Gynaecology Flashcards
Pelvic Inflammatory Disease (PID) - definition
Inflammation and infection of the organs of the pelvis caused by infection spreading up through the cervix
* Significant cause of tubular infertility and chronic pelvic pain
Relevant definitions:
* Endometritis - Endometrial inflammation
* Salpingitis - Fallopian tube inflammation
* Oophoritis - Ovarian inflammation
* Parametritis - Parametrium inflammation (connective tissue surrounding the uterus)
* Peritonitis Peritoneal membrane inflammation
PID - aetiology
STIs
* Neisseria gonorrhoeae tends to produce more severe PID
* Chlamydia trachomatis
* Mycoplasma genitalium
Non-STI Infections
* Gardnerella vaginalis - associated with bacterial vaginosis
* Haemophilus influenzae - a bacteria often associated with respiratory infections
* Escherichia coli - an enteric bacteria commonly associated with urinary tract infections
PID - risk factors
Same as other STIs:
* Not using barrier contraception
* Multiple sexual partners
* Younger age
* Existing sexually transmitted infections
* Previous pelvic inflammatory disease
* Intrauterine device (e.g. copper coil)
PID - clinical presentation
Symptoms
* Pelvic or lower abdominal pain
* Abnormal vaginal discharge
* Abnormal bleeding (intermenstrual or postcoital)
* Dyspareunia - pain during intercourse
* Fever
* Dysuria
Examination
* Pelvic tenderness
* Cervical excitation - cervical motion tenderness
* Cervicitis - inflamed cervix
* Purulent discharge
Severe Cases - Fever + signs of sepsis
PID - investigations
STI Screen
* NAAT swabs for gonorrhoea and chlamydia
* NAAT swabs for Mycoplasma genitalium if available
* HIV test
* Syphilis test
High Vaginal Swab - Look for:
* Bacterial vaginosis
* Candidiasis
* Trichomoniasis
Microscopy - Pus cells from vaginal or endocervical swabs -
* Absence of pus cells useful in excluding PID
Pregnancy Test
* Sexually active women w/ lower abdo pain - exclude ectopic pregnancy
Inflammatory Markers - CRP and ESR raised in PID
PID - management
Referral - GUM specialists where appropriate
* Management
* Contact tracing
* Empirical Abx should be started before swab results obtained (avoid delay/complications)
Treatment - CHECK LOCAL GUIDELINES
* BASSH Guidelines suggest various inpatient/outpatient regimes to cover possible causative organisms - one suggested outpatient regime is:
* Gonorrhoea cover - 1x IM Ceftriaxone 1g
* Chlamydia + MGen cover - 100mg Doxycycline BDS for 14 days
* Anaerobe cover (eg Gardnerella vaginalis) - 400mg Metronidazole BDS for 14 days
* Ceftriaxone and doxycycline will cover may other bacteria like H. Influenzae and E. coli
Severe Cases - Eg signs of sepsis or patient pregnant
* Admission to hospital for IV Abx
* Pelvic Abscess - drainage by interventional radiology or surgery
PID - complications
- Sepsis
- Abscess
- Infertility
- Chronic pelvic pain
- Ectopic pregnancy
- Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis syndrome? - definition, presentation, investigation/treatment
Inflammation/infection of Glisson’s capsule (liver capsule)
* Adhesions form between liver and peritoneum
* Bacteria may spread from pelvis via:
* Peritoneal cavity
* Lymphatic system
* Blood
Presentation
*RUQ pain - can be referred to R shoulder tip (diaphragmatic irritation)
Investigation/Treatment
* Laparoscopy - used to visualise and treat adhesions by adhesiolysis
Herpes Simplex Virus (HSV) - overview
Herpes Simplex Virus (HSV) - commonly responsible for:
* Cold sores
* Genital Herpes
Two main strains:
* HSV-1 - commonly associated with cold sores (not exclusively)
* HSV-2 - commonly associated with genital herpes (not exclusively)
Initial infection -> virus becomes latent in associated nerve ganglia:
* Cold sores - trigeminal nerve ganglia
* Genital herpes - sacral nerve ganglia
HSV - transmission
Spread through either:
* Direct contact with affected mucous membranes
* Viral shedding in mucous secretions - shedding can occur even when asymptomatic (asymptomatic individuals can spread it)
* Asymptomatic shedding more common in first 12 months following infection and where recurrent symptoms present
HSV - types and clinical course of types
HSV-1 - Predominantly cold sores
* Often contracted in childhood (<5 y/o)
* Remains dormant in trigeminal nerve ganglion
* Reactivates as cold sores - especially at times of stress
* HSV-1 causing genital herpes -
* Usually contracted through oro-genital sex, where the virus spreads from a person with an oral infection to the person that develops a genital infection
HSV-2 - Predominantly genital herpes
* Mostly an STI
* Can also cause lesions in the mouth
Signs of HSV infection
Aphthous Ulcers - Small painful oral sores in mouth
Herpes Keratitis - Inflammation of the cornea (in eye)
Herpetic Whitlow - A painful skin lesion on a finger or thumb
HSV - clinical presentation
Clinical Course
* May be asymptomatic
* May develop symptoms months or years after initial infection when latent virus is reactivated
Initial Infection - Symptoms usually appear within 2 weeks
* Initial episode often most severe - primary infection symptoms can last for 3 weeks
Recurrent Episodes
* Milder than initial infection
* Resolve more quickly
Signs and Symptoms
* Ulcers or blistering lesions affecting the genital area
* Neuropathic type pain (tingling, burning or shooting)
* Flu-like symptoms (e.g. fatigue and headaches)
* Dysuria (painful urination)
* Inguinal lymphadenopathy
HSV - diagnosis
Clinical Diagnosis History -
* Sexual contacts - including those with cold sores (establish possible source of transmission)
○ May have caught it from someone unaware they are infected/asymptomatic
Examination - findings consistent with HSV infection
Viral PCR - swab from a lesion can confirm the diagnosis and causative organism
HSV - management
Referral (If appropriate) to GUM specialist
Treatment
* Aciclovir - various regimes depending on individual circumstances
* Alternatives include - valaciclovir and famciclovir
Additional Measures/Symptom Management
* Paracetamol
* Topical lidocaine 2% gel (e.g. Instillagel)
* Cleaning with warm salt water
* Topical vaseline
* Additional oral fluids
* Wear loose clothing
* Avoid intercourse with symptoms
