CASE 11: LOWER GENITAL INFECTIONS

Case 11
36 year old G4P4 (4004) complains of vulvar pruritus of one week duration. This is accompanied by foul yellowish
discharge. LMP: 2 weeks ago. External Genitalia: vulva edematous, erythematous with excoriations. Speculum
exam: (+) yellowish frothy discharge; Cervix erythematous with multiple pinpoint hemorrhages on the surface, IE:
Cervix long firm, closed. Uterus - normal sized, anteverted, movable; Adnexa no mass, no tenderness
Lower Genital Tract:
Vulva
External Genital organs of female
Labia majora, Labia minora, Urethral orifice, vaginal
introitus, perineum & anus

VULVAR INFECTIONS
Presentation:
Pruritis, Swelling, Erythema, Abscess
Lined by Stratified Squamous Epithelium that will
O
O
mean all of the Dermatologic lesions: 1 & 2 may
be presenting manifestations.
O
1 Skin Lesions: Macule, Patch, Papule, Plaque
O
2 Skin Lesions: Scale, Crust, Erosion, Fissure
It will be the knowledge of the particular disease that
will make enable you to make a diagnosis.

Need to know some of the more common:

1.

HERPES GENITALIS

Etiology: Herpes Simplex Type 2

Clinical Manifestations: Vesicles (Blisters that
maybe confluent all over the vulva) very similar to
chicken pox. The difference is the presence of
PAIN.
By Inspection: Use Good light + Magnifying lens
Dx Procedure: Tzanck smear
To demonstrate: Do Viral culture or serologic
testing of herpes antibodies
Most of the time, you dont have to resort to
diagnostic testing because of the clinical
manifestations + pelvic findings. It can be simply
diagnosed by inspection of the vulva.
TX: Acyclovir most popular for viral infections
For chicken pox: To make the course of the
disease shorter & to lessen the lesions.
(Etiology: Varicella)
Herpes Zoster: Lesions are the same from
Varicella but pain will not be in the vulva, you
will see it along the distribution of a particular
nerve (Dermatomes)

3.

BARTHOLINS ABCESS

Most common pathology that will present as an

abscess
Fxn of Bartholins Gland: Lubrication during coitus
Similar to the development of acne, when you have
obstruction of the duct, there will be accumulation
of the secretions from the gland. So initially you
will find it as Bartholins duct cyst, this is not an
infection. But when this undergoes secondary
infection that is when you will have Bartholins duct
abscess.
Abscess & Carbuncle
A boil (furuncle) is a skin abscess, a painful bump
under the skin while carbuncle is a collection of
boils that develop under the skin.
Etiology: Neisseria gonorrhea (Most common)
Clinical manifestations: Soft swelling, fluctuant
tissue on the vulva + severe pain
Dx: Simple inspection (Location: 5 & 7 o clock),
then try to do culture & sensitivity of the purulent
content for the choice of antimicrobials.
By the way she walks with thighs far from each
other, in which she cannot put together. Or by the
way she sits, in which one buttock is on the chair,
one side is off the chair.
TX: Incision & drainage on the thinnest part of the
abscess. Usually the area of pointing, thin & color
white presenting the pus underneath then drain &
collect for Gram stain, C & S
Usually an abscess has several locules inside, stab
& drain, then make incision bigger. Place forceps &
open & try to break all the locules
Problem with I & D: High rate of recurrence

HERPES GENITALIS

2.

CONDYLOMA

CONDYLOMA ACUMINATA

Known as the genital warts

Etiology: HPV 16 & 18
Recommended:
Quadrivalent
Immunization
(Oncogenic & non-oncogenic: 6, 11, 16 & 18).
Males should have HPV Vaccine.
Clinical manifestation: Severe vulvar pruritus

She may feel something growing. The lesions of

condyloma are usually raised that grows in the
perineum, in the perianal area. She may see lesion
(a small one) thinking that this may disappear but
before you know it in 1 -2 weeks, this will become
proliferative. They multiply rapidly fast.
Dx procedure: Biopsy (Microscopic Description)
TX: The principle is to eradicate the lesions by
excision, cauterization, or laser
If the lesions are small: Do podophyllin, imiquimod,
TCA (Application of the cauterizing agent)
At term pregnancy: If the condyloma are so prolific
(in the vaginal canal to the cervix) & untreated:
Deliver CS, otherwise baby may incur the virus in
the form of laryngeal papilloma
At early pregnancy: Do not use chemical
cauterizing drugs; treat mechanically via excisions,
cauterization or cryotherapy.

Recommended: MARSUPIALIZATION, make a big

opening & try to evert then suture the everted skin
on the other side to keep the opening patent.

4.

ULCERATIVE LESIONS
Difficult to diagnose looking similar to one another

Syphillis
Etiology: Treponema pallidum
Can differentiate depending on the stage:
Stage 1: Chancre (differentiate with chancroid)
Stage 2: Condyloma lata or latum
Stage 3: Gumma formation
Usually in Stage 2 is where youll able to dx it under
dark field illumination or culture of the spirochetes
Tx: Penicillin (Big dose)
Chancroid
Etiology: Haemophilus ducreyi
Both may look similar by inspection of the vulva, to be
sure, do diagnostic procedures.
Read on different ulcerations affecting the vulva:
Granuloma inguinale
Lymphogranuloma venereum
VAGINAL INFECTIONS
Vaginal infections will usually manifest as a form of an
abnormal vaginal discharge
Differentiate the color, odor & consistency - these
will be able to tell you what is the possible
pathogen
TRICHOMONAS VAGINITIS:

Causative agent: Trichomonas vaginalis

Color: Yellowish green frothy discharge
Do wet smear: observe flagellates (Remember its a
motile protozoa, pear shaped with a flagellum)
Tx: METRONIDAZOLE (LOOK AT THE TABLE IN THE
BOOK)

NOTE:
Read fungal & mycotic vaginatis, bacterial vaginosis,
atrophic vaginitis