Vulvitis and bartholinitis

Specific lower tract infections

Infections of the external genitalia and vagina are often associated with specific flora. A striking example is trichomoniasis, which in children may present as trichomonal vulvovaginitis (the drug of choice in this case is ornidazole).

In adult patients, the acute stage of the infection is accompanied by frequent urination and abundant frothy, purulent discharge. Gynecological examination reveals pronounced edema and hyperemia of the vaginal and cervical mucosa, while colposcopy allows the identification of erosions and characteristic petechial hemorrhages. When the process becomes torpid or chronic, symptoms subside to the point of complete absence of complaints.

Basics of diagnosis and treatment:

• Laboratory investigation: it is optimal to use native (unstained) smear microscopy, as the motility of live trichomonads facilitates their detection. PCR and luminescence microscopy are also used. Important condition: local procedures and anti-cyst drugs must be discontinued one week prior to the tests.
• Therapy: systemic drugs are prescribed (metronidazole, tinidazole, ornidazole). Both partners must be treated, including asymptomatic carriers. Sexual contact is excluded or strictly protected with a condom during the course of treatment.
• In stubborn chronic courses, the vaccine Solco-Trichovac, created from lactobacillus strains, is indicated. It stimulates antibody production, normalizes microbiocenosis, and establishes long-term immunity.

Endocervicitis: cervical involvement

Ascending spread of infection or mechanical trauma (during childbirth, abortions, intrauterine device insertion) leads to inflammation of the cervical canal mucosa — endocervicitis. The disease is often associated with gonococci and chlamydia, which actively invade the columnar epithelium.

In the acute phase, patients complain of purulent or mucopurulent leukorrhea, and sometimes dull, aching lower abdominal pain. Speculum examination reveals edema and redness around the external os.

Patient management features:

1. Diagnosis: based on bacteriological culture, microscopy, and smear cytology (revealing leukocyte infiltration without signs of cellular atypia).
2. Treatment: the mainstay is systemic antibiotic therapy taking into account flora sensitivity. Any local interventions are strictly prohibited, as they facilitate pushing the infection further upwards.
3. Chronic progression: in the absence of adequate therapy, the inflammation involves the muscular layer (true cervicitis develops). The cervix becomes dense and hypertrophied, and retention Nabothian cysts (ovulae Nabothii) form within its thickness.

Endometritis and pyometra

Further progression of pathogens leads to endometritis — inflammation of the functional and basal layers of the uterine mucosa. Intrauterine interventions or complicated childbirth typically act as triggers.

Acute endometritis manifests acutely: a sharp rise in temperature, chills, severe pelvic pain, and serous-purulent discharge. On palpation, the uterus is enlarged, has a somewhat soft consistency, and is tender (especially along the lymphatic pathways at the uterine horns). Blood tests reveal leukocytosis with a left shift and an elevated ESR. Without treatment, the process rapidly spreads to the myometrium (endomyometritis) or involves the entire wall (panmetritis), threatening peritonitis, pelvic abscesses, and sepsis.

A special complication is pyometra — the accumulation of pus in the uterine cavity due to impaired outflow (e.g., when the cervical canal is narrowed by a polyp or tumor). The condition is accompanied by purulent-resorptive fever, and upon examination, discharge from the cervix is absent, although the uterus itself is spherically enlarged and acutely tender.

Instrumental diagnostics:

• Ultrasound: shows blurred boundaries between the uterine layers, altered myometrial echogenicity, and a widened cavity with hypoechoic contents.
• Hysteroscopy: allows visualization of the edematous, hyperemic mucosa and purulent suspension, as well as identification of the cause of inflammation (placental remnants, products of conception, embedded sutures, or IUDs).

Chronic endometritis and salpingo-oophoritis

Inadequate treatment of the acute phase, frequent curettage, or prolonged IUD wear lead to the development of chronic endometritis. This is a clinical and anatomical concept in which the role of the infection itself recedes into the background. The main problem becomes the reduction in sex hormone receptor numbers, which disrupts the normal cyclic transformation of the endometrium.

Morphologically, the process is characterized by stromal fibrosis, sclerosis of spiral arteries, the appearance of plasma cells and lymphoid infiltrates. The mucosa may atrophy or, conversely, undergo hyperplasia with the formation of intrauterine adhesions (synechiae).

Clinical picture is latent:

• Menstrual cycle disorders (meno- and menometrorrhagia).
• Chronic aching pain.
• Reproductive problems (infertility, recurrent pregnancy loss).

The diagnosis is confirmed by ultrasound (mismatch between M-echo thickness and the cycle phase, hyperechoic septa) and finally verified using Pipelle biopsy or diagnostic curettage followed by histology.

If the infection continues to spread in an ascending manner (or secondarily descends from the abdominal cavity), the fallopian tubes, ovaries, and ligamentous apparatus are involved — salpingo-oophoritis (adnexitis) develops, requiring comprehensive inpatient treatment.

Class and exam questions

What else to study on this topic

• Specifics of using the Solco-Trichovac vaccine in chronic trichomoniasis.
• Mechanism of formation of Nabothian cysts (ovulae Nabothii) in chronic cervicitis.
• Ultrasound and hysteroscopic criteria for intrauterine synechiae.
• Pathogenesis of purulent-resorptive fever in the development of pyometra.
• Differential diagnosis of descending and ascending pathways of infection in adnexitis.

Other topics in the "Gynecology" section

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