Upper Genital Tract Infections

Question 1

After ascending through which areas does an infection become an upper genital tract infection?

Answer 1

When an infection ascends through the cervix into the endometrium or the salpinx

Question 2

How do you diagnose endometritis?

What is its treatment?

Answer 2

1. Gold standard is endometrial biopsy
2. Ceftriaxone 250mg IM single dose
3. Cefoxitin 2mg IM single dose + probenecid 1g single dose PO
4. 3rd gen cephalosporin + Doxycycline 100mg PO bid for 14 days w/wo Metronidazole 500mg PO bid for 14 days

Question 3

What is the definition of Pelvic Inflammatory Disease?

What are the areas affected if a person has PID?

What is the pathophysiology of PID?

What are possible sequelae of PID?

What are the etiological agents of PID?

Answer 3

1. Pelvic inflammatory disease is defined as infection of the upper genital tract that is not associated pregnancy or intraperitoneal pelvic operations
2. Affected areas could be: endometrium, oviducts, ovary, uterine wall, and serosa or broad ligaments (parametritis)
3. > 99% of the cause of PID originates from ascending infection from the vagina and cervix.
4. The other <1% is from transperitoneal spread from infections material in perforated appendix or abdomen.
5. Acute PID occurs in 1-2% of young sexually active women among ages 16-25
6. 85% of infection is spontaneous while 15% of infections are from procedures that break the mucus barrier allowing bacteria to colonize the upper genital areas
7. Ectopic pregnancy 6x-10x
8. chronic pelvic pain 4x
9. infertility, depending on may factors, can be from 6-60%
10. PID is polymicrobial and usually there is no seen cause. but the two STDs associated with PID is N. gonorrhea and C. trachomatis
11. Could also be from organisms that cause bacterial vaginosis.
12. Could also be from endogenous aerobic or anaerobic bacteria

Question 4

Where does N. gonorrhea adhere to in the UGT?

What are the most affected parts? why?

Answer 4

1. fallopian tubes in the on-ciliated area
2. The ciliated areas, why? because of the inflammatory response from the body, not the organism itself leading to scarring and fibrosis of tissue.

Question 5

How long can chlamydia remain in the fallopian tubes after initial colonization? how about N. gonorrhea?

What are the Sx of primary infection of chlamydia?

Which women are more likely to have more severe conditions due to the infection?

What is the sequelae of women PID?

Answer 5

1. Chlamydia can remain in the fallopian tubes for several months while Neisseria can stay for a few days
2. Primary infection itself of chlamydia is self limited with mild symptoms and no permanent damage
3. Women with antibodies against chlamydia are more likely to have tubal scarring and FITZ-HUGH-CURTIS SYNDROME.
4. Fitz-Hugh-Curtis syndrome = adhesions between the liver and diaphragm
5. PID could be silent, but there will still be sequelae
6. Ectopic pregnancy, tubal infertility

Question 6

How pathogenic are mycoplasma?

Answer 6

1. not that pathogenic, they are mostly commensal organisms isolated with other organisms in PID

Question 7

What are the risk factors of pelvic inflammatory disease? (10)

Answer 7

1. Age at first intercourse
2. Marital status
3. Number of sexual partners
   4, Social factors
4. Sexual behaviors of teenagers (lack of contraception)
5. IUD
6. Previous tubal ligation
7. Previous acute PID, 25% have recurrent PID
8. First trimester abortions
9. transcervical penetration with instrumentation

Question 8

What is the minimum criteria, additional criteria, and definitive criteria for diagnosing PID and what are the responses to each of these criteria?

How do you determine mild, moderate, severe cases of PID?

Answer 8

1. Minimum criteria: Lower abdominal tenderness, adnexal tenderness, cervical motion tenderness
   - EMPIRIC THERAPY SHOULD BE STARTED IN SEXUALLY ACTIVE WOMEN with these criteria
2. Additional criteria: temp >38C, abnormal cervical or vaginal discharge. mucopurulent discharge with abundant WBC, cervical infection with NG or CT
3. Definitive criteria: Histopathological evidence of endometritis on endometrial biopsy,
   - transvaginal sonography showing thickened fluid filled tubes
   - GOLD STANDARD: laparoscopic abnormalities consistent with PID
4. Mild: erythema, edema, no spontaneous exudates, tubes freely moveable
5. Moderate: Gross purulent material evident; erythema and marked edema, tubes may not be freely moveable.
6. Severe: Pyosalpinx or inflammatory complex abscess

Question 9

What are the treatment objectives for PID?

What is the treatment for PID for:

A. Outpatient therapy
A.1 what about follow up?

B. Inpatient therapy

• What are the indications for hospitalization of women with PID?
• What is Regimen A?
• What is Regimen B?
• When to reassess?
• When is operative treatment indicated?
• –What are the procedures?

Answer 9

1. Short-term: elimination of signs and symptoms and eradication of organism
2. Long-term: reduction of tubal damage and preservation of fertility capacity
3. Just like endometritis, the treatment can be ceftriaxone IM 250mg single dose
4. Cefoxitin 2g IM single dose + probenecid 1g PO single dose
5. 3rd gen cephalosporin + Doxycycline 100mg PO BID for 14 days w/wo metronidazole 500mg BID PO for 14 days
6. For follow up, reexamine women within 48-72 hours of initiating outpatient therapy to to evaluate the response of the disease to oral antibiotics
7. if doing well reexamine in 4-6 weeks
8. HOSPITALIZE if response is not optimal
9. surgical emergencies
10. Patient did not respond to oral antibacterial therapy
11. Patient is unable to tolerate oraltherapy
12. Severe illness nausea, high-fever
13. Tubo-ovarian abscess
14. Regimen A includes: Doxycycline + cefoxitin or cefotetan
    - Cefotetan 2g IV every 12 hours, OR Cefoxitin 2g IV every 6 hours + Doxycycline 100mg PO or IV every 12 hours
15. good against NG, CT, and penicillinase producing NG.
16. Regimen B = Clindamycin + Gentamycin
    - Clindamycin 900mg IV every 8 hours + Gentamycin loading dose of 2mg/kg with a maintenance dose of 1.5mg/kg every 8 hours
17. for Anaerobic infections, patients with abscess, IUDs or pelvic operation related PID
18. Reassess for improvement in 3 days
19. Discontinue parenteral treatment if afebrile for 24 hours, however, doxycycline (oral therapy) must be completed for 14 days
20. Indications for operative treatment: life-threatening infections, ruptured tubo-ovarian abscess, laparoscopic drainage of abscess, removal of persistent symptomatic mass
21. Unilateral removal of tubal ovarian complex
22. Drainage of cul de sac abscess via percutaneous drainage
23. Total abdominal hysterectomy with bilateral oophorectomy

Question 10

What is the sequelae of PID?

Should the partner be examined and treated? What aree the empiric treatment for the partner?

Answer 10

1. Fitz-Hugh-Curtis syndrome
2. Tubo-ovarian abscess
3. infertility
4. ectopic pregnancy
5. recurrent PID
6. Chronic Pelvic pain
7. YES
8. Cefixime 400mg SD, Ceftriaxone 250mg SD, Doxy 100mg bid 7 days. Azithromycin 1g SD

Question 11

In pelvic tuberculosis, how does the organism travel from the lungs to the oviducts?

What is the primary and predominant site of pelvic TB?

Signs and symptoms of pelvic TB?

How do diagnose or when to suspect if a woman has pelvic TB?

Treatment?

Answer 11

1. hematogenous route
2. Oviducts
3. When a woman is not responding to conventional treatment - suspect
4. • tuberculin skin test, presence of PTB
5. endometrial biopsy on secretoryu phase: findings of giant cells and caseous necrosis
6. if you are still not sure, LAPAROTOMY OR CELIOTOMY: Distal ends of the oviducts remain EVERTED, producing tobacco pouch appearance
7. 4 treatment regimen then de-escalate to 2 drugs
8. operate if woman older than 40, persistent pelvic mass, and resistant organism
9. if multi-drug resistant - 5-drug regimen