Gynecologic Infection

By: Longmai Bunga Persik

Dec, 22
nd
2013
Normal Vaginal Flora
includes multiple aerobic or facultative species as
well as obligate anaerobic(predominant) species
Within this vaginal ecosystem, some
microorganisms produce substances such as:
lactic acid and hydrogen peroxide that inhibit
nonindigenous organisms (Marrazzo, 2006).
proteinaceous adhesions and attach to vaginal
epithelial cells.
several other antibacterial compounds, termed
bacteriocins, provide a similar role and include
peptides such as acidocin and lactacin.


Vaginal Protection
For protection from many of these toxic
substances, the vagina secretes leukocyte
protease inhibitor.
This protein protects local tissues against toxic
inflammatory products and infection.

Vaginal pH

the vaginal pH ranges between 4 and 4.5. it is
believed to result from:
production of lactic acid, fatty acids, and other
organic acids by Lactobacillus species'
amino acid fermentation by anaerobic bacteria
results in organic acid production as does bacterial
protein catabolism.
Glycogen present in healthy vaginal mucosa is
believed to provide nutrients for many
species in the vaginal ecosystem.
Altered Flora
Changing any element of this ecology may alter the
prevalence of various species.
For example, postmenopausal women not receiving
estrogen replacement and young girls have a lower
prevalence of Lactobacillus species compared with
reproductive-aged women.
The menstrual cycle may also alter normal flora.
Menstrual fluid also may serve as a source of nutrients
for several bacterial species, resulting in their
overgrowth.
Treatment with a broad-spectrum antibiotic or
menstruation may result in symptoms attributed to
inflammation from Candida albicans or other Candida
species.

Hysterectomy with removal of the cervix changes lower
reproductive tract flora, with or without prophylactic antimicrobial
administration.
Usually, more anaerobic species are recovered from the vagina
postoperatively, with a particular increase in the prevalence of:
Bacteroides fragilis
Escherichia coli
Enterococcus species.
These three species are frequently observed in cultures obtained
from women who develop pelvic infections following hysterectomy,
but similar increases are also seen in vaginal cultures obtained after
hysterectomy in asymptomatic patients (Hemsell, 1988; Ohm,
1975).
Jadi, histerektomi meningkatkan prevalence 3 bakteri di atas

Scant: sedikit, hampir
tidak ada
Curdy: dadih
Copious: banyak sekali
Vaginal Disorders
Candidiasis
Bacterial vaginosis
Trichomoniasis

1. Candidiasis
approximately 75% of women will experience an
episode of vulvovaginal candidiasis.
Caused by Candida albicans (approximately 90% of
cases)
C albicans frequently inhabits the mouth, throat,
large intestine, and vagina normally.
Clinical infection may be associated with a systemic
disorder (diabetes mellitus, human immunodeficiency
virus [HIV], obesity), pregnancy, medication
(antibiotics, corticosteroids, oral contraceptives), and
chronic debilitation.

Treatment of yeast infections consists
of 3 echelons.
Chemicals and dyes (perwarna)
1% Gentian violet is an aniline dye that when painted over vaginal
surfaces once per week is effective against C albicans and Candida
glabrata.
Boric acid compounded in a suppository form is also effective therapy
for all candida infections.
Polyenes
Nystatin is not absorbed from the gastrointestinal tract and may be
used orally to reduce the intestinal colonization. As topical agents,
they have been largely replaced by imidazoles.
ImidazolesInclude clotrimazole and oral agents such as
ketoconazole. They are mostly used as topical agents and are
effective against C albicans.
A single 150-mg oral dose of fluconazole has been shown to be
effective in treating symptomatic candidiasis in nonpregnant
patients. With severe cases of vaginal candidiasis, a 2-dose
sequential regimen has been proposed.
2. Bacterial Vaginosis (BV)
the vaginal flora's symbiotic relationship shifts to
one in which there is overgrowth of anaerobic
species including:
Gardnerella vaginalis,
Ureaplasma urealyticum,
Mobiluncus species,
Mycoplasma hominis, and
Prevotella species.
also associated with a significant reduction or
absence of the normal hydrogen peroxide-
producing Lactobacillus species.

Risk Factors
This condition is not
considered an STD,
and it is seen in
women without
previous sexual
experience.
Many risk factors:
sexual activity, and
an increased risk of
acquiring STDs

Diagnosis
The most frequent cause of vaginal symptoms resulting in health care visits.
Symptoms:
a nonirritating, malodorous vaginal discharge (but may not always be present).
no erythematous, and
cervical examination reveals no abnormalities.
Clinical diagnostic criteria :
microscopic evaluation of a saline "wet prep" of vaginal secretions,
determination of the vaginal pH, and
release of volatile amines produced by anaerobic metabolism.
Clue cells are the most reliable indicators of BV.
These vaginal epithelial cells contain many attached bacteria, which create a poorly defined
stippled cellular border. The positive predictive value of this test for the presence of BV is 95
percent.
Diagnosis
Whiff test: Adding 10 KOH to a fresh sample of vaginal secretions releases
volatile amines that have a fishy odor. Similarly, alkalinity of seminal fluid and
blood are responsible for odor complaints after intercourse and with menses.
The finding of both clue cells and a positive whiff test is pathognomonic, even in
asymptomatic patients.
the vaginal pH is >4.5 and results from diminished (berkurangnya) acid
production by bacteria.
Similarly, Trichomonas vaginalis infection is also associated with anaerobic
overgrowth and resultant elaborated amines. Thus, women diagnosed with BV
should have no microscopic evidence of trichomoniasis.
vaginitis,
endometritis,
postabortal endometritis,
pelvic inflammatory disease
unassociated with Neisseria
gonorrhoeae or Chlamydia
trachomatis,
and acute pelvic infections following
pelvic surgery, especially hysterectomy
Several
gynecologic
adverse
(merugikan)
health
outcomes have
been observed
in women with
BV, including:
Trichomoniasis
Epidemiology
This infection is the most prevalent nonviral STD in the United States (Van der
Pol, 2005, 2007).
Unlike other STDs, its incidence appears to increase with age in some studies.
more commonly diagnosed in women because most men are asymptomatic.
A marker of high-risk sexual behavior, and co-infection with other sexually
transmitted pathogens is common, especially Neisseria gonorrhoeae.
It has predilection for squamous epithelium, and lesions may increase
accessibility to other sexually transmitted species.
Vertical transmission during birth is possible and may persist for a year.
Diagnosis
Incubation requires 3 days to 4 weeks,
the vagina, urethra, endocervix, and bladder can be
infected.
one-half of women with trichomoniasis : No
symptoms, and such colonization may persist for
months or years in some women.
in those with complaints, the characteristic are:
vaginal discharge is typically described as foul, thin, and
yellow or green.
Additionally, dysuria, dyspareunia, vulvar pruritus, and
pain may be noted.
At times, symptomatology and physical findings are
identical to those of acute pelvic inflammatory disease.

the vulva may be erythematous, edematous, and excoriated.
The vagina contains the above-described discharge, and
subepithelial hemorrhages or "strawberry spots" may be seen on
the vagina and cervix.
Trichomoniasis is typically diagnosed by microscopic identification
of parasites in a saline preparation of the discharge.
anteriorly flagellated,
and therefore mobile,
anaerobic protozoa.
They are oval and slightly larger than a white blood cell (WBC) (Fig. 3-
16).
Trichomonads become less motile with cooling, and slides should
be read within 20 minutes. Inspection of a saline preparation is
highly specific, yet sensitivity is not as high as hoped (60 to 70
percent). In addition to microscopy, vaginal pH is often elevated.

Treatment
Although each is effective, some report that a 7-day treatment regimen with
metronidazole may be more effective in compliant patients.
Adverse effects may include a metallic taste and a disulfiram-like reaction if
combined with alcohol.
Recommended Treatment of Trichomoniasis:
Primary therapy
Metronidazole single 1-g dose orally or
Tinidazole single 2-g dose orally
Alternative regimen
Metronidazole 500 mg orally twice daily for 7 days
Patients who become asymptomatic or who are
asymptomatic do not require routine re-evaluation.
There are infrequent patients who have strains that
are highly resistant to metronidazole, but these
organisms are usually sensitive to tinidazole.
Oral tinidazole at doses of 500 mg orally three times
daily for 7 days or four times daily for 14 days have
been effective in curing patients with resistant
organisms (Sobel, 2001).