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  • In adult females, vagina is lined by stratified squamous epithelium. In newborn females, it is lined by transitional epithelium.
  • Squamous epithelium is resistant to gonoccocal infection. Thus, gonoccocal vaginitis cannot occur in young/ adult females.
  • Vagina has local inhabitant bacteria called as Doderlein's bacillus (lactobacilli) which breaks down the glycogen present in vaginal epithelium into lactic acid resulting in acidic pH (A vg, 4.5; Range, 4-5.5) of vagina. The acidic pH of vagina acts as a barrier for external organisms.

The pH of vagina varies with age



Viginal pH

In a newborn infanta

Between 4.5 and 7

6-week-old child



Changes from alkaline to acidic

Reproductive age qroup

4 - 5.5


3.5 - 4.5

Late postmenopausal

6 - 8

  • pH of vagina also varies along its length, being highest in the upper part because of admixture of alkaline cervical mucus.

Infectious Vulvovaginitis



M/C organism





Trichomonas vaginitis

M/C vaginitis

Trichomonas vaginalis - Flagellated protozoa

Profuse, frothy yellowish green discharge along with pruritis (itching)

-pH ≥ 5

-Strawberry vagina or angry-looking vagina

Wet mount

microscopy of

vaginal discharge

shows typical

motile f1agellaled




- Culture on



medlav or

Diamonds TYM media 



(500 mg BD or

2 g single dose


Both partners

should be treated


In pregnancy DOC

- Metronidazole in

2nd/3rd trimester


Candidiasis: M/C vaginitis during pregnancy in

OCP uses/steroid users/ Antibiotic and immuno- compromised


Candida albicans gram positive fungus.

Candida galbrata (<5%)

Candida tropicales


Intense pruritis  
Curdy white discharge



20% patients are asymptomatic

Severe vulvo- vagintis seen

Cottage-cheese like appearance of discharge

pH of discharge


Swollen inflamed genitals


On adding 10% KOH to discharge fungal elements seen (Whiff test negative) Definitive

diagnosis: Culture on Sabourauds mediaoor Nickerson media

DOC = Azole

group of antifungals

like f1uconazolel

miconozole which

can be topically

applied or given orally

Both partners

should be treated


In pregnancy

DOC is topical

azole antifungals in

2nd/3rd trimester



No inflammation

lt is termed as vaginosis and not




o No itcbing


Foul smelling dirty

white discharge


Note: Bacterial

vaginosis during


leads to preterm

labor, PROM

and postpartum


About 50%

patients are



About 50% patient are asymptomatic


Thin grey foul

smelling discharge

coating the vagina

pH of discharge

> 4.5


Amsel's Criteria

Any 3 ot the

following should

be present:



grayish white


pH of discharge

> 4.5

Wet film


shows masses

of small bacteria

coating epithelial

cells called as

clue cells.

On adding

10% KOH to the

discharge, fishy

odor should be

released (Whiff

test positive)


Metronidazole in

pregnant as well

as non-pregnant


Dose = 500 mg

twice daily for 7


Note: The 2g

one time only

dose used for


is not useful

for bacterial


No need to treat

the male partner






Trichomonal vaginitis

Bacterial vaginosis


Candida albicans

 Trichomonas vaginalis

Gardnerella vaginalis




Ureaplasma urealyticum





Discharge amount



Moderate (malodorous)


 Curdy I cheesy white

 Greenish-yellow frothy

Grayish white homogenous

pH of vagina




10% KOH +



Fishy odor (due to release of amines,




acridine, and putredine) = Whiff test



 Flagellate motile

Clue cells (vaginal epithelial cells



 organism (Hanging

Loaded with coccobacilli)



 drop preparation)


Usual treatment

 Locally: clotrimazole




 and miconazole




 Oral: fluconazole




Amsel's Criteria for Diagnosis of Bacterial Vaginosis


Grayish white discharge

pH >4.7

Clue cells on microscopy

Whiff test positive

Any three out of four should be present

Pelvic Inflammatory Disease

It is the infection and inflammation of the upper genital tracts, typically involving fallopian tubes, ovaries, and surrounding structures.


The primary organisms are sexually transmitted: gonococci, Chlamydia, and mycoplasma. The secondary organisms include Escherichia coli, group B Streptococcus, Klebsiella, ana-anaerobes.


Clinical Features of Acute PID

  1. Rise of temperature >38°C
  2. Lower abdominal tenderness
  3. Tenderness on movement of the cervix
  4. Adnexal mass
  5. Blood: leukocytosis >10,000/mm3
  6. ESR raised> 15 mm/h
  7. Laparoscopic evidences of tubal affection
  8. Culdocentesis with purulent fluid having white cell count >30,000/mL

Stages of PID (Gainesville)


Stage 1: acute salpingitis without peritonitis


Stage 2: acute salpingitis with peritonitis


Stage 3: acute salpingitis with tubal occlusion or tube-ovarian complex


Stage 4: ruptured tubo-ovarian abscess


Stage 5: tubercular salpingitis


Differential Diagnosis

  1. Appendicitis
  2. Ruptured ectopic
  3. Torsion/hemorrhage/rupture of ovarian cyst
  4. Endometriosis

Indications of Inpatient Antibiotic Therapy

  1. Suspected pelvic abscess
  2. Severe illness, temperature >38°C
  3. Uncertain diagnosis-where surgical emergencies, for example, ectopic pregnancy cannot be excluded
  4. Unresponsive to outpatient therapy for 48 h
  5. Intolerance to oral antibiotics
  6. Coexisting pregnancy
  7. Patient is known to have HIV infection

CDC Guidelines for Treatments of Pelvic Inflammatory Diseases


Outpatient Treatment


Regimen A


Ofloxacin, 400 mg orally two times daily for 14 days or


Levofloxacin, 500 mg orally once daily for 14 days With or without Metronidazole,


500 mg orally two times daily for 14 days

Regimen B


Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or


Ceftriaxone, 250 mg intramuscularly, or


Equivalent cephalosporin




Doxycycline, 100 mg orally two times daily for 14 days


With or without


Metronidazole, 500 mg orally twice a day for 14 days


Inpatient Treatment


Regimen A


Cefoxitin, 2 g intravenously every 6 h or


Cefotetan, 2 g intravenously every 12 h




Doxycycline, 100 mg orally or intravenously every 12 h

Regimen B


Clindamycin, 900 mg intravenously every 8 h




Gentamicin, loading dose intravenously or intramuscularly (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 h

Genital Tuberculosis

  • It is almost always a secondary infection, with primary sites being lungs, lymph nodes, abdomen, etc.
  • Hematogenous route is the most common mode of spread from the primary site.
  • Bilateral fallopian tubes are involved in 100% of the cases.
  • Ampulla is the most commonly affected part of the fallopian tube.
  • Initial site of infection is the submucosal layer (interstitial salpingitis).
  • Uterus is involved in 80% of the cases.
  • Cornu of the uterus is commonly affected, as it is in continuity with the fallopian tube.
  • If the patient conceives spontaneously, ectopic pregnancy is the most likely outcome. In active tuberculosis, HSG is contraindicated. HSG findings in a case of tuberculosis are:
    1. Lead pipe tubes
    2. Tobacco pouch appearance
    3. Beaded tubes
    4. Hydrosalpinx
    5. Cornual blocks
    6. Intravasation of the dye
    7. Golf club tube
    8. Sperm head tube
    9. Uterus-honeycomb appearance (Asherman syndrome)


  • Genital tuberculosis falls in category 1. The treatment is for 6 months
  • Four-drug AKT (isoniazid, ethambutol, pyrazinamide, and rifampicin)
  • Four drugs are given for 2 months, and two drugs (INH and rifampicin) are given for 4 months
  • Surgery for restoration of fertility (corrective tuboplasty) is contraindicated in genital TB
  • IVF after completion of AKT is the treatment for infertility (provided the uterine cavity is normal)
  • If the endometrium is cicatrized, then IVF and surrogacy should be recommended

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