IN THE NAME OF GOD

Genital Infection

Normal Vagina

Normal vaginal secretion : sebaceous- sweat Bartholin-Skene- exfoliated vaginal cell- cervical mucous endometrial & oviduct fluids product of microorganism - Normal flora in vagina is predominant aerobic with an average 6 different bacteria.

- PH of normal vagina is < 4.5 - Normal secretion is floccular white & in post fornix

Bacterial vaginosis

Gardnella vaginitis The most common form of vaginitis in USA - etiology is G. vaginalis Diagnosis: 1- fishy vaginal odor following coitus 2 - vaginal secretion are gray 3- PH is > 4.5

4- Mic : increased clue cell – absent WBC 5- Whiff test is positive - Culture of G.vaginalis is not recommended

Treatment: 1- Metronidazol is choice for B.V

500 mg Bd for 7 days avoid using alcohol during & 24h after treatment 2- Metronidazol gel 0.75% 5g/d or Bd for 5 days 3- singel 2g dose of metronidazol cure rate 75%-84% for above regimen 1- Clindamycin cream 2% 2- Tab clindamycin 300 mg Bd for 7 days 3- Clindamycin ovules 100 mg intravaginal for 3days Treatment of partner not recommended

Complication:

PID - postabortal PID - Post operative cuff infection after hysterectomy - abnormal cervical cytology -PROM -preterm labor - chorioamnionitis - post C/S endometritis

Trichomonal Vaginitis

- The parasite is anaerobe only in trophozoite form - transmission rate is high infected female to male is 70% male to female is higher.

- T. vaginitis often acompanies BV (60%) - Local immune factor & inoculum size influence of symptoms.

Diagnosis:

1- profuse, purulent, malodor vaginal discharge and vulvar pruritus 2- patchy vaginal erythema &colpitis macularis ( strawberry cervix) 3- PH >5 4- Mic : motile trichomonads –increase WBC 5- Clue cell 6- Whiff test

Treatment:

1- Metronidazol is choice single dose 2g – 500 mg Bd for 7 days cure rates is 95% - partner should be treated - Metronidazol gel should not be used - If not respond to initial therapy: - repeated 500 mg Bd for 7 days - singel dose 2g for 3-5 days - Cultures of parasite

Complication: post operative cuff cellulitis preterm labor PROM - women with T. vaginitis should be tsted: - N. gonoria - Chlamydia - Syphilis - HIV

Vulvovaginal Candidiasis(vvc)

- 75% women experience 1 episode of vvc - 45% will experience 2 or more episode - Etiology : Candida albicans C. glabrata C. tropicalis - Extra cellular toxin or enzyme play role hypersensitivity especially in chronic recurrent disease.

Patient with symptomatic disease >10 4 /ml concentration of microorganism - Risk factors : AB use – pregnancy - diabetes

Diagnosis:

1- sign & symptom :vaginal soreness- dysparonia vulvar burning- irritation external dysuria –erythema edema of labia & vulvar skin 2- PH is normal 3- Mic: normal in sever increase WBC 4-Whiff test is negative 5-Culture is recommended to confirm diagnosis

Treatment: 1 - azole drugs more effective than nystatin - cure rate is 80% - 90% - symptom take 2-3 days to resolve 2- oral fluconazole single 150mg /d - in sever 150mg given 72h after first dose 3- Adjunctive treatment topical steroid - 1% hydrocortisone -In chronic v vc: ketoconazole 400mg/d fluconazole 150mg/3d - prophylactic doses: keto 100mg/d fiuco150mg/w for 6 m.

Cervicit

- Cause inflamation of ectocervix: - HSV - candida - Trichomona - Cause inflamation of endocervix: - N. gonorrhoea - clamydia Diagnosis: 1- Gram stain: increase of N intracellular gram negative diplocci 2- Culture on Thayer Martin for gonorrha PCR – direct fluoresent Ab for chlamydia

Treatment:

- For Neisseria: cefixime 400mg/d ceftriaxon 125mg IM ofloxacin 400mg/d ciprofloxacin 500mg/d - For Chlamydia: Azitromycin 1g/d Doxycycline 100mg Bd ofloxacin 300mg/ Bd for 7d

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PID

Diagnosis is clinical Caused by: N.gonorrhea- chlamydia- BV respiratory pathogen Diagnosis: - Clinical - in sever PID endometrial biopsy sonography laparoscopy

Treatment: Regimen A: Ofloxacin 400mg Bd for 14d or Levofloxacin 500mg /d for 14d _+ Metronidazole 500 Bd for 14d Regimen B ; Doxycycline 100mg Bd for 14 d_+ Metronidazole Regimen A: Cefoxitin 2gq6h or cefotetan 2g BD + Docycycline 100mg BD Regimen B : Clindamycin 900mg q8h + Gentamicin 2mg/kg

Genital Ulcer Disease

- HSV - siphilis - Chancroid - LGV - granuloma inguinal - abrasions - fixed drug eruption - carcinoma - Behjet disease

Chancroid:

1-3 extremely painful ulcers + tender inguinal lymphadenopathy Adenopaty is fluctuant Treatment : - azithromycin 1 g orally single dose - ceftriaxone 250 mg IM single dose - ciprofloxacin 500 mg Bd for 3 days - erythromycin 500 mg q 6 h for 7 days Patients should be reexamined 3-7 days after initiation of therapy can be expected to heal within 2 w unless is unusually large

Lymhogranuloma venereum ( LGV)

- an inguinal bubo + no ulcer - this disease is rare and increased risk for HIV infection

Granuloma inguinal ( donovanosis)

- nonpainful ulcer + no lymphadenopaty - this ulcer is very vascular with contacted bleeding

Treatment : - Doxycyclin 100 mg 2-3 time daily for 2 w - Co- trimoxazol for 2 w - Erythromycin 30 mg/kg/d for 3 w in pregnancy

Syphilis : - nonpainful and minimally tender ulcer - no inguinal lymphadenopathy - ulcer is indurated Diagnosis: - nontreponemal test : - rapid plasma reagin (RPR ) test - VDRL - treponemal test : - FTA ABS ( fluorescent treponemal antibody absorption ) - MHA TP ( microhemagglutinin T. pallidum)

Treatment : - Parenteral penicillin G is perferred treatment of all stage of siphilis - Benzathin penicillin G 2.4 million unit IM in a single dose in primary, secondary, early latent syphilis latent syphilis : period after infection when patients are seroreactive but no other evidence of disease - latent syphilis longer than 1 yr or unknown duration : benzathin penicillin G 7.2 million unit total

Genital warts : - HPV type 6 & 11 are usually responsible for EGW - Posterior fourchette & lateral areas on the vulva ,in the vagina ,cervix - EGWs are highly contagious , more than 75% sexual partners develop HPV Management : - The goal of treatment is removal of the warts - It is not possible to erasicate the viral infection - It has not been determined Whether treatment of EGW reduces transmission of HPV - Cryotherapy , cautery , laser , podophyllin ,Trichloroacetic acid