2.4 Genital Tract Infections Flashcards
Physiological vaginal discharge is usually white/clear, non-offensive and varies cyclically:
• Contains _____________ (containing dead vaginal cells), ____________ (secreted by cervical glands), and _____________ (smaller amount)
• Lactobacilli in the vagina convert _______________ in the epithelium → acidifies the vaginal discharge (as transudate passes through) → pH 4 – 5 (inhibits multiplication of other microorganisms)
vaginal transudate;
cervical mucus;
endometrial gland secretions
glycogen to lactic acid
what is the clinical presentation of bacteria vaginosis?
60% of affected women are asymptomatic:
• Fishy-smelling, white/grey vaginal discharge (if symptomatic)
what are the complications of bacteria vaginosis?
- Obstetric: preterm birth, preterm rupture of membranes, post-abortal or postpartum infections
- Gynaecological: PID, acquisition of STIs, plasma-cell endometritis, post-hysterectomy vagina cuff cellulitis
What is the diagnostic criteria of bacteria vaginosis?
Fulfilling 3 out of 4 of the Amsel’s criteria:
- Greyish-white vaginal discharge
- Clue cells on saline wet mount involving > 20% of epithelial cells
- pH > 4.5
- Positive whiff test: 10% KOH applied to vaginal discharge sample on saline wet mount microscopy → fishy odour
What is the treatment of the bacteria vaginosis?
Metronidazole (anti-anaerobe spectrum of activity)
What is recurrent vulvovaginal candidasis?
≥ 4 episodes of symptomatic infection in 1 year
What is the clinical presentation of vulvovaginal candidasis?
Symptoms: vulvar pruritus (itching), vulva pain & irritation (may cause dysuria and dyspareunia)
Signs: curd-like discharge (on vaginal examination), erythematous vulva/vagina, vulva excoriation/fissure
What are the risk factors for vulvovaginal candiasis?
Diabetes mellitus, antibiotic use (wipes out bacterial flora → allows Candida to proliferate), increased oestrogen levels (e.g. OCP, pregnancy), immunosuppression (increased risk of fungal infections), sex
What is the diagnostic criteria of vulvovaginal candiasis?
- Presence of the characteristic clinical symptoms
2. Presence of Candida on microscopy (wet mount, Gram stain) or on vaginal culture
What is the treatment for uncomplicated infections (sporadic mild to moderate infections by C. albicans in normal hosts)
oral fluconazole (150mg x 1 dose), topical/vaginal antifungal agents (e.g. isoconazole, clotrimazole)
What is the treatment for complicated/recurrent infections (severe signs/symptoms, non-albicans species, immunocompromised state): multiple doses of oral antifungal agents for longer periods of time
3 doses of oral fluconazole 2 hours apart → followed by weekly maintenance doses
Group B Streptococcus (S. agalactiae) is a _____________ which frequently colonises the _______________.
Pathogenesis: Pregnant women: 20 – 40% maternal carriage (intermittently) → frequently affects the urinary system
• Causes ___________ (marker for heavy genital GBS colonisation; increased infection risk), cystitis, pyelonephritis
• Maternal infections (e.g. chorioamnionitis) associated with ____________ (e.g. endometritis)
Foetal: 80% maternal-to-foetal colonisation rate (0.5 in 1000 births with invasive neonatal disease)
• Most common onset of severe early onset infection in newborns
• Associated with _______________
Gram-positive coccus;
genital and gastrointestinal tracts
asymptomatic bacteriuria;
pregnancy loss, preterm delivery, postpartum infections;
generalised sepsis, pneumonia, meningitis
What is the investigation for Group B Streptococcus (S. agalactiae
GBS screening at 35 – 37 weeks of gestation or 3 – 5 weeks before the anticipated delivery date (for vaginal births)
What is the treatment for Group B Streptococcus (S. agalactiae
Prevent transmission to foetus: intrapartum antibiotic prophylaxis Treatment: IV benzylpenicillin or clindamycin (if penicillin allergy) until delivery
Actinomyces is a _____________ which is a part of the normal GI flora and often present in the vagina without symptoms/sequelae:
• Actinomyces-like organisms seen in 0.26% of Pap smears without IUCD (intrauterine contraceptive device) and 7% of Pap smears with IUCD
• If Actinomyces is seen on Pap smear, evaluate the patient for symptoms of PID and perform a _______________
Gram-positive anaerobic rod;
cervical culture for Actinomyces
what is the treatment for asymptomatic for PID + culture negative for actinomyces?
Leave IUCD in place (no further treatment)
what is the treatment for asymptomatic for PID + symptomatic for PID and/or Actinomyces on cervical culture?
Penicillin/tetracycline + empirical treatment Remove IUCD after initiation of antibiotics
Neisseria gonorrhoeae (gonococcus) is a Gram-negative diplococcus which infects the mucous membranes of the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ • 40% of patients with gonorrhoea also have \_\_\_\_\_\_\_\_\_\_\_
endocervix, urethra, rectum, pharynx, and conjunctiva;
concurrent chlamydia
What are the presentations of cervicitis due to neisseria gonorrhoea?
- Typical: mucopurulent vaginal discharge, vaginal pruritus • Other symptoms: IMB, dyspareunia
- Gonococcal cervical infection is indistinguishable from acute cervicitis of other causes
what is the presentation of urethritis due to neisseria gonorrhoea?
Presents with dysuria, frequency and urgency
what is the presentation of PID due to neisseria gonorrhoea?
Presents with abdominal pain, abnormal vaginal discharge/bleeding, dyspareunia, perihepatitis (Fitz-Hugh-Curtis syndrome) → inflammation of peritoneal coating of the liver)
what is the extragenital presentation of neisseria gonorrhoea?
Conjunctivitis, pharyngitis, proctitis (inflammation of rectum and anus)
Disseminated gonococcal infection: purulent arthritis or triad of tenosynovitis (synovium surrounding tendon), dermatitis, polyarthralgias
what are the complications of neisseria gonorrhoea?
Obstetric: chorioamnionitis, preterm birth, low birth weight
Foetal transmission: gonococcal ophthalmia neonatorum (neonatal conjunctivitis), other localised infections (neonatal vaginitis, proctitis, urethritis), disseminated infections, scalp abscess
what are the investigations of neisseria gonorrhoea?
- Nucleic acid amplification test on urogenital/ extragenital specimens
- Gram stain and culture
- Check for co-infection with Chlamydia trachomatis
what are the treatments of neisseria gonorrhoea?
IM ceftriaxone 250mg stat (immediately) → alternatives include azithromycin or doxycycline
• Contact tracing and treatment of partner is important
What are the presetations of chlamydia?
- Cervicitis (> 85% asymptomatic): symptoms are non-specific; minority may exhibit classic cervicitis signs (mucopurulent endocervical discharge, easily inducible endocervical bleeding, oedematous ectopy)
- Urethritis: dysuria, sterile pyuria
- PID
- Perihepatitis (Fitz-Hugh-Curtis syndrome)
- Proctitis, conjunctivitis, pharyngitis
- Lymphogranuloma venereum: non-painful genital ulcer → development of inguinal lymphadenopathy
What are the complications of chlamydia?
Premature rupture of membranes, preterm delivery, neonatal conjunctivitis/pneumoniasite
What are the investigations for chlamydia?
NAAT or PCR on urogenital or extragenital specimens
What are the treatments for chlamydia?
Azithromycin or doxycycline + contact tracing & treatment:
• Test of cure recommended for all pregnant women ≥ 3 weeks after treatment
What is the presentation for Trichomonas vaginalis?
Symptoms: malodorous vaginal discharge, pruritus, burning sensation, dysuria, frequency of urination, lower abdominal pain, dyspareunia, PCB
Signs: vaginal discharge (green-yellow, frothy, malodorous), “strawberry” cervix (erythematous cervix)
What is the investigation for Trichomonas vaginalis?
Microscopy showing motile trichomonads on wet mount (NAAT is expensive)
What is the treatment for Trichomonas vaginalis?
Metronidazole (antiprotozoan spectrum)
What are the stages of syphyllis?
Primary (1st image): painless chancre (genital ulcer) usually in the cervix of women and the penis of men → ~90 days post-exposure
Secondary (2nd image): reddish maculopapular rash involving trunk and extremities, sore throat, malaise, fever → 2 – 10 weeks (resolves in 6 wks)
Tertiary (3rd image): affects 1/3 of infected people without treatment (affects brain, nerves, eyes, heart, bones) → dementia, stroke, blindness, tabes dorsalis (syphilitic myelopathy; slow degeneration of dorsal columns and roots, general paresis) → 3 – 15 years post-initial exposure
How is syphyllis diagnosed?
Darkfield examination: detect directly from lesion exudate/tissue
Validated PCR: non-treponemal (VRDL, RPR), treponemal (FTA-ABS, TPPA)
How is syphyllis treated?
Penicillin G (duration of treatment depends on stage and clinical manifestation of disease)
HPV is a large family of DNA viruses with numerous subtypes that predispose/cause cervical cancer and genital warts:
• Infect _________________ → proliferative lesions
basal cells of the cervical squamous epithelia
Pelvic inflammatory disease occurs due to ________________ causing pelvic inflammation (e.g. endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis):
• Caused by _________________ (in 25%), and also Gardnerella vaginalis, anaerobes, Mycoplasma genitalium
o Less than 50% of patients with PID test positive for these organisms
• Many episodes of PID tend to go unrecognised
ascending infections from the endocervix;
Neisseria gonorrhoeae and Chlamydia trachomatis
What is the presentation of PID?
Symptoms: lower abdominal pain (typically bilateral), deep dyspareunia, abnormal vaginal bleeding (e.g. IMB, PCB), abnormal vaginal discharge (often purulent)
Signs: lower abdominal tenderness, adnexal tenderness (areas next to uterus containing ligaments, tubes, ovaries), cervical excitation, fever
What are the complications of PID?
Perihepatitis (Fitz-Hugh-Curtis syndrome), chronic pelvic pain, hydrosalpinges, tubo-ovarian abscesses, subfertility (secondary to tubal factors), ectopic pregnancy
• Women with mild/asymptomatic PID are still at risk for infertility → important to maintain the low threshold for diagnosis of PID
What are the investigations for PID?
Clinical diagnosis
Testing for gonorrhoea and chlamydia + inflammatory markers
US pelvis (if tubo-ovarian abscesses are suspected)
What are the DDx of PID?
For lower abdominal pan in young women: ectopic pregnancy, acute appendicitis, endometriosis, ovarian cyst accidents, UTIs
