Clinical & Diagnostic Aspects of LGT Infections 
Review paper 
CLINICAL AND DIAGNOSTIC ASPECTS 
OF LOWER GENITAL TRACT INFECTIONS 
E. Bokal-Vrtačnik, B. Kralj and H. Hren-Vencelj 
SUMMARY 
Lower genital tract infections, e.g. vulvovaginitis, cervicitis and urethritis included are common, both in 
females, and males, in the reproductive period of life. They are source of further spread, and may lead to 
pelvic inflammatory disease. The symptoms and signs of lower genital tract infections, such as abnormal 
vagina! discharge, pruritus as well as cutaneous and mucous lesions, are not specific enough to establish the 
diagnosis. Therefore it is necessary to apply selectively relatively simple screening and confirmatory laboratory 
tests. A precise diagnosis of lower genital tract infections would improve an early diagnosis of important STDs 
in the community, and would help in promoting management strategies for genital tract infections. 
KEY WORDS 
lower genital tract infections, vulvovaginitis, cervicitis, urethritis 
INTRODUCTION 
Differences in male and temale anatomy and 
reproductive physiology account for the greater risk 
of complications of certain sexually transmitted diseases 
(STDs) in women and also for the greater difficulty 
in differential diagnosis of urogenital infections in 
women. In fact, the difficulty in diagnosing sexually 
transmitted urogenital infections in women undoubtly 
results in delay of proper therapy, which contributes 
to the higher risk of complications in women and 
to further spread of infection in community. 
Although the etiology of certain genitourinary and 
anorectal inflammatory conditions in wonien is still 
not well understood, it is now possible to identify 
many common and potentially serious STDs in 
acta dermatovenerologica A.P A. Vol 4, 95, No 3 
women by clinical observations of symptoms and 
signs, supplemented with the selective use of relatively 
simple screening and confirmatory laboratory tests. 
VULVOVAGINITIS 
Abnormal vagina! discharge and vulvar pruritus 
are the most common symptoms with which women 
attend a gynecological health service clinics. Vagina! 
infection is mainly caused by Candida albicans, due 
to an overgrowth of certain bacteria or Trichomonas 
vaginalis (1 ). 
Trichomoniasis is the most prevalent non-viral 
sexually transmitted disease (2). The prevalence of 
the disease varies widely in different populations. In 
asymptomatic patients attending family planning clinics, 
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Clinical & Diagnostic Aspects of LGT Infections 
5% of women suffer from this disease (3). Multiple 
sexual partners, previous histmy of sexually transmitted 
diseases, coexistent infection with other STDs, and 
use of either barrier or hormonal contraceptives are 
known risk factors for . acquisition of trichomonas 
(4). 
As with other STDs, symptorns and signs of 
trichomoniasis are neither adequately sensitive nor 
specific enough and necessitate diagnostic testing. 
Trichomonal infections are asymptomatic in as many 
as 50% of male and female patients (5,6). 
The most common complaints associated with 
trichomoniasis are vaginal discharge and vulvovaginal 
irritation in women and urethral discharge in men. 
Discharge is presented in 50% to 75% of infected 
women (7). Infection is described as pruritic or 
irritating in 25% to 75% (7,8,9). Other associated 
symptoms include dyspareunia (10), dysuria, and in 
a small number of patients, some degree of lower 
abdominal pain (9). 
Excessive vaginal discharge is present in 50% to 
70% of patients (6,9,10). The classically described 
frothy or bubbly yellow-green discharge is present in 
less than one half of these patients. Vulvar erythema 
or excoriation is an uncommon finding, but vaginal 
erythema is noted in as many as 75% of the 
patients (9). "Strawberry cervix" created by capillary 
dilatation and punctate hemorrhages is visible to 
the naked eye inonly 2% of cases but by colposcopy 
is evident in as many as 90% (5) . Unless coexisting 
infection with chlamydia or Neisseria gonorrheae is 
present there should be no evidence of endocervical 
(mucopurulent) discharge with trichomonal infection. 
If findings of endocervitis are present, the patient 
should be evaluated for C. trachomatis and N. 
gonorrhoeae infections. 
The time-honored approach for the diagnosis of 
trichomonal infection has been microscopic evaluation. 
A sample of vaginal fluid is placed in normal saline 
and viewed under phase-contrast microscopy. The 
diagnosis of trichomonas is made by directly observing 
the motile parasite. Other labaratory procedures 
used for diagnosis include staining with acridine 
orange (11) or Giemsa (12), Papanicolaou stain 
(13,14) and fluorescent monoclonal antibody testing 
(13) . 
Candida is the second most common cause of 
vaginal infections and the incidence of candidal 
vaginitis bas increased. It was estimated that 75% of 
women have at least one episode of vulvovaginal 
candidiasis during their child-bearing years, and 
approximately 40-50% of these experience a second 
attack (15). 
100 
Prevalence studies indicate that candida may be 
isolated from the genital tract of approximately 20% 
of asymptomatic healthy women in their child-bearing 
years (16). 25% to 40% of women who have positive 
cultures for candida after vagina! sampling are 
asymptomatic carriers. The natura! history of asym-
ptomatic colonization is unknown, although both 
animal and limited human studies suggest that vaginal 
carriage may continue for severa! months and perhaps 
years (17). Several factors are associated with increased 
rates of asymptomatic vaginal colonization with candida. 
These include pregnancy (30%-40% ), use of high-
estrogen oral contraceptives and antibiotics, and 
uncontrolled diabetes mellitus (15,17,18). The rarity 
of candida isolation in girls before menarche and 
the lower prevalence of candidal vaginitis after 
menopause emphasize the hormona! dependence of 
this infection (17). 
Acute pruritus and vaginal discharge are the usual 
presenting complaints, but these symptoms are not 
specific for vulvovaginal candidiasis or invariably 
associated with it. The most frequent symptom is 
vulvar pruritus, which occurs in virtually ali 
symptomatic patients (19). Vagina! discharge is not 
present invariably and frequently is minimal. Although 
described as typically cottage cheese-like in character, 
the discharge may vary from watery to homogeneously 
thick. Vagina! soreness, irritation, vulvar burning, 
dyspareunia, and external dysuria commonly occur. 
Bad odor, if present, is minimal and not offensive. 
Examination frequently shows erythema and swelling 
of the labia and vulva, often with discrete pustu-
lopapular peripheral lesions. The cervix is normal, 
and vagina! mucosal erythema is present together 
with an adherent whitish discharge. Characteristically, 
the symptoms are exacerbated in the week preceding 
the onset of menses with some relief after the onset 
of menstrual flow. 
There is a clinical range of candidal vaginitis. In 
some patients, a more exudative syndrome occurs 
with copious discharge and white plaques, exemplifying 
the description of vaginal thrush. At the other end 
of the range are those patients with minimal discharge 
and severe erythema, particularly with extensive vulvar 
involvement and often extending into the inguinal 
and perianal regions . . In general, there is a quantitative 
relationship between the classic signs and symptoms 
of vulvovaginal candidiasis, notably pruritus and vulvitis, 
and the number of genital yeast present. Although 
Candida species occasionally cause extensive balano-
posthitis in male partners of women with vagina! 
candidiasis, a more frequent event is a . transient 
rash, erythema, and pruritus or a burning sensation 
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Clinical & Diagnostic Aspects of LGT Jnfections 
of the penis that occurs minutes or hours after 
unprotected intercourse (17). 
Most patients with symptomatic vaginitis can be 
diagnosed readily on the basis of simple microscopic 
examination of vagina! secretions. Accordingly, a 
wet mount or saline preparation should be done 
routinely, not only to identify the presence of yeast 
and mycelia, but also to exclude the presence of 
clue cells and trichomonas. Large numbers of 
leukocytes also invariably are absent and when present, 
should suggest a mixed infection. The potassium 
hydroxide 10% preparation is extremely useful and 
even more sensitive than the wet mount in diagnosing 
the presence of germinated yeast. The vagina! pH is 
normal in candidal vaginitis, and finding a vagina! 
pH in excess of 4.7 indicates bacterial vaginosis, 
trichomoniasis, or a mixed infection. 
The low sensitivity of light microscopy is shown 
by the finding that up to 50% of patients with 
culture-positive symptomatic candidal vaginitis will 
have negative microscopic results. Although routine 
cultures are unnecessary, vagina! cultures should be 
done in the presence of negative microscopic results 
(17). 
The Papanicolaou smear is unreliable as a diagnostic 
test, it is positive in approximately 25% of cases. 
Positive direct microscopic findings usually correlate 
with relatively high yeast concentrations in vagina! 
secretions, as confirmed by quantitative vagina! cultures 
(15). In most women, yeast number correlates with 
the severity of clinical signs and symptoms, and 
finally that commensal yeast vagina! carriage tends 
to be associated with a lower number of vaginal 
yeast (15) . Diagnosis requires a correlation between 
clinical findings, microscopic examination, and finally, 
vagina] culture. 
Gardnerella vaginalis was thought to be the 
causative agent of bacterial vaginosis. Later, this 
microbe was found to be present in the vaginas of 
40-50% of patients without bacterial vaginosis and 
also in those cured of bacterial vaginosis (20) . 
The term bacterial vaginosis was introduced to 
describe increased vagina! discharge without signs of 
clinical inflammation and noticeable absence of 
leukocytes (21 ). The vaginosis was called bacterial 
because of absence of fungi and parasites as the 
cause of this syndrome. 
This disorder is characterized by a decrease in 
aerobic lactobacilli and an increase in anaerobic 
lactobacilli and obligate anaerobes: Gardnerella and 
Mycoplasma. Predominant anaerobic organisms are 
Bacteroides sp., peptostreptococci, and Mobiluncus. 
There are clue cells, numerous free-floating bacteria, 
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and absence of leukocytes. It is a polymicrobial 
condition in which a decrease in vaginal acidity and 
in the concentration of lactobacilli is accompanied 
by an in ere ase of a 100-fold or more in the 
concentration of other organisms (22). 
Malodorous vaginal discharge and mild vulvar 
itching or buming are common symptoms of bacterial 
vaginosis. However, such symptoms could be absent 
in approximately one half of the women with bacterial 
vaginosis. At least three of the following four criteria 
must be fulfilled to establish the diagnosis: 
l. Thin homogeneous discharge that adheres to, but 
could be easily wiped from the vagina] wall . 
2. Vagina! pH more than 4.7. 
3. Presence of clue cells in the vagina] discharge. 
4. Positive amine odor test (23). 
More recently it has been demonstrated that the 
use of two of the four criteria, like clue cells and 
positive amines are enough for use as diagnostic 
criteria alone (24). 
Women with bacterial vaginosis usually complain 
of an increased vaginal discharge that is somewhat 
thin and sticky, tends to adhere to the vagina! wall, 
and might be present during introitus. The discharge 
also has a disagreeable or fishy odor that frequently 
is noticeable after intercourse . Mild to moderate 
itching may occur along with the vaginal discharge. 
Seminal fluid often can be confused with the 
malodorous discharge of bacterial vaginosis, and 
detection of sperm may aid the diagnosis. Clue cells 
and changes in bacterial flora can be found in the 
Papanicolaou smear, which normally would be an 
incidenta! finding. The presence of clue cells in the 
Pap smear showed a sensitivity of 90% and a 
specificity of 97% (25). 
Although G. vaginalis might play a role in the 
polymicrobial syndrome of bacterial vaginosis and 
there are different selective media available for its 
isolation, culturing of this organism is not re-
commended routinely in the diagnosis of bacterial 
vaginosis because it is a common member of 
endogenous vaginal flora and vaginal colonization in 
women treated for bacterial vaginosis might be 
similar to that in healthy control subjects (26). 
CERVICITIS 
Two types of cervicitis can be distinguished: 
endocervicitis also known as mucopurulent cervicitis 
and ectocervicitis. Causes of endocervicitis include 
C. trachomatis, N. gonorrhoeae, and herpes simplex 
virus. Herpes simplex virus infection can also be 
associated with ectocervicitis. 
101 
Clinical & Diagnostic Aspects of LGT Infections 
Endocervicitis 
Endocervicitis is based largely on the clinical 
diagnosis of urethritis in the male and on treatment 
of the female sex partners of men with urethritis. 
Because endocervicitis produces symptoms less often 
than male urethritis, and symptoms of endocervicitis 
( e.g., vaginal discharge) are less distinctive than 
symptoms of urethritis, the careful assessment of 
clinical signs of mucopurulent cervicitis, and the 
appropriate use of laboratory tests for detection of 
subclinical infection of females, are of paramount 
importance in the control of gonococcal and chlamydial 
infections (1 ). 
Infection of cervix represents a reservoir for sexual 
or perinatal transmission of pathogenic microorganisms, 
and might lead to at least two possible types of 
complications in the female : 
l. ascending intralumenal spread of pathogenic 
organisms from the cervix, producing endometritis 
and salpingitis 
2. ascending infection during pregnancy, resulting in 
chorioamnionitis, premature rupture of membranes, 
premature delivery, amniotic fluid infection, and 
puerperal infection. 
The lack of widely recognized objective signs of 
cervical inflammation is presented by the confusing 
nomenclature for endocervicitis. Terms such as acute 
and chronic cervicitis, cetvical erosion, mucopurulent 
cervicitis and hypertrophic cervicitis have all been 
used. This confusion results in part from the changes 
which occur in the cetvix over the reproductive 
period and during the menstrual cycle (27,28,29), 
and in part from difficulty in differentiating normal 
ectopic columnar epithelium from endocetvicitis. The 
later differentiation is complicated by the fact that 
cervical ectopy appears to be correlated with cetvical 
infection by C. trachomatis (30,31,32). Ectopy is 
present in the majority of younger teenage girls, 
and decreases steadily in prevalence with increasing 
age. Mucopurulent endocervical discharge is defined 
as yellow endocervical exudate or > 30 neutrophils 
per microscopic field ( 400x) in endocervical mucus 
as demonstrated by Gram stain. 
Mucopurulent cervicitis appears as inflamed endo-
cervix on physical examination or optimally by 
colposcopy with manifestations such as yellow endocer-
vical discharge, edema, and erythema of the zone of 
ectopy, and easily induced endocetvical bleeding (1). 
Ectocervicitis 
Routine colposcopic examination of female STD 
clinic patients has shown that cervical HSV infection 
is highly correlated with cervical ulcers or necrotic 
lesions, while trichomoniasis is correlated with colpitis 
macularis, and both C. trachomatis and cytomegalovirus 
infection of the cetvix are correlated with colposcopic 
features of immature metaplasia (33). Immature 
metaplasia was defined as faint acetowhite epithelium 
within the transformation zone . C. albicans, and T. 
vaginalis, also can produce ectocervicitis, but both 
are associated with other manifestations of in-
flammation of the contiguous stratified squamous 
vagina! epithelium. 
The presence of cervicitis can be confirmed by a 
variety of supplementary diagnostic procedures, most 
of which should be available to clinicians specializing 
in treatment of genital infections of women. These 
include Gram stain of endocervical mucus, cervical 
cytology, colposcopy, and cervical biopsy. The microbial 
etiology of cervicitis can be presumptively established 
by Gram stain of endocetvical mucus and further 
substantiated by isolation of C. trachomatis, N. 
gonorrheae, or HSV or by detection of specific 
microbial antigens, for example, by direct immu-
nofluorescence. 
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ADDRESSES 
Eda Bokal-Vrtačnik, MD, Dpt. of obstetric and gynecology, Oinical Centre 
61000 Ljubljana, Šlajmerjeva 3, Slovenia 
Božo Kralj, MD, PhD, professor of gynecology, Head of Dpt., same address 
Helena Hren-Vencelj, PhD, professor of microbiology 
Institute of microbiology, Medical Faculty, 61000 Ljubljana, Zaloška 4, Slovenia 
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