Genital tract infections Flashcards
pH of vagina
<4.5
prepubertal girls and postmenopausal women = lack of oestrogen -> thinner epithelium -> pH 6.5 - 7.5 -> reduced resistance to infection
Main flora of vagina
lactobacilli
3 common infections associated with vaginal discharge
BV, candidiasis, trichomoniasis (STI)
Bacterial vaginosis: epidemiology and physiology, diagnosis, tx
most common cause of vaginal discharge in women of reproductive age
loss of lactobacilli → increase of anaerobic and BV-associated bacteria → proteolytic enzymes (vaginal peptides into malodorous amines) → rise in pH → G. vaginalis and Atopobium vaginae → exfoliate epithelial cells and biofilm development
Diagnosis:
- grey-white discharge (fishy odour) = positive whiff test aka fishy odour when KOH added to secretions
- presence of clue cells on microscopy = epithelial cells studied with Gram-variable coccobacilli
Tx:
- symptomatic = intravaginal metronidazole/clindamycin cream
can cause 2o infection in PID
association with pre-term labour
Candidiasis (thrush): epidemiology
Candida spp, a yeast-like fungus (Fig. 10.1), is identified in the lower genital tract in:
• 10–20% of healthy women in the reproductive age group
- 6–7% of menopausal women (higher if taking hor- mone replacement therapy (HRT))
- 3–6% of prepubertal girls.
Candidiasis: risk factors
pregnancy
diabetes
use of abx
recurrent more common in immunocompromised and patients with uncontrolled diabetes
Candidiasis: symptoms
cottage cheese discharge
vulval irritation and itching
superficial dyspareunia and dysuria
vagina/vulva inflamed and red
Candidiasis: diagnosis and tx
Dx = culture
Tx = topical imidazole (e.g. clotrimazole pessary) ro oral fluconazole
What is toxic shock syndrome?
complication or retained, hyperabsorbable tampon
toxin-producing Staphylococcus aureus is responsible
high fever, hypotension and multisystem failure may occur
tx = abx and intensive care
Trichomoniasis
Trichomonas vaginalis is a flagellate protozoan
- offensive grey-green discharge
- vulval irritation
- dysuria
- superficial dyspareunia
asymptomatic 50%
Ix= NAATs and wet film microscopy
Tx = systemic metronidazole
Bacterial vaginosis mx
most common cause of vaginal discharge in women of reproductive age
loss of lactobacilli → increase of anaerobic and BV-associated bacteria → proteolytic enzymes (vaginal peptides into malodorous amines) → rise in pH → G. vaginalis and Atopobium vaginae → exfoliate epithelial cells and biofilm development
Diagnosis:
- grey-white discharge (fishy odour) = positive whiff test aka fishy odour when KOH added to secretions
- presence of clue cells on microscopy = epithelial cells studied with Gram-variable coccobacilli
Tx:
- symptomatic = intravaginal metronidazole/clindamycin cream
can cause 2o infection in PID
association with pre-term labour
Vulvovaginal candidiasis and recurrent vaginal candidiasis
Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.
The majority of women will have no predisposing factors. However, certain factors may make vaginal candidiasis more likely to develop:
- diabetes mellitus
- drugs: antibiotics, steroids
- pregnancy
- immunosuppression: HIV
Features
- ‘cottage cheese’, non-offensive discharge
- vulvitis: superficial dyspareunia, dysuria
- itch
- vulval erythema, fissuring, satellite lesions may be seen
Investigations
- a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
Prescribe antifungal treatment
Most women:
Most women:
- Local: clotrimazole pessary or cream (e.g. clotrimazole 500mg PV stat)
- Oral: itraconazole 200 mg PO BD for 1 day or fluconazole 150mg PO stat
- Girls aged 12-15 years: consider prescribing topical clotrimazole 1% or 2% applied 2-3 times per day (do not prescribe intravaginal or oral antifungal)
- Pregnant women: intravaginal clotrimazole (Do not use oral antifungals)
- If vulval symptoms: topical imidazole (clotrimazole, ketoconazole) in addition to an oral or intravaginal antifungal
- NOTE: intravaginal clotrimazole (Canesten), oral fluconazole, topical clotrimazole → OTC
Advice
- Return if symptoms have not resolved in 7-14 days
Avoid predisposing factors:
- Wash the vulval area with a soap substitute - used externally and not more than once per day
- Use simple emollient to moisturise vulval area
- Consider probiotics (e.g. live yoghurts) orally or topically to relieve symptoms
- Do not routinely treat asymptomatic sexual partner → Male partner could get candida balanitis
Summary
Either local or oral treatment
o Local: clotrimazole pessary or cream (e.g. clotrimazole 500 mg PV stat)
o Oral: itraconazole 200mg PO BD for 1 day or fluconazole 150 mg PO stat
Recurrent vaginal candidiasis
- BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
- compliance with previous treatment should be checked
- confirm the diagnosis of candidiasis
- high vaginal swab for microscopy and culture
- consider a blood glucose test to exclude diabetes
- exclude differential diagnoses such as lichen sclerosus
- consider the use of an induction-maintenance regime
- induction: oral fluconazole every 3 days for 3 doses
- maintenance: oral fluconazole weekly for 6 months
PID: RFs and PFs
Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix (can be descending from local organs such as the appendix).
RFs = young, poor, sexually active
partially PFs = COCP, IUS
PID: causatives
ausative organisms
- Chlamydia trachomatis (MOST COMMON CAUSE)
- Neisseria gonorrhoeae
- Mycoplasma genitalium
- Mycoplasma hominis
Other causes = TOP, ERPC, laparoscopy and dye test and IUD (and/or complications of childbirth and miscarriage)
PID: features
- lower abdominal pain/pelvic pain (constant, or intermittent)
- fever (unusual in chronic infection)
- deep dyspareunia
- dysuria and menstrual irregularities may occur (intermenstrual/postcoital bleeding)
- vaginal or cervical discharge
- cervical excitation
- adnexal discomfort
PID: mx
Differentiating genital tract infections summary
gonorrhoea = G= diplococci, tx with IM ceftriaxone
A 22-year-old woman presents with a thin, purulent, and mildly odorous vaginal discharge. She also complains of dysuria, intermenstrual bleeding and dyspareunia. A swab shows a Gram-negative diplococcus.
trichomoniasis = tx with IM metronidazole
A 27-year-old woman complains of an offensive ‘musty’, frothy, green vaginal discharge. On examination you an erythematous cervix with pinpoint areas of exudation.
BV Amsel’s Criteria = 3 of the following 4 points should be present:
- thin, white homogenous discharge
- clue cells on microscopy: stippled vaginal epithelial cells
- vaginal pH > 4.5
- positive whiff test (addition of potassium hydroxide results in fishy odour)
tx with oral metronidazole
A 30-year-old woman presents with an offensive ‘fishy’, thin, grey vaginal discharge. Testing the discharge shows the pH to be > 4.5.
Acute PID at a glance
