Professional Documents
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1 Gynecologic Infections 2
1 Gynecologic Infections 2
Genet Gebremedhin(MD)
Assistant Prof of gynecology & obstetrics
University of Gondar
March 4 2012
Gynecologic Infections
Gynecologic infections are frequent disorders
for which patients seek care from
gynecologists
These infections can be seen as:
1. Pathogens Causing Genital Ulcer
2. Pathogens Causing Infectious Vaginitis
3. Pathogens Causing Suppurative Cervicitis
4. Pathogens Causing Mass Lesions
5. Pathogens Causing Pruritus
Normal Vaginal Flora
Vaginal flora of a normal asymptomatic reproductive-aged
woman includes multiple aerobic or facultative species as well
as obligate anaerobic species
Of these, anaerobes are predominant and outnumber
aerobic species approximately 10: 1
The function of and reason for bacterial colonization of the
vagina remains unknown.
Bacteria do exist in a symbiotic relationship with the host and
are alterable, depending on the microenvironment.
These organisms localize where their survival needs are met,
and have exemption from the infection-preventing
destructive capacity of the host.
Normal flora contd.
Aerobes Anaerobes
Gram-positive Gram-positive cocci Yeast
Lactobacillus spp Peptostreptococcus spp Candida albicans
Diphtheroids Clostridium spp
Staphylococcus aureus Gram-positive bacilli
Staphylococcus epidermidis Lactobacillus spp
Group B Streptococcus Propionibacterium spp
Enterococcus faecalis Eubacterium spp
Staphylococcus spp Bifidobacterium spp
Gram-negative Gram-negative
Escherichia coli Prevotella spp
Klebsiella spp Bacteroides spp
Proteus spp Bacteroides fragilis group
Enterobacter spp Fusobacterium spp
Acinetobacter spp Veillonella spp
Citrobacter spp
Pseudomonas spp
Normal Flora Contd.
Within this vaginal ecosystem, some microorganisms
produce substances such as lactic acid and hydrogen
peroxide that inhibit nonindigenous organisms.
Several other antibacterial compounds, termed
bacteriocins, provide a similar role and include peptides
such as acidocin and lactacin.
Some species have the ability to produce proteinaceous
adhesions and attach to vaginal epithelial cells.
For protection from many of these toxic substances, the
vagina secretes leukocyte protease inhibitor.
This protein protects local tissues against toxic
inflammatory products and infection
Normal Flora Contd.
Typically, the vaginal pH ranges between 4 and 4.5.
Although not completely understood, it is believed to result
from Lactobacillus species' production of lactic acid, fatty acids,
and other organic acids.
In addition, amino acid fermentation by anaerobic bacteria
results in organic acid production as does bacterial protein
catabolism.
Glycogen present in healthy vaginal mucosa is believed to
provide nutrients for many species in the vaginal ecosystem.
Accordingly, as glycogen content within vaginal epithelial cells
diminishes after menopause, this decreased substrate for acid
production leads to a rise in vaginal pH
Changing any element of this ecology may alter the prevalence
of various species.
Normal Flora Contd.
Vaginal flora may be altered by
Menopause
Treatment with a broad-spectrum antibiotic
Menstruation
Total abdominal hysterectomy
Altered vaginal flora results in bacterial vaginosis(BV)
BV is not sexually transmitted disease (STD), and
It is seen in women without previous sexual experience.
Successful prevention of BV is limited, but elimination or
diminished use of vaginal douches may be beneficial
Bacterial Vaginosis (BV)
BV reflects abnormal vaginal flora, and is poorly understood.
It has been variously named, and former terms include Haemophilus
vaginitis, Corynebacterium vaginitis, Gardnerella or anaerobic
vaginitis, and nonspecific vaginitis.
For unknown reasons, the vaginal flora's symbiotic relationship
shifts to one in which there is overgrowth of anaerobic species
including Gardnerella vaginalis, Ureaplasma urealyticum,
Mobiluncus species, Mycoplasma hominis, and Prevotella species.
Bacterial vaginosis (BV) is also associated with a significant reduction
or absence of the normal hydrogen peroxide-producing
Lactobacillus species.
Whether an altered ecosystem leads to lactobacilli disappearance or
whether its disappearance results in the changes observed with BV
is unknown.
Bacterial Vaginosis contd.
Risk Factors of Bacterial Vaginosis
Oral sex
Douching
Black race
Cigarette smoking
Sex during menses
Intrauterine device
Early age of sexual intercourse
New or multiple sexual partners
Sexual activity with other women
Bacterial Vaginosis contd.
Diagnosis
Nonirritating, malodorous vaginal discharge is characteristic, but
may not always be present.
BV is associated with, vaginitis, endometritis, postabortal
endometritis, pelvic inflammatory disease unassociated with
Neisseria gonorrhoeae or Chlamydia trachomatis, and acute pelvic
infections following pelvic surgery, especially hysterectomy.
The vagina is usually not erythematous, and cervical examination
reveals no abnormalities.
Clinical diagnostic criteria were first proposed by Amsel and
associates (1983) and include:
Microscopic evaluation of a saline "wet prep" of vaginal secretions,
Determination of the vaginal PH, pH is >4.5
Release of volatile amines produced by anaerobic metabolism.
Bacterial Vaginosis contd.
Bacterial Vaginosis contd.
Clue cells are epithelial cells containing many attached
bacteria, which create a poorly defined stippled cellular
border.
Adding 10 % potassium hydroxide (KOH) to a fresh sample of
vaginal secretions releases volatile amines that have a fishy
odor. whiff test.
Similarly, alkalinity of seminal fluid and blood are responsible
for odor complaints after intercourse and with menses.
The finding of both clue cells and a positive whiff test is
pathognomonic, even in asymptomatic patients.
Trichomonas vaginalis infection is also associated with
anaerobic overgrowth and resultant elaborated amines.
Women diagnosed with BV should have no microscopic
evidence of trichomoniasis.
Bacterial Vaginosis contd.
Treatment
Cure rates 80 to 90 percent at 1 week, but within 3 months,
30 % of women have experienced a recurrence of altered
flora.
Treatment of male sexual partners does not benefit women
with this recurring condition and is not recommended.
Bacterial Vaginosis contd.
Chancre
Syphilis Contd.
Secondary Syphilis
This phase is associated with bacteremia % develops 6
weeks to 6 months after a chancre appears.
Its hallmark is a maculopapular rash that may involve the
entire body and includes the palms, soles, and mucous
membranes.
As is true for the chancre, this rash actively sheds
spirochetes.
In warm, moist body areas, this rash may produce broad,
pink or gray-white, highly infectious plaques called
condylomata lata.
Fever, malaise
The kidney, liver, joints, and central nervous system (CNS)
(meningitis) may be involved
Syphilis Contd.
Condylomata lata
maculopapular rash
Syphilis Contd.
Latent Syphilis
A. Early latent syphilis
Is first year following secondary syphilis without treatment secondary
signs and symptoms may recur.
Lesions associated with these outbreaks are not usually contagious.
B. Late latent syphilis is defined as a period greater than 1 year after
the initial infection.
Tertiary Syphilis
This phase of untreated syphilis may appear up to 20 years after
latency. Gummas
During this phase, cardiovascular, CNS, and musculoskeletal
involvement become apparent.
cardiovascular and neurosyphilis are common in males
Syphilis Contd.
Diagnosis
Early syphilis is diagnosed by dark-field examination or
direct fluorescent antibody testing of lesion exudate.
In the absence of this positive diagnosis, presumptive
diagnosis may be reached with serologic tests that are
A. Nontreponemal
Venereal disease research laboratory (VDRL) or
Rapid plasma reagin (RPR) tests
B. Treponemal-specific tests may be selected:
Fluorescent treponemal antibody-absorption (FTA-ABS) or
Treponema pallidum particle agglutination (TP-PA) tests.
Syphilis Contd.
Treatment
Benzathine penicillin is the treatment of choice.
With treatment, Jarisch-Herxheimer reaction, may occur
After treatment follow up at 6-month intervals for clinical evaluation as
well as serologic retesting.
Following treatment, sequential nontreponemal tests should be
performed.
A fourfold titer decrease (two dilutions) is required to define a clinically
significant decline.
During surveillance, the same type test should be used.
These tests usually become nonreactive after treatment and with time.
However, some women may have a persistent low rating, and these
patients are described as serofast.
Syphilis Contd.
Recommended Treatment of Syphilis
Primary, secondary, early latent (<1 year) syphilis
Recommended regimen:
Benzathine penicillin G, 2.4 million units IM once
Alternative oral regimens (penicillin-allergic, nonpregnant women):
Doxycycline 100 mg orally twice daily for 2 weeks or
Tetracycline 500 mg orally four times daily for 2 weeks
Late latent, tertiary, and cardiovascular syphilis
Recommended regimen:
Benzathine penicillin G, 2.4 million units IM weekly times 3 doses
Alternative oral regimen (penicillin-allergic, nonpregnant women):
Doxycycline 100 mg orally twice daily for 4 weeks
Chancroid
It is caused by a nonmotile, nonspore-forming, facultative, gram-
negative bacillus, Haemophilus ducreyi.
Incubation usually spans 3 to 10 days
Chancroid does not cause a systemic reaction,
Initially as an erythematous papule develops that becomes pustular
and within 48 hours, ulcerates.
Edges of these painful ulcers are usually irregular with
erythematous nonindurated margins.
The ulcer bases are usually red and granular.
Lesions are frequently covered with purulent material
Fourchette, vestibule, clitoris, and labia are usual locations
Half of patients will develop unilateral or bilateral tender inguinal
lymphadenopathy. If large and fluctuant, they are termed buboes.
Chancroid Contd.
Diagnosis
Definitive diagnosis requires growth of H ducreyi on culture
media.
A presumptive diagnosis can be made with identification of
gram-negative, nonmotile rods on a Gram stain of lesion
contents.
Before obtaining either specimen, superficial pus or crusting
should be removed with sterile, saline-soaked gauze.
Treatment
Successful treatment will result in symptomatic
improvement within 3 days, and objective evidence of
improvement within 1 week.
Lymphadenopathy resolves more slowly, and if fluctuant,
incision and drainage may be warranted. 231`
Chancroid Contd.
"groove" sign
Lymphogranuloma Venereum Contd.
Table comparing
vaginitis
Pathogens Causing Suppurative Cervicitis
68
Management Objectives
Proper diagnosis
Proper treatment begins by
-Risk assessment
-Clinical evaluation
-Confirmation
STIs Management Approaches
I. Etiological/laboratory approach:-
Done by identifying the causative agent (s) using lab.
tests and giving treatment specific to the pathogen
identified.
II. Syndromic approach:-
Identification of clinical syndrome.
Etiologic Diagnosis
Ideal approach
Important for validation of treatment algorithm
Determine prevalence
The only way to diagnose asymptomatic STI
Expensive
Time consuming
Requires lab facility
Ranges from simple laboratory tests to complex
(Microscopy, culture, Immunological tests, DNA
amplification)
Syndromic Approach
78
Patient complains
of urethral discharge
or dysuria Urethral Discharge
Take history Syndrome
& Do P/E; milk urethra
if necessary •Educate and counsel
•Offer VCT
Discharge No •Review if symptoms
Other STIs No
confirmed persist
present?
•Promote and provide
yes condoms
Treat for gonorrhea Yes
and chlamydia
•Educate
•Counsel Use appropriate
•Promote and provide condoms flow chart
•Offer VCT
•Partner management
•Advise to return in 7 days
if discharge persists
Recommended Treatment for Urethral
Discharge and Burning on Urination
Ciprofloxacin 500 mg po stat,
or
Spectinomycin 2g IM stat
and
Doxycycline 100 mg po BID for 7 days, or
Tetracycline 500 mg po QID for 7 days, or
Erythromycin 500 mg po QID for 7 days if the
patient has contraindications for Tetracyclines
80
Patient complains of Persistent or
Persistent/ recurrent
Urethral discharge or dysuria Recurrent Urethral
Take history Discharge in Men
and examine
•Educate/ counsel
No Other STIs No •Promote and
Discharge confirmed provide condoms
present
• Offer VCT
Yes
Yes
Does history
confirm reinfection
Use appropriate
or poor compliance
flow chart
No
Yes
Treat for trichomonas
vaginalis Repeat
•Educate/ counsel urethral discharge
•Promote and provide condoms treatment
•Return in 7 days
•Educate/ counsel
Improved Yes •Promote and provide condoms
No • Offer VCT
Refer
Vaginal Discharge
• Common causes:
Neisseria gonorrhea
Chlamydia trachomatis
Trichomonas vaginalis
Bacterial vaginosis
Candida albicans
82
Patient complains
of vaginal discharge or
vulval itching/ burning
Vaginal Discharge
Take history, examine patient
(external speculum and bimanual)
and assess risk Educate
No
Counsel
Abnormal discharge present Promote and provide condoms
Yes
Offer VCT
84
Patient complains of genital ulcer
Genital Ulcer
Take history & examine
Syndrome
Vesicles Or Recurrence
More than 3 ulcers No
Yes
No Solitary non vesicular Educate
Treat for HSV Non recurrent Promote and
provide
Yes condoms
Offer VCT
•Educate and counsel
•Promote and provide condoms Treat for syphilis,
•Offer VCT chancroid and HSV
•Ask the patient to return in 7 days
No
No
Ulcers healed Ulcers improving Refer
Yes
Educate and counsel Yes
Promote and provide condoms
Offer VCT
Partner management Continue treatment for further 7 days
Genital Ulcer Disease Treatment
• Recommended treatment for non-vesicular genital ulcer
– Benzanthine penicilline 2.4 million units IM stat, or Doxycycline 100
mg bid for 15 days
and
– Ciprofloxacin 500mg, po, bid for 3 days, or Erythromycin 500 mg, po,
QID for 7 days
• Recommended treatment for vesicular or recurrent genital
ulcer
– Acyclovir 200 mg five times per day for 10 days
or
– Acyclovir 400 mg TID for 10 days
86
Patient complains of
lower abdominal pain
Lower Abdominal Pain
Take history including gynecological
and examine (abdominal and vaginal)
88
Scrotal Swelling
Recommended Therapy
• Ciprofloxacin 500mg PO stat or Spectinomycin
2gm IM stat
and
• Doxycycline 100mg PO BID for 7 days, or
Tetracycline 500mg BID for 7 days
89
Patient complains of
scrotal swelling or pain
Scrotal Swelling
91
Patient complaining of
inguinal swelling Inguinal Bubo
Take history
and examine
•Educate
Any other •Counsel
Inguinal/femoral No
STI present No •Offer VCT
bubo present? •Promote and provide condoms
Yes
93
Neonatal Conjunctivitis
• Infection of the eyes of the neonate as a result
of genital infection of the mother, transmitted
during birth
• Causes:
– Neisseria gonorrhea
– Chlamydia trachomatis
94
Neonate presents with eye discharge Neonatal Conjunctivitis
Take history and examine child
No No Reassure mother,
Purulent conjunctivitis present? Signs of other illness
educate parents
present?
Review if symptoms persist
Yes
Yes
Treat baby for gonococcal and
chlamydial opthalmia Treat appropriately
AND
Treat mother and partner for gonorrhoea
and chlamydia
Educate and counsel
Review baby in 7 days or sooner
if symptoms worsen
Review in
7 days
Yes Complete treatment course,
Eye infection cleared? reinforce education and counseling
Review if necessary
No
96
Pelvic inflammatory disease
Refers to acute infection of the upper genital tract of female
pelvis not related to pregnancy or surgery
Over 80% caused by STDs like gonorrhea and Chlamydia.
Lower abdominal pain is the cardinal presenting symptom
Recent onset of pain that worsens during coitus or with jarring
movement.
The onset of pain during or shortly after menses is particularly
suggestive
The abdominal pain is usually bilateral and rarely of more than
two weeks' duration
Uterus, tubes, ovaries, pelvic peritoneum are affected
Gonococcus may give perihepatitis
PID diagnosed with minimum, additional & definitive
diagnostic criteria
PID Contd.
Perihepatitis
Perihepatitis (Fitz-Hugh Curtis Syndrome) was first associated with
gonococcal salpingitis in 1920 and subsequently with Chlamydia.
It consists of infection of the liver capsule and peritoneal surfaces of
the anterior right upper quadrant, with minimal stromal hepatic
involvement.
It manifests as a patchy purulent and fibrinous exudate in the acute
phase ("violin string" adhesions), most prominently affecting the
anterior surfaces of the liver (not the liver parenchyma)
Symptoms are typically the sudden onset of severe right upper
quadrant abdominal pain with a distinct pleuritic component,
sometimes referred to the right shoulder.
Aminotransferases are abnormal in approximately one-half of
patients
Perihepatitis
Hospitalization is indicated if
Surgical emergencies not excluded
Pregnancy
Clinical failure of oral antimicrobials
Inability to follow or tolerate oral regimen
Severe illness, nausea/vomiting, high fever
Tubo -ovarian abscess
Management of PID Contd.
Parenteral Regimen A
Ceftriaxone 1- 2 g IV q 12 hours
or
Cefoxitin 2 g IV q 6 hours
PLUS
Doxycycline 100 mg orally/IV
q 12 hrs
WITH OR WITHOUT
Metronidazole 500 mg IV/po q 8 hours
Management of PID Contd.
Parenteral Regimen B
Clindamycin 900 mg IV q 8 hours
PLUS
Gentamicin loading dose IV/IM (2 mg/kg) followed
by maintenance dose (1.5 mg/kg) q 8 hours.
Single daily dosing may be substituted.
Management of PID Contd.