Genital tract infection

 Classification of genital tract infection: Depending on

the site and affection of the infective organism
 1. Lower genital tract infections: vulvitis, vaginitis,
cervicitis
 2. Upper genital tract infection: Pelvic Inflammatory
Disease.
The femal genital tract has a defense mechanism which act as
a natural barrier against infection as the following
 Vulva :
Apocrine glands: modified sweat glands __ fungicidal acid
_ Apposition of labia closes introitus

Vagina :
_ Apposition of anterior and posterior walls
_ stratified squamous epithelium resistant to infection
_vaginal acidity
_ Flora: the G+ve Doderlein's bacilli splits glycogen into lactic acid

Cervix: closed by bacteriollytic cervical mucus

Uterus: periodic endometrial shedding during menstruation
eliminates any infection
 The normal vaginal flora is mostly aerobic, with an
average of six different species of bacteria, the most
common of which is the hydrogen peroxide–producing
lactobacillus.
 The pH of the normal vagina is lowerthan 4.5, which is
maintained by the production of lactic acid. Estrogen-
stimulated vaginal epithelial cells are rich in glycogen.
Vaginal epithelial cells break down glycogen to
monosaccharides, which can be
 converted by the cells themselves, and by lactobacilli
to lactic acid.
 Vaginal Infections :Bacterial Vaginosis
 Bacterial vaginosis (BV) 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:
 • Causes?? Decrease lactobacillus, increase
vaginal PH , G.Vaginalis
( polymicrobial)
 • Risk factor : black race ,smoking , new partner
 • Symptoms : fishy odour offensive vaginal
discharge, on examination a homogenous off-
white vaginal discharge
 Diagnosis : by evaluating a Gram stain of the vaginal
discharge using nugent criteria or by using Amsels
criteria (3 of 4 are required: homogenous discharge,
high pH, ‘clue cells’ on microscopy and a fishy odour
when 10% potassium hydroxide is added to a sample of
discharge).
 Clinical significance: BV is associated with a number of
pathologies including pelvic inflammatory disease
(PID), posthysterectomy vaginal cuff cellulitis and, in
pregnancy, preterm birth and rupture of membranes
and miscarriage. An increased risk of HIV acquisition is
observed in women at risk of BV
 • Treatment
 • Oral or intravaginal
treatments with metronidazole
or clindamycin are indicated.
 • Women with BV should be
advised that vaginal douching
or excessive genital washing
should be avoided
TRICHOMONAS VAGINITIS
 Trichomonas vaginitis is caused by the sexually
transmitted, flagellated parasite, Trichomonas vaginalis
 Trichomonas vaginitis is associated with a profuse,
purulent, malodorous vaginal discharge that may be
accompanied by vulvar pruritus. a patchy vaginal
erythema and colpitis macularis (“strawberry” cervix) may
be observed.
 Because of the sexually transmitted nature of trichomonas
vaginitis, women with this infection should be tested for
other STIs, particularly Neisseria gonorrhoeae and
Chlamydia trachomatis. Serologic testing for syphilis and
human immunodeficiency virus (HIV) infection should be
considered.
 Metronidazole is the drug of choice for
treatment of vaginal trichomoniasis.
 The sexual partner should be treated.
 Significance: association with
pregnancy outcome: preterm birth, low
 birthweight and maternal postpartum
sepsis
 VULVOVAGINAL CANDIDIASIS
 Candida albicans is responsible for 85-90% of vaginal yeast infections.
 Factors that predispose women to the development of symptomatic
VVC include antibiotic use, pregnancy, and diabetes.
 The symptoms of VVC consist of vulvar pruritus associated with a
discharge that can vary from watery to homogeneously thick curdy
white discharge. Vaginal soreness, dyspareunia, vulvar burning, and
irritation may be present.
 Examination may reveal erythema and edema of the labia and
vulvar skin. The vagina may be erythematous with an adherent,
whitish discharge. The cervix appears normal .
Diagnosis : a bacterial swab for microscopy and culture 
 Treatment
 The treatment of VVC involves the use of topically applied azole drugs,
oral fluconazole, local miconazole or clotrimazole.Adjunctive
treatment with a weak topical steroid, such as 1% hydrocortisone
cream, may be helpful in relieving some of the external irritation.
 RECURRENT VULVOVAGINAL CANDIDIASIS
 defined as four or more episodes in a year. The treatment of patients
with RVVC consists of inducing a remission of chronic symptoms with
fluconazole (150 mg every 3 days for three doses), then maintaining a
suppressive dose of this agent (fluconazole, 150 mg weekly) for 6
months
 uterine and adnexial infection
 cervical defence
_cervical glands that secrete mucus wich have bacteriocidal
effect
 uterine defense
_shedding of endometerium
_closure of the uterine ostium of fallopian tube with slightest
inflammatory reaction in theendometerium
 tubal defense
_peristalesis of the tube and the movment of the cilia toward the
uterus
_antegrated mucus plicae and epithelial cilia
 The commonest organism is chlamydia and the second is nessieria
gonorrhea other include mycobecterium genitalium , bacterial vaginosis
 risk factors ;
multiple sexual partners
history of PID
IUCD
area with high prevelance of STIs
recent instumentation of uterus
smoking and alcohol
low immunity
intercourse during menstruation
 Chlamydia
 Causes : most common bacterial STI, case by C .trichromatis
 Symptoms : usually asymptotic, altered vaginal discharge, or postcoital
bleeding ,intermenstrual bleeding or abdominal pain , urinary symptoms .
Fever ,Dysparunia, Nausea and vomiting Examination is often normal, but
cervicitis with mucopurulent discharge may be present
 Diagonsis : vulvovaginal swab using NAAT
 Complications , PID , infertility, arthritis , neonatal infection , Fitz hugh cutis
syndrome
 Treatment
• It is STI so partner should be traced and treated
• azithromycin 1g oral single dose or doxycycline 100mg twice for 7 days
 Gonorrhoea
•Causes : bacteria Neisseria gonorrhoea. G
–ve intracellular bacteria
• Symptoms asymptomatic in up to 50% of
cases,
• vaginal discharge the most common
symptom and lower abdominal pain in up
to 25% Fever Dysparunia Nausea and
vomiting
Urinary symptoms
Proctitis and rectal bleeding
• Diagnosis NAAT tests are highly sensitive
and specific,
 Treatment
parenteral third- generation cephalosporin ( cefteriaxon 250 mg
single im or ciprofloxacin 500 mg single oral )plus azithromycin 1g
single oral
 Sexually transmitted
by different route , partner should be traced and treated
 complication
• PID , Hematogenous spread ,
arthritis , ophthalmological involvement
• Neonatal infection
 General advices
-avoid intercourse before treatment
of both partners is completed
-use condoms
-contact tracing of all partners when
possible
-tests for other STIs
 Late complications
Chronic pelvic pain , infertility, ectopic
pregnancy, fallobian or pelvic
abscess wich reqiure surgical
intervention
 Pelvic inflammatory disease (PID)
 Pelvic inflammatory disease (PID) is an
inflammatory condition of the upper genital tract
organs typically involving the uterus, fallopian
tubes , ovaries, pelvic peritoneum.
Causative agent Neisseria gonorrhoeae,
chlamydia trachomatis • Most common rote of
infection it ascending from vagina
 Risk factor
• Adolescence
• History of PID • partners with gonorrhea or
chlamydia • Multiple partners• Current douching
• Insertion of IUD
 PID-Diagnosis: Clinical
 Minimum criteria
 Lower abdominal pain
 Adnexal tenderness
 Cervcial tenderness
 ADDITIONAL Criteria
* Oral temperature >38.3' C
* Abnormal cervical/ vaginal discharge x Raised CRP &/or ESR
* Lab documentation of positive cervical infection with gonorrhoea or
Chlamydia trachomatis Histopathologic evidence of tubo ovarian
complexLaparoscopic evidence of PID
 Investigations
• Pregnancy test-r/o ectopic pregnancy
• High vaginal swab - Trichomonas vaginalis, candida,
bacterial vaginosis
• Endocervical swab - gonorrhea, chlamydia
• Midstream urine - microscopy and culture
• CBC, CRP,
• Ultrasound - tubo-ovarian collection, free peritoneal
fluid (non- specific)
• Laparoscopy - diagnosis is unclear / there is no
response to treatment after 48 hours
 Antibiotics in PID
Outpatient regimen
-Oral ofloxacine 400 mg and metrondazole 400 mg twice daily for 14
days
Intamuscular ceftriaxone 500 mg single dose + oral doxycycline 100
mg + oral metronidazole 400 mg both twice daily for 14 days
Inpatient regimen
Intravenous ceftriaxone 2 gm + doxcycline 100 mg twice daily until 24
hrs after clinical improvement then shift to oral therapy Doxycycline
and metronidazole fot 14 days
Intravenous ofloxacin 400 mg twice daily + i.v metronidazole 500 mg 3
times daily for 14 days·
 CHRONIC PID
 CHRONIC PID
Failure of acute pelvic infection to resolve results in chronic tubo
ovarian masses
Hydro Salpinx
Chronic Pyosalpinx
Chronic Interstitial salipinigites
Tubo ovarian abscess
Symptoms: Contact low abdominal pain, two backache, deep
dyspareunia, menorrhagia, congestive dysmenorrhea.
 Chronic Pelvic Infection
 Investigations, imaging & diagnostic procedures Similar to Acute PID
 Management Antibiotics Broad spectrum for 3 weeks/ based on C/S
 In proved gonococcal infection as CDC guidelines
 Surgery
 Indications
Persistence of symptoms despite conservative management
Recurrence of acute attack
Increase in size of pelvic mass despite treatment
Persistent menorrhagia & deterioration in general health
&Infertility
 Differential diagnosis
 Gynaecological causes of abdominal pain
ectopic pregnancy, miscarriage, ovarian cyst (torsion,
rupture, haemorrhage), endometriosis, fibroid
degeneration, ovulation pain
 Non-gynaecological causes of abdominal pain
adhesions, appendicitis, urinary tract infection,
pyelonephritis, constipation, irritable bowel syndrome,
inflammatory bowel disease, gastroenteritis
 PID: Prevention
 Primary prevention
1. Sexual counseling
Practice safe sex
Limit number of sexual partners
Avoid contact with high risk partners
Delay in sexual activity until 16 years of age
2. Barrier methods & oral contraceptives reduce the risk
 Secondary prevention
1. Screening for infections in high risk population
2. Rapid diagnosis & effective treatment of STDs & UTI
 Tertiary prevention
1. Early intervention & complete treatment
 HIV infection
 Is a retrovirus, single strand of RNA.
 Infection with HIV results in an initial acute viral illness followed by a chronic
decline in cellular immunity due to progressive depletion of CD4-positive T
lymphocytes, and eventually resulting in one or more illnesses defined as
the acquired immune deficiency syndrome (AIDS).
 Hiv and pregnancy
HIV infection is associated with varying rates of adverse pregnancy outcomes
HIV can also adversely affect the frequency and course of many infections in
pregnancy parasitic infestations and HIV-related opportunistic infections seem
to be frequent during pregnancy and in the puerperium
 screening for hiv in pregnancy
 All Routine AN investigation as other clients also:
Viral Load: 2–4 weekly at onset and once every trimester if stable)
Liver and Renal Functions: Weekly at onset and spaced out when stable.
Full Blood Count: Monthly
Cluster of differentiation 4 (CD4) count: Every 3 months.
HIV Genotype: Baseline at onset.
 Diagnosis
The diagnosis of HIV infection can be made either directly from the detection of
the viral particles or components or indirectly by the detection of antibodies
against the virus.Screening is usually done by ELISA,Antigen test,PCR/NAAT tests
 Treatment / Management
antiretroviral agents with each cycle of replication of virus if therapy is effective
CD4 lymphocyte count rises progressively and at least partial immune
restoration occurs HIV ,infects long lived memory cells, so eradicated and cure
is unlikely ever after several years of treatment If succeful the immune system
improves after a few months These drug have potential interaction with Other
drug, they increase the rate of break down of synthetic estrogen in oral CCP
 Antepartum Management :ART not only prevents the perinatal transmission of
HIV but also inhibits the sexual (secondary) transmission of the virus. The level
of viral RNA in the blood and genital tract secretions of the mother is
diminished by strict adherence to the ART regimen
 Intrapartum Management
Women with HIV RNA viral load >1000 copies/mL or unknown levels near
delivery are delivered via scheduled cesarean section at 38 weeks.[40]
Cesarean section is not indicated when HIV RNA viral load <1000
copies/mL, and the patient is on ART. HIV positive women are found to
have a higher complication rate from cesarean section than HIV negative
women.[41] For women whose HIV RNA is <1000 copies/mL, the timing of
vaginal delivery should follow the standard OB/GYN indications. If a
scheduled cesarean delivery is performed for routine indications (other
than HIV prevention) and HIV RNA is <1000 copies/mL, it should be
performed at 39 weeks
 Postpartum Management
ART for the mother and the newborn must be provided
before hospital discharge, and the first follow-up visit to
the HIV-care provider must happen within 2-4 weeks of
discharge. These measures are of particular importance to
women who have HIV diagnosed during delivery/labor
and maximize the chances of successful viral suppression.
 hepatitis B
 What is hepatitis B.?
 Hepatitis B is a serious liver infection caused
by the hepatitis B virus. When babies become
infected with hepatitis B, they have about a
90% chance of developing a lifelong, chronic
infection. Left untreated, about 1 in 4 children
who have chronic hepatitis B will eventually
die of health problems related to their
infection, such as liver damage, liver disease,
or liver cancer
 Hepatitis B and pregnancy
All pregnant women should get a blood test for hepatitis B
as part of their prenatal care. Hepatitis B can be easily
passed from a pregnant woman with hepatitis B to her
baby at birth. This can happen during a vaginal delivery
or a c-section..
 transmitted mainly in blood, but also in other body fluids
such as saliva, semen and vaginal fluid. Drug users who
share needles are at high risk
 Clinical features
The HBV has an incubation
period of 6 weeks to six
months, Hepatitis B is a virus
that infects the liver but many
people with hepatitis B viral
infection have no symptoms
 Diagnosis
 All pregnant women are routinely screened for Hepatitis B early in
pregnancy. This is done by a blood test. If the test results are positive, there
is a good chance of transmied virus to baby during delivery
 The principal screening test for detecting maternal HBV infection is the
serologic identification of HBsAg. Screening should be performed in each
pregnancy, regardless of previous HBV vaccination or previous negative
HBsAg test results. A test for HBsAg should be ordered at the first prenatal
visit
 Treatment of HBV
The administration of hyperimmune globulin and HBV vaccine
protects 90% to 95% of infants from HBV infection. It is
recommended that 0.5 ml, of HBIG be given at birth and that three
doses of HBV vaccine be given beginning at birth
 Vaccine
The vaccine carries no known risks to the developing fetus. The
hepatitis B vaccine is recommended for pregnant people who are
at risk for acquiring hepatitis B during pregnancy (eg, due to living
with someone infected with hepatitis B) and for people who started
the vaccine series before getting pregnantnt‫ل‬Google
 Herpes
Infective organism Herpes simplex virus
(HSV) is a double-stranded DNA virus.
There are two viral types, HSV-1 and
HSV-2. The majority of orolabial
infections are caused by HSV-1. These
infections are usually acquired during
childhood through direct physical
contact such as kissing.
Genital herpes is a sexually transmitted infection and is most
commonly caused by HSV-2
 Clinical features
Genital herpes presents as ulcerative lesions on the vulva,
vagina or cervix. The woman may give a history of this being
a recurrent problem,in which case the lesion is often less
florid. A primary infection may be associated with systemic
symptoms and may cause urinary retention. Neonatal herpes
may be caused by HSV-1 or HSV-2,
as either viral type can cause genital herpes. Almost all
cases of neonatal herpes occur as a result of direct
contact with infected maternal secretions, Factors
influencing transmission include the type of maternal
infection (primary or recurrent), the presence of
transplacental maternal neutralizing antibodies,
the duration of rupture of membranes before delivery, The use
of fetal scalp electrodes and the mode of delivery.The risks are
greatest when a woman acquires a new infection
(primary genital herpes) in the third trimester, particularly within 6
Weeks of delivery, as viral shedding may persist and the baby is
likely to be born before the development of protective maternal
antibodies
 Management
Any woman with suspected first episode genital herpes should
be referred to a genitourinary physician, who will confirm the
diagnosis by viral culture or PCR, advise on management and
arrange a screen for other sexually transmitted infections. The use
of aciclovir is associated with a reduction in the duration and
severity of symptoms and a decrease in the duration of viral
shedding.
 Primary infections
Caesarean section should be recommended to all women
presenting with primary episode genital herpes lesions at the time of
delivery, or within 6 weeks of the expected date of delivery. For
women who develop primary genital herpes lesions within 6 weeks of
delivery and who opt for a vaginal birth, rupture of membranes
should be avoided and invasive procedures such as fetal scalp
electrodes, or fetal scalp pH measurement should not be used.
Intravenous aciclovir given intrapartum to the mother and
subsequently to the neonate may be considered. The
neonatologist should be informed and may advise acyclovir
treatment of the baby.
 Recurrent episodes :A recurrent episode of genital herpes
occurring during the antenatal period is not an indication for
delivery by Caesarean section
 Syphilis
 Syphilis is caused by infection with the bacterium Treponema
pallidum subspecies pallidum, which occurs through direct contact
with secretions from an infective lesion or via transplacental
passage of the bacteria during pregnancy.
The infection is classified as congenital or acquired, and each of
these as late or early.
In acquired early syphilis the initial manifestation
is the 'chancre', which develops at the site of
exposure. This is usually a single, genital lesion but
is increasingly seen on other sites such as the oral
cavity and may be multiple. Typically the lesion is
painless, indurated and exudes serous fluid
containing T. pallidum
, and there is regional lymphadenopathy. Second
phase is widespread erythematous rash typically
including the palms and soles and that can result
in alopecia, oral and genital mucous lesions and
raised lesions, usually in the anogenital area,
termed 'condylomata lata'.
 Primary :Painless ulcer (chancer)at inoculation site with clean
based,indurated ulcer with smooth firm border highly infectious
resolve in1-5 weeks
 Secondary :Generalizied body rash, fever, lymphodenopathy,
malaise, and genital or perineal condyloma latum
 Complications include neurological involvement, resulting in
meningitis, an eighth nerve palsy and consequent deafness or
tinnitus and ophthalmic involvement, most often uveitisLate
complications include: • Gummatous lesions: granulomatous,
locally destructive lesions typically affecting skin and bone.
Cardiovascular involvement: usually affecting the ascending
aorta, resulting in aortic valve incompetence.
 Neurological involvement: classified as
meningovascular disease, tabes dorsalis and a
progressive dementing illness, general paresis
 Mother-to-child transmission of syphilis in
pregnancy is associated with fetal growth
restriction (FGR), fetal hydrops, congenital syphilis
(which may cause long-term disability), stillbirth,
preterm birth and neonatal death..
 Stigmata of Congenital Syphilis
1. Ophthalmic: corneal clouding.
2. Oral: Hutchinson teeth and high
arched palate.
3. Nose: saddle nose.
4. Orthopedic: frontal bossing, saber
shin, and thickened medial clavicle.
5. Neurologic: 8th cranial nerve
palsy.
6. Positive serology for syphilis.
 Screening
Because treatment is so effective, routine antenatal screening
for all
pregnant women is recommended. These can be detected by
serological tests. Non-treponemal tests detect non-specific
treponemal antibodies and include the Venereal Diseases
Research Laboratory (VDRL) and rapid plasma reagin (RPR)
tests.
Treponemal tests detect specific treponemal antibodies and
include enzyme immunoassays (EIA), T. Pallidum
haemagglutination assay (TPHA) and the fluorescent
treponemal antibody-absorbed test (FTA-abs) Non
-treponemal tests, on the other hand, may result in false
negatives, particularly in very early or late syphilis,
In patients with reinfection or those who are HIV
positive. The VDRL may be falsely positive in women
with lupus. Therefore, positive results should be
interpreted with caution and the pregnant woman
should be referred for expert assessment and
diagnosis in a genitourinary medicine clinic.
 Management
The initial step is to confirm the diagnosis and to test for any
other sexually transmitted diseases. Once a diagnosis of
syphilis is confirmed the genitourinary medicine clinic will
institute appropriate contact tracing of sexual partners. Older
children may also need to be screened for congenital
infection.
 Parenteral penicillin has a 98 per cent success rate for
preventing congenital syphilis If a woman is not treated
during pregnancy her baby should be treated after delivery.
An infected baby may be born without signs or symptoms of
disease but if not treated immediately, may develop serious
problems within a few weeks. Untreated babies often
develop developmental delay, have seizures or die
 Genital warts
These are benign epithelial tumours caused by HPV infection.
There are over 100 genotypes of HPV and types 6 and 11 cause
over 90% of genital warts. Infection with HPV in the genital
epithelium via sexual transmission is extremely common, with
the vast majority of cases being subclinical.
 Infection with the oncogenic genotypes including
types 16 and 18 is also through sex, but these cause
anogenital dysplasia and cancer, not warts. HPV
vaccination is available as a bivalent (against types 16
and 18) or quadrivalent (types 6, 11, 16 and 18)
 treatments include ablative therapies
such as application of liquid nitrogen
or surgical techniques or patient
applied topical therapies, including
podophyllotoxin containing
preparations or the local immune
modulator imiquimod.
When genital warts are present in pregnancy
treatment is limited to ablative options.
Screening for other STIs is required and screening for
cervical cancer is as usual.
 Genital tuberculosis
 Female genital tuberculosis is a disease caused by Mycobacterium
tuberculosis infection in the female reproductive
 Etiology
Secondary to primary focus elsewhere (most common - lung)
 Mode of infection
Hematogenous&lymphatic spread - most common
From adjacent structures - few cases
 Pathology
 fallopianTube: involved in 90% most common cases
 Uterus: involved in 60-70% cases
 Ovaries: involved in 30% cases
 Cervix: involved in 1-2%
 Vulva/Vagina - ulcerative or hypertrophic growth
 Clinical picture
● Asymptomatic10% ● Infertility 35-60%
● Menstrual disorders 40-50%
● Initially menorrhagia→ Oligo/ amenorhoea →Post menopausal bleeding
● Pain lower abdomen
● Lower grade fever, malaise, weight loss
● Abdominal mass/ascites (matted gut, pyometra, TO mass, encysted ascites,
doughy feel)
● Pelvic mass is usually non-tender, unless superadded infection
● Post coital bleeding/irregular bleeding
 Investigations
● total leukocyte count(TLC) ●differential leukocyte count (DLC) ● ESR & Mantoux
● X-ray Chest Sputum for AFB in suspected cases ● ● Cervical/Vaginal biopsy ●
HSG ● PCR endometrial tissue- 80%
Treatment For 2 months - four drugs
Drug Doses side effect
INH (Isoniazid) 5mg/kg, 300mg max Hepatoxic
Rifampicin 10mg/kg, 600mg max peripheral neuritis
Ethambutol 15mg/kg, 800-1000 mg max. Hepatoxic,fever,rash
Pyrazinamide 15-30 mg/kg 1.5-2 g max. Hepatitis,Hyperuricemia
For next 4-6 months two drugs (INH , Rifampicine)
Surgical treatment : indication
● persistant mass & recurrent disease & drug resistance
Prognosis
● Disease cured in 90%
● Fertility restored in 5-7%
● Pregnancy achieved in < 2