the endometrial biopsy - sent for culture
and animal inoculation and the remaining portion
should be examined histologically
➔ findings of classic giant cells, granulomas, and
caseous necrosis confirm the diagnosis
➔ 2 of 3 women with tuberculous salpingitis will have
concomitant tuberculous endometritis
➔ Predominant presentations:
◆ infertility and
◆ abnormal uterine bleeding
➔ 35 % - mild to moderate chronic abdominal and
pelvic pain
➔ Advanced cases are often accompanied by ascites
➔ Some women may be asymptomatic
➔ pelvic examination are normal in approximately
50% of cases
➔ remaining patients have mild adnexal tenderness
and bilateral adnexal masses, with an inability to
manipulate the adnexa because of scarring and
fixation
Tuberculous salpingitis
➔ suspected when a woman is not responding to
conventional antibiotic therapy for acute bacterial
PID;
➔ (+) tuberculin skin test
➔ two of three women will have concomitant
tuberculous endometritis
➔ Treatment: medical
➔ CDC recommendation: start with a multidrug
regimen until the culture results yield specific
sensitivity
➔ Patients who have infection from MDR strains are
usually kept on a five-drug regimen
➔ Operative therapy are reserved for:
◆ persistent pelvic masses
◆ with resistant organisms
◆ older than 40 years, and
◆ endometrial cultures remain positive
➔ major sequelae of pelvic tuberculosis is infertility,
occasionally a woman will become pregnant after
medical therapy