Sexually Transmitted Infections (STIs)

Vulvovaginitis : This refers to infections involving the vulva and the vagina. These are caused commonly by micro organisms which includes the following :

• Candida albicans which is the causative agent of candidiasis. 
• Trichomonas vaginalis which is the agent that causes Trichomoniasis. 
• Gardnerella vaginalis which causes bacterial vaginosis. 

Symptoms And Signs Of Vulvovaginitis
1. Vaginal discharge : various micro organisms which cause vulva and vaginal infections cause production of various types of abnormal discharge from the vagina.

• Candidiasis : Here the discharge is whitish, thick and curdy. It is usually associated with vulva itching and labial pain. It may be moderate in amount without significant odour. 
• Trichomoniasis : Produces foul smelling vaginal discharge associated usually with itching and burning. It may occasionally be associated with painful sexual intercourse. 
• Bacterial vaginosis : This causes scanty to profuse yellowish and offensive/foul smelling vaginal discharge giving the typical fishy odour. It is also associated with increase in the pH of the vagina. It is also associated frequently with itching which leads to frequent scratching. Aggressive scratching in the vulval may therefore lead to excoriations. (scratch bruising) 

Cervicitis
Cervicitis refers to infection of the cervix which may be acute or chronic. Some of the micro organisms which cause cervicitis include the following :

• Neisseria gonorrhea 
• Chlamydia trachomatis
• Staphylococcus 
• Streptococcus 

Symptoms And Signs Of Cervicitis

• Vaginal discharge (which is usually purulent) 
• Lower abdominal pain 
• Dyspareunia (painful sexual intercourse) 
• Postcoital bleeding. 

Pelvic Inflammatory Disease (P.I.D)
PID is a broad term which can be defined as a clinical syndrome which results from an ascending spread of microorganisms from the vagina and cervix to the uterus, Fallopian tubes or ovaries.

This is said to occur when infections involves the internal genitalia ie the upper genital organs such as the uterus, Fallopian tubes and the ovaries. The infections usually starts in the lower genital tract (such as vagina and cervix) and  if left untreated may ascend to involve the upper genital tract. The micro organisms which are involved in the pelvic inflammatory disease (PID) may arise from the normal flora of the vagina or they may be introduced into the vagina during sexual intercourse with an infected male partner, unhygienic handling of the vagina such as in digital vaginal examination, use of tampons or insertion of other objects into the vagina. PID may also arise following surgical procedures such as dilatation and curettage.
PID is common among women between the ages of 15 and 35. This can be attributed to the high incidence of sexual exposures and sexually transmitted infections.

Complications Of PID

• Damage and blockage of Fallopian tubes which may lead to infertility. 
• Infertility. 
• Chronic pelvic pain. 
• Ectopic pregnancy. 

Risk Factors For PID

• Sexual promiscuity 
• Use of intra uterine contraceptive device (IUCD) 
• Women with multiple sexual partners. 
• Sexual intercourse with infected sexual partner. 

Some Micro Organisms Implicated In PID

• Neisseria gonorrhea (it is the commonest cause in our envy) 
• Chlamydia trachomatis
• Ureaplasma urealyticum
• Mycobacterium tuberculosis. 

Symptoms And Signs Of PID

• Lower abdominal pain (which may be associated with fever and vomiting) 
• Pain during sexual intercourse 
• Pain during menstruation 
• Painful urination 
• Irregular menstrual period 
• Intermenstrual bleeding 
• Excessive menstrual flow 
• Foul smelling vaginal discharge 
• Fever. 

Vaginal Discharge
Vaginal discharge is one of the commonest complaints in both general medical practice and at gynecological clinics. It is common between the age of 15-40 years. Vaginal discharge could be normal or abnormal.

Normal Vaginal Discharge
This is also known as leucorrehea. It may be referred to as increase in the normal vaginal discharge which may be colourless, or whitish, odourless and not associated with vulval itching. This may be seen during ovulation or prior to menstruation. It also occurs following sexual arousal or after regular menstrual bleeding.

Sources Of Normal Vaginal Discharge
The vagina on its own does not produce secretion unless there is an on going infection. However, most of the normal discharge is produced by the following glands:

• Endometrial glands 
• Cervical glands 
• Greater vestibular glands.

Abnormal Vaginal Discharge
Abnormal vaginal discharge usually occurs during genital tract infection as well when the normal ecosystem of the vaginal is disrupted. This could be seen in women who practice douching. The vaginal ecosystem consists of a complex interrelationship among the endogenous microflora, estrogen activities and the pH of the vagina.

Some Causes Of Abnormal Discharge Includes:

• Abuse of antibiotics 
• Hormonal imbalance 
• Certain contraceptive preparation (especially oral and topical) 
• Vaginal douching 
• Vaginal medications 
• Sexually transmitted infections
• Stress (which may cause hormonal imbalance )
• Multiple sexual partners 
• Use of nylon and/or tight undies, use of tampons. 

Lactobacilli : are a group of bacteria which for a major part of vaginal normal flora. They metabolize glycogen deposits in the vagina hence producing lactic acids which is therefore responsible for the low pH of the vagina (which is less than 4.5). This reduced pH of the vaginal provides natural defense against exogenous organisms to disease causing levels.

Some Micro Organisms Which Cause Abnormal Vaginal Discharge Including The Following :

• Neisseria gonorrhea 
• Trichomonas vaginalis 
• Candida albicans
• Gardnerella vaginalis 
• Corynebacterium species
• Escherichia coli
• Bacteroides species 
• Clostridium species
• Treponema pallidum (causal agent of syphilis).

Other Sexually Transmitted Infections Of Concern Include

• Hepatitis (caused by hepatitis B and C viruses) 
• Genital herpes (caused by herpes simplex type 2 virus) 
• Genital warts (caused by human Papillioma virus) 
• Scabies (caused by sarcoptis scabies) 
• AIDS (caused by HIV)

Pruritus Vulvae
This is also referred to as vulval itch. Itching of the vulva is a common symptom in gynecological  practice. Itching is defined as that unpleasant sensation which provokes the desire to scratch the affected area. When this involves the vulva, it is called pruritus vulvae.

Causes Of Vulval Itch (Pruritus Vulvae)
1. Infections : vulval and vaginal infections are the commonest causes of vulval itch. The 2 commonest micro organisms causing vulval itch are Candida albicans and trichomonas vaginalis. Both organisms are responsible for 80-85% of vulval itching. Other conditions that feature vulval itching are:

• Molluscum contagiosum
• Herpes genitalis 
• Genital warts 
• Chancroid
• Scabies
• Pediculosis pubis
• Threadworm

2. Contact Dermatitis : This is irritation of the vulva and vagina due to allergy or irritant substances. It may occur due to reaction to the following :

• Drugs 
• Vaginal douching with irritants
• Spermicides which are used as contraceptive 
• Soaps and creams deodorants 
• Nylon panties. 

3. Neoplasia : such as vulval intraepithelial neoplasia. Vulval cancer, lymphoma, etc.

4. General causes : This may include obstructive jaundice, chronic kidney disease, filariasis.

5. Psychogenic.