Rahma P. Utami, S.Ked.

Adviser:
Dr. dr. H. Ferry Yusrizal, Sp.OG(K)., M.Kes.

OBSTETRIC AND GYNECOLOGY DEPARTEMENT

MEDICAL FACULTY OF SRIWIJAYA UNIVERSITY | DR. MOH. HOESIN GENERAL HOSPITAL PALEMBANG | 2018
OUTLINE
01
PREFACE

02 ANATOMY OF FEMALE GENITAL TRACT

03 CHAPTER OF DISEASES
VULVITIS | VAGINITIS | CERVICITIS

04
CONCLUSION
PREFACE
FEMALE GENITAL TRACT INFECTIONS
Reproductive tract infections (RTIs)

Female genital tract infections are infections that affect the reproductive tract, which is part of the Reproductive System

STD ENDOGENIC IATROGENIC

(chlamydia, GO, (overgrowth of (associated
chancroid, & HIV) organism normally with improperly
present in the GT performed medical
of healthy women) procedure)

DISEASES BURDEN Morbidity and mortality related to RTIs deprive society of

important contributions made by women in terms of
Infections are often asymptomatic or the economic, social, and cultural development.
symptoms are not recognizable
FEMALE GENITAL TRACT
INFECTIONS

PREVALENCE
 Incidence and prevalence vary greatly between countries,
a reflection of the differences in the characteristics of each
pathogen (such as duration of infectivity and transmissibility)
as well as other biological, behavioral, medical, social, and
economic factors.

 It is difficult to interpret data on the prevalence of RTIs in deve-

loping regions in terms of internal validity or generalizability

 Rates of RTIs tend to be highest among high-risk groups

such as commercial sex workers and clients of STD clinics,
but are also prevalent in asymptomatic populations and low-
risk women, such as those attending antenatal clinics.
 TAKING HISTORY

PHYSICAL EXAMINATION 01
02

ADVANCE EXAMINATION
03

TREATMENT
04

PREVENTION & EDU

05
GOAL
ANATOMY
ANATOMY OF FEMALE GENITALIA

EXTERNAL INTERNAL
Vulva | Perineum Vagina | Uterus | Uterine Tube | Ovary
CHAPTER DISEASES
VULVITIS
 VULVITIS
Infections that affect the vulva, which is refers to those parts that are outwardly visible of GT

ETIOLOGY
0 According to the pathogens

CLINICAL MANIFESTATION
0  Asymptomatic most common
 Vulvar erythema, pruritis, burning, edema, and
pain of the labia and vulva.
 Vary, depend on pathogen that causes diseases

0 PRINCIPAL DIAGNOSTIC
Find the pathogens

PRINCIPAL TREATMENT
0 Adjusted to the founded pathogens
Vulvitis is infections that affect the vulva, which is refers to those parts that are outwardly visible of GT
Includes: Mons pubis, Labia majora, Labia minora, Clitoris, Urethral opening, Vaginal opening, & Perineum

BACTERIAL INFECTIONS
Neisseria gonorrhoeae
Chlamydia trachomatis
Treponema pallidum

PARASITE INFECTIONS
VIRAL INFECTIONS
Phthirus pubis
Sarcoptes scabiei Human Immunedeficiency Virus (HIV)
Herpes simplex virus (HSV)
Human papillomavirus (HPV)
Virus moluskum kontagiosum

PROTOZOA INFECTIONS
Trichomonas vaginalis FUNGAL INFECTIONS
(as impact of vaginal infections) Candida albicans
 TYPE OF VULVITIS

LOCALIZE VULVITIS
01  Skin infections on hair, apocrine & sebacea glands >> skin injury (laceration), folliculitis, etc
 External Urethral Orifiscium and Parauretralis glands Infections >> Neisseria gonorrhoeae
 Bartholin’s gland infections (Bartholinitis)

02 CRONIC DISEASES MANIFESTATIONS

Vulvitis as the beginning of clinical manifestations chronic diseases, such as:
 STD
 Tuberculosis
 Viral Vulvitis
 Vulvitis on Diabetes Mellitus

03 DUE TO VAGINITIS
VAGINITIS
 VAGINITIS
Vaginitis is infections that affect the vagina

CHARACTERIZED BY:
10%  Vaginal discharge
 Vulvar itching
 Irritation
15-20%  Odor
40-45%

20-25% COMMON TYPE:

 Bacterial vaginosis (40%–45%)
 Vulvovaginal candidiasis (20%–25%)
 Trichomoniasis (15%–20%)
BV VVC TV ETC  Etc (10%)
 VAGINITIS DIFFERENTIATION
Normal BACTERIAL VAGINOSIS CANDIDIASIS TRICHOMONIASIS

Symptom Itch, discomfort, Itch, discharge, ~70%

Odor, discharge, itch
presentation dysuria, thick discharge asymptomatic

Homogenous, adherent,
Thick, clumpy, white Frothy, gray or yellow-
Vaginal discharge Clear to white thin, milky white;
“cottage cheese” green; malodorous
malodorous “foul fishy”
Inflammation and Cervical petechiae
Clinical findings
erythema “strawberry cervix”

Vaginal pH 3.8 - 4.2 > 4.5 Usually < 4.5 > 4.5

KOH “whiff” test Negative Positive Negative Often positive

Clue cells (> 20%), Few to many Motile flagellated

NaCl wet mount Lacto-bacilli
no/few WBCs WBCs protozoa, many WBCs

Pseudohyphae or
KOH wet mount spores if non-albicans
species 17
BACTERIAL VAGINOSIS
EPIDEMIOLOGY
 Most common cause of vaginitis
 Prevalence varies by population
 5%–25% among college students
 12%–61% among STD patients
 Widely distributed

RISK FACTORS

 African American
 Two or more sex partners in previous six months/new sex partner
 Douching
 Lack of barrier protection
 Absence of or decrease in lactobacilli
 Lack of H2O2-producing lactobacilli
PATHOGENESIS
 Overgrowth of bacteria species normally present in vagina with
anaerobic bacteria
 BV correlates with a decrease or loss of protective lactobacilli
 Vaginal acid pH normally maintained by lactobacilli through
metabolism of glycogen.
 Hydrogen peroxide (H2O2) is produced by some Lactobacilli,sp.
 H2O2 helps maintain a low pH, which inhibits bacteria overgrowth.
 Loss of protective lactobacilli may lead to BV.

CLINICAL MANIFESTATIONS & SYMPTOMS

 Many women (50%–60%) are asymptomatic.
 Signs/symptoms, when present
 Reported malodorous (fishy smelling) vaginal discharge
 Reported more commonly after vaginal intercourse and after
completion of menses
 Symptoms may remit spontaneously.
DIAGNOSIS

 Wet Prep: Bacterial Vaginosis

 Saline: 40X objective

(Seattle STD/HIV Prevention Training
Center at the University of Washington)

Clue cells
DIAGNOSIS
AMSEL CRITERIA
Must have at least three of the following findings:
 Vaginal pH >4.5
 Presence of >20% per HPF of "clue cells" on wet mount examination
 Positive amine or "whiff" test
 Homogeneous, non-viscous, milky-white disch
 arge adherent to the vaginal walls

OTHER DIAGNOSTIC TOOLS

 Vaginal Gram stain (Nugent or Speigel criteria)
 Culture
 DNA probe
 Newer diagnostic modalities include: PIP activity & Sialidase tests
PATIENT MANAGEMENT

CDC-recommended regimens
 Metronidazole 500 mg orally twice a day for 7 days, or
 Metronidazole gel 0.75%, one full applicator (5 g) intravaginally,
once or twice a day for 5 days , or
 Clindamycin cream 2%, one full applicator (5 g) intravaginally
at bedtime for 7 days
Alternative regimens (nonpregnant)
 Tinidazole 2 g orally once daily for 2 days, or
 Tinidazole 1 g orally once daily for 5 days, or
 Clindamycin 300 mg orally twice a day for 7 days, or
 Clindamycin ovules 100 g intravaginally once at bedtime for
3 days
Multiple recurrences
 Twice weekly metronidazole gel for 4–6 months may reduce
recurrences
 Oral nitroimidazole followed by intravaginal boric acid and
suppressive metronidazole gel
PREVENTION

PARTNER MANAGEMENT
 Relapse or recurrence is not affected by treatment of sex partner(s).
 Routine treatment of sex partners is not recommended.

PATIENT COUNSELING AND EDUCATION

 Nature of the disease >> Normal vs. abnormal discharge, malodor, BV
signs & symptoms
 Transmission issues >> Association with sexual activity, ↑ female
same-sex partnerships
 Risk reduction
 Correct and consistent condom use
 Avoid douching
 Limit number of sex partners
VULVOVAGINAL
CANDIDIASIS
EPIDEMIOLOGY
 Affects most females during lifetime, with approximately 50% having
two or more episodes
 Most cases caused by C. albicans (85%–90%)
 Second most common cause of vaginitis
 Estimated cost: $1 billion annually in the U.S.

TRANSMISSION

Candida species are normal flora of skin and vagina and are not
considered to be sexually transmitted pathogens.
PATHOGENESIS
 Candida species are normal flora of the skin and vagina.
 VVC is caused by overgrowth of C. albicans and other non-albicans
species.
 Yeast grows as oval budding yeast cells or as a chain of cells
(pseudohyphae).
 Symptomatic clinical infection occurs with excessive growth of yeast.
 Disruption of normal vaginal ecology or host immunity can predispose
to vaginal yeast infections.

CLINICAL MANIFESTATIONS & SYMPTOMS

 Vulvar pruritis is most common symptom.
 Thick, white, curdy vaginal discharge ("cottage cheese-like")
 Erythema, irritation, occasional erythematous "satellite" lesion
 External dysuria and dyspareunia
DIAGNOSIS
 History, signs and symptoms
 Visualization of pseudohyphae (mycelia) and/or budding yeast (conidia)
on KOH or saline wet prep
 pH normal (4.0 to 4.5)
 If pH > 4.5, consider concurrent BV or trichomoniasis infection
 Cultures not useful for routine diagnosis

OTHER DIAGNOSTIC TOOLS

 Vaginal Gram stain (Nugent or Speigel criteria)
 Culture
 DNA probe
 Newer diagnostic modalities include: PIP activity & Sialidase tests
DIAGNOSIS

 PMNs and Yeast Pseudohyphae

Yeast
 Saline: 40X objective
(Seattle STD/HIV Prevention Training pseudohyphae
Center at the University of Washington)

Yeast
PMNs
buds
DIAGNOSIS

 Yeast Pseudohyphae Lysed squamous

epithelial cell
 10% KOH: 10X objective
(Seattle STD/HIV Prevention Training
Center at the University of Washington)
Masses of yeast
pseudohyphae
CLASSIFICATION
UNCOMPLICATED VVC
Sporadic or infrequent vulvo-
vaginal candidiasis
or
Mild-to-moderate vulvovaginal
candidiasis
or
Likely to be C. albicans
or
Vulvovaginal candidiasis in
nonimmunocompromised women
COMPLICATED VVC
Recurrent vulvovaginal
candidiasis (RVVC)
or
Severe vulvovaginal candidiasis
or
Non-albicans candidiasis
or
Vulvovaginal candidiasis in wom
en with uncontrolled diabetes, de
bilitation, or immunosuppression
 Complicated VVC
PATIENT MANAGEMENT • Recurrent (RVVC)
– Four or more epi
sodes in year
Recurrent VVC (RVVC)
 7–14 days of topical therapy, or • Severe
 100 mg, 150 mg , or 200 mg oral dose of fluconozole repeated every 3 da – Edema
ys (days 1,4,and 7) – Excoriation/
fissure formation
 Maintenance regimens (see 2010 CDC STD treatment guidelines)
• Non-albicans
candidiasis
Severe VVC
• Compromised host
• 7–14 days of topical therapy, or
• 150 mg oral dose of fluconozole repeated in 72 hours

Non-albicans
• Optimal treatment unknown
• 7–14 days non-fluconazole therapy
• 600 mg boric acid in gelatin capsule vaginally once a day for 14 days for r
ecurrences

Compromised host >> 7–14 days of topical therapy

Pregnancy >> Fluconazole is contraindicated 7-day topical agents
 Uncomplicated VVC
PATIENT MANAGEMENT • Mild to moderate
signs & symptoms
CDC-recommended regimens • Nonrecurrent 75%
Over-the-Counter Intravaginal Agents of women have at
Butoconazole 2% cream, 5 g intravaginally for 3 days or least one episode
Clotrimazole 1% cream 5 g intravaginally for 7-14 days or • Responds to short
Clotrimazole 2% cream 5 g intravaginally for 3 days or course regimen
Miconazole 2% cream 5 g intravaginally for 7 days or
Miconazole 4% cream 5 g intravaginally for 3 days or
Miconazole 100 mg vaginal suppository, 1 suppository for 7 days or
Miconazole 200 mg vaginal suppository, 1 suppository for 3 days or
Miconazole 1,200 mg vaginal suppository, one suppository for 1 day or
Tioconazole 6.5% ointment 5 g intravaginally in a single application
Prescription Intravaginal Agents
Butoconazole 2% cream, 5 g (single dose bioadhesive product) intravaginall
y for 1 day or
Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days or
Terconazole 0.4% cream 5 g intravaginally for 7 days or
Terconazole 0.8% cream 5 g intravaginally for 3 days or
Terconazole 80 mg vaginal suppository, 1 suppository for 3 days
Prescription Oral Agents
Fluconazole 150 mg oral tablet, 1 tablet in a single dose
PREVENTION

PARTNER MANAGEMENT
 VVC is not usually acquired through sexual intercourse.
 Treatment of sex partners is not recommended.
 A minority of male sex partners may have balanitis and may benefit fro
m treatment with topical antifungal agents to relieve symptoms.

PATIENT COUNSELING AND EDUCATION

 Nature of the disease >> Normal vs. abnormal vaginal discharge, signs
and symptoms of candidiasis, maintain normal vaginal flora
 Transmission Issues >> Not sexually transmitted
 Risk reduction >> Avoid douching, avoid unnecessary antibiotic use,
complete course of treatment
TRICHOMONIASIS
EPIDEMIOLOGY
 Most prevalent nonviral STI
 Estimated one million cases annually in the U.S. at a medical cost of $2
4 million
 Estimated prevalence:
• 3% in the general female population
• 1.3% in non-Hispanic white women
• 1.8% in Mexican American women
• 13.3% in non-Hispanic black women
• 40%–60% in female prison inmates and commercial sex workers
• 18%–50% in females with vaginal complaints

RISK FACTORS
 Multiple sexual partners
 Lower socioeconomic status
 History of STDs
 Lack of condom use
PATHOGENESIS
 Etiologic agent
 Trichomonas vaginalis is single-celled, flagellated, anaerobic protozoan parasite.
 Only protozoan that infects the genital tract.
 Associations with
 Preterm rupture of membranes and pre-term delivery.
 Increased risk of HIV acquisition and transmission.

CLINICAL MANIFESTATIONS & SYMPTOMS

 May be asymptomatic approximately 70% of the time
 Vaginitis
Frothy gray or yellow-green vaginal discharge | Pruritus | Cervical
petechiae ("strawberry cervix") - classic presentation, occurs in <2
% of cases
 May also infect Skene's glands and urethra, where the organisms may
not be susceptible to topical therapy
 Trichomoniasis has been associated with increased shedding of HIV in
HIV-infected women
DIAGNOSIS
 History, signs and symptoms
 Motile trichomonads seen on saline wet mount
 Vaginal pH >4.5 often present
 Culture has been the “gold standard”
 Pap smear sensitivity with traditional cytology poor, but enhanced by
use of liquid-based testing
 DNA probe
 Rapid test (antigen detection test, OSOM)
 NAAT (urine or vaginal swab)

“Strawberry cervix” due to

T. vaginalis
DIAGNOSIS

 Wet Prep: Trichomoniasis

 Saline: 40X objective

(Seattle STD/HIV Prevention Training
Center at the University of Washington)
Trichomonas*
PATIENT MANAGEMENT
CDC-recommended regimen
Metronidazole 2 g orally in a single dose or
Tinidazole 2 g orally in a single dose

CDC-recommended alternative regimen

Metronidazole 500 mg twice a day for 7 days

CDC-recommended regimen for pregnancy

Metronidazole 2 g orally in a single dose
All symptomatic pregnant women should be treated, regardless of
pregnancy stage.

 A common reason for treatment failure is reinfection. Therefore, it its critical to assur
e treatment of all sex partners at the same time.
 If treatment failure occurs with metronidazole 2 g orally in a single dose for all partner
s, treat with metronidazole 500 mg orally twice daily for 7 days or tinidazole 2 g orally
single dose.
 If treatment failure of either of these regimens, consider retreatment with tinidazole or
metronidazole 2 g orally once a day for 5 days.
PREVENTION

PARTNER MANAGEMENT
 Sex partners should be treated.
 Patients should be instructed to avoid sex until they and their sex
partners are cured (when therapy has been completed and patient and
partner(s) are asymptomatic, about 7 days).

PATIENT COUNSELING AND EDUCATION

 Nature of the disease >> May be asymptomatic in both men and women,
in women may persist for months to years, untreated trichomoniasis
might be associated with adverse pregnancy outcomes, douching may
worsen vaginal discharge, alcohol consumption is contraindicated with
metronidazole
 Transmission issues >> Almost always sexually transmitted, fomite
transmission rare, might be associated with increased susceptibility to
HIV acquisition
CERVICITIS
 CERVICITIS
Clinical syndrome characterized by the presence of a purulent or mucopurulent discharge that is visible in the
endocervical canal or that can be detected with an endocervical smear.

ACUTE CERVICITIS

CHRONIC CERVICITIS

One study reported that up to 40% of women assessed at a STD clinic showed signs and symptoms of cervicitis
ACUTE CERVICITIS
DEFINITION
0 Acute inflammation of the endocervical glands and
underlying tissues

ETIOLOGY
0  Gonococcal
 Chlamydial
 Puerperal
 Post-abortive
 Post-operative infection, after instrumentation or
cervical dilatations, cauterization or trachelorraphy
(i.e. repair of a lacerated cervix)

SYMPTOMS:
0  Mucopurulent discharge
 Mild fever
 Dyspareunia and backache
ACUTE CERVICITIS
SIGNS
0  The cervix is red swollen with mucopurulent discharge
 Marked tenderness on moving the cervix

INVESTIGATIONS
0 Culture and sensitivity of the discharge

TREATMENT:
0 Antibiotics , according to organism (broad spectrum)

COMPLICATIONS:
0  Commonly turns chronic infection due to the race
mose nature of the cervical glands
 Secondary vaginitis
 Spread to: Upper genital tract, Parametrium, and
Urinary tract
CHRONIC CERVICITIS
SYMPTOMS:
0  Mucopurulent discharge
 Congestive dysmenorrhea & menorrhagia (pelvic congestion)
 Backache (spread of infection along the uterosacral ligament)
 Contact bleeding (cervical erosion)
 Dyspareunia (parametritis)
 Infertility (hostile cervical discharge)
 Frequency of micturition (cystitis)
 Manifestations of septic focus

SIGNS BY SPECULUM EXAMINATION:

0  Mucopurulent discharge coming out from cervix (Endocervicitis)
 Cervical erosion
 Mucous polypi: reddish pedunculated small (hyperplasia of
endocervical epithelium)
 Nabothian follicles: small blue or yellowish cysts projecting on
the portiovaginalis (distended blocked cervical glands)
 Swollen, hyperaemic cervix (Chronic hypertrophic cervicitis)
 Ectropion: the anterior and posterior lips of the cervix are
everted due to bilateral cervical tears.
SIGN BY SPECULUM EXAMINATION
Mucopurulent discharge | Mucous polypi | Nabothian follicles | Swollen | Hyperaemic cervix | Ectropion
CHRONIC CERVICITIS

0 INVESTIGATIONS:
 Exclusion of malignancy
 Culture and sensitivity of the discharge.

TREATMENT:
0  Oral or vaginal Antibiotics
 Cervical Cauterization
 Trachelorraphy: to treat cervical tears
 Conization in suspicious lesions
CONCLUSION
 Reproductive tract infections continue to be a major and growing public
health issue in many parts of the world and are particularly widespread
in resource-poor settings.

 Without early diagnosis and appropriate therapy, complications of RTIs

severely compromise women’s health, fertility, and productivity; infant
health and survival; and the effectiveness of family planning programs.

 Interventions that truly decrease the burden of RTIs will involve the coor
- dination of efforts among several interrelated health initiatives and will
include changes in the outlook, knowledge, skills, and resources of all
levels of the health care system.
Thank You
“ Discussion, Question, and Answer Session
Discussion, Question, and Answer Session
Discussion, Question, and Answer Session
“