Gynecologic Infections

Genet Gebremedhin(MD)
Assistant Prof of gynecology & obstetrics
University of Gondar
March 4 2012
 Gynecologic Infections
Gynecologic infections are frequent disorders
for which patients seek care from
gynecologists
These infections can be seen as:
1. Pathogens Causing Genital Ulcer
2. Pathogens Causing Infectious Vaginitis
3. Pathogens Causing Suppurative Cervicitis
4. Pathogens Causing Mass Lesions
5. Pathogens Causing Pruritus
 Normal Vaginal Flora
Vaginal flora of a normal asymptomatic reproductive-aged
woman includes multiple aerobic or facultative species as well
as obligate anaerobic species
Of these, anaerobes are predominant and outnumber
aerobic species approximately 10: 1
The function of and reason for bacterial colonization of the
vagina remains unknown.
Bacteria do exist in a symbiotic relationship with the host and
are alterable, depending on the microenvironment.
These organisms localize where their survival needs are met,
and have exemption from the infection-preventing
destructive capacity of the host.
 Normal flora contd.
Aerobes Anaerobes
Gram-positive Gram-positive cocci Yeast
Lactobacillus spp Peptostreptococcus spp Candida albicans
Diphtheroids Clostridium spp
Staphylococcus aureus Gram-positive bacilli
Staphylococcus epidermidis Lactobacillus spp
Group B Streptococcus Propionibacterium spp
Enterococcus faecalis Eubacterium spp
Staphylococcus spp Bifidobacterium spp
Gram-negative Gram-negative
Escherichia coli Prevotella spp
Klebsiella spp Bacteroides spp
Proteus spp Bacteroides fragilis group
Enterobacter spp Fusobacterium spp
Acinetobacter spp Veillonella spp
Citrobacter spp
Pseudomonas spp
 Normal Flora Contd.
Within this vaginal ecosystem, some microorganisms
produce substances such as lactic acid and hydrogen
peroxide that inhibit nonindigenous organisms.
Several other antibacterial compounds, termed
bacteriocins, provide a similar role and include peptides
such as acidocin and lactacin.
Some species have the ability to produce proteinaceous
adhesions and attach to vaginal epithelial cells.
For protection from many of these toxic substances, the
vagina secretes leukocyte protease inhibitor.
This protein protects local tissues against toxic
inflammatory products and infection
 Normal Flora Contd.
Typically, the vaginal pH ranges between 4 and 4.5.
Although not completely understood, it is believed to result
from Lactobacillus species' production of lactic acid, fatty acids,
and other organic acids.
In addition, amino acid fermentation by anaerobic bacteria
results in organic acid production as does bacterial protein
catabolism.
Glycogen present in healthy vaginal mucosa is believed to
provide nutrients for many species in the vaginal ecosystem.
Accordingly, as glycogen content within vaginal epithelial cells
diminishes after menopause, this decreased substrate for acid
production leads to a rise in vaginal pH
Changing any element of this ecology may alter the prevalence
of various species.
 Normal Flora Contd.
Vaginal flora may be altered by
Menopause
Treatment with a broad-spectrum antibiotic
Menstruation
Total abdominal hysterectomy
Altered vaginal flora results in bacterial vaginosis(BV)
BV is not sexually transmitted disease (STD), and
It is seen in women without previous sexual experience.
Successful prevention of BV is limited, but elimination or
diminished use of vaginal douches may be beneficial
 Bacterial Vaginosis (BV)
BV reflects abnormal vaginal flora, and is poorly understood.
It has been variously named, and former terms include Haemophilus
vaginitis, Corynebacterium vaginitis, Gardnerella or anaerobic
vaginitis, and nonspecific vaginitis.
For unknown reasons, the vaginal flora's symbiotic relationship
shifts to one in which there is overgrowth of anaerobic species
including Gardnerella vaginalis, Ureaplasma urealyticum,
Mobiluncus species, Mycoplasma hominis, and Prevotella species.
Bacterial vaginosis (BV) is also associated with a significant reduction
or absence of the normal hydrogen peroxide-producing
Lactobacillus species.
Whether an altered ecosystem leads to lactobacilli disappearance or
whether its disappearance results in the changes observed with BV
is unknown.
Bacterial Vaginosis contd.
Risk Factors of Bacterial Vaginosis
Oral sex
Douching
Black race
Cigarette smoking
Sex during menses
Intrauterine device
Early age of sexual intercourse
New or multiple sexual partners
Sexual activity with other women
 Bacterial Vaginosis contd.
Diagnosis
Nonirritating, malodorous vaginal discharge is characteristic, but
may not always be present.
BV is associated with, vaginitis, endometritis, postabortal
endometritis, pelvic inflammatory disease unassociated with
Neisseria gonorrhoeae or Chlamydia trachomatis, and acute pelvic
infections following pelvic surgery, especially hysterectomy.
The vagina is usually not erythematous, and cervical examination
reveals no abnormalities.
Clinical diagnostic criteria were first proposed by Amsel and
associates (1983) and include:
Microscopic evaluation of a saline "wet prep" of vaginal secretions,
Determination of the vaginal PH, pH is >4.5
Release of volatile amines produced by anaerobic metabolism.
Bacterial Vaginosis contd.
Bacterial Vaginosis contd.
Clue cells are epithelial cells containing many attached
bacteria, which create a poorly defined stippled cellular
border.
Adding 10 % potassium hydroxide (KOH) to a fresh sample of
vaginal secretions releases volatile amines that have a fishy
odor. whiff test.
Similarly, alkalinity of seminal fluid and blood are responsible
for odor complaints after intercourse and with menses.
The finding of both clue cells and a positive whiff test is
pathognomonic, even in asymptomatic patients.
Trichomonas vaginalis infection is also associated with
anaerobic overgrowth and resultant elaborated amines.
Women diagnosed with BV should have no microscopic
evidence of trichomoniasis.
 Bacterial Vaginosis contd.
Treatment
Cure rates 80 to 90 percent at 1 week, but within 3 months,
30 % of women have experienced a recurrence of altered
flora.
Treatment of male sexual partners does not benefit women
with this recurring condition and is not recommended.
 Bacterial Vaginosis contd.

Recommended Treatment of Bacterial Vaginosis

Agent Dosage

Metronidazole 500 mg orally twice daily for 7 days

Metronidazole gel 0.75%
Clindamycin
Clindamycin cream 2%
5 g (1 full applicator) intravaginally
once daily for 5 days
300 mg, orally twice daily for 7 days
5 g (1 full applicator) intravaginally at
bedtime for 5 days
Pathogens Causing Genital Ulcer
Genital ulcer: is complete loss of the epidermal covering
with invasion into the underlying dermis.
Erosion: describes partial loss of the epidermis without
dermal penetration.
All are sexually transmitted and are associated with HIV
infections
Sexual contacts require examination and treatment
The causes of genital ulcer include
Herpes simplex infection
Syphilis
Chancroid
Lymphogranuloma venereum
Granuloma inguinale
Herpes Simplex Virus Infection
Genital herpes is the most prevalent genital ulcer disease and is a
chronic viral infection.
The virus enters sensory nerve endings and undergoes retrograde
axonal transport to the dorsal root ganglion, where the virus
develops lifelong latency.
Spontaneous reactivation by various events results in anterograde
transport of virus particles/protein to the surface.
Here virus is shed, with or without lesion formation.
Immune mechanisms control latency and reactivation.
There are two types of herpes simplex virus, HSV-1 and HSV-2.
Type 1 HSV is the most frequent cause of oral lesions.
Type 2 HSV is seen with genital lesions, although both types can
cause genital herpes.
 Herpes Contd.
Clinical features
The mean incubation period is about 1 week.
Up to 90 % of those who are symptomatic with their initial infection will
have another episode within a year.
Burning and severe pain accompany initial vesicular lesions, and urinary
symptoms such as frequency and/or dysuria may be present with those
of the vulva.
The virus infects viable epidermal cells, the response to which is
erythema and papule formation.
With cell death and cell wall lysis, blisters form.
The covering then disrupts, leaving a usually painful ulcer.
These lesions develop crusting and heal, but may become secondarily
infected.
 Herpes Contd.
The three stages of lesions are:
1. Vesicle with or without pustule formation, which lasts
about a week;
2. Ulceration; and
3. Crusting.
Virus is predictably shed during the first two phases of
an infectious outbreak.
Herpetic lesions may involve the vagina, cervix,
bladder, and rectum.
Commonly, a woman may have other signs of viremia
such as a low-grade fever, malaise, and cephalalgia.
Healing starts within 1 to 2 days.
 Herpes Contd.
Early treatment with an antiviral medication decreases the viral
load.
For a previously uninfected patient, the vesicular, or initial
stage, is longer. There is an increased period of new lesion
formation and a longer time to healing. Pain persists for the
first 7 to 10 days, and lesion healing requires 2 to 3 weeks.
If a patient has had prior exposure to HSV-2, the initial episode
is significantly less severe, with shorter pain and tenderness
duration, and time to healing approximates 2 weeks.
Recurrence following HSV-2 infection is common, and almost
two thirds of patients have a prodrome prior to lesion onset.
Heralding paresthesias are frequently described as pruritus or
tingling in the area prior to lesion formation.
prodrome symptoms may develop without actual lesion
formation.
 Herpes Contd.
Diagnosis
The gold standard for the diagnosis of a herpetic lesion(s) is
tissue culture.
Specificity is high, but sensitivity is low, and declines as
lesions heal.
In recurrent disease, less than 50 % of cultures are positive.
Polymerase chain reaction (PCR) testing is 1.5 to 4 times
more sensitive than culture and will probably replace it.
Importantly, a negative culture result does not mean that
there is no herpetic infection.
The sensitivity of HSV-2 antibody testing ranges from 80 to
98 percent.
Herpes Contd.
 Herpes Contd.
Treatment
Antiviral therapy (hasten healing and decrease symptoms,
therapy does not eradicate latent virus nor affect future
history of recurrent infections)
Analgesia with acetaminophen or codeine
Topical anesthetics such as lidocaine ointment may provide
relief.
Local care to prevent secondary bacterial infection is
important.
Patient education
See table on the next slide for treatment of herpes genitalis
 Herpes Contd.
First Clinical Episode of Genital Herpes
Acyclovir 400 mg three times daily for 7 to 10 days or
Acyclovir 200 mg five times daily for 7 to 10 days or
Famciclovir 250 mg three times daily for 7 to 10 days or
Valacyclovir 1 g twice daily for 7 to 10 days
Episodic Therapy for Recurrent Disease
Acyclovir 400 mg three times daily for 5 days or
Acyclovir 800 mg twice daily for 5 days or
Oral Suppressive Therapy Options
Acyclovir 400 mg twice daily
Famciclovir 250 mg twice daily
 Syphilis
Pathophysiology
Caused by the spirochete Treponema pallidum
The natural history of syphilis in untreated patients
can be divided into four stages.
1. Primary syphilis
2. Secondary syphilis
3. Latent syphilis
4. Tertiary syphilis
 Syphilis Contd
Primary Syphilis
The median incubation period before clinical manifestations is 21
days (range 3 to 90 days)
The incubation period is directly related to inoculum size. Without
treatment, these lesions spontaneously heal in up to 6 weeks
The hallmark lesion of this infection is termed a chancre, in which
spirochetes are abundant.
Classically, it is an isolated nontender ulcer with raised rounded
borders and an uninfected but integrated base.
However, it may become secondarily infected and can be painful.
Chancres are commonly found on the cervix, vagina, or vulva, but
may also form in the mouth or around the anus.
Syphilis Contd.

Chancre
 Syphilis Contd.
Secondary Syphilis
This phase is associated with bacteremia % develops 6
weeks to 6 months after a chancre appears.
Its hallmark is a maculopapular rash that may involve the
entire body and includes the palms, soles, and mucous
membranes.
As is true for the chancre, this rash actively sheds
spirochetes.
In warm, moist body areas, this rash may produce broad,
pink or gray-white, highly infectious plaques called
condylomata lata.
Fever, malaise
The kidney, liver, joints, and central nervous system (CNS)
(meningitis) may be involved
 Syphilis Contd.

Condylomata lata
maculopapular rash
 Syphilis Contd.
Latent Syphilis
A. Early latent syphilis
Is first year following secondary syphilis without treatment secondary
signs and symptoms may recur.
Lesions associated with these outbreaks are not usually contagious.
B. Late latent syphilis is defined as a period greater than 1 year after
the initial infection.
Tertiary Syphilis
This phase of untreated syphilis may appear up to 20 years after
latency. Gummas
During this phase, cardiovascular, CNS, and musculoskeletal
involvement become apparent.
cardiovascular and neurosyphilis are common in males
 Syphilis Contd.
Diagnosis
Early syphilis is diagnosed by dark-field examination or
direct fluorescent antibody testing of lesion exudate.
In the absence of this positive diagnosis, presumptive
diagnosis may be reached with serologic tests that are
A. Nontreponemal
Venereal disease research laboratory (VDRL) or
Rapid plasma reagin (RPR) tests
B. Treponemal-specific tests may be selected:
Fluorescent treponemal antibody-absorption (FTA-ABS) or
Treponema pallidum particle agglutination (TP-PA) tests.
 Syphilis Contd.
Treatment
Benzathine penicillin is the treatment of choice.
With treatment, Jarisch-Herxheimer reaction, may occur
After treatment follow up at 6-month intervals for clinical evaluation as
well as serologic retesting.
Following treatment, sequential nontreponemal tests should be
performed.
A fourfold titer decrease (two dilutions) is required to define a clinically
significant decline.
During surveillance, the same type test should be used.
These tests usually become nonreactive after treatment and with time.
However, some women may have a persistent low rating, and these
patients are described as serofast.
 Syphilis Contd.
Recommended Treatment of Syphilis
Primary, secondary, early latent (<1 year) syphilis
Recommended regimen:
Benzathine penicillin G, 2.4 million units IM once
Alternative oral regimens (penicillin-allergic, nonpregnant women):
Doxycycline 100 mg orally twice daily for 2 weeks or
Tetracycline 500 mg orally four times daily for 2 weeks
Late latent, tertiary, and cardiovascular syphilis
Recommended regimen:
Benzathine penicillin G, 2.4 million units IM weekly times 3 doses
Alternative oral regimen (penicillin-allergic, nonpregnant women):
Doxycycline 100 mg orally twice daily for 4 weeks
 Chancroid
It is caused by a nonmotile, nonspore-forming, facultative, gram-
negative bacillus, Haemophilus ducreyi.
Incubation usually spans 3 to 10 days
Chancroid does not cause a systemic reaction,
Initially as an erythematous papule develops that becomes pustular
and within 48 hours, ulcerates.
Edges of these painful ulcers are usually irregular with
erythematous nonindurated margins.
The ulcer bases are usually red and granular.
Lesions are frequently covered with purulent material
Fourchette, vestibule, clitoris, and labia are usual locations
Half of patients will develop unilateral or bilateral tender inguinal
lymphadenopathy. If large and fluctuant, they are termed buboes.
 Chancroid Contd.
Diagnosis
Definitive diagnosis requires growth of H ducreyi on culture
media.
A presumptive diagnosis can be made with identification of
gram-negative, nonmotile rods on a Gram stain of lesion
contents.
Before obtaining either specimen, superficial pus or crusting
should be removed with sterile, saline-soaked gauze.
Treatment
Successful treatment will result in symptomatic
improvement within 3 days, and objective evidence of
improvement within 1 week.
Lymphadenopathy resolves more slowly, and if fluctuant,
incision and drainage may be warranted. 231`
 Chancroid Contd.

Recommended Treatment of Chancroid

Azithromycin 1 g orally or
Ceftriaxone 250 mg intramuscularly or
Ciprofloxacin 500 mg orally twice daily for 3 days or
Erythromycin base 500 mg orally three times daily for 7 days
 Granuloma Inguinale
Is also known as donovanosis
Caused by the intracellular gram-negative bacterium
Calymmatobacterium (Klebsiella) granulomatis.
This disease is only mildly contagious, requires repeated exposures,
and has a long incubation period of weeks to months.
Granuloma inguinale presents as painless inflammatory nodules
that progress to highly vascular, beefy red ulcers that bleed easily
on contact.
If secondarily infected they may become painful.
These ulcers heal by fibrosis, which can result in scarring resembling
keloids.
Lymph nodes are usually uninvolved, but may become enlarged,
and new lesions may appear along these lymphatic drainage
channels
Diagnosis is by identification of Donovan bodies during microscopic
evaluation of a specimen following Wright- Giemsa staining.
Granuloma Inguinale Contd.

Recommended Treatment of Granuloma Inguinale

Doxycycline 100 mg twice daily for a minimum of 3 weeks and until lesions
have completely healed or
Azithromycin 1 g orally once a week as above or
Ciprofloxacin 750 mg orally twice daily as above or
Erythromycin base 500 mg orally four time daily as above or
Trimethoprim-sulfamethoxazole DS orally twice daily as above
Lymphogranuloma Venereum (LGV)

This ulcerative genital disease is caused by Chlamydia trachomatis,

serotypes L1, L2, and L3.
The chlamydial life cycle is comprised of three stages.
Initially, infective particles (elementary bodies) penetrate a host
cell.
Here they develop into metabolically active reticulate bodies.
Binary fission within the cell allows reticulate bodies to transform
themselves into multiple elementary bodies, which are released by
exocytosis.
This infection is commonly divided into three stages as follows:
Stage 1— Small vesicle or papule;
stage 2— Inguinal or femoral lymphadenopathy; and
stage 3— Anogenitorectal syndrome.
Lymphogranuloma Venereum Contd.

Incubation for this infection ranges from 3 days to 2 weeks.

Initial papules heal quickly and without scarring.
They appear primarily on the fourchette and posterior vaginal wall
up to including the cervix.
During the second stage, sometimes referred to as the inguinal
syndrome, progressive enlargement of inguinal and femoral lymph
nodes is observed.
Enlarged painful nodes can mat together and create a characteristic
"groove sign", which appears in up to one fifth of infected women.
In addition, enlarging nodes may rupture through the skin, and
chronically draining sinuses may result.
LGV develop systemic infection with chlamydia and manifest
malaise and fever.
Pneumonitis, arthritis, and hepatitis have been reported
Lymphogranuloma Venereum Contd.

"groove" sign
Lymphogranuloma Venereum Contd.

In the third stage of LGV, a patient develops rectal pruritus and a

mucoid discharge from rectal ulcers.
If these become infected, the discharge becomes purulent.
This is a result of lymphatic obstruction that follows lymphangitis
and that may result in elephantiasis of external genitalia initially
and fibrosis of the rectum.
Rectal bleeding, crampy, abdominal & distention, rectal pain occur .
Peritonitis may follow bowel perforation.
Stenosis of the urethra and the vagina has also been reported.
LGV is diagnosed by exclusion of other causes & positive
chlamydial testing.
A serologic titer that is greater than 1:64 can support the diagnosis.
C trachomatis culture or PCR can be used for diagnosis.
Treatment: Doxycycline, 100 mg orally twice daily for 21 days.
42
Pathogens Causing Infectious Vaginitis

The term vaginitis is the diagnosis given to women

who present complaining of abnormal vaginal
discharge with vulvar burning, irritation, or itching.
The leading causes of symptomatic vaginal discharge
are bacterial vaginosis, candidiasis, & trichomoniasis.
Between 7 & 70 percent of women who have vaginal
discharge complaints will have no definitive
diagnosis.
 Fungal Infection

Caused by Candida albicans

Candidiasis is seen more commonly in warmer climates and in
obese patients.
Additionally, immunosuppression, DM, pregnancy, & recent broad-
spectrum antibiotic use predispose women to clinical infection.
It can be sexually transmitted, and several studies have reported
an association between candidiasis and orogenital sex.
Symptoms of candidiasis include pruritus, pain, and swelling.
vulvar erythema and edema with excoriations are common
findings.
The typical vaginal discharge is described as a cottage cheese-like
discharge.
Vaginal pH is normal (<4.5) & microscopic examination of vaginal
discharge with saline and 10-% KOH allows yeast identification.
 Fungal Infection Contd.
Diagnosis
Candida albicans is dimorphic with both yeast buds & hyphal
forms.
It may be present in the vagina as a filamentous fungus
(pseudohyphae) or as germinated yeast with mycelia.
Vaginal candidal culture is not routinely recommended.
Women who have four or more candidal infections during a year
are classified as complicated (recurrent) disease, and cultures
should be obtained to confirm the diagnosis.
The treatment of patients with RVVC consists of fluconazole
(150 mg every 3 days for 3 doses).
Patients should then be maintained on a suppressive dose of
this agent (fluconazole, 150 mg weekly) for 6 months.
On this regimen, 90% of women with RVVC will remain in
remission.
Fungal Infection Contd.
Candida vulvitis with more
papulous red areas.

Candida vaginitis with cottage cheese

like discharge and red vaginal walls.
 Fungal Infection Contd.
Uncomplicated Complicated

Sporadic or infrequent Recurrent candidal infection

Mild to moderate Severe infection

Likely infecting agent is Candida albicans Non-albicans candidiasis (C tropicalis, C glabrata)

Non immunocompromised woman Uncontrolled diabetes, immunosuppression,

debilitation, pregnancy
 Fungal Infection Contd.
Recommended Treatment of Vulvovaginal Candidal Infection
Intravaginal agents
Clotrimazole 1% cream, 5 g intravaginally 7 to 14 days or
100 mg tablet intravaginally for 7 days or
100 mg tablet intravaginally, 2 tablets for 3 days or
Miconazole 2% cream, 5 g intravaginally for 7 days
100 mg suppository intravaginally for 7 days
200 mg suppository intravaginally for 3 days
1200 mg suppository intravaginally once
Nystatin 100,000-unit tablet intravaginally for 14 days
Oral agent
Fluconazole 150 mg oral tablet once
 Trichomoniasis
Trichomoniasis is more commonly diagnosed in women because
most men are asymptomatic.
This parasite is usually a marker of high-risk sexual behavior, and
co-infection with other sexually transmitted pathogens is common,
especially Neisseria gonorrhoeae.
Trichomonas vaginalis has predilection for squamous epithelium,
and lesions increase accessibility to other STIs.
Incubation with T vaginalis requires 3 days to 4 weeks, and the
vagina, urethra, endocervix, and bladder can be infected.
No symptoms may be noted in up to one-half of women with
trichomoniasis, and such colonization may persist for months or
years in some women.
vaginal discharge is typically described as foul, thin, and yellow or
green.
Dysuria, dyspareunia, vulvar pruritus, and pain may be noted.
 Trichomonas Contd.
At times, symptomatology and physical findings are
identical to those of acute pelvic inflammatory disease.
With trichomoniasis, the vulva may be erythematous,
edematous, and excoriated.
The vagina contains the above-described discharge, and
subepithelial hemorrhages or "strawberry spots" may be
seen on the vagina and cervix.
Diagnosed by microscopic identification of parasites in a
saline preparation of the discharge.
Trichomonads are anteriorly flagellated anaerobic protozoa.
Vaginal ph is often elevated
Culture in Diamond media is the most sensitive diagnosis.
 Trichomonas Contd.

Trichomonas vaginitis Strawberry cervix Trichomonas vaginalis

Giemsa stain
 Trichomonas Contd.

Recommended Treatment of Trichomoniasis

Primary therapy
Metronidazole single 1-g dose orally or
Tinidazole single 2-g dose orally
Alternative regimen
Metronidazole 500 mg orally twice daily for 7 days
Recurring infections
Tinidazole 500 mg orally three times daily for 7 days or four times daily for 14
days
Category Physiologic Bacterial Candidiasis Trichomoniasis Bacterial
(normal) Vaginosis (streptococcal,
staphylococcal,
E coli)
Chief None Bad odor, Itching, Frothy discharge, Thin, watery
complaint increased after burning, bad odor, dysuria, discharge,
intercourse discharge pruritis, spotting pruritis

Discharge White, clear Thin, gray or White "cottage Green-yellow, Purulent

white, adherent, cheese like" frothy, adherent,
often increased discharge increased

KOH "whiff Absent Present (fishy) Absent May be present Absent

test"
Vaginal pH 3.8–4.2 >4.5 <4.5 >4.5 >4.5

Microscopic N/A "Clue cells", Hyphae and Trichomonads Many WBCs

findings slight increase in buds in 10- (protozoa with 3-5
WBCs, clumps of percent KOH flagella) may be
bacteria (saline solution (wet seen moving on
wet mount) mount) saline wet mount

Table comparing
vaginitis
Pathogens Causing Suppurative Cervicitis

The cause of cervical inflammation depends on the epithelium

affected.
The ectocervical epithelium can become inflamed by the same
micro-organisms that are responsible for vaginitis.
Conversely, N. gonorrhoeae and C. trachomatis infect only the
glandular(culumunar) epithelium
Diagnosis
The diagnosis of cervicitis is based on the finding of a purulent
endocervical discharge, generally yellow or green in color and
referred to as “mucopus”
Gram stain of mucopus shows increased number of neutrophils (30
per high-power field).
Intracellular gram-negative diplococci, gonococcal endocervicitis,
Gram stain negative diagnosis is chlamydial
The microbial etiology of endocervicitis is unknown in about 50% of
cases in which neither gonococci nor chlamydia is detected.
 Neisseria gonorrhoeae

Gonococcal infections among women are frequently asymptomatic.

Screening of high risk group is recommended
Risk factors for gonococcal carriage and potential upper
reproductive tract infection are:
Age < 25 years
History of sexually transmitted infections
A history of previous gonococcal infection
New or multiple sexual partners
Lack of barrier protection
Illicit drug use, and
Commercial sex work
 Neisseria gonorrhoeae contd.
Symptoms include cervicitis.
Cervicitis commonly describe a profuse odorless,
nonirritating, and white-to-yellow vaginal discharge.
Gonococcus can also infect the Bartholin and Skene glands,
the urethra, and ascend into the endometrium and fallopian
tube to cause upper reproductive tract infection.
Neisseria gonorrhoeae is a gram-negative coccobacillus that
invades columnar and transitional epithelial cells, becoming
intracellular. For this reason, the vaginal epithelium is not
involved.
For gonococcal identification, NAATs are available, and ideal
specimens are recovered from the endocervix.
These tests have replaced culture in most laboratories.
 Neisseria gonorrhoeae contd.

Recommended Single-Dose Treatment of Uncomplicated Gonococcal Infection

of the Cervix, Urethra, or Rectum
Ceftriaxone 125 mg IM or
Cefixime 400 mg orally or
Ciprofloxacin 500 mg orally or
Ofloxacin 400 mg orally or
Levofloxacin 250 mg orally
 Chlamydia trachomatis
This obligate intracellular parasite is dependent on host cells for
survival
It causes columnar epithelial infection.
Thus presenting symptoms reflect endocervical glandular infection,
with resultant mucopurulent discharge or endocervical secretions.
If infected, the endocervical tissue is commonly edematous and
hyperemic.
Urethritis is another lower genital tract infection that can develop,
and dysuria is prominent.
Diagnosis
Microscopic inspection of secretions following a saline preparation
typically reveals 20 or more leukocytes per high-power field.
More specifically, culture, NAAT, and enzyme-linked
immunosorbent assay (ELISA) are available for endocervical
specimens.
Chlamydia trachomatis Contd.

Recommended Treatment of Chlamydial Infection

Primary treatment
Azithromycin 1 g orally once or
Doxycycline 100 mg orally twice daily for 7 days
Alternative regimens
Erythromycin base 500 mg orally four times daily for 7 days or
Ofloxacin 300 mg orally twice daily for 7 days or
Levofloxacin 500 mg orally daily for 7 days
Pathogens Causing Mass Lesions
External Genital Warts
These lesions are created from productive infection with the
human papillomavirus (HPV)
Genital warts have various morphologies, and appearances range
from flat papules to the classic verrucous, exophytic lesions, termed
condyloma acuminata .
Lesions are found on lower reproductive tract, urethra, anus, or
mouth.
Diagnosed by clinical inspection, and biopsy is not required unless
co-existing neoplasia is suspected.
Condyloma acuminata may remain unchanged or spontaneously
resolve
Treatment: Podophyllin application/ Surgical removal
 Mass Lesions contd.
Molluscum Contagiosum
The molluscum contagiosum pox virus.
It is transmitted by intimate contact.
The host response to viral invasion is papular with central
umbilication, giving a characteristic appearance.
It may be single or multiple and is commonly seen on the vulva,
vagina, thighs, and/or buttocks
Diagnosis usually clinical.
Giemsa, Gram, or Wright stains may demonstrate molluscum
bodies, large intracytoplasmic structures.
Most lesions spontaneously regress over 6 to 12 months.
If removal is preferred, lesions may be treated by cryotherapy,
electrosurgical needle coagulation, or sharp needle-tip curettage of
a lesion's umbilicated center.
Pathogens Causing Pruritus
Scabies
Sarcoptes scabiei infect skin and result in an intensely pruritic rash.
The mite causing this infection is crab-shaped, and the female digs into
the skin and remains there for approximately 30 days, elongating her
burrow.
Several eggs are laid daily and begin hatching after 3 to 4 days.
The baby mites furrow their own burrows, becoming reproductive adults
in approximately 10 days.
Mites crawl at a rate of two and a half centimeters per minute, and
sexual transmission is the most likely cause of initial infection, although it
can be seen in household contacts
A delayed-type 4 hypersensitivity reaction to the mites, eggs, and feces
develops and results in erythematous papules, vesicles, or nodules in
association with skin burrows.
Definitive testing requires scraping across the burrow with a scalpel blade
and mixing these fragments in immersion oil on a microscope slide.
Identification of mites, eggs, egg fragments, or fecal pellets is diagnostic
 Pruritus Contd.
Treatment
Once diagnosed, 1-percent lindane cream is a commonly used
agent.
It is recommended that all family members be treated with the
exception of pregnant or lactating women and children younger
than 2 years.
Treatment is effective within 4 hours.
Eight to 12 hours after application, a shower or bath should be
taken to remove the medication.
Only one application is necessary, and bed linens and recently worn
clothing should be washed to prevent reinfection.
5-percent permethrin cream (Elimite), which is effective after a
single application. It should be washed off in 8 to 12 hours and is
safe in children older than 2 months and in pregnant women.
 Pruritus Contd.
Pediculosis
Lice are small ectoparasites that measure approximately one millimeter in
length.
Three species infest humans and include the body louse (Pediculus
humanus), the crab louse (Phthirus pubis), and the head louse (Pediculus
humanus capitis).
Lice attach to the base of human hair with claws, and it is this claw's
diameter that determines the infestation site.
For this reason, the crab louse is found on pubic hair and other hair of
similar diameter, such as axillary and facial hair, including eyelashes and
eyebrows.
Lice depend on frequent human blood meals, and pubic lice may travel up
to 10 centimeters in search of darkness and a new attachment site for
blood. They leave voluntarily if the victim becomes febrile, dies, or if there
is close contact with another human.
Accordingly, pubic lice usually are sexually transmitted, whereas head
and body lice may be transmitted by sharing personal objects such as
combs, brushes, and clothing.
 Pruritus Contd.
The main symptom from louse attachment & biting is
pruritus.
Patients may develop pyoderma and fever if secondarily
infected.
Each female adult pubic louse lays approximately four eggs
a day, which are glued to the base of hairs. Incubation is
about 1 month.
Their attached eggs, termed nits, can be seen attached to
the hair shaft away from the skin line as hair growth
progresses.
Pediculicides kill not only adult lice, but also the eggs. A
single application is usually effective, but a second
application is recommended within 7 to 10 days to kill new
hatches.
Treatment : 1-percent lindane shampoo can also be used.
Sexually Transmitted Infections
The term "sexually transmitted diseases" is used to
denote disorders spread principally by intimate contact.
Although this usually means sexual intercourse, it also
includes close body contact, kissing, cunnilingus,
anilingus, fellatio, mouth–breast contact, and anal
intercourse.
Caused by more than 20 micro organisms (some bacterial
other viral)
Most present with
Urethral discharge
Genital ulcer
Vaginal discharge
Swollen glands
 STI Contd.

Produce Considerable morbidity and

mortality
High incidence and prevalence
High rate of complications
Bigger problem in women and young people
Facilitate HIV transmission
 STI versus STD
STI – Infections acquired through sexual intercourse
(may be symptomatic or asymptomatic)
STD – Symptomatic disease acquired through sexual
intercourse
STI is most commonly used because it applies to both
symptomatic and asymptomatic infections

68
 Management Objectives

Proper diagnosis
Proper treatment begins by
-Risk assessment
-Clinical evaluation
-Confirmation
 STIs Management Approaches

I. Etiological/laboratory approach:-
Done by identifying the causative agent (s) using lab.
tests and giving treatment specific to the pathogen
identified.
II. Syndromic approach:-
Identification of clinical syndrome.
 Etiologic Diagnosis
Ideal approach
Important for validation of treatment algorithm
Determine prevalence
The only way to diagnose asymptomatic STI
Expensive
Time consuming
Requires lab facility
Ranges from simple laboratory tests to complex
(Microscopy, culture, Immunological tests, DNA
amplification)
 Syndromic Approach

A syndrome is a group of symptoms that

patients describe, combined with the signs that
providers observe during examination.
This approach entails identification of a clinical
syndrome and giving treatment targeting all the
locally known pathogens which can cause the
syndrome.
Syndromic approach focuses on common STIs
such as syphilis, chancroid, gonorrhea, chlamydial
infection, trichomoniasis and candidiasis.
 Why Syndromic Approach?

STI sign and symptoms are rarely specific to a

particular causative agent;
Laboratories are either non-existent or non
functional due to lack of resources;
Dual infections are quite common and both clinician
and laboratory may miss one of them;
Waiting time for lab. results may discourage some
patients;
Failure of cure at first contact
Shortage of STI specialists
 The Main Features of the Syndromic Approach

Grouping the main infectious agents according to the

clinical syndromes they cause,
Using flow-charts as tools,
Treating patients for all the important causes of a
syndrome,
Educating patients, promoting condoms and
emphasizing the importance of partner referral.
 Identifying the Syndromes

The syndromes identified in Syndromic approach are:

1. Urethral discharge in men
2. Scrotal swelling
3. Vaginal discharge
4. Lower abdominal pain
5. Genital ulcer
6. Inguinal bubo
7. Neonatal conjunctivitis
Components of Syndromic Management
of STIs

Take proper history & physical examination

Treat for (the cause/causes)
Educate the patient
Counsel if needed
Promote/provide condoms
Partner management
Offer HIV counseling and testing
Advice to return if necessary
 What do you need

Room with auditory privacy

Chaperon
Adequate light
Speculum
Glove
Slides and cotton swab
Others
Management is based on flow charts of specific
syndrome.
 Urethral Discharge Syndrome
• Possible etiologies:
– Gonococcal infection
– Chlamydia Trachomatis

78
 Patient complains
of urethral discharge
or dysuria Urethral Discharge
Take history Syndrome
& Do P/E; milk urethra
if necessary •Educate and counsel
•Offer VCT
Discharge No •Review if symptoms
Other STIs No
confirmed persist
present?
•Promote and provide
yes condoms
Treat for gonorrhea Yes
and chlamydia
•Educate
•Counsel Use appropriate
•Promote and provide condoms flow chart
•Offer VCT
•Partner management
•Advise to return in 7 days
if discharge persists
 Recommended Treatment for Urethral
Discharge and Burning on Urination
Ciprofloxacin 500 mg po stat,
or
Spectinomycin 2g IM stat
and
Doxycycline 100 mg po BID for 7 days, or
Tetracycline 500 mg po QID for 7 days, or
Erythromycin 500 mg po QID for 7 days if the
patient has contraindications for Tetracyclines
80
 Patient complains of Persistent or
Persistent/ recurrent
Urethral discharge or dysuria Recurrent Urethral
Take history Discharge in Men
and examine
•Educate/ counsel
No Other STIs No •Promote and
Discharge confirmed provide condoms
present
• Offer VCT
Yes
Yes
Does history
confirm reinfection
Use appropriate
or poor compliance
flow chart
No
Yes
Treat for trichomonas
vaginalis Repeat
•Educate/ counsel urethral discharge
•Promote and provide condoms treatment
•Return in 7 days

•Educate/ counsel
Improved Yes •Promote and provide condoms
No • Offer VCT
Refer
 Vaginal Discharge
• Common causes:
Neisseria gonorrhea
Chlamydia trachomatis
Trichomonas vaginalis
Bacterial vaginosis
Candida albicans

82
 Patient complains
of vaginal discharge or
vulval itching/ burning
Vaginal Discharge
Take history, examine patient
(external speculum and bimanual)
and assess risk Educate
No
Counsel
Abnormal discharge present Promote and provide condoms
Yes
Offer VCT

Lower abdominal tenderness Yes

or cervical motion tenderness
No
Yes
Was risk assessment positive?
Is discharge from the cervix?
Use flow chart for lower abdominal pain
Treat for chlamydia, gonorrhea,
bacterial vaginosis and trichomoniasis

No Vulva\l edema/curd like discharge

Erythema excoriation present
Treat for bacterial vaginosis No
Yes

Educate Treat for

Counsel Candida
Promote and provide condoms albicans
83 Offer VCT
 Recommended Treatment for
Vaginal Discharge
Risk Assessment Positive for STI Risk Assessment Negative for
STI

Ciprofloxacin 500mg PO stat, or Metronidazole 500mg PO BID for

Spectinomycin 2gm IM stat 7 days
and and
Doxycycline 100mg PO BID for 7 Clotrimazole vaginal tabs 200mg
days at bed time for 3 days
and
Metronidazole 500mg BID for 7
days

84
Patient complains of genital ulcer

Genital Ulcer
Take history & examine
Syndrome
Vesicles Or Recurrence
More than 3 ulcers No
Yes
No Solitary non vesicular Educate
Treat for HSV Non recurrent Promote and
provide
Yes condoms
Offer VCT
•Educate and counsel
•Promote and provide condoms Treat for syphilis,
•Offer VCT chancroid and HSV
•Ask the patient to return in 7 days

No
No
Ulcers healed Ulcers improving Refer
Yes
Educate and counsel Yes
Promote and provide condoms
Offer VCT
Partner management Continue treatment for further 7 days
 Genital Ulcer Disease Treatment
• Recommended treatment for non-vesicular genital ulcer
– Benzanthine penicilline 2.4 million units IM stat, or Doxycycline 100
mg bid for 15 days
and
– Ciprofloxacin 500mg, po, bid for 3 days, or Erythromycin 500 mg, po,
QID for 7 days
• Recommended treatment for vesicular or recurrent genital
ulcer
– Acyclovir 200 mg five times per day for 10 days
or
– Acyclovir 400 mg TID for 10 days

86
 Patient complains of
lower abdominal pain
Lower Abdominal Pain
Take history including gynecological
and examine (abdominal and vaginal)

Any of the following present Any other

Is there cervical excitation tenderness illness
•Missed overdue period
No Or lower abdominal tenderness found
•Recent delivery/ abortion No
And vaginal discharge
•Miscarriage
•Abdominal guarding Yes
Yes
•And or rebound tenderness
•Abdominal mass Manage for PID
Manage
•Abnormal vaginal bleeding Review in three days
appropriately
Yes
No
Patient has improved Refer patient
Refer the patient for surgical or
Yes
gynecological opinion
and assessment Continue treatment until completed
Before referral set up •Educate and counsel
an Iv line and resuscitate •Offer VCT
87 if required •Promote and provide condom
•Ask patient to return if necessary
 Scrotal Swelling
• Common STI causes of scrotal swelling are
similar to those of urethral discharge
– Neisseria gonorrhea
– Chlamydia trachomatis
• Exclude non-STI causes of scrotal swelling:
– TB
– Inguinal hernia
– Testicular torsion, etc

88
 Scrotal Swelling
Recommended Therapy
• Ciprofloxacin 500mg PO stat or Spectinomycin
2gm IM stat
and
• Doxycycline 100mg PO BID for 7 days, or
Tetracycline 500mg BID for 7 days

89
 Patient complains of
scrotal swelling or pain
Scrotal Swelling

Take history, examine,

offer HIV test

Reassure patient, educate,

Scrotal swelling or No Signs of other No
counsel, provide condoms.
pain present? STI present?
Review if symptoms persist
Yes
Yes

History of trauma or testis Treat according to

elevated or rotated? appropriate flowchart
or
No
Treat for chlamydia
Diagnosis in doubt?
and gonorrhea.
Yes
Review in 7 days

No Complete treatment course,

Refer patient to Yes
Patient has improved? reinforce
hospital
education and counseling
90 Review if symptoms persist
 Inguinal Bubo
• Swelling of inguinal lymph nodes as a result of
STIs (or other causes)
• Common causes:
– Treponema pallidum (syphilis)
– Chlamydia trachomatis (LGV)
– Hemophylus ducreyi (chancroid)
– Calymatobacterium granulomatis (granuloma
inguinale)

91
 Patient complaining of
inguinal swelling Inguinal Bubo
Take history
and examine
•Educate
Any other •Counsel
Inguinal/femoral No
STI present No •Offer VCT
bubo present? •Promote and provide condoms
Yes

Use appropriate flow chart

Ulcers Yes
present Use genital ulcer flow chart
No
Treat for LGV, GI and chancroid
•Aspirate if fluctuant
•Educate on treatment compliance
•Counsel on risk reduction
•Promote and provide condoms
•Partner management
•Offer VCT if available
•Advise to return in 07 days
•Refer if no improvement
 Inguinal Bubo
• Recommended treatment:
– Ciprofloxacin 500mg PO BID for 14 days
and
– Erythromycin 500mg PO QID for 14 to 21 days

93
 Neonatal Conjunctivitis
• Infection of the eyes of the neonate as a result
of genital infection of the mother, transmitted
during birth
• Causes:
– Neisseria gonorrhea
– Chlamydia trachomatis

94
 Neonate presents with eye discharge Neonatal Conjunctivitis
Take history and examine child

No No Reassure mother,
Purulent conjunctivitis present? Signs of other illness
educate parents
present?
Review if symptoms persist
Yes
Yes
Treat baby for gonococcal and
chlamydial opthalmia Treat appropriately
AND
Treat mother and partner for gonorrhoea
and chlamydia
Educate and counsel
Review baby in 7 days or sooner
if symptoms worsen

Review in
7 days
Yes Complete treatment course,
Eye infection cleared? reinforce education and counseling
Review if necessary
No

Refer for specialist opinion

and management
Neonatal Conjunctivitis: Treatment
• Treatment:
– Spectinomycin 50mg/kg IM stat
or
– Ceftriaxone 125mg IM stat
and
– Erythromycin 50mg/kg PO in 4 divided doses for
10 days
• May lead to blindness if not treated properly

96
 Pelvic inflammatory disease
Refers to acute infection of the upper genital tract of female
pelvis not related to pregnancy or surgery
Over 80% caused by STDs like gonorrhea and Chlamydia.
Lower abdominal pain is the cardinal presenting symptom
Recent onset of pain that worsens during coitus or with jarring
movement.
The onset of pain during or shortly after menses is particularly
suggestive
The abdominal pain is usually bilateral and rarely of more than
two weeks' duration
Uterus, tubes, ovaries, pelvic peritoneum are affected
Gonococcus may give perihepatitis
PID diagnosed with minimum, additional & definitive
diagnostic criteria
 PID Contd.
Perihepatitis 
 Perihepatitis (Fitz-Hugh Curtis Syndrome) was first associated with
gonococcal salpingitis in 1920 and subsequently with Chlamydia.
It consists of infection of the liver capsule and peritoneal surfaces of
the anterior right upper quadrant, with minimal stromal hepatic
involvement.
It manifests as a patchy purulent and fibrinous exudate in the acute
phase ("violin string" adhesions), most prominently affecting the
anterior surfaces of the liver (not the liver parenchyma)
Symptoms are typically the sudden onset of severe right upper
quadrant abdominal pain with a distinct pleuritic component,
sometimes referred to the right shoulder.
Aminotransferases are abnormal in approximately one-half of
patients
Perihepatitis 

"violin string" adhesions

 PID Diagnostic Criteria
I. Minimum Diagnostic II. Additional Diagnostic
Criteria
Uterine tenderness
adnexal tenderness
cervical motion tenderness
Lower abdominal
tenderness
Criteria
Oral tem >38.3 C
Elevated ESR
Elevated CRP
Abnormal cervical or vaginal
mucopurulent discharge
Presence of abundant
numbers of white blood
cells (WBCs) on saline
microscopy of vaginal
secretions
 Pelvic Inflammatory Disease

III. Definitive Diagnostic Criteria

Endometrial biopsy with histopathologic evidence of
endometritis
Transvaginal sonography or MRI showing thick fluid-
filled tubes
Laparoscopic abnormalities consistent with PID
 Management of PID

Hospitalization is indicated if
Surgical emergencies not excluded
Pregnancy
Clinical failure of oral antimicrobials
Inability to follow or tolerate oral regimen
Severe illness, nausea/vomiting, high fever
Tubo -ovarian abscess
Management of PID Contd.

Parenteral Regimen A
Ceftriaxone 1- 2 g IV q 12 hours
or
Cefoxitin 2 g IV q 6 hours
PLUS
Doxycycline 100 mg orally/IV
q 12 hrs
WITH OR WITHOUT
Metronidazole 500 mg IV/po q 8 hours
 Management of PID Contd.

Parenteral Regimen B
Clindamycin 900 mg IV q 8 hours
PLUS
Gentamicin loading dose IV/IM (2 mg/kg) followed
by maintenance dose (1.5 mg/kg) q 8 hours.
Single daily dosing may be substituted.
Management of PID Contd.

Alternative Parenteral Regimens

Ciprofloxacin 500 mg IV q 12 hours
or
Levofloxacin 500 mg IV once daily
WITH OR WITHOUT
Metronidazole 500 mg IV q 8 hours
or
Ampicillin/ Sulbactam 3 g IV q 6 hrs
PLUS
Doxycycline 100 mg orally/IV q 12 hrs
Management of PID Contd.
Oral Regimen A
Ciprofloxacin 500 mg single dose
Plus
Doxycycline 100 mg BID for 14 days
WITH OR WITHOUT
Metronidazole 500 mg twice daily for 14 days
Management of PID Contd.
Oral Regimen B
Ceftriaxone 250 mg IM in a single dose
or
Spectinomycin 2gm IM single dose
PLUS
Doxycycline 100 mg twice daily for 14 days
WITH or WITHOUT
Metronidazole 500 mg twice daily for 14 days
Management of Sex Partners

Male sex partners of women with PID should be

examined and treated for sexual contact 60 days
preceding pt’s onset of symptoms
Sex partners should be treated empirically with
regimens effective against CT and GC
Thank you