Inflammation of the Female
Reproductive Tract
Self-cleaning
(lactobacillus)
Mucus
1,Vulvitis (外阴炎 )
Bartholinitis/Bartholin’s cyst
(前庭大腺炎／前庭大腺囊肿 )
2,Vaginitis (阴道炎 )
3,Cervicitis (宫颈管炎 )
4,Pelvic inflammatory disease (PID) (盆腔炎 )
?Genital tuberculosis (生殖器结核 )
?Sexually transmitted diseases (STD) (性传
播疾病 )
Vulvitis (外阴炎 )
Clinical Manifestation
Vulvar pruritus (瘙痒 )
Pain
Burning sensation
Congestion (充血 )
Swelling
Eczema (湿疹 )
Etiology
Specific organisms or non-infective dermatitis (皮炎 )
? Irritation from vaginal discharge (分泌物 ) or menses
? Lack of vulvar hygiene
? Glycouria
Treatment
? Keep the vulva clean and dry
? Remove the cause
? 1/5000 kMnO4 (potassium permanganate,PP)
solution bath
? Antibiotics ointment
Bartholinitis (前庭大腺炎 )
Infection of the major vestibular
glands (前庭大腺 )
(Bartholin’s glands) (巴氏腺 )
Bartholin’s Cyst (前庭大腺囊肿 )
Major vestibular glands (Bartholin’s glands)
Bartholinitis
Etiology
Staphylococcus,E.coli,streptococcus,enterococcus,
gonococcus,and polymicrobial infection is common.
Clinical manifestation
Symptoms of a local infection
Abscess of Bartholin gland,a painful red swelling
Treatment
Antibiotics (Ampicillin) in the early stage
Drain the abscess (excision of an elliptical piece of skin)
? Marsupialization (造口术 )
for preservation of the
gland function
? Excision for recurrent
cases
Bartholin’s Cyst
? Trichomonal vaginitis (滴虫性阴道炎 )
? Candidal Vulvovaginitis (假丝酵母菌性外阴阴道炎 )
? Bacterial Vaginosis (BV) (细菌性阴道病 )
? Senile vaginitis (老年性阴道炎 )
? Infantile vulvovaginitis (婴幼儿外阴阴道炎 )
Vaginitis
Trichomonal Vaginitis
滴虫性阴道炎
(Trichomoniasis)
Etiology
Trichomonad (毛滴虫 )：
A flagellate protozoan (有鞭毛原虫 )
Best living environment, Moist,anaerobic,
pH,5.2-6.6
Transmission
1,Sexual contact (70% male infection,
asymptomatic carrier)
2,Nonsexual transmission (iatrogenic)
Pathogenesis
? The trichomonad lives on glycogen and iron of
the host cell
? Direct contact and damage of the target cell
? Induction of immune reaction resulting in
inflammation
Clinical Picture
Latent period,4-28 days
Asymptomatic,25-50%
Symptoms：
Main,Profuse vaginal discharge and pruritus
Occasional,odor,pain,dyspareunia,dysuria,
infertility
Characteristics of the vaginal discharge
Copious (大量的 ),
Purulent (脓性的 ),
Gray to yellow color,
Malodorous (恶臭的 ),
Frothy (起泡沫的 )
Strawberry cervix:
Tiny,punctate hemorrhages
(点状出血 )
grossly visible on the mucosa
Diagnosis
1,Microscopic (wet mount) identification of the
trichomonad (60%-70%)
2,Precautions for the examination
Avoid, intercourse 1-2 days before examination
washing and medication
lubricant
heat preservation
3,Culture for suspected cases
4,PCR (Polymerase chain reaction)
Treatment (1)
1,Systemic therapy (First choice)
Oral metronidazole (甲硝唑，灭滴灵）
a) 2g single dose
b) 400mg,twice or 3 times a day,for 7 days.
2,Topical application (≤50%)
a) Effervescent tablets (泡腾片 )of metronidazole
200mg/day,7-10 days
b) Metronidazole gel
c) Acidification of vagina with 1% lactic acid or
0.5% acetic acid
Treatment (2)
Criterion for cure:
Negative finding in postmenstrual examination
of the vaginal discharge for three times
Failure rate,5%-10%
Poor compliance
Repeated infection
To avoid repeated infection:
Sterilization of underwear,towels,etc
Treatment of the sexual partner
Metronidazole is still effective in recurrent cases.
Candidal Vulvovaginitis
假丝酵母菌性外阴阴道炎
(Vulvovaginal Candidiasis)
Etiology
1,Very common
a) About 1/3 of vaginitis cases are caused by
fungal infection.
b) About 75% of women develop candidiasis at
least once in life.
2,The etiologic agent is Candida (假丝酵母菌 /念珠菌 ).
Candida albicans (白假丝酵母菌 ) is responsible
for 80-90% of vulvovaginal candidiasis.
3,Candida albicans is an opportunistic pathogen.
1) Suitable environment,acidic (＜ 4.5),warm,and moist
2) Candida albicans can be isolated from 10-20%
nonpregnant and 30% pregnant asymptomatic women.
Treatment
is not
indicated
unless
symptoms
are
present.
Predisposing factors
1,Pregnancy
2,Diabetes mellitus
3,Immunosuppressants
4,Broad-spectrum antibiotics
suppressing the vaginal normal flora
(esp,lactobacillus)
5,Others,restrictive synthetic underwear,obesity,
contraceptive medication
Transmission
1) Endogenous infection (most often)
Vagina,oral cavity,intestinal tract
2) Sexual contact
3) Contacting fomites (污染物 )
Pathogenesis
Two phases of candida albicans
1) Yeast spores (芽孢相 ),
Asymptomatic parasitism
2) Pseudohyphae (菌丝相 ):
Pathogenic
3) Mechanism:
a) Candida at the pseudohypha phse penetrate vaginal
epithelium for nutrients
b) Growing candida albicans release proteolytic enzymes
and toxins etc,resulting in inflammation reaction
Clinical Picture
1,Vulvovaginal pruritus (main)
usually intense,coincident with menses or intercourse
2,Increased vaginal discharge
The classic finding is white,thick,curd-like discharge
forming patches adherent to the vaginal walls,
Diagnosis
1,Wet mount microscopic identification of
candida albicans in the discharge
Saline,30-50%
10% KOH,70-80%
2,Gram’s stain,80%
3,Culture,higher sensitivity and drug test
4,Measurement of pH value may be useful for
discovering cases of complicated infection
(4.0-4.7).
a pH<4.5 simple infection
a pH>4.5 combined infection
Treatment
1,Elimination of predisposing factors
2,Topical application of antifungal agents
Vaginal suppositories(栓剂 )：
1) Miconazole (咪康唑 /达克宁 )
a) 200mg/day for 7days
b) 400mg/day for 3 days
2) Clotrimazole (克霉唑 )
a) 150mg/day for 7 days
b) 150mg,twice a day for 3 days
c) 500mg single dose
3) Nystatin (制霉菌素 /米可定 )
100,000units/day for 10-14 days
4) Methyl violet (龙胆紫 )
0.5-1%,3-4 times/week for 2 weeks.
3,Systemic medication
Oral agents are used only for cases that can not be
treated with topical application of antifungal drugs.
1) Fluconazole (氟康唑 /大扶康 )
150mg,single use.
2) Itraconazole(伊曲康唑 /斯皮仁诺 )
a) 200mg/day for 3-5 days
b) 400mg for 1 day divided in two doses
3) Ketoconazole (酮康唑 )
200mg,once or twice/day until culture result is negative
Hepatotoxicity may occur.
Points of note for treating VVC
? Treatment should be followed-up with a premenstrual
examination of the vaginal discharge.
? Approximately 10% of cases will not respond to
initial therapy.
? Prolongation of treatment up to 14 days may cure
some patients.
? Identification and elimination of predisposing
factors is important.
? Recurrent VVC should be treated with oral therapy
followed by prophylactic doses.
Treatment of sexual partner?
No treatment for asymptomatics.
15% should be treated
Bacterial Vaginosis
细菌性阴道病
Etiology
1,Imbalance of normal vaginal flora
Diminution of Doderlein lactobacillus and
increase in other bacteria,in particular,
anaerobic bacteria.
2,Causative factors of the imbalance are unknown
Gardnerella vaginalis (加德纳菌 )
Clinical Picture
Symptoms:
1,10-40% asymptomatic
2,Mild pruritus or burning
sensation
3,Increased vaginal discharge
and fishy odor
Signs:
Discharge,thin,greyish-white,
homogenous,but not sticky
No inflammation reaction
(No epithelial edema or erythema)
Diagnosis
Identification of clue cells *(wet mount in saline)
together with 2 of the following 3 items
1,Vaginal discharge,homogenous,thin and white
2,pH>4.5,in virtually all cases,usu,5.0-5.5
3,Positive Whiff test (with 10% KOH)
* Clue cells are desquamated epithelial cells covered
with clumps of coccobacili esp,Gardnerella
vaginalis (加德纳菌 ),which gives the cells a
speckled (有小斑点 ) appearance.
Whiff test
Treatment (1)
1,Systemic therapy (oral) (80%)
1) Metronidazole
400mg,2-3 times a day for 7 days
2) Clindamycin (克林霉素 /氯林霉素 /氯洁霉素 )
300mg,twice a day for 7 days
2,Topical therapy (80%)
1) Effervescent tablets of metronidazole
200mg/day,for 7-10 days
2) 2% Clindamycin cream,once a day for 7 days
3,Vaginal washing
1-3% H2O2,1% lactic acid,0.5% acetic acid
Treatment (2)
1,Systemic or topical treatment has the same cure rate (80%).
2,Patients who are asymptomatic,but scheduled to
have a gynecologic surgical procedure should be treated.
3,Patients who are pregnant can be treated with oral
metronidazole.
4,Follow-up examination should be given 1-2 and 3-4
weeks (postmenstrual) after the treatment.
Criteria for cure:
Absence of clue cells with at least 1 of the following items:
a) Normal vaginal discharge
b) pH≤4.5
c) Whiff test negative
Other forms of vulvovaginitis
1,Senile vaginitis (老年性阴道炎 )
Atrophic vaginitis(萎缩性阴道炎 )
2,Infantile vulvovaginitis
(婴幼儿外阴阴道炎 )
Differential Diagnosis of vaginitis
Bacterial Vaginosis Candidiasis Trichomoniasis
Complaints
Vaginal
discharge
Vaginal
epithelium
Vaginal pH
Whiff test
Microscopic
examination
discharge↑m
ild pruritus
severe pruritus
burning
discharge↑
mild pruritus
white
homogenous
fishy
white
curd-like
thin
purulent
frothy
normal edema
erythema
punctate
hemorrhage
＞ 4.5 (4.7-5.7) ＜ 4.5 ＞ 5 (5.6-6.5)
＋ － －
Clue cells
WBC rare
Candida
WBC some
Trichomonad
WBC many
Inflammation of the Cervix
1,Common,50% women of reproductive age
2,May lead to pelvic infection
3,Need to identify a venereal disease and
differentiate from malignancies
Cervicitis,Vaginal portion of the cervix (Ectocervix)
Mucosa of the cervical canal (Endocervix)
Acute Cervicitis
Etiology
1,Neisseria gonorrhoeae (淋病奈瑟菌 )
Chlamydia trachomatis (沙眼衣原体 )
causing superficial infection of the cervical
columnar mucosa
2,Staphylococcus (葡萄球菌 ),
streptococcus (链球菌 ),
enterococcus (肠球菌 )
causing infection after an abortion,puerperium,
cervical injury,foreign bodies
Clinical Picture
Symptoms
1,Asymptomatic
2,Mucopurulent vaginal discharge
Vaginal irritation symptoms:pruritus,burning sensation
Lumbosacral pain,
Intermenstrual bleeding,postcoital bleeding
Symptoms of the lower urinary tract
Signs
Inflammation of the cervix with mucopurulent
discharge (MPC for mucopurulent cervicitis)
Diagnosis
1,Gram’s stain of the cervical discharge for leukocyte
≥30/HP or ≥10/× 1,000
2,Tests for gonococcus and chlamydia
3,Wet mount microscopy for trichomonads
Management
Systemic medication
Choice of drugs depends on the pathogens.
Examples,
Gonorrhea infection,Third generation Cephalosporins
Ceftriaxone Sodium (头孢曲松钠 /头孢三嗪 /菌必治 /罗氏芬 )
(头孢克 )
Spectinomycin (大观霉素 /壮观霉素 /淋必治 )
Chlamydia trachomatis
Doxycycline (多西环素 )
Azithromycin (阿奇霉素 )
Erythromycin (红霉素 )
Ofloxacin (氧氟沙星 )
Chronic Inflammation of
the Cervix
Cervical Erosion
Etiology
1,When the stratified epithelium (复层上皮 ) which
normally covers the vaginal portion of the cervix
is replaced by columnar epithelium which is
continuous with that of the cervical canal.
2,Most erosion are not infected,nor they are the
result of inflammation.
3,Occurs in the newborns,pregnancy,oral
contracepives
Clinical Features
Symptoms
The only symptom is a mucoid discharge.
A slight postcoital bleeding (but malignancy should
be excluded)
Signs
A red area is seen around the external os.
Classification
Depends on the depth and area of the lesion
Types,simple,granular,papillary
Grades,I (＜ 1/3),II (1/3-2/3),III (＞ 2/3)
Treatment
? Erosion found on routine examination should
not be treated unless it is causing troublesome
discharge.
? A cervical smear is needed before the treatment,
and if necessary,colposcopy (阴道镜 ) and biopsy.
? Cervical ectropion (宫颈外翻 )
Physical therapy
Thermal cauterization,
Cryotherapy,
Laser therapy
Cervical Polyps
Small pedunculated neoplasms of the cervix
? Endocervical polyp,
Originating from the endocervix
? Ectocervical polyp,
Originating from the vaginal portion
Pathology
Gross appearance:
Endocervical polyp,Red or pink,rounded or tongue-like
Ectoervical polyp,Pale,flesh-colored,smooth,rounded
with a broad pedicle
Microscopic:
Vascular connective tissue stroma covered with columnar
or squamous epithelium or both,Congestion,edema or
leukocytein filtration may be present.
Clinical Features
Some are asymptomatic.
Slight postcoital bleeding
Treatment
Cervical polyp should be treated.
? Malignant change (<1%)
? Polypoid cervical cancer
Twisting off a polyp without an anesthetic
and cauterizing the base,Recurrent cases
are treated with canal dilation and cauterization
of the stalk,
Chronic Endocervicitis (宫颈粘膜炎 )
(Infection)
Etiology
Pathogens:
Normal cervical and vaginal flora
Pathology
? Thickened endocervix that produces a whitish pus
? A cervical os surrounded by a reddish area
? Hypertrophy of the lacerated cervix
Clinical Features
1,Persistent leukohrrea usu,mucopurulent
2,Slight postcoital staining
3,Pains
lower abdominal discomfort,lumbosacral
backache,dysmenorrhea,dyspareunia
4,Infertility
5,Urinary symptoms
frequency,urgency,dysuria due to
subvesical lymphangitis not to cystitis
Diagnosis
? The characteristic discharge from external os of the
cervix,
? Cytologic and colposcopic studies are helpful,but
only biopsy is definitive.
? Cultures are not so helpful.
Treatment
Even if chronic endocervicitis is asymptomatic,
it should be treated,
1,Medical treatment
Systemic rather than topical
Based on culture and sensitivity test
2,Surgical treatment
A note of caution,postoperative bleeding,infection,
stricture formation,infertility.
Methods,thermal therapy,cryotherapy,laser therapy
conization,hysterectomy.
Nabothian Cysts
Retention cysts of the cervical glands caused by
obstruction of the gland orifices by the growth
of squamous epithelium,The cysts may be infected
and contain pus.
Cervical Hypertrophy
Cervical Hypertrophy
Pelvic Inflammatory Disease (PID)
Infection of the upper genital tract
Terms:
Endometritis (子宫内膜炎 )
Salpingitis (输卵管炎 )
Oophoritis (卵巢炎 )
Myometritis (子宫肌炎 )
Pyosalpinx (输卵管积脓 )
Hydrosalpinx (输卵管积水 )
Peritonitis (腹膜炎 )
Tubal ovarian abscess (TOA) (输卵管卵巢脓肿 )
Epidemiology
Sexual activity
A disease of sexually active,menstruating women.
Acute PID occurs in 1-2% of young sexually
active women annually.
Age
The peak incidence occurs in their late teens
and early twenties.
The most common serious infection in women
of 16-25 years of age
Contraceptive practices
Contraceptive methods No.of PID/woman-years
Sexually active,using no contraception,3.42
Oral contraceptives,0.91
Barrier methods 1.39
Intrauterine devices (IUD) 5.21
Financial cost
In USA,$3.5 billion annually in 1990s
Medical sequelae
Ectopic pregnancy,6-10 fold increase
PID accounts for 50%
Chronic pain,4 fold increase
Infertility,acute PID account for 5-60% of cases
Tubal obstruction,11.4%,23.1%,54.3% from 1,2,3
episodes of infection
Mortality,septic shock and death
Etiology
Pathogens that are sexually transmitted
1) Neisseria gonorrhoeae,in USA,40-50% cases of PID
2) Chlamydia trachomatis,in USA,10-40% cases of PID
The two pathogens may account for 2/3 of the PID
3) Mycoplasma (支原体 )
Recovered from the pus in 2-20% cases of salpingitis
Endogenous bacteria
1) Aerobic,streptococci,staphylococci,Escherichia coli
2) Anaerobic,Bacteroides fragilis (脆弱类杆菌 ),
peptococcus (消化球菌 ),
peptostreptococcus (消化链球菌 )
Spreading Route of Infection
1,Ascending along the reproductive tract
For non-pregnant and non-puerperal women
Gonococcus,C,trachomatis,staphylococcus
2,Lymphatic vessels
In puerperal infection,post-abortion infection
and IUD associated infection
Streptococcus,E.coli,anaerobic bacteria
3,Blood vessels
Tuberculosis
4,Direct spreading
Infection from other visceral organs.
Acute PID
Predisposing Factors
1,Intrauterine manipulation
e.g,artificial abortion,IUD,etc.
2,Infection in the lower reproductive tract,esp,STD
3,Sexual activity
4,Bad hygiene
4,Direct spreading from adjacent viscera
6,Acute onset of a chronic PID
Pathology
1,Acute endometritis and myometritis
2,Acute salpingitis,pyosalpinx and
tubo-ovarian abscess (TOA)
3,Acute pelvic peritonitis
4,Acute inflammation of the peritoneal
connective tissue (parametritis)(宫旁结缔组织炎 )
5,Septicemia (败血症 ) and pyemia (脓毒血症 )
6,Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome
? Perihepatitis,inflammation of Glisson’s capsule
without involvement of the liver parenchyma,
Suppurative (脓性 ) and fibrous exudation of the
capsule occurs causing adhesion between the capsule
and the anterior peritoneum,
? It happens in 5-10% cases of salpingitis.
? It is caused by gonococcus or Chlamydia trachomatis.
? Edema and adhesion of the capsule may lead to pain
in the upper abdominal region.
Clinical Features
Symptoms
Vary depending on severity and extent of the infection
and types of pathogens
Most common,lower abdominal pain,fever,increase
in vaginal discharge.
Gonorrhea/Chlamydia Trichomatis
Signs
Variable
Typical,
Bimanual examination:
Diagnosis
Criteria for the diagnosis of PID
Minimum:
1) Pain on compression of uterine body
or the adnexal region
2) Tenderness of the cervix
Specific:
1) Biopsy of the endometrium showing endometritis
2) Ultrasound/MRI identification of liquid-filled
enlarged oviducts or TOA
3) Laparoscopic examination
Additional:
Differential Diagnosis
Appendicitis
Rupture or abortion of tubal pregnancy
Torsion or rupture of an ovarian tumor
Treatment (1)
1,Systemic medication
(Ideal) Based on drug sensitivity test
(Empirical) Combination use of drugs
Patient’s condition and possible pathogens
1) Oral,Ofloxacin (氧氟沙星 ) Metronidazole for 14 days
2) Intravenous,Penicillin or Erythromycin (红霉素 )
Gentamycin (庆大霉素 ) or Amikacin (阿米卡星 /丁胺卡那霉素 )
Metronidazole for endogenous bacteria
3) Cefuroxime sodium (头孢呋辛钠 /西力欣 ) for gonococcus
4) Doxycycline (多西环素 /强力霉素 ) or Azithromycin (阿奇霉素 )
for chlamydia or mycoplasma
5) Clindamycin (克林 /氯林 /氯洁霉素 ) for anaerobic bacteria
Treatment (2)
2,Surgical treatment
for TOA or peritoneal abscesses that can not be
controlled by drugs (2-3 days)
Indications:
1) Failure of drug therapy
2) Persistent existence of abscesses (2-3 weeks)
3) Rupture of the abscess
3,Traditional Chinese medicine
Chronic PID
Etiology
1,Incomplete treatment of the acute PID
2,Infection from certain pathogens such
as Chlamydia trachomatis
3,Residual lesions from previous acute PID
Characteristics of chronic PID:
1,Persistence of the condition
2,Difficult to identify the pathogens
Pathology
1,Chronic endometritis
2,Chronic salpingitis and hydrosalpinx
3,Salpingo-oophoritis and tubo-ovarian cyst
4,Chronic inflammation of pelvic connective tissue
Clinical Features
1,Chronic pelvic pain
2,Infertility (20-30%) and ectopic pregnancy
3,Abnormal menstrual cycle
4,Systemic symptoms
5,Signs
Pelvic congestion or varicosity (静脉曲张 )
Endometriosis
Tumors
Ultrasound and laparoscopic examination is helpful
Diagnosis
Based on history of acute PID,symptoms and signs
Differential diagnosis
Treatment
According to place of the lesion and
the patient’s complaint
Usu,comprehensive treatment is required.
1,Physical
2,Traditional Chinese medicine (赤丹丸 )
3,Antibiotics (抗炎 II号栓 )
4,Drugs that dissolve and absorb
inflammatory lesions
5,Surgical treatment
Reproductive Tract
Self-cleaning
(lactobacillus)
Mucus
1,Vulvitis (外阴炎 )
Bartholinitis/Bartholin’s cyst
(前庭大腺炎／前庭大腺囊肿 )
2,Vaginitis (阴道炎 )
3,Cervicitis (宫颈管炎 )
4,Pelvic inflammatory disease (PID) (盆腔炎 )
?Genital tuberculosis (生殖器结核 )
?Sexually transmitted diseases (STD) (性传
播疾病 )
Vulvitis (外阴炎 )
Clinical Manifestation
Vulvar pruritus (瘙痒 )
Pain
Burning sensation
Congestion (充血 )
Swelling
Eczema (湿疹 )
Etiology
Specific organisms or non-infective dermatitis (皮炎 )
? Irritation from vaginal discharge (分泌物 ) or menses
? Lack of vulvar hygiene
? Glycouria
Treatment
? Keep the vulva clean and dry
? Remove the cause
? 1/5000 kMnO4 (potassium permanganate,PP)
solution bath
? Antibiotics ointment
Bartholinitis (前庭大腺炎 )
Infection of the major vestibular
glands (前庭大腺 )
(Bartholin’s glands) (巴氏腺 )
Bartholin’s Cyst (前庭大腺囊肿 )
Major vestibular glands (Bartholin’s glands)
Bartholinitis
Etiology
Staphylococcus,E.coli,streptococcus,enterococcus,
gonococcus,and polymicrobial infection is common.
Clinical manifestation
Symptoms of a local infection
Abscess of Bartholin gland,a painful red swelling
Treatment
Antibiotics (Ampicillin) in the early stage
Drain the abscess (excision of an elliptical piece of skin)
? Marsupialization (造口术 )
for preservation of the
gland function
? Excision for recurrent
cases
Bartholin’s Cyst
? Trichomonal vaginitis (滴虫性阴道炎 )
? Candidal Vulvovaginitis (假丝酵母菌性外阴阴道炎 )
? Bacterial Vaginosis (BV) (细菌性阴道病 )
? Senile vaginitis (老年性阴道炎 )
? Infantile vulvovaginitis (婴幼儿外阴阴道炎 )
Vaginitis
Trichomonal Vaginitis
滴虫性阴道炎
(Trichomoniasis)
Etiology
Trichomonad (毛滴虫 )：
A flagellate protozoan (有鞭毛原虫 )
Best living environment, Moist,anaerobic,
pH,5.2-6.6
Transmission
1,Sexual contact (70% male infection,
asymptomatic carrier)
2,Nonsexual transmission (iatrogenic)
Pathogenesis
? The trichomonad lives on glycogen and iron of
the host cell
? Direct contact and damage of the target cell
? Induction of immune reaction resulting in
inflammation
Clinical Picture
Latent period,4-28 days
Asymptomatic,25-50%
Symptoms：
Main,Profuse vaginal discharge and pruritus
Occasional,odor,pain,dyspareunia,dysuria,
infertility
Characteristics of the vaginal discharge
Copious (大量的 ),
Purulent (脓性的 ),
Gray to yellow color,
Malodorous (恶臭的 ),
Frothy (起泡沫的 )
Strawberry cervix:
Tiny,punctate hemorrhages
(点状出血 )
grossly visible on the mucosa
Diagnosis
1,Microscopic (wet mount) identification of the
trichomonad (60%-70%)
2,Precautions for the examination
Avoid, intercourse 1-2 days before examination
washing and medication
lubricant
heat preservation
3,Culture for suspected cases
4,PCR (Polymerase chain reaction)
Treatment (1)
1,Systemic therapy (First choice)
Oral metronidazole (甲硝唑，灭滴灵）
a) 2g single dose
b) 400mg,twice or 3 times a day,for 7 days.
2,Topical application (≤50%)
a) Effervescent tablets (泡腾片 )of metronidazole
200mg/day,7-10 days
b) Metronidazole gel
c) Acidification of vagina with 1% lactic acid or
0.5% acetic acid
Treatment (2)
Criterion for cure:
Negative finding in postmenstrual examination
of the vaginal discharge for three times
Failure rate,5%-10%
Poor compliance
Repeated infection
To avoid repeated infection:
Sterilization of underwear,towels,etc
Treatment of the sexual partner
Metronidazole is still effective in recurrent cases.
Candidal Vulvovaginitis
假丝酵母菌性外阴阴道炎
(Vulvovaginal Candidiasis)
Etiology
1,Very common
a) About 1/3 of vaginitis cases are caused by
fungal infection.
b) About 75% of women develop candidiasis at
least once in life.
2,The etiologic agent is Candida (假丝酵母菌 /念珠菌 ).
Candida albicans (白假丝酵母菌 ) is responsible
for 80-90% of vulvovaginal candidiasis.
3,Candida albicans is an opportunistic pathogen.
1) Suitable environment,acidic (＜ 4.5),warm,and moist
2) Candida albicans can be isolated from 10-20%
nonpregnant and 30% pregnant asymptomatic women.
Treatment
is not
indicated
unless
symptoms
are
present.
Predisposing factors
1,Pregnancy
2,Diabetes mellitus
3,Immunosuppressants
4,Broad-spectrum antibiotics
suppressing the vaginal normal flora
(esp,lactobacillus)
5,Others,restrictive synthetic underwear,obesity,
contraceptive medication
Transmission
1) Endogenous infection (most often)
Vagina,oral cavity,intestinal tract
2) Sexual contact
3) Contacting fomites (污染物 )
Pathogenesis
Two phases of candida albicans
1) Yeast spores (芽孢相 ),
Asymptomatic parasitism
2) Pseudohyphae (菌丝相 ):
Pathogenic
3) Mechanism:
a) Candida at the pseudohypha phse penetrate vaginal
epithelium for nutrients
b) Growing candida albicans release proteolytic enzymes
and toxins etc,resulting in inflammation reaction
Clinical Picture
1,Vulvovaginal pruritus (main)
usually intense,coincident with menses or intercourse
2,Increased vaginal discharge
The classic finding is white,thick,curd-like discharge
forming patches adherent to the vaginal walls,
Diagnosis
1,Wet mount microscopic identification of
candida albicans in the discharge
Saline,30-50%
10% KOH,70-80%
2,Gram’s stain,80%
3,Culture,higher sensitivity and drug test
4,Measurement of pH value may be useful for
discovering cases of complicated infection
(4.0-4.7).
a pH<4.5 simple infection
a pH>4.5 combined infection
Treatment
1,Elimination of predisposing factors
2,Topical application of antifungal agents
Vaginal suppositories(栓剂 )：
1) Miconazole (咪康唑 /达克宁 )
a) 200mg/day for 7days
b) 400mg/day for 3 days
2) Clotrimazole (克霉唑 )
a) 150mg/day for 7 days
b) 150mg,twice a day for 3 days
c) 500mg single dose
3) Nystatin (制霉菌素 /米可定 )
100,000units/day for 10-14 days
4) Methyl violet (龙胆紫 )
0.5-1%,3-4 times/week for 2 weeks.
3,Systemic medication
Oral agents are used only for cases that can not be
treated with topical application of antifungal drugs.
1) Fluconazole (氟康唑 /大扶康 )
150mg,single use.
2) Itraconazole(伊曲康唑 /斯皮仁诺 )
a) 200mg/day for 3-5 days
b) 400mg for 1 day divided in two doses
3) Ketoconazole (酮康唑 )
200mg,once or twice/day until culture result is negative
Hepatotoxicity may occur.
Points of note for treating VVC
? Treatment should be followed-up with a premenstrual
examination of the vaginal discharge.
? Approximately 10% of cases will not respond to
initial therapy.
? Prolongation of treatment up to 14 days may cure
some patients.
? Identification and elimination of predisposing
factors is important.
? Recurrent VVC should be treated with oral therapy
followed by prophylactic doses.
Treatment of sexual partner?
No treatment for asymptomatics.
15% should be treated
Bacterial Vaginosis
细菌性阴道病
Etiology
1,Imbalance of normal vaginal flora
Diminution of Doderlein lactobacillus and
increase in other bacteria,in particular,
anaerobic bacteria.
2,Causative factors of the imbalance are unknown
Gardnerella vaginalis (加德纳菌 )
Clinical Picture
Symptoms:
1,10-40% asymptomatic
2,Mild pruritus or burning
sensation
3,Increased vaginal discharge
and fishy odor
Signs:
Discharge,thin,greyish-white,
homogenous,but not sticky
No inflammation reaction
(No epithelial edema or erythema)
Diagnosis
Identification of clue cells *(wet mount in saline)
together with 2 of the following 3 items
1,Vaginal discharge,homogenous,thin and white
2,pH>4.5,in virtually all cases,usu,5.0-5.5
3,Positive Whiff test (with 10% KOH)
* Clue cells are desquamated epithelial cells covered
with clumps of coccobacili esp,Gardnerella
vaginalis (加德纳菌 ),which gives the cells a
speckled (有小斑点 ) appearance.
Whiff test
Treatment (1)
1,Systemic therapy (oral) (80%)
1) Metronidazole
400mg,2-3 times a day for 7 days
2) Clindamycin (克林霉素 /氯林霉素 /氯洁霉素 )
300mg,twice a day for 7 days
2,Topical therapy (80%)
1) Effervescent tablets of metronidazole
200mg/day,for 7-10 days
2) 2% Clindamycin cream,once a day for 7 days
3,Vaginal washing
1-3% H2O2,1% lactic acid,0.5% acetic acid
Treatment (2)
1,Systemic or topical treatment has the same cure rate (80%).
2,Patients who are asymptomatic,but scheduled to
have a gynecologic surgical procedure should be treated.
3,Patients who are pregnant can be treated with oral
metronidazole.
4,Follow-up examination should be given 1-2 and 3-4
weeks (postmenstrual) after the treatment.
Criteria for cure:
Absence of clue cells with at least 1 of the following items:
a) Normal vaginal discharge
b) pH≤4.5
c) Whiff test negative
Other forms of vulvovaginitis
1,Senile vaginitis (老年性阴道炎 )
Atrophic vaginitis(萎缩性阴道炎 )
2,Infantile vulvovaginitis
(婴幼儿外阴阴道炎 )
Differential Diagnosis of vaginitis
Bacterial Vaginosis Candidiasis Trichomoniasis
Complaints
Vaginal
discharge
Vaginal
epithelium
Vaginal pH
Whiff test
Microscopic
examination
discharge↑m
ild pruritus
severe pruritus
burning
discharge↑
mild pruritus
white
homogenous
fishy
white
curd-like
thin
purulent
frothy
normal edema
erythema
punctate
hemorrhage
＞ 4.5 (4.7-5.7) ＜ 4.5 ＞ 5 (5.6-6.5)
＋ － －
Clue cells
WBC rare
Candida
WBC some
Trichomonad
WBC many
Inflammation of the Cervix
1,Common,50% women of reproductive age
2,May lead to pelvic infection
3,Need to identify a venereal disease and
differentiate from malignancies
Cervicitis,Vaginal portion of the cervix (Ectocervix)
Mucosa of the cervical canal (Endocervix)
Acute Cervicitis
Etiology
1,Neisseria gonorrhoeae (淋病奈瑟菌 )
Chlamydia trachomatis (沙眼衣原体 )
causing superficial infection of the cervical
columnar mucosa
2,Staphylococcus (葡萄球菌 ),
streptococcus (链球菌 ),
enterococcus (肠球菌 )
causing infection after an abortion,puerperium,
cervical injury,foreign bodies
Clinical Picture
Symptoms
1,Asymptomatic
2,Mucopurulent vaginal discharge
Vaginal irritation symptoms:pruritus,burning sensation
Lumbosacral pain,
Intermenstrual bleeding,postcoital bleeding
Symptoms of the lower urinary tract
Signs
Inflammation of the cervix with mucopurulent
discharge (MPC for mucopurulent cervicitis)
Diagnosis
1,Gram’s stain of the cervical discharge for leukocyte
≥30/HP or ≥10/× 1,000
2,Tests for gonococcus and chlamydia
3,Wet mount microscopy for trichomonads
Management
Systemic medication
Choice of drugs depends on the pathogens.
Examples,
Gonorrhea infection,Third generation Cephalosporins
Ceftriaxone Sodium (头孢曲松钠 /头孢三嗪 /菌必治 /罗氏芬 )
(头孢克 )
Spectinomycin (大观霉素 /壮观霉素 /淋必治 )
Chlamydia trachomatis
Doxycycline (多西环素 )
Azithromycin (阿奇霉素 )
Erythromycin (红霉素 )
Ofloxacin (氧氟沙星 )
Chronic Inflammation of
the Cervix
Cervical Erosion
Etiology
1,When the stratified epithelium (复层上皮 ) which
normally covers the vaginal portion of the cervix
is replaced by columnar epithelium which is
continuous with that of the cervical canal.
2,Most erosion are not infected,nor they are the
result of inflammation.
3,Occurs in the newborns,pregnancy,oral
contracepives
Clinical Features
Symptoms
The only symptom is a mucoid discharge.
A slight postcoital bleeding (but malignancy should
be excluded)
Signs
A red area is seen around the external os.
Classification
Depends on the depth and area of the lesion
Types,simple,granular,papillary
Grades,I (＜ 1/3),II (1/3-2/3),III (＞ 2/3)
Treatment
? Erosion found on routine examination should
not be treated unless it is causing troublesome
discharge.
? A cervical smear is needed before the treatment,
and if necessary,colposcopy (阴道镜 ) and biopsy.
? Cervical ectropion (宫颈外翻 )
Physical therapy
Thermal cauterization,
Cryotherapy,
Laser therapy
Cervical Polyps
Small pedunculated neoplasms of the cervix
? Endocervical polyp,
Originating from the endocervix
? Ectocervical polyp,
Originating from the vaginal portion
Pathology
Gross appearance:
Endocervical polyp,Red or pink,rounded or tongue-like
Ectoervical polyp,Pale,flesh-colored,smooth,rounded
with a broad pedicle
Microscopic:
Vascular connective tissue stroma covered with columnar
or squamous epithelium or both,Congestion,edema or
leukocytein filtration may be present.
Clinical Features
Some are asymptomatic.
Slight postcoital bleeding
Treatment
Cervical polyp should be treated.
? Malignant change (<1%)
? Polypoid cervical cancer
Twisting off a polyp without an anesthetic
and cauterizing the base,Recurrent cases
are treated with canal dilation and cauterization
of the stalk,
Chronic Endocervicitis (宫颈粘膜炎 )
(Infection)
Etiology
Pathogens:
Normal cervical and vaginal flora
Pathology
? Thickened endocervix that produces a whitish pus
? A cervical os surrounded by a reddish area
? Hypertrophy of the lacerated cervix
Clinical Features
1,Persistent leukohrrea usu,mucopurulent
2,Slight postcoital staining
3,Pains
lower abdominal discomfort,lumbosacral
backache,dysmenorrhea,dyspareunia
4,Infertility
5,Urinary symptoms
frequency,urgency,dysuria due to
subvesical lymphangitis not to cystitis
Diagnosis
? The characteristic discharge from external os of the
cervix,
? Cytologic and colposcopic studies are helpful,but
only biopsy is definitive.
? Cultures are not so helpful.
Treatment
Even if chronic endocervicitis is asymptomatic,
it should be treated,
1,Medical treatment
Systemic rather than topical
Based on culture and sensitivity test
2,Surgical treatment
A note of caution,postoperative bleeding,infection,
stricture formation,infertility.
Methods,thermal therapy,cryotherapy,laser therapy
conization,hysterectomy.
Nabothian Cysts
Retention cysts of the cervical glands caused by
obstruction of the gland orifices by the growth
of squamous epithelium,The cysts may be infected
and contain pus.
Cervical Hypertrophy
Cervical Hypertrophy
Pelvic Inflammatory Disease (PID)
Infection of the upper genital tract
Terms:
Endometritis (子宫内膜炎 )
Salpingitis (输卵管炎 )
Oophoritis (卵巢炎 )
Myometritis (子宫肌炎 )
Pyosalpinx (输卵管积脓 )
Hydrosalpinx (输卵管积水 )
Peritonitis (腹膜炎 )
Tubal ovarian abscess (TOA) (输卵管卵巢脓肿 )
Epidemiology
Sexual activity
A disease of sexually active,menstruating women.
Acute PID occurs in 1-2% of young sexually
active women annually.
Age
The peak incidence occurs in their late teens
and early twenties.
The most common serious infection in women
of 16-25 years of age
Contraceptive practices
Contraceptive methods No.of PID/woman-years
Sexually active,using no contraception,3.42
Oral contraceptives,0.91
Barrier methods 1.39
Intrauterine devices (IUD) 5.21
Financial cost
In USA,$3.5 billion annually in 1990s
Medical sequelae
Ectopic pregnancy,6-10 fold increase
PID accounts for 50%
Chronic pain,4 fold increase
Infertility,acute PID account for 5-60% of cases
Tubal obstruction,11.4%,23.1%,54.3% from 1,2,3
episodes of infection
Mortality,septic shock and death
Etiology
Pathogens that are sexually transmitted
1) Neisseria gonorrhoeae,in USA,40-50% cases of PID
2) Chlamydia trachomatis,in USA,10-40% cases of PID
The two pathogens may account for 2/3 of the PID
3) Mycoplasma (支原体 )
Recovered from the pus in 2-20% cases of salpingitis
Endogenous bacteria
1) Aerobic,streptococci,staphylococci,Escherichia coli
2) Anaerobic,Bacteroides fragilis (脆弱类杆菌 ),
peptococcus (消化球菌 ),
peptostreptococcus (消化链球菌 )
Spreading Route of Infection
1,Ascending along the reproductive tract
For non-pregnant and non-puerperal women
Gonococcus,C,trachomatis,staphylococcus
2,Lymphatic vessels
In puerperal infection,post-abortion infection
and IUD associated infection
Streptococcus,E.coli,anaerobic bacteria
3,Blood vessels
Tuberculosis
4,Direct spreading
Infection from other visceral organs.
Acute PID
Predisposing Factors
1,Intrauterine manipulation
e.g,artificial abortion,IUD,etc.
2,Infection in the lower reproductive tract,esp,STD
3,Sexual activity
4,Bad hygiene
4,Direct spreading from adjacent viscera
6,Acute onset of a chronic PID
Pathology
1,Acute endometritis and myometritis
2,Acute salpingitis,pyosalpinx and
tubo-ovarian abscess (TOA)
3,Acute pelvic peritonitis
4,Acute inflammation of the peritoneal
connective tissue (parametritis)(宫旁结缔组织炎 )
5,Septicemia (败血症 ) and pyemia (脓毒血症 )
6,Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome
? Perihepatitis,inflammation of Glisson’s capsule
without involvement of the liver parenchyma,
Suppurative (脓性 ) and fibrous exudation of the
capsule occurs causing adhesion between the capsule
and the anterior peritoneum,
? It happens in 5-10% cases of salpingitis.
? It is caused by gonococcus or Chlamydia trachomatis.
? Edema and adhesion of the capsule may lead to pain
in the upper abdominal region.
Clinical Features
Symptoms
Vary depending on severity and extent of the infection
and types of pathogens
Most common,lower abdominal pain,fever,increase
in vaginal discharge.
Gonorrhea/Chlamydia Trichomatis
Signs
Variable
Typical,
Bimanual examination:
Diagnosis
Criteria for the diagnosis of PID
Minimum:
1) Pain on compression of uterine body
or the adnexal region
2) Tenderness of the cervix
Specific:
1) Biopsy of the endometrium showing endometritis
2) Ultrasound/MRI identification of liquid-filled
enlarged oviducts or TOA
3) Laparoscopic examination
Additional:
Differential Diagnosis
Appendicitis
Rupture or abortion of tubal pregnancy
Torsion or rupture of an ovarian tumor
Treatment (1)
1,Systemic medication
(Ideal) Based on drug sensitivity test
(Empirical) Combination use of drugs
Patient’s condition and possible pathogens
1) Oral,Ofloxacin (氧氟沙星 ) Metronidazole for 14 days
2) Intravenous,Penicillin or Erythromycin (红霉素 )
Gentamycin (庆大霉素 ) or Amikacin (阿米卡星 /丁胺卡那霉素 )
Metronidazole for endogenous bacteria
3) Cefuroxime sodium (头孢呋辛钠 /西力欣 ) for gonococcus
4) Doxycycline (多西环素 /强力霉素 ) or Azithromycin (阿奇霉素 )
for chlamydia or mycoplasma
5) Clindamycin (克林 /氯林 /氯洁霉素 ) for anaerobic bacteria
Treatment (2)
2,Surgical treatment
for TOA or peritoneal abscesses that can not be
controlled by drugs (2-3 days)
Indications:
1) Failure of drug therapy
2) Persistent existence of abscesses (2-3 weeks)
3) Rupture of the abscess
3,Traditional Chinese medicine
Chronic PID
Etiology
1,Incomplete treatment of the acute PID
2,Infection from certain pathogens such
as Chlamydia trachomatis
3,Residual lesions from previous acute PID
Characteristics of chronic PID:
1,Persistence of the condition
2,Difficult to identify the pathogens
Pathology
1,Chronic endometritis
2,Chronic salpingitis and hydrosalpinx
3,Salpingo-oophoritis and tubo-ovarian cyst
4,Chronic inflammation of pelvic connective tissue
Clinical Features
1,Chronic pelvic pain
2,Infertility (20-30%) and ectopic pregnancy
3,Abnormal menstrual cycle
4,Systemic symptoms
5,Signs
Pelvic congestion or varicosity (静脉曲张 )
Endometriosis
Tumors
Ultrasound and laparoscopic examination is helpful
Diagnosis
Based on history of acute PID,symptoms and signs
Differential diagnosis
Treatment
According to place of the lesion and
the patient’s complaint
Usu,comprehensive treatment is required.
1,Physical
2,Traditional Chinese medicine (赤丹丸 )
3,Antibiotics (抗炎 II号栓 )
4,Drugs that dissolve and absorb
inflammatory lesions
5,Surgical treatment
