INFECTIONS OF THE UPPER & LOWER

GENITAL TRACT

TERESITA R. TABLIZO FPOGS, FPSUOG

 FEMALE GENITAL TRACT
• LOWER: • UPPER:
1. VULVA 1. UTERUS
2. VAGINA 2. FALLOPIAN TUBES/OVIDUCTS
3. CERVIX 3. OVARIES

*Remember, however, that the female genital tract has

anatomic & physiologic continuity, thus, infectious
agents that colonize & involve one organ often infect
adjacent organs.
Lower Genital Tract
Infections
INFECTIONS OF THE VULVA
• 3 MOST COMMON VIRAL INFECTIONS OF THE VULVA:

1. Herpes Genitalis

2. Condyloma Acuminatum\

3. Molluscum Contagiosum
 INFECTIONS OF THE VULVA

• ACUTE BACTERIAL CYSTITIS

- experienced by 10-20% of adult women

- an individual woman’s risk of developing at least

one UTI is 50%

- highest incidence is at early 20s

INFECTIONS OF THE VULVA

• ACUTE BACTERIAL • Other Risk Factors:

CYSTITIS 1. Sexual intercourse
- why is a woman 2. Use of vaginal diaphragm
predisposed to UTI? or spermicide
1. shortness of female 3. Previous UTI
urethra
4. Recent exposure to
2. distal 1/3 of the antibiotics
female urethra is often
colonized by bacteria
from the vulvar
vestibule
MAJOR INFECTIOUS CAUSES OF ACUTE DYSURIA IN WOMEN
Condition Pathogen Pyuria Hematuria Symptoms, Signs & Factors

cystitis E. coli, S. + sometimes Abrupt onset, severe

saprophyticus, symptoms, multiple symptoms
Proteus sp., (dysuria, frequency & urgency),
Klebsiella sp. suprapubic or lower back pain,
suprapubic tenderness

urethritis C. trachomatis, N. + rarely Gradual onset, mild symptoms,

gonorrhea, Herpes vaginal discharge or bleeding
simplex virus (d/t concomitant cervicitis),
lower abdominal pain, new
sexual partner, cervicitis or
vulvovaginal herpetic lesions on
examination

vaginitis Candida sp., rarely rarely Vaginal discharge or odor,

Trichomonas pruritus, dyspareunia, external
vaginalis dysuria, no increased frequency
or urgency; vulvovaginitis on
examination
RECOMMENDED 3-DAY REGIMENS FOR ACUTE UNCOMPLICATED
CYSTITIS IN YOUNG WOMEN

DRUG DOSAGE

TRIMETHOPRIM/ 160/180 MG Q 12H

SULFAMETHOXAZOLE

QUINOLONES
CIPROFLOXACIN 250MG Q 12
ENOXACIN 400MG Q 12
LOMEFLOXACIN 4 400MG Q 12
NORFLOXACIN 400MG Q 12

OFLOXACIN 200MG Q 12
 Recurrent cystitis

Relapse Reinfection
Seek occult source of infection If woman is using a diaphragm or
Or urologic abnormality spermicide, consider changing the method
of contraception

Treat longer (2-6 wks)

Urologic evaluation not routinely indicated

≥ 3 UTI/yr ≤ 2 UTI / yr

No relation to coitus Temporarily related Patient-initiated therapy

To coitus For symptomatic episodes

Daily or thrice weekly Recommended:

Postcoital prophylaxis
prophylaxis Same as 3 day regimen for
Recommended: Recommended: uncomplicated cystitis
TMP-STX:40/200mg TMP-STX:40/200mg
Nitrofurantoin:50-100mg Nitrofurantoin:50-100mg
Norfloxacin 200mg Cephalexin 250mg
Cephalexin 250mg
INFECTION OF THE BARTHOLIN’S
GLAND
•Bartholin’s gland: 2 rounded, pea-sized
glands deep in the perineum at 5 & 7 o clock
position, normally cannot be palpated

•Bartholin’s duct: 2 cm in length & opens in a

groove b/w the hymen & the labia minora in
the posterior lateral wall of the vagina
INFECTION OF THE BARTHOLIN’S
GLAND
• Bartholin’s duct cyst: usually asymptomatic, 1-8 cm in
diameter, unilateral, tense & nonpainful; usually
unilocular, recurrent cysts may be loculated

• Bartholin’s gland abscess: develop rapidly, usually over

2-4 days; vulvar pain, dyspareunia, pain during walking &
w/o tx may rupture spontaneously by the 3rd or 4th day
INFECTION OF THE
BARTHOLIN’S GLAND
• Bartholin’s gland abscess:
- tx: broad spectrum antibiotics
incision & drainage
Marsupialization: an elliptical wedge
of tissue is removed & the edges
of the duct or abscess everted &
sutured to the surrounding skin;
w/ 5-10% recurrence rate
biopsy in women over 40
 PEDICULOSIS PUBIS & SCABIES

• 2 Most common mites:

1. Crab louse (Phthirus pubis)

2. Itch mite (Sarcoptes scabiei)

• Lice in the pubic hair are the most contagious

of all sexually transmitted disease
PEDICULOSIS PUBIS & SCABIES
• Life Cycle of the Mite:

egg (nit)
↓
Nymph
↓
adult
PEDICULOSIS PUBIS & SCABIES

• Pediculosis Pubis: predominant symptom is

constant itching in the pubic area d/t allergic
sensitization
- incubation period is approximately 30 days
- gross dx: “pepper grain” appearance ; feces
adjacent to hair shaft
PEDICULOSIS PUBIS & SCABIES

• Pediculosis Pubis:
- tx: permethrin – 1% cream, applied on
affected area then rinsed off after 10 min

lindane – shampoo, rinsed off after 4 min

pyrethrins w/ pipenonyl butoxide – applied
to affected area then rinsed off in 10 mins
SCABIES
• Epidemic outbreaks occur every 20-30 yrs

• widespread over the body w/o predilection for hairy

areas

• Predominant sxs: severe but intermittent itching w/ more

intense itching at night

- papules, vesicles & burrows (pathognomonic sign;

twisted line on the skin surface with a vesicle at one end)
 SCABIES

• Most common involved areas: hands, wrist, breasts, vulva &

buttocks

• Tx: permethrin cream 5% applied from neck down & rinsed off
after 8-14 hours

• To avoid reinfection, treat sexual partners w/in previous 6 wks &

other close household contacts; clothing & beddings should be
decontaminated
MOLLUSCUM CONTAGIOSUM
• Pox virus

• Chronic localized infxn consisting of flesh-colored, dome-

shaped papule w/ umbilicated center

• Spread by direct skin to skin contact

• Incubation period: 2-7 wks

• Mildly contagious, common in immunosuppressed women

MOLLUSCUM CONTAGIOSUM
• Dx: appearance of lesions on the skin

1 – 20 lesions may be present randomly distributed over the

vulva

• Usually self-limiting

• Tx: excision of nodules under local anesthesia

CONDYLOMA ACUMINATA

• Most common viral sexually transmitted disease of the vulva,

vagina, rectum & cervix

• Caused by the Human papilloma virus (HPV)

• HPV 16, 18: assoc’d w/ premalignant & malignant lesions of

the cervix
 GENITAL HPV TYPES

HPV type Morphology Potential for CA

6,11 Genital warts, Low (negligible)

LSIL, RRP

40,52,53,57,66,84 LSIL Low (negligible)

16,18,31,33,35,39, LSIL High

45,51,52,56,58,59, HSIL
68,73,82 Cancer

61,62,67,69,70 ? Uncertain
Estimated prevalence rate of genital HPV
infection among sexually active men & women
age 15-49 in the US

Genital warts
1%
Subclinical infxn detected
by colpo or paps
4%

Subclinical infxn detected

by DNA or RNA studies
10%

Prior infxn, probable Abs

60%
to HPV

No prior or
25% current infxn
Anatomic Distribution of Anogenital HPV Infection in
Female Patients

SITE PERCENTAGE
(%)
CERVIX 70

VULVA 25

VAGINA 10

ANUS 20
CONDYLOMA ACUMINATA

• Risk factors:
1. Immunosuppression
2. Diabetes mellitus
3. Pregnancy
4. trauma
TREATMENT OF WARTS: PATIENT
ADMINISTERED
PODAFILOX 0.5% IMIQUIMOD 5%
sol’n or gel(condylox) cream (aldara)

dose BID x 3 days, 4 days Daily q HS, 3x a wk up

off up to 4 cycles to 16 wks, wash 6-10
min after rx
mode of action antimitotic Immune enhancer

Side effects Mild to moderate pain, Mild to moderate local

local irritation inflammation

pregnancy contraindicated contraindicated

TREATMENT OF WARTS: PROVIDER
ADMINISTERED
CRYOTHERAPY PODOPHYLLIN THRICHOLORO-
RESIN ACETIC ACID
(TCA)
dose Wkly q 1-2 wks weekly Weekly
(no cryoprobe in (frosting)
vagina)
Mode of action Thermal- antimitotic Chemical
induced coagulation of
cytolysis proteins
Side effects Pain, necrosis + Local irritation Pain, adjacent
blistering damage (use
soap, soda)

pregnancy ok contraindicated ok
 GENITAL ULCERS : CLINICAL FEATURES
Syphilis Herpes Chancroid Lymphogranuloma Donovanosis
venereum
Incubation period 2-4 wks (1-12 wks) 2-7 days 1-14 days 3 days-6 wks 1-4 wks (upto 6
mos)
Primary lesion papule vesicle Papule or pustule Papule, pustule or papule
vesicle
Number of lesions Usually one Multiple may Usually multiple, Usually one variable
coalesce may coalesce
Diameter (mm) 5-15 1-2 2-20 2-10 variable

Edges Sharply erythematous Unermined, ragged, Elevated, round or Elevated, irregular

demarcated, irregular oval, irregular
elevated, round or
oval
depth Superficial or deep Superficial excavated Superficial or deep elevated

Base Smooth, Serous, purulent variable Red & rough

nonpurulent erythematous (beefy)
Induration firm none soft Occasionally firm firm

Pain unusual common Usually very tender variable uncommon

Lymphadeno-pathy Firm, nontender, Firm, tender, often Tender, may Tender, may pseudoadenopathy
bilateral bilateral suppurate, suppurate,
unilateral loculated, unilateral
GENITAL HERPES

• 80% of individuals are unaware they have the infection

• Highly contagious
• 2 types of virus:
1. HSV1 – 13-40% of lower genital tract infxns; infxn does not
protect from HSV2
2. HSV2- infxn confers some protection against HSV1
GENITAL HERPES

• Incubation period: 3-7 days

• 1° infxn: both local & systemic; paresthesia of the vulva, then
appearance of lesions, with simultaneous involvement of the vagina
& cervix, severe vulvar pain, tenderness & inguinal adenopathy,
general malaise & fever
GENITAL HERPES

• Recurrent infxn: sxs less severe than 1° infxn

- in 50% of cases recurrence occurs within 6 mos of
initial infxn
• Tx can be given in:
1. Primary episode
2. Recurrent episode
3. Daily suppression
GENITAL HERPES
ANTIVIRAL TREATMENT FOR HSV – NONPREGNANT PATIENT

Indication Valacyclovir Acyclovir Famciclovir

1st clinical episode 100mg BID x 7-10 200 mgs 5x a day 250mgs TID x 7-
days or 400mg TID x 10 days
7-10 days
Recurrent episode 1000mg daily or 400mgs TID x 5 125 mg BID x 5
500mg BID x 3-5 days, 800mgs BID days, 1000mg bid
days x 5 days, 800mg x 1 day
TID x3 days
Daily suppression 500mg daily (≤ 8 400 mg BID 250mg BID
therapy recurrences/yr) or
1000 mg/day or
250mg BID (> 9
recurrences/yr)
GRANULOMA INGUINALE

• a.k.a.: Donovanosis
• Chronic ulcerative dse of the skin & subcutaneous
tissue of the vulva
• Common in tropical climates
• Causative agent: Calymmatobacterium
granulomatosis
• DX: donovan bodies in smear fr the ulcer (cluster of
dark-staining bacteria w/ safety pin, bipolar
appearance found in the cytoplasm of large
mononuclear cells
GRANULOMA INGUINALE

• Tx: doycycline 100mg orally BID for a minimum of

3 wks
• Altenative regimens:
- Azithromycin 1gm orally/ wk x 3 weeks
- Ciprofloxacin 750mg BID x 3 wks
- Erythromycin 500mg QID x 3 wks
- TMP-SMZ 80/400 BID x 3 wks
• Sexual contacts during the 60 days preceding the
onset of symptoms should be examined
LYMPHOGRANULOMA
VENEREUM
• Caused by Chlamydia trachomatis serotypes L1,L2,L3
• Common in the tropics
• Majority of cases occur in males (5:1)
• Vulva is the most common site of infection
• Other sites: urethra, rectum & cervix
• Incubation period :3-30 days
LYMPHOGRANULOMA
VENEREUM
• 1° infxn: shallow painless ulcer of the vestibule or labia usually heals
rapidly w/o tx
• 2° infxn: begins 1-4 wks after primary infxn;painful adenopathy in the
inguinal and perirectal areas
• 3° infxn: bubos (tender lymphnodes)
• Groove sign:double genitocrural fold
LYMPHOGRANULOMA
VENEREUM
• Tx: doxycycline 100mg BID x 21 days
• Altenative regimens:
• Azithromycin 1 gm orally once a wk x 3 wks
• Ciprofloxacin 750mg BID x 3 wks
• Erythromycin 500 mg QID x 21 days
CHANCROID

• Sexually transmitted, ulcerative dse of the vulva

• Soft chancre, always painful & tender
• Facilitate HIV infection
• Caused by Haemophilus ducreyi (school of fish)
• Incubation period: 3-6 days
• Initial lesion is a small papule that ulcerates w/in
48-72 hrs
• Bubos when present are unilateral on the side of
the affected vulva
CHANCROID

• Tx: Azithromycin 1 gm orally SD

• ceftriaxone 250mg IM SD
• ciprofloxacin 500mg orally BID x 3 days
SYPHILIS

• Caused by Treponema pallidum

• 1°: papule w/c is painless, 2-3 wks after exposure
w/c ulcerates to form the chance w/c is hard,
painless & usually found in the vulva, vagina or
cervix, heals w/o tx w/in 2-6 wks
• 2° : hematogenous spread; develops b/w 6 wks & 6
mos after the 1° chancre; rash over the palms of the
hands & the soles of the feet; mucous patches,
condyloma latum & painless lymphadenopathy
SYPHILIS

• Latent: may last 2-20 yrs; (+) serology w/o s/sxs of dse
• Early : < 1 yr
- Late : > 1 yr
3°: systemic w/ potentially devastating effects in the CNS,CV &
musculoskeletal systems; optic atrophy, tabes dorsalis, generalized
paresis, aortic aneurysm & gummas of the skin & bones
SYPHILIS

• Gumma: similar to a cold abscess, w/ necrotic center & the

obliteration of the small vessels by endarteritis
• Tx: penicillin G 2.4 mi “U” SD IM
tetracycline 500 mg QID x 14 days
doxycycline 100mg BID x 2 wks
CDC Recommended Treatment of Syphilis

Early Syphilis : (1°,2° & early latent syphilis); Pen G 2.4 mi “u” IM SD,
doxycycline 100mg orally BID x 2 wks; tetracycline 500mg orally QID x
2 wks
Late Latent Syphilis: benzathine pen G 7.2 mi “u” given as 2.4 mi “u”
IM at 1 wk interval; doxycycline 100 mg BID x 4 wks; tetracycline 500
mg QID x 4 wks
Neurosyphilis: aqueous crystalline penicillin G, 18-24 mi units daily,
administered as 3-4 mi units IV every 4 hrs; for 10-14 days; procaine
pen 2.4 mi “u” IM daily for 10-14 days plus probenecid 500mg PO QID
x 10-14 days
Syphilis in pregnancy: penicillin regimen appropriate for stage of
syphilis; for women with history of penicillin allergy should be skin
tested & desensitized
Syphilis among HIV-infected Pxs: for 1° & 2° syphilis: recommended
penicillin regimens plus 3 wkly doses of pen G as in late syphilils; for
latent syphilis benzathine pen G 7.2 mi “u” as 3 wkly doses of 2.4 mi
“u” each
VAGINITIS

• Vaginal discharge: most common gyne sx

• Other sxs: dyspareunia
dysuria
odor
vulvar burning
pruritus
• 3 most common vaginitis:
1. Fungal (candidiasis) – 25%
2. Protozoal (trichomoniasis) - 25%
3. bacterial vaginosis – 50%
Bacterial Vaginal Flora among Asymptomatic Women
Without Vaginitis

• Facultative organisms • Anaerobic organisms

Gram + rods: peptococcus sp
lactobacilli peptostreptococcus sp
diphtheroids
bacteroides sp
Gram + cocci
fusobacterium sp
S. epidermidis
S. aureus clostridium sp
Beta-hemolytic strep eubacterium sp
Grp D strep veillonella sp
Gram – organisms
E. coli
Klebsiella sp.
others
 TYPICAL FEATURES OF VAGINITIS
condition S / sxs Findings on pH Wet mount comment
examination

Bacterial ↑ discharge Thin, whitish >4.5 Clue cells, shift in Greatly ↓

vaginosis (white, thin), gray flora lactobacilli,
↑ odor homogenous Amine odor after greatly ↑
discharge, adding KCL to cocci, bacilli,
sometimes wet mount small curved
frothy rods
candidiasis ↑ discharge, Thick, curdy <4.5 Hyphae or spores Can be
thick, white, discharge, mixed infxn
pruritus, vaginal w/ b.
dysuria, erythema vaginosis, T.
burning vaginalis or
both
trichomoniasis ↑ discharge, Yellow, frothy >4.5 Motile More
yellow, discharge with trichomonads symptoms at
frothy, ↑ or without higher
odor, vaginal or ↑ white cells vaginal pH
pruritus, cervical
dysuria erythema
 Diagnostic Tests Available for Vaginitis
Test Sensitivity Specificity Comment
(%) (%)

B. Vaginosis
pH > 5 97 64
Amsel’s criteria 92 77 Must meet 3 of 4 clinical criteria (pH>4.5, thin
watery discharge, >20% clue cells , + whiff’s
test) but similar results achieved if 2 of 4
criteria met
Nugent Criteria
Gram’s morphology score of 1-3 indicates
normal flora and score of 7-10 bacterial
vaginosis; high interobserver reproducibility
pap smear 49 93
point of care tests
quick vue advance, 89 96 + if pH > 4.7
pH + amines
quick vue advance, 91 >95 Test for proline imidopeptidase activity in
g. vaginalis vaginal fluid; if used when pH >4.5 sensitivity
OSOMB BV blue 90 <95 95%; specificity 99%
Test for vaginal sialidase activity
 Diagnostic Tests Available for Vaginitis
Test Sensitivity Specificity Comment
(%) (%)

Candida
Wet mount
overall 50 97
growth of 3-4+ on 85 C. albicans a commensal in 15-20% of women
culture
growth of 1+ on 23
culture If sxs present, pH ↑ if mixed infxn
pH > 4.5 Usual
pap smear 25 72
T. Vaginalis
wet mount 45-60 95 ↑ visibility of microorganisms w/ ↑ burden of
Infxn
culture 85-90 >95
pH >4.5 56 50
pap smear 92 61 False + rate of 8% for standard paps & 4%
for liquid based cytology test
point of care tests
10 min required to perform test
OSOM 83 98.8
 Recommendations for Acute Vaaginitis
Disease Drug Dose

B. vaginosis Metronidazole (flagyl) 500 mg BID x 7 days

0.75% metronidazole gel (metrogel) 1 5-gm application daily x 5 days
2% clindamycin cream (cleocin vaginal) 1 5-gm application HS x 7 days
2% extended-release clindamycin One application intravaginally
cream (Clindesse)

Vulvovaginal candidiasis Azoles

uncomplicated 2%butoconazole cream (Mycelex-3) 5 gm/day x 4 days
Intravaginal tx 2% sustained-release butoconazole One 5 gm dose
cream (Gynazole)
1 % clotrimazole cream (Myceles-7) 5 gm x 7-14 days
clotrimazole (Gyne-Lotrimin 3) 2 100mg vaginal tablets/day x 3 days
1 500 mg vaginal tablet
2% miconazole cream 5 gm / day x 7days
Miconazole (Monistat 7) 1 100mg suppository/day x 7 days
Miconazole (Monistat 3) 1 200 mg suppository/day x 3 days
Miconazole (Monistat 1) 1 1200 mg vaginal suppository
6.5% Tioconazole ointment (Monistat 1-day) 1 5 gm dose
0.4% Terconazole cream (Terazol 7) 5 gm/ day x 7 days
0.8 terconazole ream (Terazol 3) 5 gm/day x 3 days
Terconazole vaginal 1 80mg suppository/ day x 3 days
Nystatin vaginal 1 100,000 U vaginal tablet/day x 14 days
Oral therapy Fluconazole (Diflucan) 1 150 mg dose
 Recommendations for Acute Vaginitis

Disease Drug Dose

Vulvovaginal candidiasis
complicated
Intravaginal Azole 7-14 days
Oral Fluconazole (Diflucan) 2 150 mg doses orally 72 hrs apart

Trichomoniasis Metronidazole (Flagyl) 2 gm dose orally SD

500mg orally BID x 7 days
Tinidazole (tindamex) 2 gm orally SD
TOXIC SHOCK SYNDROME

• CASE DEFINITION OF TSS:

1. Fever (T 38.9°C or 102°F)
2. Rash (diffuse macular erythroderma)
3. Desquamation occurring 1-2 wks after onset of illness (in
survivors)
4. Hypotension (SBP≤90 mm Hg) or orthostatic sycope
5. Involvement of 3 or more of the ff organ systems:
a. GI (vomiting, diarrhea at onset of illness)
b. Muscular (myalgia or Creatinine phosphokinase level
of twice normal)
c. Mucous membrane: (vaginal, oropharyngeal or
conjunctival hyperemia)
TOXIC SHOCK SYNDROME

• CASE DEFINITION OF TSS:

d. Renal (BUN, Crea levels twice the normal or ≥ 5
WBC/HPF in the absence of URI
e. Hepatic (total bilirubin, SGOP,SGPT twice normal
level)
f. Hematologic (platelet ct ≤ 100,000/mm3
g. CNS (disorientation or alteration in consciousness w/o
focal neurologic signs when fever & hypotension are
absent)
h. CP (ARDS, pulmonary edema, new onset 2nd or 3rd
degree heartblock, myocarditis)
6. Negative throat & CSF culture
7. Negative serologic tests for Rocky mountain spotted
fever, leptospirosis or rubeola
TOXIC SHOCK SYNDROME:
Laboratory Abnormalities
• Present in > 85% of patients: • Present 70% of patients:
• Coagulase + staphylococci in • Platelet count < 150,000 / mm3
cervix or vagina
• • Pyuria > 5 WBC/HPF
Immature & mature PMN > 90%
of WBCs • Proteinuria ≥ 2
• Total lymphocyte count of • BUN > 20mg/dL
<650/mm3
• Aspartate aminotransferase > 41U/L
• Total serum protein level < 5.6
mg/dL
• Serum albumin level < 3.1 g/dL
• Serum creatinine clearance >
1.0mg/dL
• Serum bilirubin value >1.5 mg/dL
• Serum cholesterol level ≤
120mg/dL
• Prothrombin time > 12 sec
TOXIC SHOCK SYNDROME

• TREATMENT:
Clindamycin 600mg IV q 8 hrs +
Nafcillin / oxacillin 2 gm IV q 4 hrs
x 7-14 days
CERVICITIS

• Caused by either N. gonrrhea or C. trachomatis

• Could be endocervicitis or ectocervicitis
• Dx: pesence of yellow mucopurulent discharge on direct visualization
> 10 PMN / MF
Recommended Regimen for Treatment of Chlamydia
Infection

• Recommended regimen:
Azithromycin 1 gm PO SD
Doxycycline 100mg PO BID x 7 days
• Alternative regimen:
Erythromycin 500mg PO QID x 7 days
Erythromycin 800mg PO QID x 7 days
Ofloxacin 300 mg PO BID x 7 days
 Recommended Treatment of Uncomplicated Gonococcal
Infections of the Cervix, Urethra & Rectum in Adults
• Recommended regimen:
Cefixime 400 mg PO SD
Ceftriaxone 125 mg IM SD
Ciprofloxacin 500mg PO SD
Ofloxacin 400mg PO SD or Levofloxacin
250 mg PO SD plus Azithromycin
1 gm SD
doxycycline 100 mg PO BID x 7 days
• Alternative Regimens
Spectinomycin 2gm IM SD
Ceftizoxime 500mg IM, CEfotaxime 500 mg IM, Cefoxitin 2gm IM
+ probenicid 1 gm PO, all SD
Cefpodoxime 400 mg PO
Gatifloxacin 400mg PO, Lomefloxacin 400 mg PO,
Norfloxacin 800 mg PO, all SD
Upper Genital Tract
Infections
ENDOMETRITIS

• Infection of the uterine lining

• Gold standard for Dx: endometrial biopsy of at least 1 plasma cell /
120 x field of endometrial stroma plus 1 or more neutrophils / 400 x
field
ENDOMETRITIS

• Treatment regimen:
Regimen A: Levofloxacin 500 mg PO daily
x 14 days or Ofloxacin
400mg BID PO x 14 days
w/ or w/o
Metronidazole 500mg PO BID
x 14 days
Regimen B: Ceftriaxone 250 mg IM SD and
Doxycycline 100mg PO BID x 14
days w/ or w/o
Metronidazole 500mg PO BID x 14
days
PELVIC INFLAMMATORY
DISEASE
• Infection of the upper genital tract not associated
with pregnancy or intraperitoneal operation
• 99% results from ascending infection from bacterial
flora of the vagina & cerix
• Occurs in 1-2% of all young, sexually active women
• Most common serious infection in women ages 16-
25
• Extremely rare in women who are amenorrheic or
not sexually active
PELVIC INFLAMMATORY
DISEASE
• ↑ the risk for ectopic pregnancy 6-10 fold
• ↑ the infertility rate by 6-60%
• Etiology: acute PID: N. gonorrhea, C. trachomatis
• Risk factors: younger age at 1st contact
older sex partner
involvement w/ a child protective
agency
prior suicide attempt
alcohol use before intercourse
current C. trachomatis infxn
multiple sexual partners
 Methods of Preventing STDs, Mechanism of Action &
Efficacy
Method Mechanism Efficacy

Behavioral
Monogamy ↓likelihood of exposure to infected person Not well studied; theoretic efficacy
↓likelihood of exposure to infected person
Reducing # of partners

Avoiding certain sexual practices

Inspecting & questioning partners
Barrier
Condom Protects partner from direct contact with
semen, urethral discharge or penile lesion
Protects wearer from direct contact with
partner’s mucosal secretions
Chemically inactivates infectious agents
Spermicide
Mechanical barrier, covers the cervix
Diaphragm
Effective in vitro barrier to Chlamydia,
CMV& HIV, partial protection HSV
↓ risk for acquiring GC,PID, partial HPV
protection, effect on acquiring NGU not
well established
Nonvaginal use has not been studied
Inactivates gonococci, syphilis
spirochetes,trichomonads, HSV,
ureaplasma and HIV
100mg gel dose & contraceptive sponge
associated with epithelial ulcers &
abrasions
Decreases risk of acquiring cervical GC &
PID
 Methods of Preventing STDs, Mechanism of Action &
Efficacy
Method Mechanism Efficacy

Vaccines Induce antibody response that renders Commercially available hepa B vaccine
host immune to the disease safe & effective
Results of clinical trials on gonococcal &
herpes simplex vaccine ongoing
Gonnococcal, HIV & HSV vaccines
research in progress
Quadrivalent HPV vaccine safe & effective
Oral Antibiotics
Penicillin Kill infectious agent on or shortly after No studies among women or civilian men
exposure before infection is established
Sulfathioazole ↓risk of acquiring GC and hard and soft
chancre but use not recommended
Tetracycline analogues
Local
Postcoital urination Flushes infectious agents out of urethra & Poorly studied
Postcoital washing washes infectious agents of genital skin &
mucous membrane
Inactivates & washes infectious agents
Postcoital antiseptic douching Poorly studied, not recommended,
out of the vagina increased risk of endometritis
PELVIC INFLAMMATORY
DISEASE
• S/ SXS: fever, ↑ES, adnexal tenrness or mass (classic triad), pain on
the hypogastrium (most frequent symptom)
• Dxtics: laparoscopy
endometrial biopsy
Severity of PID by Laparoscopic Examination

Severity Findings

Mild Erythema, edema, no spontaneous purulent

exudates; tubes freely movable

Moderate Gross purulent material evident; erythema &

edema, more marked; tubes may not be freely
movable & fimbria stoma may not be patent

Severe Pyosalpinx or inflammatory complex abscess

Acute Salpingitis : Clinical Criteria for Diagnosis
• Abdominal direct tenderness w/ or
w/o rebound tenderness
• Tenderness w/ motion of cervix &
uterus All 3 necessary for diagnosis
• Adnexal tenderness
Plus
• G/S of endocervix + for gram –
intracellular diplococci
• T (>38° C)
• Leukocytosis (>10,000)
1 or more necessary for
• Purulent material from peritoneal diagnosis
cavity by culdocentesis or
laparoscopy
• Pelvic abscess on bimanual exam
or sonography
CDC Guidelines for Diagnosis of Acute PID Clinical Criteria
for Initiating Therapy
• Minimum criteria:
Empiric tx of PID should be
initiated in sexually active
young women & others at
risk for STDs if all of the ff
minimum criteria are
present and no other causes
for ill ness can be identified:
lower abdominal
tenderness
adnexal tenderness
cervical motion
tenderness
• Routine Criteria for Dx PID:
oral temperature > 38°C
abnormal cervical or vaginal
discharge
(mucopurulent)
+ abundant WBCs on
microscopy of secretions
elevated ESR
elevated C-reactive protein
+ lab confirmation of
N. gonorrhea or
C. trachomatis infxn
CDC Guidelines for Diagnosis of Acute PID Clinical Criteria
for Initiating Therapy

• Definitive criteria for dx:

histoplathologic evidence of endometritis on
endometrial biopsy
TVS or MRI showing thickened fluid-filled tubes with
or without free pelvic or tuboovarian complex
Laparoscopic abnormalities consistent with PID
Although initial tx can be made before bacteriologic
dx of C. trachomatis & N. gonorrhea infxn, such a dx
emphasizes the need to treat sex partners
 Microorganisms Isolated from the Fallopian Tubes of Patients
with Acute PID

Type of agent Organisms

Sexually transmitted disease Chlamydia trachomatis

Neisseria gonorrhea
Mycoplasma hominis

Endogenous Agent aerobic or Streptococcus sp

facultative Staphylococcus sp
Haemophilus sp
Escherichia coli
Anaerobic Bacteroides sp
Peptococcus sp
Peptostreptococcus sp
Clostridium sp
Actinomyces sp
 CDC Ambulatory Management for Acute PID

• Regimen A:
Levofloxacin 500mg PO OD x 14 days
or
Ofloxacin 400 mg PO OD x 14 days
w/ or w/o
Metronidazole 500 mg PO BID x 14 days
• Regimen B:
Ceftriaxone 250mg IM SD
or
Cefoxitin 2gm IM SD, & probenicid 1 gm PO SD
or
other parenteral third-generation cephalosporins
plus
doxycycline 100mg PO BID x 14 days
w or w/o
Metronidazole 500 mg PO BID x 14 days
Indications for Hospitalizing Patients with Acute PID

• Surgical emergencies cannot be excluded

• The patient is pregnant
• The patient does not respond clinically to oral
antimicrobial therapy
• The patient is unable to follow or tolerate an
outpatient oral regimen
• The patient has severe illness, nausea & vomiting,
or high fever
• The patient has tuboovarian abscess
 CDC Inpatient Management of Acute PID
• Parenteral Regimen A
Cefotetan 2 gm IV z 12 hrs
or
Cefoxitin 2 gm IV q 6 hrs
plus
Doxycycline 100mg PO/IV q 12 hrs
• Parenteral Regimen B:
Clindamycin 900mg IV q 8 hrs
plus
Gentamycin LD (2mg/kg BW) then
MD (1.5mg/kg BW) q 8 hrs
• Altenative Parenteral Regimens:
Levofloxacin 500 mg IV OD
or
Ofloxacin 400 mg IV q 12 hrs
w/ or w/o
Metronidazole 500mg IV q 8 hrs
Ampicillin/Sulbactam 3 gm IV q 6 hrs
plus
Doxycycline 100 mg PO/IV q 12 hrs
PELVIC INFLAMMATORY
DISEASE
• Sequelae:
d/t scarring & adhesion formation
1. Ectopic pregnancy
2. Chronic pain – most common sequelae
3. Infertility – PID is one of the major causes of female infertility
ACTINOMYCES INFECTION

• Rare
• Caused by Actinomyces israelii
• Cause chronic endometritis with foul-smelling discharge
• Histopath: sulfur granules
• Tx: oral penicillins or doxycycline or fluoroquinolones x 12 wks after
operation
TUBERCULOSIS

• Caused by: M. tuberculosis or M. bovis

• By hematogenous spread fr the lungs to the oviduct
• Present as AUB or infertility
• May have mild to moderate pain in 35% of cases
• Advanced cases may present w/ ascites
• Dx: endometrial biopsy
• Histopath: classic giant cells, granulomas & caseation
necrosis
• Laparoscopy: tobacco punch appearance of fallopian tubes
• Tx: multiple 5 drug regimen