GENITAL TRACT INFECTIONS Flashcards
INTRODUCTION
INTRODUCTION
• There are a number of infections that involve the female genital tract • Sexually transmitted
• Non-sexually transmitted
• Many are associated with discharges, itching and pain
• A number of important complications may be associated with some of these infections
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UPPER GENITAL TRACT INFECTIONS
UPPER GENITAL TRACT INFECTIONS • Infection of the genital tract above the internal os
• Structures above the internal os include:
A. uterus (endometritis and myometritis), B. fallopian tubes (salpingitis),
C. parametria (parametritis),
D. ovaries (oophoritis),
E. pelvic peritoneum (peritonitis)
• Example—PID
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PID
PELVIC INFLAMMATORY DISEASE (PID)
⎯ is an infectious and inflammatory disorder of the upper genital tract of a female.
⎯ acute or chronic
• Aetiology and pathogenesis
• Causative organisms—polymicrobial in about 30-40% of cases
⎯ Two most common sexually transmitted infections that often start it as primary organisms: Chlamydia trachomatis and Neisseria gonorrhoea
⎯ Secondary opportunistic organisms quickly join: bacteriodes sp., peptococcus, Peptostrptococcus, E coli, Staph, Strep, anaerobes, herpes simplex virus 2, etc)
• Risk factors— STIs, multiple sexual partners, unprotected penetrative vaginal sex, young age at first intercourse, invasive procedures, etc.
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• OTHER WAYS PID CAN RESULT
1. Following termination of pregnancies (birth and abortion)
2. Following invasive procedures of the genital tract (insertion of IUCD, hysterosalpingography, D&C, etc)
3. Infection in other organs (e.g., appendicitis, can spread to tubes and ovaries)
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CLINICAL FEATURES
History
Physical examination
CLINICAL FEATURES
• Acute or chronic
• Nausea,
• vomiting,
• pelvic and abdominal pain of varying severity, • fever,
• abnormal vaginal discharge in about 75% of cases, • unanticipated vaginal bleeding, often post coital
Hx
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Examination
• Abdominal— tenderness, rebound tenderness, guarding
• On pelvic examination, 1 or more of the following is present • Cervical motion tenderness
• Uterine tenderness
• Adnexal tenderness
• Digital vaginal examination—mucopurulent discharge on fingers, often offensive
• According to Molander et al, the following are significant predictors of the diagnosis,
• Adnexal tenderness
• Fever
• Elevated erythrocyte sedimentation rate (ESR)
DIAGNOSIS AND INVESTIGATIONS
DIAGNOSIS AND INVESTIGATIONS
• Diagnosis in emergency situation is often based on clinical criteria, with or without additional laboratory and imaging evidence
• Laparoscopy— standard for the diagnosis of PID
vRadiological
1. Laparoscopy
Investigations
2. Transvaginal ultrasonographic scanning
3. Magnetic resonance imaging (MRI) showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian abscess (TOA)
4. Endometrial biopsy showing endometritis
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vNon-radiological
1. FBC
2. ESR; CRP
3. Blood culture
4. C/S of mucopurulent discharge 5. HVS; Endocervical swab—C/S 6. Urethral swab—C/S
7. Viral screen
8. Urine—R/E; C/S
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Additional criteria that improve diagnostic specificity:
ØOral temperature higher than 38.3° C (101° F)
ØAbnormal cervical or vaginal mucopurulent discharge
ØAbundant white blood cells (WBCs) on saline microscopy of vaginal secretions
ØElevated erythrocyte sedimentation rate (ESR) (≥40 mm/h)
ØElevated C-reactive protein (CRP) level (≥ 60 mg/L)
ØLaboratory evidence of cervical infection with N gonorrhoeae or C trachomatis (via culture or DNA probe)
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Treatment
TREATMENT
• Main aim of treatment
• relief of acute symptoms,
• eradication of current infection,
• minimisation of the risk of long-term complications
• Managed as in-patients or out-patients depending on severity In-patient Rx
• Admit
• IV access—for resuscitation, drugs, samples of blood • Bed rest
• Pain relief
• Antibiotics (broad spectrum)
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• Surgical Rx— drainage, adhesiolysis, copious irrigation or unilateral adnexectomy.
• IUCD may still be left in situ (CDC)
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Complications
COMPLICATIONS
• Repeated episodes of PID
• Chronic pelvic pain
• Abscesses (e.g., in tubes, ovaries) • Ectopic pregnancies
• Infertility
• Peritonitis
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LOWER GENITAL TRACT INFECTIONS
LOWER GENITAL TRACT INFECTIONS
• Infections of the genital tract below the level of the internal os
• E.g.,
• vulva (vulvitis),
• infections in the bartholin’s glands (Bartholin’s abscesses,
• infections in the paraurethral glands,
• vagina (vaginitis),
• cervix (cervicitis),
• endocervix (endocervicitis).
Common causes of vaginitis and vaginal discharges
Common causes of vaginitis and vaginal discharges
TRICHOMONAS VAGINALIS (TV) INFECTION
• TV is a motile, flagellated, anaerobic protozoan
• Causes Trichomoniasis
• Mode of transmission—sexual. That is, it is an STD
CLINICAL FEATURES
vAbout 50% of TV infections are asymptomatic
vVaginal discharge. Typical discharge is frothy (bubbly) yellow-green
and offensive.
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vVulvar pruritus or irritation
vDeep dyspareunia
vDysuria
vLower abdominal pain
vVaginal erythema
vStrawberry cervix due to capillary dilatation and punctate haemorrhages
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Diagnosis
Treatment
DIAGNOSIS
• Clinical
• Hx + examination
• Laboratory
• Wet prep microscopy: Motile protozoa by direct observation in wet prep in 60-80%
• Immediate Diamond media culture
• Currently, molecular diagnositic tests are recommended.
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TREATMENT
• Antibiotics (mainly the 5-nitro-imidazoles—metronidazole, tinidazole).
⎯ Systemic therapy is essential as TV in the urethra and paraurethral glands may escape local applications
• Since it is an STI, both the patient and their sexual partner must be treated.
• Antihistamins for vulva itch (pruritus)
CANDIDA INFECTIONS
CANDIDA INFECTIONS
• Candida organisms—are gram- positive fungi
• Causes—candidiasis
• Candida is part of the normal flora of the vagina
• They are commensal saprophytic organisms of the vaginal mucosal surface and are found in low numbers in 25% of asymptomatic women.
• NOT an STI
• Pathophysiologically, Candidal vulvovaginitis occurs
when Candida species superficially penetrate the mucosal lining of the vagina and cause an inflammatory response.
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PATHOGENESIS OF VULVOVAGINAL CANDIDIASIS
ØThere is yeast overgrowth in the vagina
• Circumstances leading to this overgrowth:
• dark and moist areas in the perineum serving as good media for growth.
• wearing of tight clothes and nylon panties
• extra folds of skin—making them areas good for growth
ØGrowth also occurs when the normal bacteria in the vagina change (as can happen with antibiotic intake) or when there are hormonal changes (as can happen with contraceptive intake or pregnancy)
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CLINICAL FEATURES
CLINICAL FEATURES
• Infection produces vulvovaginitis
• Symptoms are often worse before onset of menses and improve during menstruation
vVulvar pruritus
vVaginal soreness, irritation, or burning
vSuperficial dyspareunia
vErythema and swelling of labia
vErythema of vaginal mucosa
vExternal dysuria
vNormal cervix
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vVaginal discharge.
• Typically, discharge is—
⎯ non-offensive,
⎯ thick,
⎯ cheese-like,
⎯ contain floccules,
⎯ is adherent to the vaginal mucosa as whit plaques, which when peeled or scraped off reveal punctate haemorrhages. Discharge may vary from watery to thick homogenous.
vMinutes to hours after intercourse without a condom, partners may complain of a transient rash, erythema, pruritus, or burning sensation of the penis.
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Diagnosis
Treatment
DIAGNOSIS
• Clinical
• Hx +examination
• Laboratory
• Microscopy
⎯ 10% KOH wet prep microscopy • Culture
⎯ Nickerson’s medium or Sabouraud-dextrose agar plate 4-Feb-2022 26
TREATMENT
• Antifungals
⎯ Pessaries ⎯ Oral
• Antihistamins for itching • Pain relief
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BACTERIAL VAGINOSIS
BACTERIAL VAGINOSIS
• Not clear whether it is an STI or not
• One cannot get it from toilet seats, bedding, or swimming pools (CDC)
• Common organisms—are anaerobes (Gardnerella, Ureaplasma, etc)
• It is a result of an imbalance of “good” and “harmful” bacteria in the vagina. That is, it is caused by a change in the natural balance of bacteria in the vagina
Risk factors
- Douching,
- Recent antibiotic use
- Decreased oestrogen production
- Wearing an intrauterine device (IUD)
- Lack of condom use
- Multiple sex partners or new sexual partners
