PHYSIOLOGY

PHYSIOLOGICAL VAGINAL
DISCHARGE
WHITE
BECAME YELLOWISH IN CONTACT WITH
AIR(OXIDATION)
CONSIST OF DESQUAMATE EPI.CELL
FROM VAGINAL AND CERVIX,MUCOS
FROM CERVICAL GLAND,BACTERIAL
AND FLUID
ACIDIC PH MAINTAINED BY
LACTOBACILLI AND PRODUCTION OF
LACTIC ACID BY VAGINAL EPI
METABOLOZE GLYCOGEN

DIFERENTIAL DIAGNOSIS FOR

VAGINAL DISCHARGE
SM AND SG

CANDIDIA
SIS

BACTERIAL
VAGINOSIS

TRICHOMO
NIASIS

CERVICITIS

ITCHINES
AND
SORENESS

++

++

SMELL

MAY BE
YEASTY

OFFENSIVE,FI
SHY

MAY BE
OFFENSIVE

COLOUR

WHITE

WHITE/YELLO
W

YELLOW/GRE CLEAR
EN

CONSISTENC CURDY
Y

THIN,HOMOG
ENOUS

THIN,HOMO
GENOUS

MUCOID

PH

<4.5

4.5-7

4.5-7

<4.5

CONFIRMED
BY

MICROSCOP MICROSCOPY
Y AND
CULTURE

MICROSCOP
Y AND
CULTURE

MICROSCOP
Y

VAGINAL CADIDIASIS
WOMEN
CARRIED IN GUT,UNDER NAILS,IN
VAGINA,ON SKIN
80% CANDIDA ALBICANS
RISK FACTOR
IMMUNOSUPPRESION

Vaginal candidiasis

TREATMENT
CLOTRIMAZOLE VAGINA TABLET
-5OOMG ON 1/7
-2OOMG OD 3/7
-1OOMG OD 6/7
RECURRENT (=/> 4 EPISODE per year)
-FLUCONAZOLE 50MG OD 1/52,F/BY
150MG
MONTHLY FOR 3-6 MONTHS

TRICHOMONIASIS
CAN BE CARRIED ASYMPTOMATIC FOR
SEVERAL MONTHS
IN WOMEN CAUSE VULVOVAGINITIS=FROTHY
GREENISH DISCHARGE,VAGINAL BURNING
SENSATION,PRURITUS VULVAE
DIAGNOSIS:
MOTILE PROTOZOA SEEN MICROSCOPICALLY
WHEN VAGINAL DISCHARGE IS PLACED IN A
DROP OF SALINE ON A ASLIDE
TREATMENT
T.FLAGYL 400MG TDS 1/52 BOTH HUSBAND AND
WIFE

BACTERIAL VAGINOSIS
POLYMICROBIAL INFECTION(Gardnerella
vaginalis,Bacteroides spp,mycoplasma
hominis)
DIAGNOSIS BY AMSEL CRITERIA/GRAM STAIN
- homogeneous, thin, white discharge that
smoothly coats the vaginal walls;
- presence of clue cells on microscopic
examination;
- pH of vaginal fluid >4.5; and
- a fishy odor of vaginal discharge before or
after addition of 10% KOH (i.e., the whiff test).

Bacterial vaginosis

TREATMENT
TREAT HUSBAND AND WIFE
ORAL METRONIDAZOLE 400MG TDS 7/7
OR METRODINAZOLE GEL 0.75% BD 5/7
OR
ORAL CLINDAMYCIN 300MG BD 7/7 OR
CLINDAMYCIN VAGINAL CREAM 2% 5GM
ON 7/7

PREGNANT WOMEN
Women with BV at greater risk 2nd
trimester miscarriage and preterm
delivery
Women with prior h/o of 2nd trimester
loss/idiopathic preterm birth should
be screened for BV and treated with
metronidazole early in 2nd trimester

BARTHOLINS ABSCESS
BARTHOLIN GLAND AT EITHER SIDE
OF VAGINA,OPENING INTO VESTIBULE
IF OPENING BLOCK,CYST
DEVELOPPAINLESS SWELLING
MAY BE INFECTEDABSCESS
PE: HOT,TENDER
CULTURE:MIXED ORGANISM

Bartholin abscess

TREATMENT
START T DOXYCYLINE 100MG BD AND
T METRODINAZOLE 400MG TDS FOR
7/7
MARSUPIALIZATION UNDER GA
PUS FEME AND C&S
ANALGESICS

UPPER GENITAL TRACT

INFECTION
GONORRHOEA
CHLAMYDIA
PID

GONORRHOEA
PREVALENCE <1% IN WOMEN IN CHILD BEARING AGE
CAUSE BY NEISSERIA GONORRHEAE
CHRONIC ASYMPTOMATIC INFECTION IS COMMON(50%
WOMEN HAS NO SG AND SM OF INFECTION)
MUCOPURULENT PV DISCHARGE,DYSURIA AND
DYSPAREUNIA
70% IN MEN SYMPTOMATIC=URETHRITIS WITH GREEN
URETHRAL DISCHARGE AN DYSURIA
ALSO CAUSE PROCTITIS IN WOMEN AND HOMOSEXUAL
MEN=PURULENT DISCHARGE,BLEEDING AND RECTAL
PAIN

DIAGNOSIS
ON MICROSCOPY GRAM-VE
INTRACELLULAR DIPLOCOCCI
CULTURE IN THAYER-MARTIN PLATE IS
GOLD STANDARD OF DIAGNOSIS

TREATMENT
1) UNCOMPLICATED URETHRITIS, RECTAL, PHARYNGEAL
IM PROCAINE PENICILLIN 2.4 MEGA UNIT BOTH
BUTTOCKS(TOTAL 4.8 MREGA UNIT) SINGLE
DOSE AFTER TEST DOSE +/- PROBENECID 1GM
ORALLY
IF ALLERGY TO PENICILLIN USE T EES STAT
IF GONOCCOCAL RESISTANT TO PENICILLIN
IM CEFTRIAXONE 250MG STAT
2) IF PID (DUE TO GONOCCOCI)
IM CEFUROXIME 1.5GM TDS 3/7
OR SPECTINOMYCIN 2GM BD 3/7

CHLAMYDIA TRACHOMATIS
COMONNEST BACTERIAL STI IN INDUSTRIALIZED COUNTRIES
OBLIGATE INTRACELLULAR PATHOGEN
CAN CAUSE
CERVICITIS,URETHRITIS,CONJUCTIVITIS,MUCOPURULENT
CERVICAL DISCHARGE
MANY ARE ASYMPTOMATIC (50%=MEN,80%WOMEN)
IN WOMEN IT CAUSE CERVICITIS AND PID
IN PREGNANT WOMEN,CAN CAUSE PRETERM
LABOUR,SPONTAEOUS ABRTION,MUCOSA LACERATION AND
NEONATAL PNEUMONIA

COMPLICATION:SKENITIS(inflammation of Skene's
glands=Paraurethral), BARTHOLINITIS, ENDOMETRITIS,
PERIHEPATITIS

DIAGNOSIS
TISSUE CULTURE
IMUNOFLUORESCENT TEST,ELISA-AGAB TEST

TREATMENT
T DOXYCYCLINE 100MG BD 2/52 OR
T TETRACYCLINE 1-2GM OD 2/52 OR
T EES 800MG BD 2/52

*CDC RECOMMEND ALL GONOCOCCAL

INFECTION PATIENT ALSO BE TREATED
FOR
CHLAMYDIA (BOTH COMMONLY OCCUR
TOGETHER

PELVIC INFLAMMATORY
DISEASE
CLINICAL SYNDROME ATTRIBUTED TO
THE ASCENDING SPREAD OF MICRO
ORGANISM(UNRELATED TO
PREGNANCY OR SURGERY) FROM
VAGINA AND CERVIX TO
ENDOMETRIUM,FALLOPIAN TUBE
AND/OR ADJACENT STRUCTURE

COMMON ORGANISM

CLINICAL SYMPTOM

PHYSYCAL EXAMINATION
1)CERVICAL EXCITATION
2)LOWER GENITAL TRACT INFECTION

IX:PYREXIA WITH RAISED

TWC(NEUTROPHILS
RAISED)
ESR

RELATED RISK

DIAGNOSIS
70-80% CLINICAL DIAGNOSIS
ACCURATE
LAPAROSCOPY GOLD STANDARD FOR
DIAGNOSIS

LAP FINDING IN WOMEN

SUSPECTED PID

TREATMENT
INPATIENT
IV CEFUROXIME 750MG TDS 1/7 OR
IV CEFOTAXIME 1GM BD 1/7
F/BY
T DOXY 100MG BD 2/52 AND T FLAGYL 400MG TDS
2/52

OUT PATIENT:T DOXY 100MG BD AND T FLAGYL

400MG TDS 2/52
ADMISSION: FEVER> 38DEGREE CELCIUS AND ADNEXAL
MASS
INDICATION FOR SURGERY:GEN PERITONITIS AND TUBOOVARIAN ABSCESS

GENITAL ULCER

SYPHILIS-EARLY

SYPHILIS -LATE
NEUROSYPHILIS
-DEVELOP 5 YEARS
-MENINGOVASCULAR
SYPHILIS(STROKE)
TABES DORSALIS
CARDIOVASCULAR SYPHILIS (AORTIC
ANEURYSM,AORTIC REGURGITATION)

INVESTIGATION
DARKFIELD MICROSCOPY(DIRECT
OBSERVATION OF SPIROCHETES)
VDRL
PRIMARY:MOSTLY VE
SECONDARY : 1:32 OR GREATER
TPHA

TREATMENT

Syphilis

HERPES INFECTION

DIAGNOSIS
TISSUE CULTURE(GOLD STANDARD)
AG-AB TEST:ELISA TEST

Genital herpes

COMPLICATION
NEUROLOGICAL:ASEPTIC
MENINGITIS,TRANSVERSE MYELITIS
RESOLUTION TAKE 1-2 MONTHS
HERPES KERATITIS:CORNEAL
SCARRING AND BLINDNESS

HERPES KERATITIS

HUMAN PAPILLOMA VIRUS

CAUSE GENITAL WART
BY HUMAN PAPILLOMA VIRUS(TYPE 6
AND 11-LITTLE ONCOGENIC
POTENTIAL)
HPV 16&18 CAUSE FLAT WART,
LINKED TO DEVELOP CERVICAL
CANCER

HUMAN PAPILLOMA VIRUS

SM:PAINLESS FUNGATING GROWTH IN
GENITALIA REGION
TX
-PODOPHYLLIN 20% LA(CONTRACINDICATE
IN
PREGNANCY)
-CRYOCAUTERY WITH LIQUID NITROGEN IN
SKIN
CLINIC
-TRICHLOROACETIC ACID LA

CHANCROID
CAUSE BY HAEMOPHILUS DUCREYI
START WITH SMALL,SHALLOW ULCER
WHICH ARE MULTIPLE AND PAINFUL
EGDES AR IRREGULAR AND A/W
LOCALIZED LYMPHADENOPATHY
SORES PERSIST FOR SEVERAL MONTHS
TX: T.CLO-TRIMOXAZOLE 2/2 BD 2/52
OR SPECTINOMYCIN 1GM IM OD 2/52

CHANCROID

REFERENCES
CENTRE FOR DISEASE CONTROL AND
PREVENTION 2006
OBSTETRICS TEN TEACHER
OBSTETRIC AND GYNAECOLOGY
PROTOCOL KEDAH