Professional Documents
Culture Documents
Reproductive Tract
Self-cleansing
(lactobacillus)
Mucus
1. Vulvitis ( 外阴炎 )
Bartholinitis/Bartholin’s cyst
( 前庭大腺炎/前庭大腺囊肿 )
2. Vaginitis ( 阴道炎 )
3. Cervicitis ( 宫颈管炎 )
4. Pelvic inflammatory disease (PID) ( 盆腔炎 )
Genital tuberculosis ( 生殖器结核 )
Sexually transmitted diseases (STD) ( 性传
播疾病 )
Inflammed, Congestion
Vulvitis ( 外阴炎 )
Clinical Manifestation
Vulvar pruritus ( 瘙痒 )
Pain
Burning sensation
Congestion ( 充血 )
Swelling 肿胀
Eczema ( 湿疹 )
Profuse frothy greenish
Etiology
Specific organisms or non-infective dermatitis ( 皮炎 )
Clinical manifestation
Symptoms of a local infection
Abscess of Bartholin gland: a painful red swelling
Treatment
Antibiotics (Ampicillin) in the early stage
Drain the abscess (excision of an elliptical piece of skin)
Bartholin’s Cyst
( 前庭大腺囊肿 )
• Marsupialization ( 造口术 )
for preservation of the
gland function
• Excision for recurrent
cases
Vaginitis
• Trichomonal vaginitis ( 滴虫性阴道炎 )
• Candidal Vulvovaginitis ( 假丝酵母菌性外阴阴道炎
)
• Bacterial Vaginosis (BV) ( 细菌性阴道病 )
• Senile vaginitis ( 老年性阴道炎 )
• Infantile vulvovaginitis ( 婴幼儿外阴阴道炎 )
Trichomonal Vaginitis
滴虫性阴道炎
(Trichomoniasis)
Etiology
Trichomonad ( 毛滴虫 ) :
A flagellate protozoan ( 有鞭毛原虫 )
Best living environment : Moist, anaerobic 厌
氧的 ,
pH value: 5.2-6.6, 25℃-42 ℃
滴虫性阴道 炎
(trichomonal vaginitis)
• 一种由 阴道毛 滴虫
引起的 常见的 阴道
炎。
临床表现
Typical symtom
典型
症状
稀薄 的泡沫 状白 带增多
persistent discharge+
外阴 瘙痒 pruritus vulvae
正常图像 滴
虫图像
Transmission 传播
1. Sexual contact (70% male infection,
asymptomatic 无症状的 carrier)
2. Nonsexual transmission (iatrogenic 医源性的 )
Pathogenesis
• The trichomonad lives on glycogen and iron of
the host cell
• Direct contact and damage of the target cell
• Induction of immune reaction resulting in
inflammation
Clinical Picture
Latent period 潜伏期 : 4-28 days
Asymptomatic: 25-50%
Symptoms :
Main: Profuse 大量的 vaginal discharge and pruritus
Occasional: odor, pain, dyspareunia , dysuria 排尿困难
infertility ( sperm )
Characteristics of the vaginal discharge
Copious ( 大量的 ) ,
Purulent ( 脓性的 ),
Gray to yellow color,
Malodorous ( 恶臭的 ),
Frothy ( 起泡沫的 )
Strawberry cervix:
Tiny, punctate hemorrhages
( 点状出血 )
grossly visible on the mucosa
滴虫的“草莓状宫颈 strawberry
cervix”
Treatment
is not
indicated
unless
symptoms
are
present.
Predisposing factors 易感 因素
1. Pregnancy
2. Diabetes mellitus
3. Immunosuppressants 免疫抑制剂
4. Broad-spectrum antibiotics
suppressing the vaginal normal flora 菌丛
(esp. lactobacillus)
5. Others: restrictive synthetic underwear,
obesity, contraceptive medication
Transmission
1) Endogenous infection (most often)
vagina, oral cavity, intestinal tract
2) Sexual contact
3) Contacting fomites ( 污染物 )
Pathogenesis
Two phases of candida albicans
1) Yeast 酵母 spores ( 芽孢相 ):
Asymptomatic parasitism
2) Pseudohyphae ( 菌丝相 ):
Pathogenic
3) Mechanism:
a) Candida at the pseudohypha phase penetrate
vaginal epithelium for nutrients
b) Growing candida albicans release proteolytic 蛋白水
enzymes and toxins etc. resulting in
inflammation reaction
Clinical Picture
1. Vulvovaginal pruritus (main)
usually intense, coincident with menses or intercourse
典型症
状
• 白色稠厚豆渣样 白带增多
• +
• 外阴剧烈瘙痒
霉菌性阴道炎 TCT 图像
Yeast spores
Pseudohyphae
Treatment
1. Elimination 除去 of predisposing factors
2. Topical application of antifungal agents 抗真菌剂
Vaginal suppositories ( 栓剂 ) :
1) Miconazole ( 咪康唑 / 达克宁 )
a) 200mg/day for 7days
b) 400mg/day for 3 days
2) Clotrimazole ( 克霉唑 )
a) 150mg/day for 7 days
b) 150mg, twice a day for 3 days
c) 500mg single dose
3) Nystatin ( 制霉菌素 / 米可定 )
100,000units/day for 10-14 days
4) Methyl violet ( 龙胆紫 )
0.5-1% , 3-4 times/week for 2 weeks.
3. Systemic medication
Oral agents are used only for cases that can not be
treated with topical application of antifungal drugs.
8) Fluconazole ( 氟康唑 / 大扶康 )
150mg, single use.
2) Itraconazole ( 伊曲康唑 / 斯皮仁诺 )
a) 200mg/day for 3-5 days
b) 400mg for 1 day divided in two doses
3) Ketoconazole ( 酮康唑 )
200mg, once or twice/day until culture result is negative
Hepatotoxicity may occur.
Points of note for treating VVC
• Treatment should be followed-up with a premenstrual
examination of the vaginal discharge.
• Approximately 10% of cases will not respond to
initial therapy.
• Prolongation of treatment up to 14 days may cure
some patients.
• Identification and elimination of predisposing
factors is important.
• Recurrent VVC should be treated with oral therapy
followed by prophylactic doses.
Treatment of sexual partner?
No treatment for asymptomatics.
15% should be treated
Bacterial Vaginosis
细菌性阴道病
Etiology
1. Imbalance of normal vaginal flora
Diminution 减少 of Doderlein lactobacillus and
increase in other bacteria, in particular,
anaerobic bacteria.
2. Causative factors of the imbalance are unknown
Gardnerella vaginalis ( 加德纳菌 )
Clinical Picture
Symptoms:
1. 10-40% asymptomatic
2. Mild pruritus or burning
sensation
3. Increased vaginal discharge
and fishy odor
Signs:
Discharge: thin, greyish-white,
homogenous, but not sticky
No inflammation reaction
(No epithelial edema 水肿 or erythema 红斑 )
Diagnosis
Identification of clue cells *(wet mount in saline)
together with 3 of the following 4 items
1. Vaginal discharge: homogenous, thin and white
2. pH>4.5: in virtually all cases, usu. 5.0-5.5
3. Positive Whiff test (with 10% KOH)
4. Clue cells
* Clue cells are desquamated 脱屑的 epithelial cells
covered with clumps 丛,簇 of coccobacili 球杆
菌 esp. Gardnerella vaginalis ( 加德纳菌 ), which
gives the cells a speckled ( 有小斑点 ) appearance.
Whiff test
Ammonia odor
诊 断
• 1. Vaginal discharge:
homogenous, thin and white
fishy odor
• Endocervical polyp:
Originating from the endocervix
• Ectocervical polyp:
Originating from the vaginal portion
Pathology
Gross appearance:
Endocervical polyp: Red or pink, rounded or tongue-like
Ectocervical polyp: Pale, flesh-colored, smooth, rounded
with a broad pedicle
Microscopic:
Vascular connective tissue stroma covered with columnar
or squamous epithelium or both. Congestion, edema or
leukocytein filtration may be present.
Clinical Features
Some are asymptomatic.
Slight postcoital bleeding
Treatment
Cervical polyp should be treated.
• Malignant change (<1%)
• Polypoid cervical cancer
Etiology
Pathogens:
Normal cervical and vaginal flora
Pathology
• Thickened endocervix that produces a whitish pus
• A cervical os surrounded by a reddish area
• Hypertrophy of the lacerated cervix
Clinical Features
1. Persistent leukohrrea usu. mucopurulent
2. Slight postcoital staining
3. Pains
lower abdominal discomfort, lumbosacral
backache, dysmenorrhea, dyspareunia
4. Infertility
5. Urinary symptoms
frequency, urgency, dysuria due to
subvesical lymphangitis not to cystitis
Diagnosis
• The characteristic discharge from external os of the
cervix.
• Cytologic and colposcopic studies are helpful, but
only biopsy is definitive.
• Cultures are not so helpful.
Treatment
Even if chronic endocervicitis is asymptomatic,
it should be treated.
1. Medical treatment
Systemic rather than topical
Based on culture and sensitivity test
2. Surgical treatment
A note of caution: postoperative bleeding, infection,
stricture formation, infertility.
Methods: thermal therapy, cryotherapy, laser therapy
conization, hysterectomy.
Nabothian Cysts
Retention cysts of the cervical glands caused by
obstruction of the gland orifices by the growth
of squamous epithelium. The cysts may be infected
and contain pus.
Cervical Hypertrophy
Pelvic Inflammatory Disease (PID)
Infection of the upper genital tract
Terms:
Endometritis ( 子宫内膜炎 )
Salpingitis ( 输卵管炎 )
Oophoritis ( 卵巢炎 )
Myometritis ( 子宫肌炎 )
Pyosalpinx ( 输卵管积脓 )
Hydrosalpinx ( 输卵管积水 )
Peritonitis ( 腹膜炎 )
Tubal ovarian abscess (TOA) ( 输卵管卵巢脓肿 )
Epidemiology
Sexual activity
A disease of sexually active, menstruating women.
Acute PID occurs in 1-2% of young sexually
active women annually.
Age
The peak incidence occurs in their late teens
and early twenties.
The most common serious infection in women
of 16-25 years of age
Contraceptive practices
Contraceptive methods No.of PID/woman-years
Sexually active, using no contraception: 3.42
Oral contraceptives: 0.91
Barrier methods 1.39
Intrauterine devices (IUD) 5.21
Financial cost
In USA, $3.5 billion annually in 1990s
Medical sequelae
Ectopic pregnancy: 6-10 fold increase
PID accounts for 50%
Chronic pain: 4 fold increase
Infertility: acute PID account for 5-60% of cases
Tubal obstruction: 11.4%, 23.1%,54.3% from 1, 2, 3
episodes of infection
Mortality: septic shock and death
Etiology
Pathogens that are sexually transmitted
1) Neisseria gonorrhoeae: in USA, 40-50% cases of PID
2) Chlamydia trachomatis: in USA, 10-40% cases of PID
The two pathogens may account for 2/3 of the PID
3) Mycoplasma ( 支原体 )
Recovered from the pus in 2-20% cases of salpingitis
Endogenous bacteria
1) Aerobic: streptococci, staphylococci, Escherichia coli
2) Anaerobic: Bacteroides fragilis ( 脆弱类杆菌 ),
peptococcus ( 消化球菌 ) ,
peptostreptococcus ( 消化链球菌 )
Spreading Route of Infection
1. Ascending along the reproductive tract
For non-pregnant and non-puerperal women
Gonococcus, C. trachomatis, staphylococcus
2. Lymphatic vessels
In puerperal infection, post-abortion infection
and IUD associated infection
Streptococcus, E.coli, anaerobic bacteria
3. Blood vessels
Tuberculosis
4. Direct spreading
Infection from other visceral organs.
Acute PID
Predisposing Factors
1. Intrauterine manipulation
e.g. artificial abortion , IUD, etc.
2. Infection in the lower reproductive tract, esp. STD
3. Sexual activity
4. Bad hygiene
4. Direct spreading from adjacent viscera
6. Acute onset of a chronic PID
Pathology
1. Acute endometritis and myometritis
2. Acute salpingitis, pyosalpinx and
tubo-ovarian abscess (TOA)
3. Acute pelvic peritonitis
4. Acute inflammation of the peritoneal
connective tissue (parametritis)( 宫旁结缔组织炎 )
5. Septicemia ( 败血症 ) and pyemia ( 脓毒血症 )
6. Fitz-Hugh-Curtis syndrome
Fitz-Hugh-Curtis syndrome
Perihepatitis: inflammation of Glisson’s capsule
without involvement of the liver parenchyma.
Suppurative ( 脓性 ) and fibrous exudation of the
capsule occurs causing adhesion between the capsule
and the anterior peritoneum.
• It happens in 5-10% cases of salpingitis.
• It is caused by gonococcus or Chlamydia trachomatis.
• Edema and adhesion of the capsule may lead to pain
in the upper abdominal region.
Clinical Features
Symptoms
Vary depending on severity and extent of the infection
and types of pathogens
Most common: lower abdominal pain, fever, increase
in vaginal discharge.
Gonorrhea/Chlamydia Trichomatis
Signs
Variable
Typical:
Bimanual examination:
Diagnosis
Criteria for the diagnosis of PID
Minimum:
4) Pain on compression of uterine body
or the adnexal region
2) Tenderness of the cervix
Specific:
1) Biopsy of the endometrium showing endometritis
2) Ultrasound/MRI identification of liquid-filled
enlarged oviducts or TOA
3) Laparoscopic examination
Additional:
Differential Diagnosis
Appendicitis
Rupture or abortion of tubal pregnancy
Torsion or rupture of an ovarian tumor
Treatment (1)
1. Systemic medication
(Ideal) Based on drug sensitivity test
(Empirical) Combination use of drugs
Patient’s condition and possible pathogens
1) Oral: Ofloxacin ( 氧氟沙星 ) Metronidazole for 14 days
2) Intravenous: Penicillin or Erythromycin ( 红霉素 )
Gentamycin ( 庆大霉素 ) or Amikacin ( 阿米卡星 / 丁胺卡那霉
素)
Metronidazole for endogenous bacteria
3) Cefuroxime sodium ( 头孢呋辛钠 / 西力欣 ) for gonococcus
4) Doxycycline ( 多西环素 / 强力霉素 ) or Azithromycin ( 阿奇霉
素)
for chlamydia or mycoplasma
Treatment (2)
2. Surgical treatment
for TOA or peritoneal abscesses that can not be
controlled by drugs (2-3 days)
Indications:
1) Failure of drug therapy
2) Persistent existence of abscesses (2-3 weeks)
3) Rupture of the abscess
3. Traditional Chinese medicine
Chronic PID
Etiology
1. Incomplete treatment of the acute PID
2. Infection from certain pathogens such
as Chlamydia trachomatis
3. Residual lesions from previous acute PID
Differential diagnosis