Infections of the Lower Genital Tract

Gynecology 101 Infections of the Lower Genital Tract Dra. Bautista First Shifting / November 26, 2008 Lynne, Deusah, Adriane, Buf Vaginitis is diagnosed by office-based testing.

Bacterial Vaginosis

More prolonged antifungal therapy is indicated for women with complicated vulvovaginal candidiasis (VVC) than for those with uncomplicated disease.

Bacterial vaginosis (BV) has previously been referred to as nonspecific vaginitis or Gardnella vaginitis.

Women with normal physical examination findings and no evidence of fungal infection disclosed by microscopy are unlikely to have VVC and should not be treated empirically unless results of a vaginal yeast culture are positive.

It is an alteration of normal vaginal bacterial flora that results in the loss of hydrogen peroxide–producing lactobacilli and an overgrowth of predominantly anaerobic bacteria

Cervicitis is commonly associated with bacterial vaginosis (BV), which, if not treated concurrently, leads to significant persistence of the symptoms and signs of cervicitis.

Numerous studies have shown an association of BV with significant adverse sequelae. Women with BV are at increased risk for pelvic inflammatory disease (PID), postabortal PID, postoperative cuff infections after hysterectomy, and abnormal cervical cytology.

Metronidazole should be included in the antimicrobial regimen used to treat patients with pelvic inflammatory disease (PID) if concurrent bacterial vaginosis is present.

Pregnant women with BV are at risk for premature rupture of the membranes, preterm labor and delivery, chorioamnionitis, and postcesarean endometritis.

Trocar drainage, with or without placement of a drain, is successful in as many as 90% of patients with PID complicated by tubo-ovarian abscess that fails to respond to antimicrobial therapy within 72 hours.

Diagnosis

Because false-negative results are common with herpes simplex virus (HSV) cultures, especially in patients with recurrent infections, type-specific glycoprotein G-based antibody assay tests are useful in confirming a clinical diagnosis of genital herpes.

1.

Suppressive treatment partially decreases symptomatic and asymptomatic viral shedding and the potential for transmission.

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The pH of these secretions is higher than 4.5 (usually 4.7 to 5.7).

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Microscopy of the vaginal secretions reveals an increased number of clue cells, and leukocytes are conspicuously absent. In advanced cases of BV, more than 20% of the epithelial cells are clue cells.

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The addition of KOH to the vaginal secretions (the “whiff” test) releases a fishy, aminelike odor.

THE NORMAL VAGINA

The four criteria (Amsel criteria) for the diagnosis of bacterial vaginosis are:

Vaginal secretions are gray and thinly coat the vaginal walls.

The normal vaginal flora is mostly aerobic, with an average of six different species of bacteria, the most common of which is hydrogen peroxide–producing lactobacilli. The pH level of the normal vagina is lower than 4.5, which is maintained by the production of lactic acid. Normal vaginal secretions are floccular in consistency, white in color, and usually located in the dependent portion of the vagina (posterior fornix). Clue cells are superficial vaginal epithelial cells with adherent bacteria, usually Gardnerella vaginalis, which obliterates the crisp cell border when visualized microscopically. Potassium hydroxide 10% (KOH) may be added to the slide, or a separate preparation can be made, to examine the secretions for evidence of fungal elements. The results are negative in women with normal vaginal microbiology. Gram stain reveals normal superficial epithelial cells and a predominance of gram-positive rods (lactobacilli).

A fishy vaginal odor, which is particularly noticeable following coitus, and vaginal discharge are present.

For the clinician three of the four criteria are sufficient for a presumptive diagnosis. Nugent 1. 2. 3. 4.

criteria: Uses differential bacterial counting on gram stain 6 bacterial vaginosis

Treatment Metronidazole, an antibiotic with excellent activity against anaerobes but poor activity against lactobacilli, is the drug of choice for the treatment of BV. A dose of 500 mg administered orally twice a day for 7 days should be used. Patients should be advised to avoid using alcohol during treatment with oral metronidazole and for 24 hours thereafter.

Vaginal Infections:

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU RACHE ESTHER JOEL GLENN TONI

Subject: Topic: Page 2 of 9 Metronidazolegel, 0.75%, one applicator (5 g) intravaginally once or twice daily for 5 days, may also be prescribed. Clindamycin in the following regimens also is effective in treating BV: 1.

Clindamycincream, 2%, one applicator full (5 g) intravaginally at bedtime for 7 days

2.

Clindamycin, 300 mg, orally twice daily for 7 days

3.

Clindamycin ovules, 100 mg, intravaginally once at bedtime for 3 days

4.

Clindamycin bioadhesive cream, intravaginally in a single dose

2%,

100

mg

Trichomonas Vaginitis Trichomonas vaginitis is caused by the sexually transmitted, flagellated parasite, Trichomonas vaginalis. The transmission rate is high; 70% of men contract the disease after a single exposure to an infected woman, which suggests that the rate of male-to-female transmission is even higher. The parasite, which exists only in trophozoite form, is an anaerobe that has the ability to generate hydrogen to combine with oxygen to create an anaerobic environment. It often accompanies BV, which can be diagnosed in as many as 60% of patients with trichomonas vaginitis. Diagnosis Trichomonas vaginitis is associated with a profuse, purulent, malodorous vaginal discharge that may be accompanied by vulvar pruritus.

Metronidazole gel, although highly effective for the treatment of BV, should not be used for the treatment of vaginal trichomoniasis. Women who do not respond to initial therapy should be treated again with metronidazole, 500 mg, twice daily for 7 days. If repeated treatment is not effective, the patient should be treated with a single 2-g dose of metronidazole once daily for 5 days or tinidazole, 2 g, in a single dose for 5 days. Patients who do not respond to repeated treatment with metronidazole or tinidazole and for whom the possibility of reinfection has been excluded should be referred for expert consultation. Vulvovaginal Candidiasis Candida are dimorphic fungi existing as blastospores, which are responsible for transmission and asymptomatic colonization, and as mycelia, which result from blastospore germination and enhance colonization and facilitate tissue invasion. The extensive areas of pruritus and inflammation often associated with minimal invasion of the lower genital tract epithelial cells suggest that an extracellular toxin or enzyme may play a role in the pathogenesis of this disease. Classification of Vulvovaginal Candidiasis Uncomplicated Complicated Sporadic or infrequent in Recurrent symptoms occurrence Mild to moderate symptoms Severe symptoms Likely to be Candida albicans Non-albicans Candida Immunocompetent women

Immunocompromised, diabetic women

e.g.,

Vaginal secretions may exude from the vagina.

Diagnosis

In patients with high concentrations of organisms, a patchy vaginal erythema and colpitis macularis (“strawberry” cervix) may be observed.

The symptoms of VVC consist of vulvar pruritus associated with a vaginal discharge that typically resembles cottage cheese.

The pH of the vaginal secretions is usually higher than 5.0. Microscopy of the secretions reveals motile trichomonads and increased numbers of leukocytes. Clue cells may be present because of the common association with BV. The whiff test may be positive. Damson’s medium used in culture, is the gold standard. Pregnant women with trichomonas vaginitis are at increased risk for premature rupture of the membranes and preterm delivery. Treatment Metronidazole is the drug of choice for treatment of vaginal trichomoniasis. Both a single-dose (2 g orally) and a multidose (500 mg twice daily for 7 days) regimen are highly effective and have cure rates of about 95%. The sexual partner should also be treated.

The discharge can vary from watery to homogeneously thick. External dysuria (“splash” dysuria) may occur when micturition leads to exposure of the inflamed vulvar and vestibular epithelium to urine. Examination reveals erythema and edema of the labia and vulvar skin. The cervix appears normal. The pH of the vagina in patients with VVC is usually normal ( ulcerates -> beefy-red ulcer with fresh granulation tissue -> multiple ulcer coalesce  If not treated, may destroy vulvar architecture leading to the chronic form -> scarring and lymphatic obstruction -> marked enlargement of the vulva

E.

LGV (Lymphogranuloma venereum) • Chronic infection of lymphatic tissue caused by Chlamydia trachomatis (serotypes L1, L2, L3) • Vulva is the frequent site • Urethra, rectum, cervix • Incubation: 3-30 days • Majority in men (5:1 ratio) • 3 phases: 1. Primary infection a. Shallow painless ulcer of the vestibule or labia b. May be near the rectum or urethra c. Heals rapidly without therapy 2. Secondary infection a. Begins 1-4 weeks after infection b. Painful adenopathy in inguinal and perirectal areas c. Untreated infected nodes – tender – enlarge to become buboes d. Groove’s sign – double genitocrural fold i. Depression between grooves or inflamed nodes ii. Classic sign 3. Tertiary infection a. Spontaneous rupture of buboes in 7 to 15 days b. Extensive tissue destruction of the external genitalia and anorectral region c. Elephantiasis, multiple fistulas, and stricture formation of anal canal and rectum

Herpes • Recurrent incurable STD • HSV 1 • infect epithelium above the waist • HSV 2

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ulceration below the waist dorsal root ganglia S2, S3, S4 primary infx – local and systemic initial infx – 15 to 35 years old incubation – 3 to 7 days viral shedding – 2 to 3 weeks after vulvar lesions appear Symptoms o Severe vulvar pain, tenderness, and inguinal adenopathy o Pain, pruritus and discharge – peaks at 7 to 11 days o General malaise and fever Indications for hospitalization: o Severe headache o CNS involvement o Extreme pain o Difficulty in walking o Severe pain on urination o Acute urinary retention o o o o o

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•

C.

Syphilis • Treponema pallidum • Stages: o Primary syphilis  Chance 21-35 days or anytime between 10-90 days o Secondary syphilis  Mucocutaneous lesion o Latent syphilis  Early/latent latent o Tertiary syphilis  Gumma, CNS, CVS • Primary lesion: painless hard chancre; red round ulcer with firm well-formed raised edges • Secondary lesions: o Hematogenous lesions o Systemic disease o Derived between 6 weeks to 6 months after the primary chancre o Red macules and papules over palms and soles o Vulvar lesion  Mucus patches • Condyloma latum associated with painless lymphadenopathy • Latent o follows secondary syphilis o Duration of 2 to 20 years o Positive serology without SSx of the disease • Tertiary o Devastating

Effects on CNS, CVS, musculoskeletal system Manifestation of late syphilis: optic atrophy, tabes dorsalis, generalized paresis, aortic aneurysm, gummas of skin and bones

________________________________________________________________ Diagnosis of genital ulcers:

Subject: Topic: Page 5 of 9 A diagnosis based on history and physical examination alone often is inaccurate. Therefore, all women with genital ulcers should undergo a serologic test for syphilis. A painless and minimally tender ulcer, not accompanied by inguinal lymphadenopathy, is likely to be syphilis, especially if the ulcer is indurated. A nontreponemal rapid plasma reagin (RPR) test, or venereal disease research laboratory (VDRL) test, and a confirmatory treponemal test—fluorescent treponemal antibody absorption (FTA ABS) or microhemagglutinin—T. pallidum (MHA TP), should be used to diagnose syphilis presumptively. Grouped vesicles mixed with small ulcers, particularly with a history of such lesions, are almost always pathognomonic of genital herpes. Culture is the most sensitive and specific test; sensitivity approaches 100% in the vesicle stage and 89% in the pustular stage and drops to as low as 33% in patients with ulcers.

Herpes: A first episode of genital herpes should be treated with acyclovir, 400 mg orally three times a day; or famciclovir, 250 mg orally three times a day; or valacyclovir, 1.0 orally twice a day for 7 to 10 days or until clinical resolution is attained. Episodic or recurrent (acyclovir 400 mg TID, 200 mg 5 times a day; famcyclovir 125 mg BID; valacyclovir 500 mg BID or 1 g OD) Daily suppressive therapy (acyclovir, 400 mg orally twice daily; or famciclovir, 250 mg twice daily; or valacyclovir, 1.0 g orally once a day) reduces the frequency of HSV recurrences by at least 75% among patients with six or more recurrences of HSV per year. Syphilis: Parenteral administration of penicillin G is the preferred treatment of all stages of syphilis. Benzathine penicillin G, 2.4 million units intramuscularly in a single dose, is the recommended treatment for adults with primary, secondary, or early latent syphilis. The Jarisch-Herxheimer reaction—an acute febrile response accompanied by headache, myalgia, and other symptoms—may occur within the first 24 hours after any therapy for syphilis Latent syphilis is defined as those periods after infection with T. pallidum when patients are seroreactive but show no other evidence of disease. Patients with latent syphilis of longer than 1 year's duration or of unknown duration should be treated with benzathine penicillin G, 7.2 million units total, administered as three doses of 2.4 million units intramuscularly each, at 1-week intervals. Quantitative nontreponemal serologic tests should be repeated at 6 months and again at 12 months. An initially high titer (1:32) should decline at least fourfold (two dilutions) within 12 to 24 months. Granuloma inguinale: Tetracycline 500 mg q 6 hours for 3 to 5 weeks until complete clinical response; can also use TMP-SMZ twice a day or doxycyline 100 mg twice a day LGV: Erythromycin base 500 mg QID PO for 21 days; sulfasoxazole 500 mg q 6 hours; doxycycline 100 mg BID q 21 days; aspiration of fluctulant nodes to prevent sinus formation, incision, drainage, are contraindicated ____________________________________________________________ Genital Warts (Condyloma acuminata)

One to three extremely painful ulcers, accompanied by tender inguinal lymphadenopathy, are unlikely to be anything except chancroid.

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An inguinal bubo accompanied by one or several ulcers is most likely chancroid. If no ulcer is present, the most likely diagnosis is LGV.

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Granuloma inguinale: identification of Donovan antibodies  drak staining bacteria with bipolar (safety pin) appearance found in the cytoplasm of large mononuclear cells

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LGV: culture of pus/aspirate for tender lymph node; complement fixation antibody titer ________________________________________________________________ Treatment of Genital Ulcers Chancroid: Recommended regimens for the treatment of chancroid include azithromycin,1 g orally in a single dose; ceftriaxone, 250 mg intramuscularly in a single dose; ciprofloxacin, 500 mg orally twice a day for 3 days; or erythromycin base, 500 mg orally 4 times daily for 7 days.

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Most common viral STD External genital warts are a manifestation of human papillomavirus (HPV) infection. The nononcogenic HPV types 6 and 11 are usually responsible for external genital warts. (vs the oncogenic types 16 and 18) The warts tend to occur in areas most directly affected by coitus, namely the posterior fourchette and lateral areas on the vulva. Four morphological subtypes: cauliflower, smooth popular, keratotic, flat

External genital warts are highly contagious; more than 75% of sexual partners develop this manifestation of HPV infection when exposed. The goal of treatment is removal of the warts; it is not possible to eradicate the viral infection. Recurrences more often result from reactivation of subclinical infection than reinfection by a sex partner; therefore, examination of sex partners is not absolutely necessary.

Subject: Topic: Page 6 of 9 Diagnosis: • Macroscopic lesion • Subclinical o Colposcopy  3-5% acetic acid  Shining white areas at infection with irregular borders/satellite lesions o Cytology  Nuclear atypia, delayed maturation, hyperkeratosis, parakeratosis, and koilocytosis Differential Dx: maculapapillomatous labialis, seborrheic keratosis, nevi, condyloma lata, molluscum contagiosum, neoplasia, giant condyloma, bowenoid papulosis, SCCA

Treatment Options for External Genital and Perianal Warts Modality Efficacy (%) Recurrence Risk Cryotherapy 63–88 21–39 Imiquimod 5% 33–72 13–19 cream* Podophyllin 10%– 32–79 27–65 25% Podofilox 0.5%* 45–88 33–60 Trichloroacetic acid 81 36 80% Electrodesiccation 94 22 or cautery Laser** 43–93 29–95 Interferon 44–61 0–67 *May be self-applied by the patients at home **Expensive; reserve for patients who have not responded to other regimens. URINARY TRACT INFECTIONS Acute Cystitis Abrupt onset of multiple, severe urinary tract symptoms including dysuria, frequency, and urgency associated with suprapubic or lowback pain. Suprapubic tenderness may be noted on physical examination. Urinalysis reveals pyuria and sometimes hematuria. Diagnosis Esherichia coli is the most common pathogen isolated from the urine of young women with acute cystitis, and it is present in 80% of cases. Staphylococcus saprophyticus is present in an additional 5% to 15% of patients with cystitis. The pathophysiology of cystitis in women in reproductive age involves the colonization of the vagina and urethra with coliform bacteria from the rectum. In post-menopausal women, lack of estrogen effect on orovaginal epithilum and presence of residual urine after voiding Independent risk factors for development of bacterial cyctitis: 1. Sexual intercourse 2. Use of vaginal diaphragm/ spermicide 3. Previous urinary tract infections 4. Recent exposure to antibiotics 5. Concurrent diagnosis of a bacterial vaginosis Diagnostic steps: • Pyuria seen in microscopic exam

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Women with classic symptoms and confirmation of pyuria – urine culture not needed Patients treated with same symptoms in the past – clean voided urine culture

Indications of urine culture • Patients with complicated history • UTI within the past month • Urinary symptomatology that has been present for >7 days • Cyctitis in >65 years old women • Pregnancy • Current disease like DM or immunosuppression Criterion in diagnosis of bacteriuria in: • Asymptomatic cases - >10(5) uropathogens/ mL • Symptomatic - >10(2) uropathogens/mL Treatment High concentrations of trimethoprim and fluoroquinolone (160/180 mg q 12 h (BID) for three days) in vaginal secretions can eradicate E. coli while minimally altering normal anaerobic and microaerophilic vaginal flora. Nitrofurantoin (macrocrystals, 100 mg orally twice daily for 7 days) or a fluoroquinolone (ciprofloxacin, 250 mg orally twice daily for 3 days) are the optimal choices for empirical 3-day therapy for uncomplicated cystitis. (For resistant cases) Advantages of 3 day therapy vs. traditional 7-14 day therapy 1. Simplicity 2. Better patient compliance 3. Lower cost 4. Reduction of side effects such as diarrhea and vaginitis • Standard empiric regimens for acute bacterial cystitis should be reassessed periodically because of changing pattern of resistance to antibiotics • Women with chronic infection, systemic manifestations, renal disease, anatomical abnormalities of urinary tract, pregnancy, DM prolonged therapy • Failure to respond necessitates quantitative culture of urine and culture of endocervix and urethra for Chlamydia and Gonorrhea • Differential relapse is reinfection • Modification of lifestyles i. Discontinue diaphragm use ii. Increase fluid intake iii. Increase voiding frequency iv. Voiding immediately after intercourse Recurrent Cystitis About 20% of premenopausal women with an initial episode of cystitis have recurrent infections. More than 90% of these recurrences are caused by exogenous reinfection. Patients may be treated by one of three strategies: (i) continuous prophylaxis, (ii) postcoital prophylaxis, or (iii) therapy initiated by the patient when symptoms are first noted. Postmenopausal women may also have frequent reinfections. Hormonal therapy or topically applied estrogen cream, along with antimicrobial prophylaxis, is helpful in treating these patients. Urethritis

Subject: Topic: Page 7 of 9 More gradual onset of mild symptoms, which may be associated with abnormal vaginal discharge or bleeding related to concurrent cervicitis.

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Physical examination may reveal the presence of mucopurulent cervicitis or vulvovaginal herpetic lesions. C. trachomatis, N. gonorrhoeae, or genital herpes may cause acute urethritis.

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Pyuria is present on urinalysis, but hematuria is rarely seen. Infections of Bartholin’s glands Bartholin’s glands • 2 round, pea-sized glands found deep in the perineum • Located at the entrance of vagina at the 5 and 7 o’clock position • Normally not palpable

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Bartholin’s duct • >2 cm in length • Opens in a groove between the hymen and the labia minora • 2% of women have enlargement of 1 or both glands Causes:

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Cystic dilatation of Batholin’s duct o Most common o Adenitis or abscess formation Mechanical obstruction of duct o Precedes overt infection

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Polymicrobial necrotizing subcutaneous infection o Most serious sequela of infection Adenocarcinoma of Bartholin’s glands o >40 years old o Rare

Bartholin’s Duct Cyst • lined with transitional epithelium • found in labia majora • most are asymptomatic 1 to 8 cm, unilateral, tense, non-painful and unilocular • can also occur bilaterally • Tx: none if asymptomatic and < 40; antibiotic and hot bath for acute adenitis • Chronic or recurrent cyst – multilocular Etiology • Obstruction of duct secondary to non-specific inflammation or trauma • Subsequently symptomatic enlargement may be related to adenitis or abscess formation • >40 years old may be caused by adenocarcinoma Differential Dx: • Mesonephric cyst at vagina – more anterior and cephalad • Epithelial inclusion cyst – more superficial • Lipoma, fibroma, hernia, hydrocele Abscess of Bartholin’s glands • Base of labia minora • Develop rapidly over 2 to 4 days • Symptoms: erythema, acute tenderness, acute vulvar pain, dyspareunia, pain duting walking, edema, cellulites of surrounding tissue Treatment:

Depends on symptomatology Asymptomatic 40 to dx adenocarcinoma o Complications:  Hemorrhage  Hematoma  Scarring  Dyspareunia

Pediculus pubis

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Skin of the vulva – frequent site of infestation by crab louse Phthirus pubis Incubation – 30 days Most contagious of all STD’s

Transmission Direct sexual contact Non-sexual: towels or beddings Symptoms: constant itching Diagnosis: demonstration of eggs, adult lice or PEPPER GRAIN feces adjacent to the hair shaft Definitive Dx: Demonstration of miniature with 6 legs that has claws on them Treatment: Permethrine 1% cream rinse applied to affected areas then wash off after 10 minutes - preferred (less potential for toxicity) Gamma-benzene Hexachloride 1% shampoo applied for 4 minutes the wash off – not recommended for pregnant, lactating omen, children below 2 years (neurotoxic) Alternative treatment: pyrimethrin with piperonylbutoxide Scabies • • • • • •

Parasitic infection by the itch mite Sarcoptes scabiei transmited by close contact Can spread anywhere and all over the body without predilection for hairy parts Female itch mite digs a burrow just beneath the skin and lays egg for 1 month (life span) Adult itch mite