Female Genital Tract
CHAPTER
7
Microbiology, Inflammation,
and Viral Infections
Prabodh K Gupta and Cindy McGrath
Contents
In tro d u c tio n
C h la m y d ia l I n fe c tio n
V a g in a l M ic ro b io lo g y
F u n g a l In fe c tio n s
G e n e ra l Fe a tu re s
C o n c lu d in g R e m a rk s
B a c k g r o u n d C h a n g e s
C e llu la r C h a n g e s
In fe c tio n s o f th e F e m a le G e n ita l T ra c t
B a c te ria l In fe c tio n s
V ira l In fe c tio n s
Introduction *
The lower female genital tract includes the vulva, the vagina, the
cervix, and the uterine cavity. It is in direct communication with
the external environment, and prone to various noninfectious
and infectious inflammatory reactions. Although most of these
infections remain confined locally; they can progress and the
organisms may ascend to the fallopian tubes and the ovaries.
Occasionally, microbial infections from the lower genital tract
can disseminate via the peritoneal space or the hematogenous
or lymphatic routes.
It must be appreciated that while a large number of women har-
boring genital infections may remain asymptomatic, vaginal infec-
tion can produce a number of clinical symptoms. Increased vaginal
secretions, along with sloughed vaginal epithelial cells, other infec-
tive organisms, bacteria, and inflammatory cells, constitute acute
vulvovaginitis. Inappropriate use of over-the-counter medications,
personal hygiene, tight clothing, impermeable panty hose (panty
hose vulvitis), reaction to various laundry detergents, and washed
clothes may contribute to the symptoms of vulvovaginitis.1
Often
personal and social reasons delay medical intervention.
Key features of vulvovaginitis
• Increased vaginal secretions;
• Sloughed vaginal epithelial cells;
• Bacteria;
• Infectious organisms; and
• Inflammatory cells.
Vaginitis accounts for nearly 6 million visits to the healthcare
providers per year with an annual cost of over a billion dollars
to society.1
Vulvovaginal irritation, itching, pain, ulceration
with bleeding, dyspareunia, and warty growths are some of the
common presenting features of vaginal infections. Most often,
a woman may remain minimally symptomatic and may not seek
medical help for various personal and social reasons.
Vaginal Microbiology
Among healthy women, the vaginal milieu is polymicrobial and
contains a large number and variety of aerobic as well as obli-
gate and facultative anaerobic organisms.2 The most frequently
recovered bacteria include lactobacilli,
Streptococcus viridans,
and
Staphylococcus epidermidis;
none of which cause symptoms.
Bacteroides
and
Gardnerella vaginalis
may be culturable from 20
and 30%, and 50% of the asymptomatic women, respectively.
Staphylococcus
occurs infrequently in the healthy vaginal flora.
Table 7.1 lists the microorganisms that can be commonly
recovered from vaginal specimens.
Pregnancy, besides causing a growth of lactobacillary flora,
does not appear to affect the microbial composition of the
vagina significantly. Estrogenic hormones and similar substances
help in the epithelial maturation of the vagina and support the
growth of an extraordinary number of microbes. Transplacental
hormonal exchanges also influence the vaginal epithelium of
the newborn infant. Bacterial composition and an adult type of
microenvironment may occur in a newborn female infant.
Menarche and menopausal changes also affect the bacterial
makeup of the vagina. Hormone or hormone-like medications,
contraceptives, intrauterine contraceptive devices (IUDs), bar-
rier diaphragms, pessaries, and other similar substances and
contraception may directly or indirectly influence the micro-
bial balance of the lower genital tract.3 Common factors influ-
encing the vaginal microbial flora are presented in Table 7.2.
It must be appreciated that the vaginal flora is in a dynamic
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