Genital inflammatory
diseases
朱 芝 玲
复旦大学附属妇产科医院
Female Reproductive Organs
NORMAL VAGINAL FLORA & DISCHARGE
HEALTHY VAGINA IS AN ECOSYSTEM
DYNAMIC EQUILIBRUM EXIXTS BETWEEN:
- Epithelium
- Normal Colonizing Organisms
(mostly Lactobacilli SPP)
- Local Secretory and Celluar Immune Factors
- Vaginal pH maintained
o Acidic (3.8 – 4.4)
o Creates unfavourable environment for Pathogens
NORMAL pH MECHANISM
? Estrogen increases Epithelial
Glycogen
? Lactobacilli Metabolise Glycogen
into Lactic Acid
? Lactic Acid maintains acid pH
SIMPLE OFFICE ANALYSIS
? pH – litmus/nitrazine paper
(nitrazine turns blue)
?,Whff” test – 10% KOH – 2
drops
? Microscopy – Wet mount,
WBCS,Trichomonas,Monilia
? If no microscope available
o Add hydrogen peroxide
o Foaming bubbles if there are
WBCs
o No bubbles if no WBCs (BV,
Yeast)
PATHOLOGIC VAGINAL DISCHARGE
Common causes in lower genital tract
1) Bacterial vaginosis
2) Candidal vulvo vaginitis
3) Trichomonas vaginalis
Bacterial Vaginosis
? Affects 25% of women
? 50% of women asymptomatic
? Commonest cause of vaginal complaint.
? Specific trigger not known,but BV related to:
o Intercourse – especially new partner,sexual aids
o Spermicides,douches
o Other infections
BACTERIAL VAGINOSIS
BV
DIAGNOSIS
1) Gray homogenous discharge
adherent to vaginal walls – no
erythema/edema.
2) pH akaline (over 4.5)
3) Presence of,Clue cells”
o Cells studded with bacteria
o Cell wall indistinct
4) Fishy amine odor when 10%
KOH added (TV,semen also
causes odor releases.
5) Paucity of lactobacilli
6) Relative absence of WBCs.
Bacterial Vaginosis
MEDICATION ALTERNATIVES
1) Oral metronidazole 400mg BD for 7 days
2) Oral clindamycin 300mg BD for 7 days
3) Metronidazole Gel (0.75%) BD for 5 days
4) Clindamycin Cream (2%) qid for 7 days
5) Single 3% Hydrogen Peroxide vaginal washout
6) No treatment for partner? (Rx unrelated to recurrence)
Recurrence not uncommon – 1) Repeat treatment
- 2) Longer course
7) In pregnancy,use Ampicillin
CANDIDIASIS
CANDIDA VAGINITIS
Second most common cause of discharge.
Epidemiology:
o Candida albicans most common organism
o Non albicans SSP.e.g,C,tropicalis,C,glabrata more
resistant to treatment.
RISK FACTORS
? Altered immune response,immune suppressive drugs,
HIV with low CD4 count
? Increased blood glucose levels
? Eradication of lactobacillus with broad spectrum
antibiotics.
? Occurs in acidic estrogen-rich environment
DIAGNOSIS
? Chief complaint – itching/
burning more severe at
nights.
? Clinical findings
1) Vulvar erthema / edema /
fissure
2) Excoriation from scratching
3) White vaginal discharge
(varies from thin white to
curdy)
4) Normal vaginal pH (acidic)
5) Wet mount with KOH 100%
specific (psuedohyphae)
PSEUDOHYPHAE
MANAGEMENT – IMIDAZOLE
/TRIAZOLE PREPARATIONS
1) Antifungal creams,suppositories eg
o Butoconazole
o Clomitrazole
o Miconazole
o Tioconazole
o Terconazole
For seven to ten days (may get burning/irritation)
2) Single isoconazole pessary
3) Pregnancy – local therapy only
TREATMENT (CANDIDA)
Oral antifungal agency
o Nausea
o Abdominal pain
o Headache
o Potentially hepatotoxic
? Three day oral therapy (itraconazole)
? Single dose oral fluoconazole (150 mg or itraconzole
300 mg),No treatment necessary for asymptomatic
partner,
(Does not reduce recurrence),
TREATMENT (CANDIDA)
Recurrence,Repeat with
1) Longer course (local RX weekly x 4
2) Monthly single dose imidazole x 6
3) Hypersensitivity to local RX – 1% G.V,(Culture)
4) Natural yoghurt on a tampon nightly x 3
Trichomoniasis
? Trichomonas vaginalis
? Found in semen or urine of
males carriers
? Vaginal infection causes
irritation and profuse
discharge
? Diagnosis by microscopic
identification of protozoan
? Treatment,metronidazole
TRICHOMONAS VAGINALIS
Epidemiology
o Humans are the only host
(75% of prostitutes)
o Sexually transmitted
protozoal parasite with four
flagella
o Resides asymptomatically
in male semen (90%) and
50% of women
o Both partners require
treatment
DIAGNOSIS
? Vulvar erythema and edema
? Profuse,offensive,frothy,green-yellow
discharge
? Trichomonas cervicitis – red,punctuate
lesions –“strawberry cervix” (10%).
? Vaginal pH alkaline (over 4.5)
? Wet prep – detects 70% - more organisms.
Culture – 100% Specific.
?Strawberry? Cervix
MANAGEMENT
(TRICHOMONAS)
? Metronidazole 400 – 500 mg BD for seven days (both
partners)
? Fasigyn – single dose (2g)
? Avoid in pregnancy and lactation (use local Canestan)
recurrence – reinfection,repeat Rx (85%),Repeat
treatment – longer course (14 days)
? Higher dose (Metronidazole 800mg 12 hourly for five
days) ESP,if on Dilantin,phenobarb).
? Single vinegar vaginal washout
Note,Disulfuram effect with alcohol.
PID,an acute clinical syndrome
associated with the spread of
microorganisms through the vagina
into the uterus,fallopian tubes,and
ovary (upper genital tract)
Pathogenesis of
PID
Primary
endocervicitis
? N,gonorrhoeae
? C,trachomatis
? other?
Factors influencing spread of
bacteria
? cervical and endometrial infection
? state of cervical mucus
? retrograde menstruation
? uterine instrumentation
Consequences of ascending
infection
? hydrosalpinx
? tuboovarian abscess
? peritonitis,perihepatitis
Long-term sequellae
? chronic pain
? infertility
? tubal pregnancy
PID - Clinical Features
Lower abdominal pain all
Vaginal discharge ~1/2
Vaginal bleeding ~1/2
Dysuria ~1/4
Nausea,vomiting,anorexia ~1/4
SYMPTOMS
PID - Clinical Features
Abdominal or adnexal
tenderness all
Cervical tenderness all
Adnexal enlargement ~1/3
Fever ~1/3
RUQ tenderness up to 1/3
SIGNS
Microbiology of PID
Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium,
Anaerobes
other organisms may also be implicated.
Treatment for acute PID
Must include activity against:
? gonococcus
? streptococci
? community-acquired enteric Gram-
negatives
? obligate anaerobes (e.g.,Bacteroides)
? chlamydia
Surgical treatment
? Severe cases
? Where there is clear evidence of
a pelvic abscess.
? Rupture of abscess
PID - Prognosis
Chronic pain 15%
Subsequent PID 20-25%
Infertility
after 1 infection 10-15%
after 2 infections 25-35%
after 3 infections 50-75%
Ectopic pregnancy
(with next pregnancy) 7%*
CONSEQUENCES FREQUENCY
* 6-10 fold increase over normal incidence
diseases
朱 芝 玲
复旦大学附属妇产科医院
Female Reproductive Organs
NORMAL VAGINAL FLORA & DISCHARGE
HEALTHY VAGINA IS AN ECOSYSTEM
DYNAMIC EQUILIBRUM EXIXTS BETWEEN:
- Epithelium
- Normal Colonizing Organisms
(mostly Lactobacilli SPP)
- Local Secretory and Celluar Immune Factors
- Vaginal pH maintained
o Acidic (3.8 – 4.4)
o Creates unfavourable environment for Pathogens
NORMAL pH MECHANISM
? Estrogen increases Epithelial
Glycogen
? Lactobacilli Metabolise Glycogen
into Lactic Acid
? Lactic Acid maintains acid pH
SIMPLE OFFICE ANALYSIS
? pH – litmus/nitrazine paper
(nitrazine turns blue)
?,Whff” test – 10% KOH – 2
drops
? Microscopy – Wet mount,
WBCS,Trichomonas,Monilia
? If no microscope available
o Add hydrogen peroxide
o Foaming bubbles if there are
WBCs
o No bubbles if no WBCs (BV,
Yeast)
PATHOLOGIC VAGINAL DISCHARGE
Common causes in lower genital tract
1) Bacterial vaginosis
2) Candidal vulvo vaginitis
3) Trichomonas vaginalis
Bacterial Vaginosis
? Affects 25% of women
? 50% of women asymptomatic
? Commonest cause of vaginal complaint.
? Specific trigger not known,but BV related to:
o Intercourse – especially new partner,sexual aids
o Spermicides,douches
o Other infections
BACTERIAL VAGINOSIS
BV
DIAGNOSIS
1) Gray homogenous discharge
adherent to vaginal walls – no
erythema/edema.
2) pH akaline (over 4.5)
3) Presence of,Clue cells”
o Cells studded with bacteria
o Cell wall indistinct
4) Fishy amine odor when 10%
KOH added (TV,semen also
causes odor releases.
5) Paucity of lactobacilli
6) Relative absence of WBCs.
Bacterial Vaginosis
MEDICATION ALTERNATIVES
1) Oral metronidazole 400mg BD for 7 days
2) Oral clindamycin 300mg BD for 7 days
3) Metronidazole Gel (0.75%) BD for 5 days
4) Clindamycin Cream (2%) qid for 7 days
5) Single 3% Hydrogen Peroxide vaginal washout
6) No treatment for partner? (Rx unrelated to recurrence)
Recurrence not uncommon – 1) Repeat treatment
- 2) Longer course
7) In pregnancy,use Ampicillin
CANDIDIASIS
CANDIDA VAGINITIS
Second most common cause of discharge.
Epidemiology:
o Candida albicans most common organism
o Non albicans SSP.e.g,C,tropicalis,C,glabrata more
resistant to treatment.
RISK FACTORS
? Altered immune response,immune suppressive drugs,
HIV with low CD4 count
? Increased blood glucose levels
? Eradication of lactobacillus with broad spectrum
antibiotics.
? Occurs in acidic estrogen-rich environment
DIAGNOSIS
? Chief complaint – itching/
burning more severe at
nights.
? Clinical findings
1) Vulvar erthema / edema /
fissure
2) Excoriation from scratching
3) White vaginal discharge
(varies from thin white to
curdy)
4) Normal vaginal pH (acidic)
5) Wet mount with KOH 100%
specific (psuedohyphae)
PSEUDOHYPHAE
MANAGEMENT – IMIDAZOLE
/TRIAZOLE PREPARATIONS
1) Antifungal creams,suppositories eg
o Butoconazole
o Clomitrazole
o Miconazole
o Tioconazole
o Terconazole
For seven to ten days (may get burning/irritation)
2) Single isoconazole pessary
3) Pregnancy – local therapy only
TREATMENT (CANDIDA)
Oral antifungal agency
o Nausea
o Abdominal pain
o Headache
o Potentially hepatotoxic
? Three day oral therapy (itraconazole)
? Single dose oral fluoconazole (150 mg or itraconzole
300 mg),No treatment necessary for asymptomatic
partner,
(Does not reduce recurrence),
TREATMENT (CANDIDA)
Recurrence,Repeat with
1) Longer course (local RX weekly x 4
2) Monthly single dose imidazole x 6
3) Hypersensitivity to local RX – 1% G.V,(Culture)
4) Natural yoghurt on a tampon nightly x 3
Trichomoniasis
? Trichomonas vaginalis
? Found in semen or urine of
males carriers
? Vaginal infection causes
irritation and profuse
discharge
? Diagnosis by microscopic
identification of protozoan
? Treatment,metronidazole
TRICHOMONAS VAGINALIS
Epidemiology
o Humans are the only host
(75% of prostitutes)
o Sexually transmitted
protozoal parasite with four
flagella
o Resides asymptomatically
in male semen (90%) and
50% of women
o Both partners require
treatment
DIAGNOSIS
? Vulvar erythema and edema
? Profuse,offensive,frothy,green-yellow
discharge
? Trichomonas cervicitis – red,punctuate
lesions –“strawberry cervix” (10%).
? Vaginal pH alkaline (over 4.5)
? Wet prep – detects 70% - more organisms.
Culture – 100% Specific.
?Strawberry? Cervix
MANAGEMENT
(TRICHOMONAS)
? Metronidazole 400 – 500 mg BD for seven days (both
partners)
? Fasigyn – single dose (2g)
? Avoid in pregnancy and lactation (use local Canestan)
recurrence – reinfection,repeat Rx (85%),Repeat
treatment – longer course (14 days)
? Higher dose (Metronidazole 800mg 12 hourly for five
days) ESP,if on Dilantin,phenobarb).
? Single vinegar vaginal washout
Note,Disulfuram effect with alcohol.
PID,an acute clinical syndrome
associated with the spread of
microorganisms through the vagina
into the uterus,fallopian tubes,and
ovary (upper genital tract)
Pathogenesis of
PID
Primary
endocervicitis
? N,gonorrhoeae
? C,trachomatis
? other?
Factors influencing spread of
bacteria
? cervical and endometrial infection
? state of cervical mucus
? retrograde menstruation
? uterine instrumentation
Consequences of ascending
infection
? hydrosalpinx
? tuboovarian abscess
? peritonitis,perihepatitis
Long-term sequellae
? chronic pain
? infertility
? tubal pregnancy
PID - Clinical Features
Lower abdominal pain all
Vaginal discharge ~1/2
Vaginal bleeding ~1/2
Dysuria ~1/4
Nausea,vomiting,anorexia ~1/4
SYMPTOMS
PID - Clinical Features
Abdominal or adnexal
tenderness all
Cervical tenderness all
Adnexal enlargement ~1/3
Fever ~1/3
RUQ tenderness up to 1/3
SIGNS
Microbiology of PID
Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium,
Anaerobes
other organisms may also be implicated.
Treatment for acute PID
Must include activity against:
? gonococcus
? streptococci
? community-acquired enteric Gram-
negatives
? obligate anaerobes (e.g.,Bacteroides)
? chlamydia
Surgical treatment
? Severe cases
? Where there is clear evidence of
a pelvic abscess.
? Rupture of abscess
PID - Prognosis
Chronic pain 15%
Subsequent PID 20-25%
Infertility
after 1 infection 10-15%
after 2 infections 25-35%
after 3 infections 50-75%
Ectopic pregnancy
(with next pregnancy) 7%*
CONSEQUENCES FREQUENCY
* 6-10 fold increase over normal incidence
