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LOWER GENITAL TRACT INFECTIONS

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Bugra Coskun Mehmet Ferdi Kinci

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 CHAPTER 11

LOWER GENITAL TRACT INFECTIONS

Buğra ÇOŞKUN, Mehmet Ferdi KINCI

INTRODUCTION
Vaginitis is one of the most common problems in women’s lives, as well as the most common cause
of admission to Gynecology outpatient clinic. Although women usually complain of discharge and
smell, it can also be detected during a routine vaginal examination.
Vaginal Anatomy-Physiology-Histology
The urethra lies at the top of the entrance to the vagina. The rectum along with the anal sphincter
lies at the bottom of it’s entrance. The vagina is a tube-shaped organ that resembles a fibromuscular
layer and it’s length is approximately 7-9 cm in distance. Along its extension, it is accompanied by
the rectum at the back and the bladder at the front surface. The length of vagina increases during
sexual intercourse. Its histological layers consist of mucosa, muscularis mucosa and adventisia la-
yers. On the inner side, it is paved with a layer of flat epithelium with multiple layers. Although the
structure of the glands in the vagina does not have active secretions, the sebaceous secretions from
vulva, secretions from Bartholin, Skene and sweat glands, the secretions of glands in the uterus and
cervix, the transudated secretions leaked from vaginal epithelium, spilling cells from the cervix and
vagina, and the microorganisms and their metabolites forms the vaginal secretions.
This tube has a distinctive flora that is vital for childbirth and sexual intercourse. This flora varies
according to the age, hormonal status, systemic diseases, sexual status and drug use. The most
important factor is the presence of estrogen. Estrogen allows vaginal epithelium to proliferate and
store glucogen in epithelial cells. The collection of glucogen also results in the formation of lactic
acid. Therefore, the vaginal pH is between 3.5-4.5. In the pre-puberty and postmenopausal period,
when estrogen is not dominant, the vaginal pH is between 6-8.
The most common bacteria in the flora are lactobacilli, which are aerobic, producing hydrogen
peroxide. Other major flora elements are Bacteroides, Peptococci, S.epidermitis, Corinobacteria,
Peptostreptococci, Group B and D streptococci, E.coli. Gardnella vaginalis and Trichomonas vagi-
nalis are also present in the flora. Candida albicans is found in low amounts in the vaginal flora, but
increases in certain circumstances. This means that it is not the presence of these elements, but the
relative increase in their amount is important in the diagnosis of vaginitis. But Neisseria gonorrho-
eae, Herpes Simplex Virus (HSV) and Human Papilloma Virus (HPV) are not elements of vaginal
flora. The presence of these elements in the vaginal flora is pathognomonic for vaginitis.
DIAGNOSIS
The most important step in the approach to vaginitis is detailed history and examination menopau-
sal status, being sexually active, the presence of a co-morbid disease that can affect the flora, such
as diabetes, the use of drugs such as oral contraceptives and antibiotics, and vaginal showering
should be questioned. The presence and the quality of the discharge is very important when qu-
estioning the patient’s symptoms. Physiological vaginal discharge is a white-colored, nonfragrant
discharge that is not accompanied by discomfort and itching. In non-physiological discharge, some
of the symptoms like redness, increased heat, fragrant discharge, and itching may be together.
During clinical evaluation, speculum examination is recommended if possible. It is also recom-
mended to evaluate the cervix during the examination. Microscopic examination, whiff test and Ph
measurement are very useful. These tests will be mentioned later.

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Bacterial Vaginosis
It is the dominancy of anaerobic bacteria as the bacterial flora of the vagina (decrease in the propor-
tion of lactobacilli) deteriorates. For diagnosis, it is necessary to have at least 3 of 4 Amsel criteria.
These criteria include a homogeneous discharge, a positive Whiff test when examining vaginal
discharge, clue cells are found on microscopic examination, and a vaginal pH above >4.5. Because
the microbiological elements that cause infection are present in the flora, smear examination and
vaginal culture are not suitable for diagnosis. There is no increase in PID risk. It has been associated
with miscarriage, premature membrane rupture and preterm birth. The success rate of clindamycin
and metronidazole in treatment is quite similar. No difference in efficacy has been shown in topical
and oral use of antibiotics, but the topical form is primarily recommended for lack of side effects
and shorter duration of use. Sexual partner treatment does not needed. Treatment of bacterial va-
ginosis, which can be seen in pregnant women by up to 30%, is similar to that of non-pregnant
women, and with treatment, the preterm birth rate decreases.
Vulvovaginal Candidiasis
About 75% of women experience vulvovaginal candidiasis infection at least once and 40-50% of
women experience recurrent vulvovaginal candidiasis in their lifetime. The causes such as immu-
nosuppressive diseases (AIDS, Malignancy), drug use (steroids, antibiotics), systemic diseases (un-
controlled diabetes), oral sex are risk factors. Along with severe itching, redness and heat increase
due to inflammation can be observed in the vulvar area and inside the vagina. Cheesy discharge is
present, such as white sour milk. The symptoms are often disturbing relative to the symptoms of
bacterial vaginosis. It is important to display hyphae after 10% KOH drip in microscopic exami-
nation. Non-albicans candida is common in patients with recurrent vulvo-vaginal candidiasis with
uncontrolled diabetes. There are differences in treatment depending on the underlying etiology,
whether it is complicated or not. In uncomplicated vulvovaginal candidiasis, miconazole, nystatin,
thiocanazole, flucanazole are used orally or topically in doses ranging from 3 days to 14 days.
Flucanazole is recommended if it is complicated vulvovaginal candidiasis. In non-candida albicans
vulvovaginitis, boric acid or non-flucanazole anti-fungals are recommended.
Trichomonas Vaginitis
Unlike the vaginitis mentioned above, it is a condition that does not have a normal flora element
and also affects men. It is a flagellated protozoan. Unlike other sexually transmitted infections, it
is often asymptomatic in women. Because it is often accompanied by bacterial vaginosis, there
are deficiencies in diagnosis. Persistent abundant sparkling, foul-smelling, green-colored vaginal
discharge is characteristic. It is important to monitor a large number of small petechiae (strawberry
cervix) in the cervix. In the sample taken from vaginal discharge, when examined with saline soluti-
on, the diagnosis is made by showing mobile, flagellated protozoa. The culture is the gold standard
method for detection. Oral metronidazole 2 g is recommended for treatment without distinction
between pregnant and non-pregnant.
Chlamydia Vaginitis
Chlamydia can cause cervicitis more common than vaginitis. In addition to asymptomatic course,
it can be manifested by mucopurulated service, dysuria and post-coital bleeding. The routine sc-
reening of sexually active women and pregnant women is recommended. During childbirth, it can
infect the newborn and cause conjunctivitis. It is associated with infertility and ectopic pregnancy
by causing damage to the cervix and tuba. C.trachomatis diagnosis can be made by culture, direct
fluorescent antibody test, enzyme immunoassay or nucleic acid amplification tests. Doxycycline
100 mg orally, for 7 days or a single dose of azithromycin 1 g is recommended for treatment. Er-
ythromycin, Ofloxacin, Levofloxacin are other treatment options. Doxycycline, Levofloxacin and
Ofloxacin should not be used during pregnancy and lactation periods.
Gonorrhea Vaginitis
The main target of this microorganism, which may be associated with chlamydia, is the cervix and
tubes. For this reason, it is largely asymptomatic. It may cause salpingitis, tuboovaryan abscess,
peritonitis, ectopic pregnancy and infertility. It can cause conjunctivitis by infecting the newborn
during birth. Diagnosis is made by the appearance of gram-negative coffee bean-shaped gonococci
in leukocytes under microscope. In uncomplicated cases of treatment, a single dose of ceftriaxone
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GYNECOLOGICAL EMERGENCIES

125 mg IM is recommended. Cefixime, Ciprofloxacin, Ofloxacin, Levofloxacin are other treatment

options. An effective antibiotic should be added to the treatment of chlamydia.
Atrophic Vaginitis
We have already mentioned the need of estrogen for the formation and continuity of vaginal flora.
Due to insufficient amount of estrogen, especially in the pre-puberty and post-menopausal period,
the vaginal pH may become alkaline. This condition causes the vaginal epithelium to become thin-
ner and susceptible to trauma. A history of recurrent post-coital bleeding is especially important in
diagnosis. During physical examination, pain and bleeding may occur during the entrance of the
speculum. Atrophy can also be observed in the external genitalia. Topical estrogen is recommended
in treatment. In women accompanied by vasomotor symptoms, systemic estrogen can be used if
there is no contraindication.
Non-infectious Vaginitis
It is an irritating contact dermatitis that occurs against substances used for contraception, sper-
micides, latex-containing products, perfumes, and substance used for cleaning such as soaps and
similars. Discontinuation of the use of the causative agent is the primary approach.
Vaginitis due to foreign body
It is the vaginitis that is caused by paper, cotton, toys especially in children in the pre-puberty
period, as well as the appearance of objects inserted into the vagina for sexual purposes in adults
stays for a long time, materials that are forgotten or not changed for a long time in post-menopausal
women, such as pessary. Foul-smelling vaginal discharge and bleeding are typical. It can be accom-
panied by ulcers. Removal of the foreign body that causes, is the primary approach.
Toxic Shock Syndrome
It is the multiple organ failure caused by improper use of hyper-absorbent tampons during menst-
ruation. The mortality is around 25%. They are often young patients. Fever, sore throat, vomiting,
diarrhea, hypotension, syncope, skin lesions are observed in patients. It has become quite rare after
abolition of these tampons. The first step in treatment is to remove the tampon and clean the vagina.
Beta-lactamase-resistant penicillins or vancomycin should be used for at least 10 days.
Parasitic Infections
Parasitic infections are caused by fecal contamination. It is accompanied by perianal itching and
hyperemia. It is common in underdeveloped and developing countries. The most common cause of
these type of infections is the Enterobius family parasites. Anti-parasitic drugs specific to the agent
is recommended for treatment.
CONCLUSION
The vaginitis can negatively affect the quality of life of women of all age groups, especially women
of reproductive age. The correct management of the vaginitis, which we encounter most in daily
gynecology practice, is very important. The complications can be prevented by making a correct
diagnosis and adding the correct treatment regimen, when necessary, to the treatment of the sexual
partner is very important. Although there is no need for a life-threatening urgent condition except
toxic shock syndrome, vaginitis is an issue that will always be up to date for both clinicians and
women.

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 CHAPTER 11: LOWER GENITAL TRACT INFECTIONS

Table-1: Management of common types of vaginitis

Types of Etiology Risk Factors Symptoms Treatment Other

vaginitis
Bacterial Increase in Causes that disrupt Fishy smell, Clindamycin, Increased risk of
Vaginosis Anaerobic the vaginal flora (low discharge Metronidazole HIV, gonorrhea,
Bacteria socio-economic level, after inter- chlamydia, herpes
oral sex, smoking, course
new sexual partner)
Vulvovagi- Candida Diabetes, Antibiotic Itching, Miconazole, Investigate the
nal Candi- Albicans and use, steroid use, OC burning, Nystatin, underlying cause
diasis Non-Al- use, immunosuppres- white cheesy Tioconazole, of recurrent vul-
bicans sion, pregnancy discharge Fluconazole vovaginal candida
Candida
Trichomo- Trichomonas Low socio-econo- Green-colo- Metronidazole HIV, increased
nas vaginalis mic level, smoking, red foamy risk of preterm
Vaginitis unprotected sexual discharge, labor; other sexu-
intercourse, drug vaginal pain, ally transmitted
abuse, other STD strawberry infections should
cervix be screened
Atrophic Estrogen Menopause, radiothe- Vaginal Topical est- -
vaginitis absence / rapy, chemotherapy, dryness, rogen
deficiency lactation, oophorec- dispareunia,
tomy, POF, endocrine itching
disorder, anti-est-
rogen usage
Non-infecti- Contact Usually reproductive Burning, Avoiding -
ous vaginitis irritants age women ( latex, itching, pain contact, Topical
tamponade, diaphg- Steroid
ram, pesser, drugs,
sperm)
Foreign Pessary, sex Forgotten foreign Pain, blee- Foreign body -
body vagi- toys, cotton body (latex, tampo- ding, foul removal
nitis nade, diaphgram, smelling
pessary) discharge

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