Lower Genital Tract Infection Diagnosis

Anatomy and Physiology of the Vagina

• The vaginal epithelium is lined by stratified squamous epithelium during the reproductive age group under the influence of estrogen.
• The pH of the vagina is usually between 3.5 and 4.5, and lactobacilli are the most common organisms present.
• Following menopause, the influence of estrogen is diminished, making the vaginal epithelium atrophic with a more alkaline pH of 7.0.
• Physiological discharge occurs in response to hormonal levels during the menstrual cycle.

Lower Genital Tract Infections

• Lower genital tract infections can be divided into vulvovaginal candidiasis, trichomonas vaginalis, and bacterial vaginosis.
• Infections can occur from the vagina and cervix to the uterine cavity and to the Fallopian tubes through direct spread or via the lymphatics, leading to severe pelvic inflammatory disease and pelvic peritonitis.

Vulvovaginal Candidiasis

• Caused by Candida albicans in around 80-92% of cases.
• Signs and symptoms: vulval itching and soreness, thick curdy vaginal discharge, and dysuria.
• Diagnosis: confirmed with a perineal and/or vaginal swab.
• Predisposing factors: pregnancy, high-dose combined oral contraceptive pill, immunosuppression, broad spectrum antibiotics, diabetes mellitus, hormone replacement therapy, and HIV-infected women.
• Treatment: azoles/imidazoles (e.g., clotrimazole, econazole, miconazole) as a local topical application or oral preparations.

Trichomonas Vaginalis

• A flagellate protozoan that can cause severe vulvovaginitis.
• Signs and symptoms: vulval soreness and itching, foul-smelling vaginal discharge, dysuria, and abdominal discomfort.
• Diagnosis: microscopy of vaginal discharge and culture in Finnberg-Whittington or Diamond's medium.
• Management: patient and husband should be treated and screened for other sexually transmitted infections.
• Treatment: metronidazole in a single oral dose of 2g, or 400mg twice daily, or tinidazole in a single oral dose of 2g.

Bacterial Vaginosis

• Presence of bacterial vaginosis in the first trimester can lead to late second trimester miscarriages and preterm labor with its associated complications.
• Women with a previous history of second trimester loss or preterm delivery should have a vaginal swab performed in early pregnancy and if bacterial vaginosis is detected, it should be actively treated in the early second trimester of pregnancy.

Vaginal Discharge in Children

• Vaginal discharge in children is not uncommon and can be a source of distress for the girl, caregiver, and health provider.
• Low estrogen levels in girls predispose the vaginal epithelium to infection.
• Physiological discharge in children can be mucoid often bloody in the first fourteen days of life and milky white or clear mucoid discharge in prepubertal age.
• Any discharge other than physiological should be viewed as pathological.