Vaginal Infections
Symptoms caused by VAGINAL INFECTIONS are the most common complaints in gynecological patients.
Vaginitis is characterized by discharge, odor, itching, pain during sexual intercourse (dyspareunia) or painful urination (dysuria).
Normally, the vagina contains many microorganisms including lactobacilli, diphtheroids, candida and other flora. The physiologic pH of the vagina is about 4.0, i.e. acidic, and this prevents harmful bacteria from multiplying. However, the vagina contains a physiological discharge consisting of bacterial flora, water, electrolytes, vaginal and cervical epithelium. The discharge is typically white and odorless. It turns yellowish when left in the laundry.
a. Bacterial Vaginosis (BV) is the most common cause of vaginitis. Rather than a single microbial agent, a change in the composition of the normal vaginal flora, including Prevo-tella, Gardnerella vaginalis, Mobiluncus species, up to a 10-fold increase in anaeorob flora and a decrease in the concentration of lactobacilli, is responsible for the infection.
Bacterial Vaginosis is not sexually transmitted!!!
However, if it occurs during pregnancy it can lead to premature birth!!!!
i. Diagnosis: Smear and vaginal culture tests
Treatment: Antibiotic groups such as metronidazole, ornidazole or clindamycin are used.
Follow-up: Bacterial Vaginosis is a frequently recurrent infection. Following antibiotic treatment, it is important to maintain the balance of vaginal flora.
b. Trichomoniasis is a sexually transmitted disease caused by the protozoan Trichomonas vaginalis.
Trichomonas can survive on wet towels and other surfaces and thus can be transmitted non-sexually. It can occur within 4-28 days after infection.
Diagnosis:
On examination, erythema or edema may be found in the vulva and vagina. The cervix may be red and tender. Diagnosis is made with smear and vaginal culture tests
Treatment consists of a single oral dose of 2 g metronidazole (oral) or 2 g tinidazole (oral).
Alternatively, 500 mg oral metronidazole may be given for 7 days.
The patient's partner should also be treated.
Trichomonas increases the risk of premature rupture of membranes and preterm labor.
Many organisms are sensitive to metro-nidazole, but if treatment fails, either 2 g tinidazole or
metronidazole once daily for 5 days is recommended. Sexual partners should be treated and patients should be asked to abstain from sexual intercourse until treatment is complete.
Candida vaginitis is not a sexually transmitted infection.
Candida is present in normal vaginal flora in 25% of women and Candida albicans is responsible for 90% of patients with vulvo-vaginal candidiasis.
Risk factors for Candida Infection include:
Diabetes mellitus,
Hormonal changes (e.g. pregnancy),
Broad-spectrum antibiotic therapy
Obesity
Immunodeficiency states, especially HIV infection,
Signs and symptoms are usually severe itching, vaginal irritation, and/or dysuria (painful urination).
Diagnosis. It is diagnosed with direct candida in vaginal swab or candida growth in culture tests.
Treatment. Symptomatic patients, including pregnant women, should be treated.
For treatment, oral antifungal agents (such as itrokanazole, flucanazole) and antifungal ovules used vaginally are generally recommended.
Boric acid is also very effective in local treatments. Boric acid washing solutions and ovules are available.
Only topical and local treatment is recommended in pregnancy.
Treatment of the male partner is not necessary, but treatment of the male partner is recommended for recurrent and persistent infections.
Cervicitis
It is an infection characterized by inflammation of the cervix. The primary causative agents of cervicitis, characterized by thick discharge, are Chlamydia trachomatis and Neisseria ganorrhoeae, both of which are sexually transmitted.
1. Chlamydia Risk factors:
Younger than 24 years of age
Low socio-economic status,
Multiple sexual partners and
Not being married
What are the Symptoms of Chlamydia Infection?
Chlamydial cervicitis is asymptomatic in 75% of cases (i.e. it is a silent infection and does not cause any symptoms).
Patients with chlamydia infection,
abnormal vaginal discharge,
burning in the urine,
spotting or
They may complain of post coital bleeding.
On examination, the cervix may appear erosion and fragile (strawberry appearance). Yellow-green mucopurulent discharge may be present.
c. The diagnosis is made by cell culture. The culture sample should be taken by swabbing the endocervix.
Treatment: Tetracycline, doxycycline and azithromycin group drugs can be used. The treating physician determines which drug will be used at which dose according to the patient and culture results.
Sexual partner treatment is essential.
2. Gonorrhea.
It is caused by the bacterium N Gonorrhoeae. The urogenital tract is the most common site of infection. Pharyngeal or disseminated gonorrhea are other forms of infection. Transmission time is 3-5 days.
Signs and Symptoms. Like chlamydia infection, patients are often asymptomatic, although vaginal discharge, dysuria or abnormal uterine bleeding may be present. The most common site of infection is the endocervix.
Diagnosis. Diagnosed by cervical canal culture.
Treatment Sexual partners should be referred for treatment.
Oral administration of 2 gr azithromycin is effective against uncomplicated gonorrhea. In addition, ciprofloxacin, oflaxacin, ceftriaxone are also commonly used antibiotics.
Cystitis and Urethritis. Lower urinary tract infections are the most common bacterial infections in adult women and the most common medical complications in pregnancy. They are often associated with vaginal and cervical canal infections and have similar symptoms.
Infections of the vulva. Itching and burning of the vulva is reported in approximately 10% of gynecologic examinations.
1. Human Papilloma Virus (HPV). Condyloma acuminata (sexually transmitted genital warts) is a lesion of the vulva, vagina or cervix caused by HPV that infects and transforms epithelial cells. HPV infection is the most common sexually transmitted disease (15% prevalence)
The incidence peaks between the ages of 15 and 25.
Pregnant women, immunocompromised and diabetic patients are at increased risk.
The vulva shows soft, sessile and/or stalked cauliflower-shaped lesions of varying size and shape.
The lesions are usually asymptomatic, although itching, burning and pain are not uncommon.
The vulva is characterized by soft, sessile and/or stalked cauliflower-shaped lesions of varying size and shape.
The lesions are usually asymptomatic, although itching, burning and pain are not uncommon.
Bleeding may occur if the lesions are traumatized or secondary infection develops.
Diagnosis
It is diagnosed by the typical appearance of the lesions.
Colposcopic examination helps to diagnose cervical and vaginal lesions.
PAP smear test with HPV typing confirms the diagnosis.
Treatment includes cauterization, application of various topical cyto-destructive agents and immune modulators.
The virus can be completely eradicated despite no treatment. The HPV vaccine (which protects against 4 and 9 different HPV types) has been licensed by the US FDA for use by women aged 9-45 years.
Vaccination is given as 3 consecutive injections at intervals of 6 months or more. The second and third vaccination should be given 2 and 6 months after the first dose, respectively.
Molluscum contagiosum can be transmitted by close contact as well as by autoinoculation.
is a benign poxvirus infection of the skin (sexual or non-sexual) that spreads.
The duration of transmission can vary from a few weeks to 1 month.
Signs and symptoms consist of round, pearly, pearly lesions 1-5 mm in diameter with a depressed center. Numerous lesions can be seen but usually less than 20.
Lesions are usually asymptomatic, rarely pruritic. Lesions are usually self-limiting and may persist for up to 6-9 months.
Diagnosis is made by microscopic examination of the white, waxy material released from the lesion
Treatment
Removal of white material,
It consists of excision of the nodule by dermal curettage and treatment of the base with ferric subsulfate (Monsel's solution) or 85% trichloracetic acid.
Cryotherapy with liquid nitrogen may also be used.
Sexual partners should be examined and treated.
Parasite Infections
a. Pediculosis pubis (pubic lice) is the most contagious of the sexually transmitted diseases, transmitted through sexual and non-sexual contact and through items that can transmit the infection, such as towels or bed linen. The disease is usually confined to the groin, perineum and perianal area, but can also infect the eyelids and other body parts. The parasite stores its eggs at the base of hair follicles. The transmission time is 1 week
It is characterized by severe itching and red lesions in the pubic area.
Diagnosis; It is made by seeing eggs or lice in the pubic area.
Scabies (due to the itchy scabies bug) is transmitted through close contact (sexual or non-sexual) and is especially common on the elbows, wrists, between the fingers, axillae and buttocks.
It can infect any part of the body, including curved areas such as the skin. The adult female burrows under the skin, lays eggs and moves rapidly across the skin.
Symptoms of infection include intermittent itching, which can be insidious in onset, severe but worse at night.
Treatment of pubic lice and scabies requires agents that kill eggs and adult organisms.
Itching is treated with antihistamines.
Genital Ulcers
1. Genital herpes is a chronic sexually transmitted infection caused by Herper Simplex Virus (HSV) Type 2.
It is characterized by the formation of vesicles on the vulva with intense pain and irritation. They are usually numerous and cause superficial, painful, coalescing ulcers. Multiple vesicles and ulcers can be seen at 2-6 weeks. Symptoms peak on day 7 and may last for about 14 days.
They are recurrent infections.
Painful vesicles followed by ulcerative lesions are typical.
Treatment
The main goal of treatment is to shorten the clinical duration, reduce infectiousness and prevent complications and recurrences.
The virus cannot be completely eradicated.
There is currently no effective HSV vaccine.
A caesarean section is recommended for women with active genital lesions or prodromal symptoms of HSV during labor.
Syphilis
It is a chronic, systemic disease caused by Treponema pallidum.
The disease is contagious in the primary, secondary phase and during the first year of the late stage.
The causative agent can enter through the skin, with an incubation period of 10 days to 3 months.
a. Primary syphilis is usually found in the vulva, vagina or cervix as a hard painless solitary chancre, although extragenital lesions may occur. Lesions in the cervix or vagina often pass unnoticed.
b. Secondary syphilis is a systemic disease that occurs 6 weeks to 6 months after hematogenous spread of the causative agent by primary infection. Patients in this phase show skin and mucous membrane lesions (diffuse red rash involving palms and soles, large, raised gray-white lesions) and diffuse lymphadenopathy. Symptoms resolve spontaneously in 2-6 weeks.
c. Late-stage syphilis can persist for up to 2-20 years.
d. Tertiary syphilis develops in up to one-third of untreated or inadequately treated patients. Signs and symptoms include involvement of the cardiovascular system (e.g. endarteritis, aortic aneurysm and aortic insufficiency), musculoskeletal system and central nervous system (CNS).
e. Diagnosis is based on nonspecific serologic tests such as the VDRL and Rapid Plasma Reagin (RPR) tests. Serologic tests may be positive 4 or 6 weeks after exposure to the causative agent, usually 1-2 weeks after the onset of primary chancre.
Depot penicillin is effective in primary treatment. Ceftriaxone, tetracycline and ciprofloxacin can also be used
Infections of the Upper Genital Canal
Pelvic Inflammatory Disease (PID) is an infection of the upper genital tract. The disease involves the endometrium, fallopian tubes, ovaries, myometrium, parametria and pelvic peritoneum.
PID is caused by the spread of infection through the cervix. Although PID is associated with sexually transmitted infections of the lower genital tract, the disease process is polymicrobial. N gonorrhoeae or C. trachomatis are present in the majority of cases.
Risk factors,
prior history of PID,
multiple sexual partners,
RIA use can increase the risk of PID 6-fold, but only in the first 3 weeks after insertion.
Use of non-barrier contraception is also a factor that increases the risk.
The most common symptom at diagnosis is abdomino-pelvic pain.
Other complaints are variable, including vaginal discharge, bleeding, fever, chills, nausea and dysuria.
Painful movement of the cervix
Adnexal tension
Uterine tenderness
fever >38.3C
Abnormal cervical or vaginal discharge
Increased sedimentation rate
Increased C-reactive protein
Laboratory evidence of cervical infection with N. Gonorrhoeae and C. Trachomatis are important findings for diagnosis.
Treatment for PID should be aimed at preventing tubal damage and chronic infection leading to infertility and ectopic pregnancy. Many patients can be successfully treated on an outpatient basis
Hospitalization Criteria are as follows:
Surgical emergencies, pregnant patients, patients who do not respond clinically to oral antimicrobial therapy, patients who cannot follow and tolerate outpatient oral therapy, patients with severe illness, nausea, vomiting and high fever, patients with tubo-ovarian abscess.
Approximately 25% of PID patients experience long-term sequelae. Depending on the severity, infertility due to tubal obstruction anywhere following an episode of PID affects between 6% and 60% of women.
The risk of ectopic pregnancy is approximately 6-10 times the normal risk.
Chronic pelvic pain and dyspareunia have also been reported.
B. Endometritis
Endometritis occurs when pathogens invade the endometrium from the cervix. Pathogens include N. Gonorrhoeae and C. Trachomatis, Streptococcus agalactiae, cytomegalovirus, HSV and Mycoplasma hominis. Organisms causing bacterial vaginosis can cause histologic endometritis even in women without symptoms. Endometritis is also an important part of PID and may be an intermediate step in the spread of infection to the fallopian tubes.
Chronic Endometritis. Many women are asymptomatic. The classic symptom of chronic endometritis is vaginal bleeding between periods.
Other symptoms include bleeding after intercourse, menorrhagia and persistent lower abdominal pain.
b. Acute Endometritis. It is characterized by intense tenderness in the uterus.
Endometritis is diagnosed by endometrial biopsy and culture.
Treatment. The treatment option for chronic endometritis is oral doxycycline for 10 days. A broad spectrum including anaerobic organisms should be considered, especially in the presence of bacterial vaginosis.
