8.1 Infections of the reproductive tract

Question 1

What bacteria is found in the vagina and what is its function?

What is the average pH of the vagina?

Answer 1

The vaginal epithelium contains glycogen due to the action of circulating estrogens

Some Lactobacilli colonise the vagina and metabolise the glycogen to produce lactic acid.

The presence of lactic acid means the normal vaginal is pH 4-5

Question 2

Why is an acidic pH of the vagina beneficial?

Answer 2

Acidic pH of the vagina inhibits colonisation by other bacteria (except lactobacilli and some streptococci and diphtheroids)

Question 3

What is the relationship between Glycoproteins in the vagina and hormones?

Answer 3

Glycoproteins have strong interaction with circulating oestrogen ➞ as oestrogen levels fluctuate the susceptibility to infection can also change

Question 4

List another reason why the vagina is particularly susceptible to infections?

List one way that infection may be introduced into the vagina?

Answer 4

• It lacks cleansing mechanisms

- Introduction of foreign bodies may carry pathogens into the vaginal area

Question 5

List 3 things a microorganism may have to allow invasion into the vagina

Answer 5

1) specific mechanisms for attaching to vaginal or cervical mucosa
2) takes advantage of minute local injuries during coitus (genital warts, syphilis)
3) takes advantage of impaired defences (presence of tampons, oestrogen imbalance).

Question 6

What is Vulvovaginal Candidas caused by?

Give 2 reasons why this infection may occur

Answer 6

Most commonly caused by Candida albicans (normally lives in competition with the lactobacilli)

Infection may occur due to:

1) an alteration in the normal vaginal pH causing an alkaline environment
2) changes in the normal flora due to antibiotics (can cause Candida to rapidly multiply)

Question 7

Give 4 symptoms of Vulvovaginal Candidas

Answer 7

1) pruritus (itch)
2) vaginal soreness
3) dyspareunia (pain during sex)
4) external dysuria
5) abnormal vaginal discharges

Question 8

Give 4 signs of Vulvovaginal Candidas

Answer 8

1) vulvar edema
2) fissures
3) excoriations (skin picking)
4) thick curdy vaginal discharges

Question 9

Describe the transmission and symptoms of STI’s/STD’s

Answer 9

Passed through sexual activity including vaginal, oral, and anal sex.

Don’t always cause symptoms or may only cause mild symptoms, so it is possible to have an infection and not know it

Question 10

What are the 5 P’s that should be discussed with a patient

Answer 10

1) Partners
2) Practices
3) Prevention of Pregnancy
4) Protection from STDs
5) Past history of STDs

Question 11

List 3 ways STI’s are spread sexually and 3 other ways they can be spread

Answer 11

1) Penis, vagina, rectum
2) Breaks in skin
3) Mucous membranes

1) Needle Sharing
2) Blood contact
3) Vertical transmission (Mother-to-child)

Question 12

Give 4 common symptoms of STI’s

Why may people go undiagnosed and why is this dangerous?

Answer 12

1) Pain during urination
2) Bump/sores
3) Bleeding between periods
4) Unusual discharge
5) Pain during intercourse
6) Rash

Many people are asymptomatic BUT can still pass on a STI

Question 13

List 4 common STIs caused by bacteria

Answer 13

1) Chlamydia
2) Gonorrhea
3) Bacterial Vaginosis
4) Syphilis

Question 14

List 4 common STIs caused by viruses

Answer 14

1) Herpes
2) Hepatitis B
3) Genital Warts (HPV)
4) HIV/AIDS

Question 15

List 3 common STIs caused by parasites

Answer 15

1) Pubic Lice
2) Scabies
3) Trichomoniasis

Question 16

Compare treatment and prognosis of an STI caused by a bacteria vs a virus

Answer 16

Bacterial infections are curable (medication does not
protect against future exposure)

Viral infections are mostly NOT curable ➞ can be treated and managed to reduce symptoms and transmission

Question 17

List 2 diseases characterised by genital ulcers

Answer 17

1) Syphilis

2) Genital herpes

Question 18

What bacteria is responsible for Syphilis?

How is it spread and how do we test for it?

Answer 18

Caused by Treponema pallidum ➞ helical cell spirochete

Spread by sexual contact, blood or mother to baby (congenital syphilis)

Diagnosis by blood test

Question 19

What are the 4 stages of an untreated Syphilis infection and what is seen in each?

Answer 19

1) Primary: spirochetes adhere to skin and break it down to form chancres ➞ initial painless, open sores
2) Secondary: after ~6 weeks, spirochetes disseminate throughout body and proliferate ➞ formation of condylomas, palmar/plantar rashes, nikle/dime lesions (mouth) and flu-like symptoms
3) Latent: bacteria become dormant within host, asymptomatic (still detectable by blood cultures)
4) Tertiary: chronic inflammation against spirochetes produces degenerative lesions called gummas (hypersensitivity), CVS problems (inflammation of aorta), CNS (paralysis, meningitis, deafness), blindness

Question 20

What is the treatment of Syphilis?

Answer 20

A single intramuscular injection of medication will cure a person (usually antibiotic)

Syphilis is curable, but the damage to the body and organs is not reversible.

Question 21

List 4 symptoms of a vaginal infection

Answer 21

1) Vaginal discharge
2) Superficial dyspareunia (pain during sex)
3) Dysuria
4) Odor
5) Vulvar burning
6) Pruritus (itch)

Question 22

List 3 conditions characterised by vaginal discharge?

Answer 22

1) Bacterial vaginosis
2) Trichomoniasis
3) Vulvovaginal Candidiasis

Question 23

What is the cause of Bacterial vaginosis?

Answer 23

When the normal H202-producing Lactobacillus in the vagina is replaced with high concentrations of anaerobic bacteria

e.g Prevotella, Mobiluncus, G. vaginalis, and Mycoplasma hominis.

Question 24

What are the characteristics of Bacteria vaginosis?

What is the cell change that can be observed and why?

Answer 24

• milky white vaginal discharge from cervix
• ‘fishy’ odour
• may be some itching

Normally cells are very clear, in BV “clue cells” are seen due to the bacteria sticking to the cells

Question 25

Give 4 risk factors associated with BV (LMNL)

Answer 25

1) multiple sexual partners (male or female)
2) a new sex partner
3) lack of condom use
4) lack of vaginal lactobacilli
5) douching

Note: Women who have never been sexually active can be affected

Question 26

How do you treat BV?

List 3 things that may occur if untreated?

Answer 26

curable with either oral antibiotics or suppositories

If untreated:

1) Bacteria may spread and infect the uterus and fallopian tubes
2) May be transmitted to sex partners and newborns
3) If pregnant baby is at increased risk for premature birth

Question 27

List 2 conditions characterised by Urethritis and Cervicitis

Answer 27

1) Gonococcal infections

2) Chlamydial infections

Question 28

Give 3 signs of Cervicitis
What would be seen in the cervix?
What is meant by Mucopurulent Cervicitis?

Answer 28

1) vaginal discharge
2) deep dyspareunia
3) postcoital bleeding

Cervix is hypertrophic and edematous (swollen, excessive fluid)

Mucopurulent Cervicitis: gross visualization of yellow mucopurulent material on a white cotton swab (macrophages)

Question 29

What bacteria causes Chlamydia?

Describe the features of this bacteria including its 2 forms

Answer 29

Chlamydia Trachomatis: gram negative bacteria that can replicate ONLY within a host (obligatory intracellular bacteria)

Two forms:

1) Elementary bodies: small transmittable particles that reside outside cells, detection of these indicates a “new infection”
2) Reticulate bodies: found within the cell and are larger

Question 30

Describe the unique lifecycle of Chlamydia Trachomatis

Answer 30

1) The elementary attached to the columnar epithelial cells and infiltrates the host cell
2) In the host it transforms into the metabolically active reticulate body which replicated via binary fusion
3) The reticulate bodies then re-organises into their resistant elementary body form which are released from the cell

Question 31

List 4 common symptoms of Chlamydia in males and females

Answer 31

Males:

1) small amounts of clear or cloudy discharge from tip of the penis
2) Painful urination
3) Burning and itching around the opening of the penis
4) Pain and swelling around the testicles

Females:
1) abnormal vaginal discharge that may have an odor
2) bleeding between periods or painful periods
3 abdominal pain with fever
4) pain when having sex
5) Itching or burning in or around the vagina
6) Pain when urinating

Note: sometimes symptoms are not present in the beginning and it can lay dormant for a while

Question 32

What are the 2 general antibiotics prescribed to treat and cure Chlamydia in non-pregnant women?

Answer 32

1) a single dose of azithromycin
OR
2) a week dosage of doxycycline (twice daily)

Question 33

List 2 consequences of an untreated chlamydia infection in females

Answer 33

1) Infertility in females by infecting and causing scar tissue within the fallopian tubes
2) ectopic pregnancy

Question 34

How can both chlamydia and gonorrhoea lead to ectopic pregnancies?

Answer 34

Normal cervix contains many ciliated cells ➞ in both chlamydia and gonorrhoea the surface of these cells can become altered causing a change in the environment required for correct implantation

Question 35

What 2 potential consequences to a newborn if mother has untreated chlamydia?

Answer 35

1) Premature births

2) Infection can be transmitted to child during birth ➞ causing an eye infection, blindness, or pneumonia in the newborn

Question 36

What are 2 specific conditions males can experience as a result of a chlamydia infection?

Answer 36

Nongonococcal urethritis (NGU) ➞ an infection of the urethra and/or epididymitis

Proctitis ➞ inflammation of the rectum

Question 37

What bacteria causes Gonorrhoea and what are some features of this bacteria?

How is it transmitted?

Answer 37

Caused by: Neisseria gonorrhoea

• gram (-) BUT have lipooligosaccharide (LOS) rather than LPS
• kidney shaped diplococci
• can replicate ONLY within a host (obligatory)

Transmission:

• sexual contact
• birth

Question 38

List 4 Virulent features of Gonorrhoea

Answer 38

1) Pilus: aids attachment to human mucosal epithelium
2) Por proteins: forms pores through outer membrane
3) LOS: endotoxin activty
4) IgA protease: released by cell to destroy IgA1

Question 39

What are 3 ways Pathogenic Neisseria are able to change their surface antigens?

Answer 39

1) mutation of individual amino acids,
2) phase variation (switching genes on and off)
3) horizontal exchange of DNA material.

Question 40

How does Neisseria gonorrhoea infect the host

Answer 40

1) invasion through columnar epithelial cells
2) Release IgA protease ➞ enzyme that breaks down secretory IgA in the mucous to protect themselves from the host immune systems
3) damages and destroys the ciliated cells producing and inflammatory response

Question 41

Neisseria gonorrhoea is non-motile, list 2 ways it therefore be spread throughout the body

What can this cause?

Answer 41

1) can attach itself to sperm and be carried up the uterine tubes causing PID
2) can survive and multiply when phagocytosed by neutrophils ➞ offers protection from host immune cells and allows them to travel throughout the body which can lead to meningitis or endocarditis

Question 42

What is Disseminated Gonococcal Infection?

Who is it most common in and who Is at a higher risk?

Answer 42

Caused by spread of Neisseria gonorrhoeae and can lead to infections of pharynx, urethra, cervix

More common in females and patients with congenital deficiency of C7, C8, C9 are at a higher risk

Question 43

List 3 common symptoms of Gonorrhoea in males and females

Answer 43

Men (symptoms appear 2-7 days):

1) Acute inflammation
2) Painful urination (dysuria)
3) Purulent discharge (white, yellow, or green)

Females: often asymptomatic, symptoms don’t usually arise until complications (PID) have occurred

Initial symptoms and signs may be:

1) dysuria
2) increased vaginal discharge
3) vaginal bleeding between periods

Question 44

What is the primary infection site of urogenital infections in women?
What other sites are commonly affected?

Answer 44

Primary site: endocervical canal

Infection of Bartholin’s gland ducts is also common

Question 45

Where are the Bartholin’s glands located and what is their function?

What are the most common infections of the Bartholin’s glands? include features of each

Answer 45

Located at entrance of the vagina at 5 o’clock and 7 o’clock. produce lubricant into vagina

1) Cystic dilation (unilateral, tense, and nonpainful)
2) Abscess (erythema, tenderness, edema and occasional cellulitis of surrounding tissue)
3) Adenocarcinoma

Question 46

What is treatment for cysts and abscesses of Bartholin’s glands?

Answer 46

Asymptomatic cysts in women under 40 do not need treatment

Aymptomatic cyst or abscess: surgery to develop a fistulous tract to “marsupialize” the duct

Question 47

How do we collect a specimen of Gonococci?

Answer 47

Endocervical swab to examine gonococci

How: vaginal speculum used for clear sight of the cervix, swab is rubbed in and around the ontroitus of the cervix and withdrawn without contamination from the vaginal wall

Question 48

What are the main antibiotics prescribed to treat a gonococcal infection? (dosages/routes of administration?)

Answer 48

1) single intramuscular dose of Ceftriaxone (250 mg)
OR
2) single dose of oral Cefixime (400mg) orally
OR
3) single dose injectable cephalosporin regimens

Question 49

What are 4 potential neonatal consequences of vertical transmission of a gonococcal infection?

Answer 49

1) Ophthalmia neonatorum (conjunctivitis)
2) Disseminated gonococcal infection
3) sepsis, arthritis, meningitis
4) Scalp abscess
5) Vaginal and rectal infections
6) Pharyngeal infections

Question 50

What swabs are done to test for the following in females:

1) Vaginitis, vaginosis or uterine sepsis
2) Gonorrhoea
3) Chlamydia

How do we test in males?

What other test can we perform?

Following swab results what do we use to detect genetic material of infection?

Answer 50

1) Vaginitis, vaginosis or uterine sepsis ➞ high vaginal swab
2) Gonorrhoea ➞ cervical and urethral swabs
3) Chlamydia ➞ endocervical swabs, vulvo-vaginal or urine samples

Males: urethral swabs or urine

Other: Eye swabs

Following swabs use Nucleic Acid Detection Tests (NAT) to detect presence of the genetic material of the infection