GYNECOLOGY

LOWER GENITAL TRACT INFECTIONS

Alice D. Bautista, MD | 26 September 2018
S2T1a
OUTLINE BARTHOLIN’S GLAND ABSCESS
I. Introduction III. Infections of the Vagina • Develop rapidly over 2-4 days
II. Infections of the Vulva A. Vaginitis • Symptoms:
A. Infections of Bartholin’s B. Toxic Shock Syndrome o Acute vulvar pain, dyspareunia, pain in walking
Glands IV. Infections of the Cervix o Pain and tenderness is secondary to rapid enlargement,
B. Pediculosis Pubis and A. Cervicitis hemorrhage, and infection
Scabies B. AIDS
• Signs
C. Molluscum Contagiosum
D. Condyloma Acuminatum o Erythema, acute tenderness, edema, cellulitis of surrounding
E. Genital Ulcers subcutaneous tissue
o No treatment because abscess ruptures spontaneously on 3rd
or 4th day
• Bilateral enlargement of Bartholin’s gland is NOT ANYMORE a
I. INTRODUCTION pathognomonic sign of gonococcal infection
• Divided into those of the lower genital tract, the vulva, vagina, and
cervix; and those of the upper genital tract, the endometrium and TREATMENT OF INFECTIONS OR ENLARGEMENT OF
fallopian tubes BARTHOLIN’S GLANDS
• Female genital tract has anatomic and physiologic continuity Medical treatment options
o Infectious agents that colonize and involve one organ often (Symptomatic management)
infect adjacent organs
o Lower genital tract infections may ascend and bring about upper Asymptomatic cysts in
genital tract infections patients <40 years old No treatment
• Symptoms caused by infections of the lower genital tract produce
the most common conditions seen by gynecologists
• Many of the infections may be acquired through sexual contact Acute adenitis without • Broad spectrum antibiotics
[sexually transmitted infections (STIs)] abscess formation • Hot spitz baths
o STIs are really a public health concern
• Simple incision and drainage
o STIs often coexist e.g. Chlamydia trachomatis and Neisseria
(I&D)- abscess can still recur
gonorrhoeae
• Marsupialization (Figure 1)
o Has 5-10% recurrence
Symptomatic cyst or o Classic surgical treatment
II. INFECTIONS OF THE VULVA abscess o Incise → suture the edges so it
• Stratified squamous epithelium with hair follicles and sebaceous, • Development of will remain open (like
sweat, and apocrine glands fistulous tract from marsupials)
• Sensitive to hormonal, metabolic, and allergic influences dilated duct to the • Word catheter
• Three most prevalent primary viral infections of the vulva: vestibule o Short catheter with inflatable
o Herpes genitalis Foley balloon
o Condyloma acuminatum o Placed for 4 to 6 weeks
o Molluscum contagiosum • Carbon dioxide laser
• Vulvar itching or burning of acute and short duration suggest o Produces neostoma
infection or contact dermatitis • Indications for excision of Bartholin’s duct and gland
• Erythema, edema, and superficial skin ulcers of vulva suggest o Persistent deep infection
infection o Multiple recurrences of abscesses
o Enlargement of gland in >40 years old → biopsy to exclude to
INFECTIONS OF BARTHOLIN’S GLANDS adenocarcinoma of Bartholin’s gland (yes yes! Important to r/o
• Bartholin’s glands malignancy!)
o Two rounded, pea-sized glands deep in the perineum o REMEMBER: Bartholin’s gland secretion provides moisture for
o Located at the entrance of vagina at 5 and 7 o’clock the epithelium of vestibule but not important for lubrication
o Cannot be palpated normally during sex so di masyado kawalan mga siz ;)
• Bartholin’s duct
o 2 cm in length
o Open in a groove between the hymen and labia minora in the
posterior lateral wall of the vagina
• 2% adult women develop enlargement of 1 or both glands
• The most common cause is cystic dilatation of Bartholin’s duct
o Etiology: obstruction of duct secondary to non-specific
infection, inflammation or trauma

BARTHOLIN’S DUCT CYST

• Differential diagnosis:
o Mesonephric cysts of vagina – more anterior and cephalad in
vagina
o Epithelial inclusion cyst – more superficial
o Rarely: lipoma, fibroma, hernia, vulvar varicosity, hydrocele
• Mostly asymptomatic
• 1-8 cm, usually unilateral (at the 5 or 7 o’clock positions), tense, Figure 1. Marsupialization of Bartholin's duct cyst. Left: A vertical
and non-painful incision is made over the center of the cyst to dissect it free of mucosa.
• Majority unilocular but may be multilocular when cyst is chronic or Right: The cyst wall is everted and approximated to the edge of the
recurrent vestibular mucosa with interrupted sutures.

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 GYNECOLOGY
LOWER GENITAL TRACT INFECTIONS
PEDICULOSIS PUBIS AND SCABIES SCABIES
• Skin of the vulva- frequent site of infestation of animal parasites • Great dermatologic imitator
o Crab louse- insects • Itch mite, Sarcoptes scabiei
o Scabies mites- arachnids • Widespread infection without predilection for hairy skin
• sexually transmitted infections (STIs)] o scabies can affect non-hairy skin (pediculosis pubis is
• To avoid reinfection by pediculosis pubis or scabies confined to hairy areas)
o Treat sexual contacts, close household contacts within the • <0.5 mm long, travels rapidly 2.5cm/min
previous 6 weeks o smaller than pediculosis but travels faster
o Decontaminate clothing and bedding • Female itch mite digs a burrow beneath the skin
• Life span: approximately 1 month
PEDICULOSIS PUBIS • Severe but intermittent itching (‘yung sa pediculosis is constant
• Crab louse, pubic louse – Phthirus pubis pruritus!)
• 1 mm long, moves slowly o Predominant clinical symptom of scabies
• Incubation period: 30 days • Pathognomonic sign- burrow in the skin
• Confined to hairy areas of vulva, occasionally eyelids • Any area of skin: hands, wrists, breasts, vulva, buttocks (most
• Most contagious of all STIs common)
o 90% of sexual partners are infected after a single exposure • Diagnosis:
• Transmission: o Slide/Scratch Technique- mites lacks lateral claw legs with 2
o Direct sexual contact anterior triangular hairy buds
o Nonsexual – towels/beddings
• Constant pubic pruritus
o Predominant clinical symptom of louse infestation caused by
allergic sensitization
• Initial sensitization may take 5 days to several weeks following initial
infection
• Pruritus may occur within 24 hours after reinfection
• Diagnosis: demonstration of eggs, adult lice and “pepper grain”
feces adjacent to hair shafts
• Miniature crab with 6 legs with claws- definitive diagnosis

Figure 3. Burrow in the skin of scabies

Treatment of Scabies
Medical treatment options
5% Permethrin • Apply to all areas of the body from neck
cream rinse or down then wash off after 8-14 hours
pyrethrins with • For Pediculosis Pubis, 1% lang. See the
piperonylbutoxide difference? hahaha
Figure 2. Pediculosis pubis
200 ug/kg orally; repeat in 2 weeks if
Treatment of Pediculosis Pubis Ivermectin
necessary
Medical treatment options
1% Permethrin • 1 oz of lotion or 30 g cream at all areas of
cream rinse or Apply to affected areas and wash off after the body, then wash off after 8 hours
pyrethrins with 10 minutes • Not recommended as first line therapy
piperonylbutoxide because of toxicity
Alternatives:
• Should not be used immediately after a
• Malathion ▪ 1% Lindane
Alternatives: bath or shower
o 0.5% lotion; or apply for 8-12 hours
▪ Malathion • Should not be used by persons who have
then wash off
▪ Ivermectin extensive dermatitis, women who are
• Ivermectin pregnant or lactating, or children younger
o 250 ug/kg; repeat in 2 weeks than 2 years old
• Retreatment might be necessary if lice are found or if eggs are • Women should be examined 1 week following initial therapy and
observed at the hair-skin junction retreated with an alternative regimen if live mites are observed (for
• Patients with pediculosis pubis should be evaluated for other STDs both scabies and pediculosis pubis)
• Patients who do not respond to one of the recommended regimens • Treat sexual contacts & close household contacts within six weeks
should be retreated with an alternative regimen • Decontaminate clothing and beddings
• All treatment should not be applied to the eyelids • Prevent reinfection
o Pediculosis of the eyelashes should be treated by applying
occlusive ophthalmic ointment to the eyelid margins twice a MOLLUSCUM CONTAGIOSUM
day for 10 days. • Caused by poxvirus by direct skin to skin contact; spread by
• Bedding and clothing should be decontaminated (i.e., either dry autoinoculation
cleaned or machine-washed and dried using the heat cycle) or • Incubation period: 2–7 weeks
removed from body contact for at least 72 hours. • In children, may present over the entire body
• Fumigation of living areas is not necessary (CDC) • In adult, asymptomatic viral disease primary of vulvar skin
• Women should be examined 1 week following initial therapy and • Mildly contagious unlike other STIs
retreated with an alternative regimen if live mites are observed • If widespread in adult, it is related to immunodeficiency like HIV
infection, chemotherapy or corticosteroid administration

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• Self-limiting infection • Transmission
• Diagnosis: o Sexual intercourse
o Characteristic lesion is a flesh-colored, dome-shaped papule o Autoinoculation
with umbilicated center, 1‐5 mm in diameter • 4 morphological types
• “Water wart” – with umbilicated center o Cauliflower-shaped
• Resembles furuncles when secondarily infected o Smooth papular – 1-4 mm papules
• Major complication is bacterial superinfection o Keratotic – looks like seborrheic keratosis
• Diagnosis: Simple inspection o Flat
• Intracytoplasmic molluscum bodies with Wright or Giemsa
stain confirms the diagnosis

Figure 6. Condyloma acuminatum in perianal area (left) and vulva

(right)
Figure 4. Left: Characteristic lesion of Molluscum contagiosum; Right:
Mollusks of the sea • Indications to perform biopsy in genital warts:
o Lesions do not respond to standard therapy
Treatment of Molluscum Contagiosum o The condition accelerates during therapy
• May be self-limiting o Woman is immunocompromised
Medical treatment options o Growths are pigmented, indurated, fixed, or ulcerated
• Symptoms:
• Evacuate caseous material, excise nodule o Depend on the size and location
Primary with sharp dermal curette, base is treated o Pain, itching, tendency to bleed when friable, odor when
Ferric subsulate with ferric subsulfate (Monsel’s solution) secondarily infected
or 85% TCA • Diagnosis:
Alternative: o Macroscopic lesion
• Cathardin – a chemical blistering agent
Cathardin o Subclinical
• Cryotherapy ▪ Colposcopy
Cryotherapy
- 3-5% acetic acid
CONDYLOMA ACUMINATUM - Shiny, white areas of infection with irregular
• STD of vulva, vagina, rectum, or cervix border/satellite lesions (get sample)
• Caused by HPV ▪ Cytology
o HPV subtypes 16 and 18 - Nuclear atypia, delayed maturation, hyperkeratosis,
▪ Associated with aneuploidy, premalignant, or malignant parakeratosis, and koilocytosis
lesions of genital tract • Differential diagnosis:
o HPV subtypes 6 and 11 o Micropapillomatous labialis
▪ Associated with benign, euploid o Seborrheic keratosis
o Nevi
o Condylomata
o Molluscum contagiosum
o Neoplasia
▪ Giant condyloma
▪ Bowenoid papulosis
▪ Squamous cell CA

Treatment of Condyloma Acuminatum

• Depends on location, size, and extent, and if pregnant
• Most important priority: remove symptomatic growth

CDC Recommended Treatment for External Genital Warts

• Podofilox – 0.5% solution or gel BID for 3
PATIENT- days, 4 days off, up to 4 cycles (CI:
APPLIED pregnancy); or
Podofilox • Imiquimod – 5% cream 3x/week, up to 16
Imiquimod weeks, wash 6-10 minutes after treatment;
Figure 5. Estimated prevalence of genital HPV infection among Sinecatechins or
sexually active men and women 15-49 years of age • Sinecatechins - % ointment
PROVIDER- • Cryotherapy – with liquid nitrogen or
• Also known as genital, venereal, or anogenital warts ADMINISTERED cryoprobe, repeat applications every 1-2
• Most common viral STD Cryotherapy weeks; or
• 30% clinically recognizable – macroscopic lesion Podophyllin • Podophyllin resin – 10-25% in a
• 70% unrecognizable – subclinical infection TCA/BCA compound tincture of benzoin (CI:
Surgery pregnancy); or

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• Trichloroacetic aced (TCA) or o Viral shedding – 2 to 3 weeks after vulvar lesions appear
bichloroacetic acid (BCA) – 80-90 %; or o Occasionally primary pelvic infection is subclinical
• Surgical removal – either by tangential
scissor excision, tangential shave excision,
curettage, or electrosurgery
• Topical 5-fluoroacil
Other chemical
• Epinephrine
treatments
• Bovine collagen gel
• Cryotherapy
Lesions larger
• Electrocautery
than 2-3 cm
• Laser therapy

Prevention/Vaccines
• Quadrivalent HPV (6, 11, 16, 18) recombinant Figure 6. Genital ulcers in vagina (left) and penis (right)
Gardasil vaccine
• 3 doses: 0, 2, 6 • Symptoms:
• Bivalent HPV (16, 18; 70% of cervical cases o General malaise
Cervarix worldwide) o Fever
• 3 doses: 0, 1, 6 o Severe vulvar pain, tenderness, and inguinal adenopathy
• Nonvalent (quadrivalent HPV plus 31, 33, 45, o Pain, pruritus, and discharge – peaks 7-11 days of primary
Gardasil-9 infection
52, and 58)
• Vaccines do not work on existing infection or associated pre- • Recurrent Genital Herpes
invasive or invasive disease, and it is therefore most effective if o Local disease with less severe symptoms
given prior to sexual debut and exposure to HPV • Common features of recurrences:
• CDC recommended vaccine administration o Prodromal phase of sacroneuralgia
o HPV vaccine be given to both boys and girls between age 11 o Vulvar burning
and 12 years (two shots of HPV vaccine 6 to 12 months apart) o Tenderness
but can be given as early as 9 years o Pruritus few hours to 5 days before vesicle formation
o Catch-up vaccination • Indications for hospitalization:
▪ For females aged 13-26 years old who are previously not o Severe headache
vaccinated o CNS involvement
• POGS recommendation o Extreme pain
o HPV 2 and 4 for female patients 9-19 years old o Difficulty in walking
o Catch-up vaccination o Severe pain on urination
▪ HPV2 – 19-55 years old o Acute urinary retention
▪ HPV4 – 19-45 years old
o Males: HPV 4 9-26 years old
o Contraindication
▪ Severe allergy to a prior dose
o Dose
▪ <15 years old – HPV 2/4 (0, 6-12)
▪ >15 years old – HPV 2 (0, 1, 6), HPV 4 (0, 2, 6)
o If pregnant, give remaining doses after pregnancy

GENITAL ULCERS Figure 7. Vulvar ulcers of Genital Herpes are PAINFUL

• Genital Herpes
• Granuloma inguinale (Donovanosis) Diagnosis of Genital Herpes
• Lymphogranuloma inguinale (LGV) • Vulvar ulcers – painful when touched
• Chancroid Clinical Inspection
(vs syphilis which is painless)
• Syphilis • Useful in confirming diagnosis in
*See Appendix for the Clinical Features of Genital Ulcers Viral Culture primary episode but less useful in
recurrent episode
GENITAL HERPES
• Most accurate and sensitive
• Recurrent, incurable STD PCR Assay
technique for identifying herpes virus
• Caused by HSV
• Helpful in determining past infection
o HSV 1
• Persons presenting for an STI
▪ Infects epithelium above the waist
evaluation, especially for those with
▪ May cause lower genital tract infection between 13-40% HSV serologic test
multiple sexual partners or HIV infection
▪ Most commonly acquired genital herpes by orolabial
and at increased risk for HIV
lesions to vulva or from genital to genital contact
acquisition
o HSV 2
▪ Causes ulceration below the waist • Most specific to diagnose recurrent
• Dorsal root ganglion of S2, S3, S4 herpes, unrecognized, or subclinical
Western blot assay infection
• Primary Genital Herpes
o Primary infection – local and systemic • Not widely available and difficult to
o Initial infection: 15-35 years old perform
o Incubation period: 3-7 days ELISA and
• Available for HSV-1 and HSV-2
o Paresthesia of vulvar skin → eruption of multiple vesicles → immunoblot assay
progress to shallow, superficial ulcers

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Treatment of Genital Herpes • Highly vascular ulcers bleed easily when touched
• Basis may be on 3 different clinical scenarios • Painless unless secondarily infected, without regional adenopathy
o Primary episode • Vulvar edema especially labia
o Recurrent episode • Untreated, chronic form – scarring and lymphatic obstruction →
o Daily suppression marked vulvar enlargement
▪ Recommended when the woman has 6 or more episodes • Diagnosis:
annually or for psychological distress o Clinical manifestation
• Antiviral medication should be started as early as possible during the o Identification of Donovan bodies
prodrome, and definitely within 24 hours of the appearance of ▪ Clusters of dark staining bacteria with prominent bipolar
lesions granules (safety pin appearance) found in cytoplasm of
large mononuclear cells
CDC Recommended Treatment
• Acyclovir – 200 mg 5x/day or 400mg
TID; or
First Clinical
• Famciclovir – 250mg TID; or
Episode
• Valacyclovir – 1000mg BID
• Duration – 7-10 days
• Acyclovir – 400mg TID x 5 days or
800mg BID x 5 days or 800mg TID x 2
days; or
• Famciclovir – 125mg BID x 5days or
Recurrent Episode
500mg OD x 2 days or 100mg BID x 1 Figure 9. Donovan bodies (SAFETY PIN APPEARANCE) → miniscule
day; or purple-stained structures
• Valacyclovir – 1000mg daily x 5 days
or 500mg BID x 3 days Treatment of Donovanosis
• Acyclovir – 400mg BID or 1000mg/day; CDC Recommended Treatment
or • Azithromycin – 1g orally once per week
Recommended
Daily HSV • Famciclovir – 250mg BID; or Regimen
or 500mg daily for at least 3 weeks and
Suppressive • Valacyclovir – 1000mg daily (≥10 until lesions have completely healed
Therapy recurrences/year) or 500mg daily (≤ 9 • Doxycycline – 100mg orally 2x/day; or
recurrences/year) • Ciprofloxacin – 750mg orally 2x/day; or
• Orally for 12 months • Erythromycin base – 500mg orally
• Acyclovir Alternative
4x/day; or
o Relative minimal toxicity Treatment • Trimethoprim-sulfamethoxazole – one
o Daily therapy is safe with acyclovir for as long as 6 years and double strength (160/800mg) tablet orally
with valacyclovir or famciclovir for 1 year based on studies 2x/day
• CDC Recommendation: Acyclovir or other suppressive drugs • Duration: for at least 3 weeks and until
should be discontinued after 12 months of suppressive therapy all lesions have completely healed
to determine the subsequent rate of recurrence for each • Acyclovir
individual woman o Relative minimal toxicity
o Daily therapy is safe with acyclovir for as long as 6 years and
GRANULOMA INGUINALE (DONOVANOSIS) with valacyclovir or famciclovir for 1 year based on studies
• Chronic, ulcerative, bacterial infection of skin and subcutaneous of • CDC Recommendation: Acyclovir or other suppressive drugs
vulva should be discontinued after 12 months of suppressive therapy
• Caused by Klebsiella granulomatis to determine the subsequent rate of recurrence for each
o Intracellular gram (-), non-motile, encapsulated rod individual woman
• Transmission:
o Sexually and close, non-sexual contact LYMPHOGRANULOMA VENEREUM (LGV)
• Asymptomatic nodule → gradually progress into a painless (like • Chronic infection of lymphatic tissue
syphilis), slowly progressing ulcer surrounded by highly vascular • Caused by Chlamydia trachomatis serotypes L1, L2, and L3
tissue → beefy-red ulcer (characteristic lesion) • Vulva – frequent site
• Other sites: urethra, rectum, cervix
• Incubation period: 3-30 days

3 Distinct Phases of Vulvar and Perirectal LGV

• Shallow, painless ulcer that heals rapidly
without therapy
Primary
• Typically located on the vestibule or labia
Infection
but occasionally in perirectal region

• Begins 1-4 weeks after primary infection

• Painful adenopathy in inguinal and
perirectal areas
Secondary • Untreated → infected nodes → tender,
Phase enlarges, matted → BUBOES (tender
Figure 8. Characteristic lesion of Donovanosis (BEEFY RED ULCER) lymph nodes)
• GROOVE SIGN
O Double genitocrural fold

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O Depression between groups of Treatment of Chancroid
inflamed nodes Medical Treatment Options
O Classic clinical sign of LGV Azithromycin 1g PO single dose
Ceftriaxone 250mg IM single dose
Ciprofloxacin 500mg PO DIB x 3 days
Erythromycin 500mg PO TIB x 7 days
• Needle aspiration to prevent
For Fluctuant nodes rupture of abscess
• If >5cm – incision and drainage
• Sexual partners should be treated in a similar fashion
• Successful antibiotic therapy results in symptomatic and
objective improvement within 5-7 days of initiating therapy
Figure 10. Groove sign • Large ulcers may require 2-3 weeks to heal, with clinical
• Within 7-15 days, rupture of bubo → resolution of lymphadenopathy slower than that of ulcers
multiple draining sinuses and fistula • Buboes respond at a slower rate than skin ulcers
• Extensive tissue destruction of external
Tertiary Phase genitalia and anorectal region → SYPHILIS
elephantiasis, multiple fistulas, and • Caused by Treponema pallidum – spirochete
stricture formation of anal canal and • Moderately contagious disease
rectum (Classic signs of tertiary phase) o 3-10% of patients contract the disease from a single sexual
encounter with an infected partner
Diagnosis of Vulvar and Perirectal LGV
• Using pus/aspirate from tender Stages of Syphilis
Culture
lymph nodes • Chancre (21-35 days or anytime b/w 10-90
Compliment Fixation • Antibody titer >1.64 is indicative of days)
Antibody Titer active infection • Painless, hard chancre
Primary
• Red, round ulcer with firm, well-formed, raised
Treatment of Vulvar and Perirectal LGV edges, with non-purulent clean base and yellow-
CDC Recommended Treatment gray exudate
• Doxycycline 100mg PO BID for 21 • Mucocutaneous lesion
Recommended Regimen
days • Hematogenous dissemination
• Erythromycin base 500mg PO • Systemic disease
Alternative Regimen
QID for 21 days • Develops b/w 6 weeks and 6 months after
primary chancre
CHANCROID • Classic rash – red macules and papules over
• Caused by Haemophilus ducreyi palms and soles
o Highly contagious, small, non-motile gram (-) rod • Vulvar lesions
o Classic appearance of streptobacillary chains; “school of o Mucous patches
fish” Secondary o Condyloma latum associated with painless
o Extracellular lymphadenopathy
• Soft, painful chancre (vs. syphilis – hard painless chancre) o Ulcers are larger than herpetic ulcers and are
• Incubation period: 3-6 days nontender unless secondarily infected
• Unable to invade or penetrate normal skin • Latent syphilis
• Preceded by tissue trauma o Early/Late
o Follows secondary syphilis
• From small papule → 48-72 hrs → pustule → ulcer
o Duration: 2-20 years
• Ulcers have dirty gray, necrotic, foul-smelling exudate; induration at o Positive serology without signs and
base is absent (soft chancre), painful, ragged edge symptoms of the disease
• Buboes • GUMMA
• Diagnosis: • Devastating
o Gram staining
• Duration: 2-20 years
o Cultures of purulent material from lymph node
• Characterized as positive serology without signs
o PCR
and symptoms of the disease
• Potentially destructive effects on CNS, CVS,
Tertiary musculoskeletal system
• Manifestations of late syphilis:
o Optic atrophy
o Tabes dorsalis
o Generalized paresis
o Aortic aneurysm
o Gummas of skin and bones
• Woman with syphilis is most infectious during the first 1-2
years of the disease, with decreasing infectivity thereafter

Figure 11. Chancroid ulcer

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• Some experts recommend additional
therapy:
- 2nd dose of Benzathine Pen G 2.4M
units IM, 1 week after the initial dose
for those who have primary,
secondary, or early latent syphilis
• Alternative regimen: for pregnant
women with a history of penicillin allergy
(should be skin-tested and desensitized)
• Primary and secondary syphilis
- Benzathine Pen G 2.4M units IM
Single dose
• Some experts recommend additional
treatment:
Syphilis in HIV- - 3 weekly doses of Benzathine Pen G
related patients • Penicillin allergic patients:
- Should be desensitized and treated
with Penicillin regimen
• Latent Syphilis (w/ normal CSF
examination)
- Benzathine Pen G 7.2M units
Figure 12. First time course of syphilis
Jarisch-Herxheimer Reaction
• Adverse reaction to Pen G
Diagnosis of Syphilis
• Acute febrile reaction with flu-like symptoms (headache and
• Venereal Disease Research Laboratories (VDRL)
Screening myalgia)
• Rapid Plasma Reagin (RPR)
• First 24 hrs after parenteral Pen G treatment for early syphilis
• Fluorescent-labeled Treponema Antibody
Absorption (FTA-Abs)
Validation
• Microhemagglutination assay for antibodies
to T. pallidum (MHA-TP or TPHA) III. INFECTIONS OF THE VAGINA
Follow-up • Quantitative VDRL/RPR VAGINITIS
• Diagnosis of syphilis is complicated by the fact that the • Symptoms: vaginal discharge, superficial dyspareunia, odor, vulvar
organism cannot be cultivated in vitro burning and pruritus
• Definitive diagnosis is through darkfield microscopy to • 3 common infections of the vagina:
detect T. pallidum in lesion exudate or tissue o Candidiasis: Fungal
• Serologic tests – for presumptive diagnosis and sceening o Trichomoniasis: Protozoan
- Nonspecific nontreponemal o Bacterial vaginosis: Bacterial
- Specific antitreponemal antibody tests
DIFFERENTIATION OF ETIOLOGIES OF VAGINITIS
• All women diagnosed with syphilis should be screened for HIV
Bacterial Trichomon Candidal
Parameter Normal
Treatment of Syphilis Vaginosis iasis Vaginitis
CDC RECOMMENDED TREATMENT Discharge No Yes Yes No
• Recommended regimen: Color Yellow-
Early syphilis White Gray White
- Benzathine Pen G 2.4M units IM, gray
(primary, Viscosity High Low Low High
Single dose
secondary, and Consistency Homogene Homogene
• Alternative: (penicillin-allergic non- Floccular Floccular
early latent syphilis ous ous
pregnant patients)
<1yr duration) Presence in
- Doxycycline 100mg PO BID x 2wks Dependent Adherent to Adherent to Adherent to
• Recommended regimen: Vagina
portion vaginal wall vaginal wall vaginal wall
- Benzathine Pen G 7.2M units total
Late latent administered as 3 doses of 2.4M *See appendix for typical features and diagnostic tests for vaginitis.
syphilis units IM at 1 week intervals
(>1yr duration, • Alternative: BACTERIAL VAGINOSIS
gummas, and CV - Doxycycline 100mg PO BID for 2 • Shift in vaginal flora from lactobacilli dominant to mixed flora (genital
syphilis) weeks if <1yr, for 4 weeks if >1yr microplasma, Garnerella vaginalis and anaerobes,
- Tetracycline 500mg PO QID for 2 Peptostreptococci, Prevvotella & Mobiluncus)
weeks if <1yr, for 4 weeks if >1yr • NOT CLASSIFIED AS AN STD because of inability to find a
• Recommended regimen: transmissible agend = thus, no need to treat the partner
- Aqueous crystalline Pen G 18-24M • Described as “sexually associated” rather than STD
units daily, administered as 3-4M • Risk factors of bacterial vaginosis:
units IV every 4 hrs for 10-14 days o New or multiple sex partners
Neurosyphilis • Alternative: o Lesbian couples sharing sex toys
- Procaine penicillin 2.4M units IM o Douching
daily for 10-14 days PLUS o Social stressors
Probenecid 500mg mg PO QID for • Vaginosis rather than vaginitis due to absence of inflammation on
10-14 days biopsy
• Recommended regimen: • Associated upper genital tract infections: endometritis, PID, post-
Syphilis in
- Penicillin regimen appropriate for operative vaginal cuff cellulitis, PROM in pregnancy
Pregnancy
stage of syphilis

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Diagnosis of Bacterial Vaginosis
Amsel criteria (3 • Thin white homogeneous discharge
of 4 must be • Clue cells on microscopy – vaginal
satisfied for a epithelial cells with clusters of bacteria
presumptive adherent to the external surface (clue cells
diagnosis) >20% of the number of vaginal epithelial
cells)
• pH > 4.5
• Positive amine test – Whiff’s Test
- 10% KOH Figure 13. Strawberry shortcake loljk cervix
- Get discharge + 10% KOH = fishy odor
Gram Stain – • Uses a differential bacterial count on gram- Treatment of Trichomoniasis
Nugent criteria staining
Metronidazole • 500mg BID x 7 days
(basis of scoring • <4 normal
below) • 4-6 intermediate Topical therapy is NOT RECOMMENDED because it won’t
• >6 bacterial vaginosis penetrate deep enough and cannot eliminate those reservoirs in
the Bartholin and Skene glands
<1 1-5 6-30 >30
Types None CANDIDIASIS
(OIO) (OIO) (OIO) (OIO)
Large G(+) • Caused by:
4 3 2 1 0 o Candida albicans – 90%
rod
Small G(-) o Candida glabrata or tropicalis – 5-10%
0 1 2 3 4 • Pathogenesis: Disturbed ecosystem of the vagina → proliferation of
rod
Curved G(-) opportunistic pathogens
0 1 2 3 4 o Hormonal: pregnancy and menstruation
rod
o Depressed cell immunity
• Mushy or fishy vaginal odor o Antibiotics – penicillins, tetracyclines, cephalosporins
o Most frequent symptom of bacterial vaginosis • Pruritus – predominant symptom
• Thin and gray-white discharge • Vulvar burning, external dysuria, dyspareunia
o Same to thin paste made of flour • Erythema and edema – more extensive vulvar involvement vs.
• Frothy vaginal discharge in 10% of patients trichomoniasis just limited to vestibule and labia majora
• Rarely associated with pruritus or vaginal irritation • pH <4.5
o Unlike in bacterial vaginosis and trichomoniasis which are both
associated with elevated pH
Treatment of Bacterial Vaginosis • COTTAGE CHEESE-LIKE DISCHARGE, no odor
Metronidazole • 500mg BID x 7 days
• Single-dose oral therapy of 2g is nolonger
recommended because of high failure rates

Alternatives: • If allergic to metronidazole or in resistant

Tinidazole cases:
Clindamycin • Tinidazole 2g oral x 3 days or 1g oral x 5
days
• Clindamycin 300mg q12h x 7 days
• Clindamycin ovules 100mg intravaginally
once at bedtime x 3 days Figure 14. Cottage cheese-like discharge
Recall that it is not an STD so treatment of the partner is not needed
• Recurrent vulvovaginal candidiasis (RVVC)
TRICHOMONIASIS o Defined as 4 or more episodes of symptomatic lower tract
• Trichomonas vaginalis infection within 12 months
o Unicellular protozoan
o Inhabits the vagina and lower urinary tract especially the
Skene’s duct in females Classification of Candidiasis
• Most prevalent non-viral, non-chlamydial STD Uncomplicated Complicated
• Copious discharge (feeling “wet”) is the primary symptom • Sporadic or infrequent VVC • Recurrent VVC
• Copious white, gray, yellow or green discharge • Mild to moderate VVC • Severe VVC
o Frothy (with bubbles) discharge often with unpleasant odor • Likely to be C. albicans • Non-albicans VVC
found in 10-25% of patients • Non-immunocompromised • Women with uncontrolled DM,
o Classic discharge of Trichomonas but not diagnostic because debilitation or
also present in bacterial vaginosis immunosuppression
• Strawberry appearance of upper vagina and cervix <10%of cases
• Diagnosis: Diagnosis of Candidiasis
o Nucleic Acid Amplification Tests (NAAT) – 3-5x more • Filamentous forms
sensitive than wet prep Wet smear 10- • Mycelia
o Wet smear 20% KOH • Pseudohyphae-associated with active
o Pap smear disease
o pH 5.0-7.0
• Nickerson medium
Culture
• Sabouraud medium

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 GYNECOLOGY
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• Differential diagnoses: • Central nervous system
o Bacterial vaginosis (disorientation or alteration in
o Trichomonas vaginitis consciousness without focal
o Atrophic vaginitis neurologic signs when fever and
o Non-infectious causes hypotension are absent)
▪ Allergic reactions • Cardiopulmonary (ARDS,
▪ Contact dermatitis Pulmonary edema, new onset of
▪ Chemical irritants 2nd/3rd degree heart block,
▪ Lichen planus – rare myocarditis)
Negative throat and CSF • A positive blood culture does not
Treatment of Candidiasis cultures exclude a case
Uncomplicated • Topical azoles (miconazole, clotrimazole,
VVC butoconazole, tioconazole) vaginal prep x 1- • For Rocky Mountain Spotted
Negative serologic tests
(Patient should 3 days; or Fever, Leptospirosis, Rubeola
abstain) • Fluconazole – 150mg single oral dose • Most characteristic manifestation
• Topical azoles (same examples) vaginal of TSS
Complicated prep x 1-3 days; or - 1st 48 hrs – sunburn
VVC • Fluconazole- 150mg then give the 2nd dose - Few days – erythema →
72 hours after macular
Skin changes
- 12-15 days – fine, flaky
• Topical azoles (same examples) vaginal
desquamation of skin over face
prep x 7-14 days; or
and trunk with sloughing of
• 3 doses of fluconazole 3 days apart (day
entire skin thickness of palms
1, 4, 7) then maintenance therapy will help
and soles
prevent recurrence of symptoms
• Oral fluconazole (e.g., 100, 150, or 200mg Vaginal mucosa • Hyperemic
Recurrent VVC dose) weekly for 6 months is typically first-
line treatment. However topical treatments
External genitalia • Tender
used intermittently as a maintenance
regimen may be considered
• Women with recurrent vulvovaginitis should
TREATMENT OF TSS
receive a vaginal fungal culture to determine
species and sensitivities • Management:
o ICU or expert in critical care medicine
*Note: Remind patient which drugs are intravaginal and which are oral
o Eliminate hypotension produced by exotoxin
o Copious IV fluids
TOXIC SHOCK SYNDROME (TSS)
o Mechanical ventilator for ARDS
• Acute febrile illness produced by bacteria exotoxin with fulminating
o Obtain cervical, vaginal, and blood cultures for S. aureus
downhill course involving dysfuntion of multiple organ systems
o Wash out the vagina with saline or dilute iodine solution to
• 50% are not related to menses diminish the amount of exotoxin
• Non-menstrual TSS may be a sequelae of focal staph infection of
• Clindamycin- 600mg IV every 8hours +
the skin and subcutaneous tissue, often following a surgical For TSS
nafcillin or oxacillin 2g IV every 4 hours
procedure – usually first 48 hours post operation caused by
• Most experts recommend a 1-2-week course
• Tampon use is a risk factor for TSS Methicillin-
of therapy with an anti-staphylococcus such
• 3 requirements for the development of classical TSS: susceptible S.
as clindamycin or dicloxacillin, even in the
o Must be colonized or infected with S. aureus aureus
absence of a positive S. aureus culture
o Bacteria must produce TSS toxin (TSST-1)
• Clindamycin + vancomycin- 30mg/kg/day IV
o Toxin must have a route of entry into systemic circulation
in two divided doses; or
For TSS
• Linezolid- 600mg oral or IV every 12 hours
CASE DEFINITION caused by
• If the diagnosis is questionable, it’s best to
Fever • 38.9⁰C or 102⁰F MRSA
include an aminoglycoside to obtain coverage
• Characterized by diffuse macular for possible gram-negative sepsis
Rash
Skin erythroderma • If the underlying cause TSS is infection, the infected site should be
changes • Occurring 1-2 weeks after onset of drained and debrided
Desquamation
illness (in survivors) • Treatment with mupirocin to decrease colonization is
Hypotension or orthostatic recommended, applying half of the ointment from a single-use
• SBP ≤ 90 mmHg in adults tube into one nostril and the other half into the other nostril twice
syncope
daily for 5 days
• GI (Vomiting or diarrhea at onset
of illness) • In summary:
o Treatment of TSS depends on the severity of the involvement of
• Muscular (myalgia or creatinine
individual organ systems
phosphokinase x2 of normal)
o Not all patients develop a temperature of >38.9⁰C and
• Mucous membrane (vaginal,
hypotension
oropharyngeal, or conjunctival
o Clinicians should be aware of the manifestations of the
Involvement of ≥3 organ hyperemia)
syndrome
systems • Renal (BUN or creatinine ≥2x of
o The foundation of treatment of the disease is prompt and
normal or ≥5 WBC/hpf urinalysis
aggressive management because of the rapidity with which the
in absence of UTI
disease may progress
• Hepatic (total bilirubin, SGOT, or
SGPT twice normal level)
• Hematologic (platelets
≤100,000/μL)

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 GYNECOLOGY
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IV. INFECTIONS OF THE CERVIX • All women with a chlamydial or gonorrheal infections and their
partners should be treated
CERVIX
• Potential reservoir for N. gonorrhea, C. trachomatis, HSV, HPV, and  Age <25 years
Mycoplasma sp.  New or multiple sex partners
• Acts as a barrier between the abundant bacterial flora of vagina and  Unprotected sex
bacteriologically sterile endometrial cavity and oviducts • Patients should be instructed to refer all sex partners of the last
• Primary cervical infection 60 days for evaluation and treatment and to avoid sexual
o Secondary ascending infection including PID, perinatal infection intercourse until therapy is completed and there is resolution of
of membranes, amniotic fluid and parametria symptoms

HISTOPATHOLOGY OF ENDOCERVICITIS NEISSERIA GONORRHEA

• Characterized by a severe inflammatory reaction in the mucosa and • Gram-negative diplococci found in the epithelium of the
submucosa genitourinary tract, rectum, pharynx, or the eye
• The tissues are infiltrated with a large number of polymorphonuclear
cells and monocytes and, occasionally, there is associated epithelial Diagnosis of N. gonorrhea
necrosis • Of urine and cervix
Nuclear Acid
• Most sensitive and specific
Amplification Test
MUCOPURULENT CERVICITIS diagnostic tool for identifying
(NAAT)
• 2 simple, definitive, objective criteria for diagnosis: gonorrheal infections
o Gross visualization of yellow mucopurulent material on white Culture • Use of Thayer-Martin medium
cotton swab (Condensed milk) Gram stain • Gram-negative diplococci
o Presence of 10 or more PMN/microscopic field x 1000 Enzyme immunoassay
magnification on gram stain smear obtained from endocervix
• Alternative clinical criteria of mucopurulent cervicitis Treatment of N. gonorrhea
o Erythema and edema in an area of cervical ectopy; or Ceftriaxone • 250 mg IM single dose
o Bleeding secondary to endocervical ulceration; or Cefixime • 400 mg PO single dose
o Friability when the endocervical smear is obtained
Single Dose Injectable
o Increased vaginal discharge and intermenstrual vaginal
Cephalosporin • Plus treatment for Chlamydia
bleeding
Regimen
• Two other considerations are given high priority when choosing
an antibiotic
 Single-dose efficacy
 Simultaneously treating coexisting chlamydial infection
• C. trachomatis has frequently been found to simultaneously
colonize women with gonorrhea
• Azithromycin 2 g may be used in cephalosporin-allergic patients
Figure 15. Right: Mucopurulent cervicitis as demonstrated by the
• In addition to the antibiotics for gonorrhea, the CDC
Cotton Swab Test (Condensed Milk-Like material)
recommends treating with azithromycin 1 g orally in a single
dose or oral doxycycline 100 mg twice daily for 7 days, if
CHLAMYDIA TRACHOMATIS
Chlamydia has not been ruled out
• Cause of cervical infection in most women with mucopurulent
• If the woman is asymptomatic, follow-up testing is no longer
cervicitis
recommended by the CDC as a test of cure for lower tract
• Columnar cells of endocervix: most common site of chlamydia
infections (uncomplicated gonorrhea)
infection in the female reproductive tract
• Studies have shown a high rate of reinfection, so rescreening of
patients is prudent
Diagnosis of C. trachomatis
• Women with positive cultures for gonorrhea should have a
Nuclear Acid
• Gold standard in identifying C. serologic test for syphilis in 4-6 weeks, even though patients
Amplification Test
trachomatis infection with incubating syphilis are usually cured by antibiotic
(NAAT)
combinations of ceftriaxone and tetracycline
• Cytobrush: optional instrument for
• Similarly, patients should be offered informed consent and
Culture appropriate sampling for Chlamydia
testing for HIV infection
culture
AIDS
Treatment of C. trachomatis
• Advance disease state manifestations of viral infections by HIV
Azithromycin • 1 g PO single dose
• Virus has predilection for cells of immune system, specifically
Doxycycline • 100 mg PO BID 7 days “helper” lymphocytes (lymphocytes with CD4 marker) and
Alternatives • Erythromycin: base 500 mg QID for 7 days; monocytes
or • 3 primary methods of contracting HIV
• Erythromycinethyl succinate: 800 mg PO o Intimate sexual contact
QID for 7 days; or o Use of contaminated needles or blood products, especially
• Ofloxacin: 300 mg PO BID for 7 days; or hemophiliacs
• Levofloxacin: 500 mg PO once daily for 7 o Perinatal transmission from mother to child
days
• Women treated for chlamydia should be instructed to abstain
from sexual intercourse for 7 days after single-dose therapy or
until completion of the 7-day regimen REFERENCES
• When mucopurulent cervicitis is clinically diagnosed, empirical 2019 Trans
therapy for C. trachomatis is recommended for women at Lecture Notes
increased risk of this common STI Comprehensive Gynecology

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 GYNECOLOGY
LOWER GENITAL TRACT INFECTIONS
Alice D. Bautista, MD | 26 September 2018
S2T1a
APPENDIX
II. E. Genital Ulcers

III. A. Vaginitis

TYPICAL FEATURES OF VAGINITIS

(From Compre Gyne)

Condition S/S Findings pH Wet Mount Comment

• Thin, whitish gray, • Greatly decreased
• Increased
homogeneous • Clue cells (>20%) shift in flora lactobacilli
discharge (white,
Bacterial vaginosis discharge >4.5 • Amine odor after adding KOH to • Greatly increased
thin)
• Cocci wet mount cocci, small curved
• Increased odor
• Sometimes frothy rods
• Increased • Can be a mixed
discharge (white, infection with
• Thick, curdy
thick) bacterial vaginosis,
Candidiasis discharge <4.5 • Hyphae or spores
• Dysuria T. vaginalis, or
• Vaginal erythema
• Pruritus both, and have a
• Burning higher pH
• Increased
• Yellow, frothy
discharge (yellow,
discharge
frothy) • Motile trichomonads • More symptoms at
Trichomoniasis • With or without >4.5
• Increased odor • Increased white cells higher vaginal pH
vaginal or cervical
• Dysuria
erythema
• Pruritus

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 GYNECOLOGY
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DIAGNOSTIC TESTS FOR VAGINITIS
(From Compre Gyne)
Condition Test Sensi Speci Comments
pH > 4.5 97 64
Must meet 3 or four clinical criteria (pH >4.5, thin watery discharge, >20% clue cells,
positive whiff test), but similar results achieved if two of four criteria meet Nugent
Amsel’s criteria 92 77 criteria; Gram stain morphology score (1-10) based on lactobacilli and other
morphotypes; score of 1-3 indicates normal flora, score of 7-10 bacterial vaginosis;
high interobserver reproducibility
Bacterial Pap Smear 49 93
vaginosis
Point-of-care tests
• QuickVue 89 96 Positive if pH >4.7
Advance, pH +
amines
• QuickVue 91 >95 Tests for proline iminopeptidase activity in vaginal fluid; if used when pH >4.5,
Advance, G. sensitivity is 95% and specificity is 99%
vaginalis
• OSOM BV Blue 90 <95 Tests for vaginal sialidase activity

Wet mount
• Overall
50
• Growth of 3-4+
85 C. albicans is a commensal agent in 15-20% of women
on culture 97
Candidiasis • Growth of 1+ on 23
culture
If symptoms present, pH may be elevated if mixed infection with bacterial vaginosis or
pH ≤ 4.5 Usual
T. vaginalis present
Wet mount 45-60 95 Increased visibility of microorganisms with a higher burden of infection
Culture 85-90 >95
Trichomoniasis pH >4.5 56 50
Pap smear 92 61 False-positive rate of 8% for standard Pap test and 4% for liquid-based cytologic test
POCT: OSOM 83 98.8 10 min required to perform tests for T. vaginalis antigens

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