Infections in gynecology
Dr Hiba Ahmed Suhail M.B. Ch. B./F.I.B.O.G. College of medicine University of MosulDischarge arising from the vagina can be physiological or pathological Physiological discharge
Normal vaginal discharge is white ,thin ,odorless , and becoming yellowish on contact with air, due to oxidation not associated with itching nor pain . It consists of desquamated epithelial cells from the vagina and cervix , mucus originating mainly from the cervical glands, bacteria and fluid , which is formed as a transudations from the vaginal wall. pH is 3.5-4.5.
Physiological discharge increases due to increased mucus production from the cervix in: Mid-cycle. Pregnancy When women begin using a combined oral contraceptive pill.
Lower genital tract infections Vs Upper genital tract infections
Lower genital tract infections (vulvovaginitis )Vaginal candidiasis
It is the most common lower genital tract infection The organism is carried in the gut, under the nails, in the vagina and on the skin The yeast Candida albicans is implicated in more than 80 per cent of cases; C. glabrata, C. krusei and C. tropicalis account for the rest. It is not a sexually transmitted disease (STD).The clinical presentation
Itching and soreness of the vagina and perineum with A curdy, thick, white discharge, which may smell yeasty, but in some cases there may be itching and redness with a thin, watery discharge. The pH of vaginal fluid is usually normal, between 3.5 and 4.5. Microscopy and culture of the vaginal fluid can confirm a diagnosis Asymptomatic women from whom Candida is grown on culture do not require treatment.
Predisposing factors
• Immunosuppression• HIV• Immunosuppressive therapy, e.g. steroids• Diabetes mellitus• Vaginal douching , tight clothing, • Increased oestrogen• Pregnancy• High-dose combined oral contraceptive pill• Underlying dermatosis, e.g. eczema• Broad-spectrum antibiotic therapyRecurrent and relapsing candida:
Recurrent Candida, or Candida not responding to treatment, is relatively uncommon. Differential diagnoses Herpes simplex. Dermatological conditions such as eczema &lichen sclerosis .Treatment
Topical It is better to use a rather than a systemic This minimizes the risk of systemic side effects Vaginal creams and pessaries can be used . For uncomplicated Candida, a single dose vaginal suppository or cream , such as clotrimazole 500 mg or 100 mg daily for 5 days , nystatin , miconazole Systemic use of oral therapy, particularly if treatment is required at the time of menstruation. A single 150 mg tablet of fluconazole is usually effective, but its activity is limited to C. albicans strains. Longer courses of treatment are needed when there are predisposing factors that cannot be eliminated, such as steroid therapy. If recurrences occur frequently, a full blood count is done to check for diabetes, anemia and thyroid function, In recurrent candidiasis treatment to be taken once or twice a month for 6 months to suppress recurrencesBacterial vaginosis
Bacterial vaginosis is the commonest cause of abnormal vaginal discharge in women of childbearing age ( 12 per cent) . Predisposing factors It is commoner in women of Afro-Caribbean origin In those who have an intrauterine device (IUD) Women undergoing elective termination of pregnancy Women with STIs. It is reported in un married woman . The condition often arise around the time of menstruation and may resolve spontaneously in mid-cycle.Pathophysiology
When BV develops, the predominantly anaerobic organisms that are usually present in the vagina at low concentration increase in concentration up to a thousand- fold. This is accompanied by a rise in vaginal pH to between 4.5 and 7.0, The lactobacilli may disappear. The organisms most commonly associated with BV are Gardnerella vaginalis, Bacteroides (Prevotella) spp., Mobiluncus spp. and Mycoplasma hominis.Clinical features
The principal symptom of BV is an offensive fishy smelling discharge. It is characteristically thin, homogeneous and adherent to the walls of the vagina and may be white or yellow. There is no itching or soreness.
The diagnosis
The diagnosis is commonly made in clinical practice using the (Amsel) criteria:• Vaginal pH > 4.5.• Release of a fishy smell on addition of alkali (10% potassium hydroxide).• A characteristic discharge on examination.• Presence of 'clue cells' on microscopy. 'Clue cells' are vaginal epithelial cells so heavily coated with bacteria that the border is obscured.Gram-stained vaginal smear.Large numbers of Gram-positive and Gram-negative cocci are seen, with reduced or absent large Gram positive bacilli (lactobacilli) .Culture of a high vaginal swab yields mixed anaerobes and a high concentration of Gardnerella vaginalisTreatment
Systemic metronidazole 400 mg twice a day for 5 days, or 2 g as a single dose. Topical preparations are available in the form of metronidazole gel 0.75% or clindamycin cream 2%. Initial cure rates are over 80 per cent, but up to 30 per cent of women relapse within 1 month of treatment. BV may develop and remit spontaneously. Symptomatic women with recurrent BV get benefit from regular treatment once or twice a month with oral or topical metronidazoleComplications and risks of BV
Women with BV are at a greater risk of : 1- Second trimester miscarriage 2-Preterm delivery during pregnancy which may result in perinatal mortality or cerebral palsy. 3-Women with BV are also at increased risk of infections after surgery. Women with a prior history of second trimester loss or idiopathic preterm birth should be screened for BV and treated with metronidazole early in the second trimester.Trichomoniasis
This sexually transmissible infection can be carried asymptomatically for several months before causing symptoms. In men it is carried asymptomatically, but may present as non-gonococcal urethritis (NGU). Presentation Woman presented with vulvovaginitis as a yellow or green vaginal discharge (purulent), sometimes Offensive in odor. Dysuria With itching and soreness . . Punctuate hemorrhages can occur on the cervix, giving the appearance of a 'strawberry cervix'.Diagnosis
Microscopy of the vaginal secretions mixed with saline for detecting the organism.,numerous polymorphonuclear cells are seen and the motile organism is identified from its shape and four moving flagellae. Culture preferably in a specific medium such as Fineberg-Whittington.Treatment
Metronidazole, either 2 g as a single dose or 400 mg twice a day for 5 days. The husband should be treated . Occasionally persistent trichomoniasis is seen, this may be due to: Poor compliance with medication. Poor absorption . Resistant organism Re infection treated with higher doses of metronidazole, 400 mg three times a day for 7 daysUpper genital tract infections
Pelvic inflammatory disease(PID )is a broad term used to cover upper genital tract infection: Infection of the uterus ( endometritis ¶metritis) Infection of the tubes ( salpingitis ) Infection of the ovary (oophoritis). Infection of the pelvic peritoneum.Source of infection
usually direct spread from the vagina or cervix through the uterine cavity . Lymphatic spread may either parametrially or along the surface of the uterus. Infection spread from the bowel blood borne.Causative organism
Different organisms can cause PID , but 80 per cent of cases are triggered by a sexually transmissible infection (STI) - either Chlamydia or gonorrhoea. Endogenous anaerobes, such Bacteroides spp. Mycoplasma genitalium and Mycoplasma hominis, as secondary invaders and are responsible for tubal abscess formation.Chlamydia trachomatis
It is STI(sexually transmiteded infection ) Is a small bacterium that is an obligate intracellular pathogen. It invade columnar epithelium . Serovars A-C cause trachoma, infecting the conjunctiva. Serovars D-K cause genital infections. serovars (Ll-L3) cause LGV. Many infections are asymptomatic: approximately 50 per cent in men and 80 per cent in women.Diagnosis of Chlamydia
Chlamydial diagnose by specific tests on samples collected from the endo cervix , and urethral swab Cell culture techniques is expensive and has 60 percent sensitivity so not routinely recommended. Enzyme linked immunosorbent assay (ELISA) tests are used previously and replaced now by Nucleic acid amplification test with more than 90%senstivity . . Tests that detect DNA, such as the PCR and the ligase chain reaction (LCR), are sensitive. . A direct fluorescent antibody (DFA) test Micro-immunofluorescence can be used to detect serum antibodies, which are not present in all infected individualTreatments for uncomplicated Chlamydia infection:
• Doxycycline 100 mg twice a day for 14days• Azithromycin 1 g as a single dose• Ofloxacin 400 mg daily for 14days.in pregnancy:• Azithromycin 1 g as a single dose• Erythromycin 500 mg twice a day for 14 daysGonorrhea
It is STI Chronic asymptomatic infection is common: 50 per cent of women have no symptoms or signs of infection. 30 per cent of men. In men, gonorrhoea causes a severe urethritis, with green urethral discharge and dysuria. In women, the spectrum of disease is similar to that of Chlamydia. Neisseria gonorrhoeae may be carried in the throat or cause an exudative tonsillitis, conjunctivitis, proctitis Neisseria gonorrhoeae is a Gram-negative diplococcus, which colonizes columnar or cuboidal epithelium.The diagnosis of gonorrhea
Is made by Microscopically observing typical Gram-negative intracellular diplococci on Gram-stained smears of urethral, cervical swab. Culture it is a fastidious organism, requiring a carbon dioxide concentration of 7 percent media such as blood agar and antibiotics to inhibit the growth of other organisms. DNA-based detection tests are available for screening . Nucleic acid amplification testTreatment of gonorrhea
The following are effective for sensitive strains of gonorrhoea infection:• Amoxycillin 1 g with probenecid 2 g as a single dose.• Ciprofloxacin 500 mg as a single dose.• Azithromycin 1 g as a single dose.• Ceftriaxone 250mg as a single dose (IM)• Cefixime 400 mg as a single dose.Pathophysiology of Pelvic inflammatory disease
As infection ascends into the uterus, endometritis develops Salpingitis (infection of the tube ) mucosal inflammation with swelling, redness and deciliation with the invasion by WBC. Inflammatory exudates fills the lumen of the tube, and adhesions develop between mucosal folds. Subsequent scarring may lead to the fimbriael adhesion and sealing the ends of the tubes. Pus exudes from the fimbriae to the pelvis A hydrosalpinx is caused by accumulation of fluid within the tube , pyosalpinx or tubo-ovarian abscesses may develop uterus and tubes pulled back into the pelvis by adhesions, becoming fixed and retroverted. pelvic peritonitis with congestion . Pelvic adhesions results in matting the pelvic organs together .Clinical features
the clinical diagnosis is 70-80 per cent accurate. Most chlamydial and gonococcal infections are Asymptomatic and discovered during screening. Alteration of the normal vaginal discharge or purulent vaginal discharge Pelvic pain and lower abdominal pain . Deep dyspareunia . Inter menstrual bleeding ,post coital bleeding and HMB may be caused by endometritis. Urinary tract infection. It is not uncommon for women to have an associated dysuria and urethral dischargeOn examination:
Patient may be asymptomatic or systemically unwell. Lower abdominal tenderness +_mass . Endo cervical discharge with contact bleeding . Cervical motion tenderness (called cervical excitation) with or without uterine and adnexal tenderness. Tender adnexal mass .Differntial diagnosis :
Lower genital tract infection: BV, trichomoniasiso have an associated cervicitis. Appendicitis Endometriosis Bleeding corpus luteum Ectopic pregnancy Complicated ovarian cyst Uretric stone and UTI. Pelvic kidney .Investigation
• Raised neutrophil count and a raised erythrocyte sedimentation rate (ESR)( in more severe cases) .A high vaginal swab & endocervical swabs should be taken for the detection of C. trachomatis and N. gonorrhoeae &Trichomonas vaginalis.Ultrasound to exclude other pathology and an adnexal mass(abcess ) which may be present in 20 per cent of cases . Laparoscopy is regarded if there is any doubt about the diagnosis.Pregnancy test should be performed if there is any doubt about the possibility of pregnancy.Consequence of PID: PID is associated with tubal damage leading to ectopic pregnancy Tubal factor infertility . Chronic pelvic pain .
Treatment of PID:
Patients with mild to moderate symptoms can be Treated as outpatients. The antibiotic regimen should Cover both Chlamydia and gonorrhoea, as well as an anaerobic organism. Doxycycline100 mg twice a day with metronidazole 400 mg twice a day with ciprofloxacin 500 mg twice a day for 14 days . An alternative is to use ofloxacin400 mg daily for 2 weeks with metronidazole 400 mg twice a day. Ceftrixone 250 mg single IM injection with oral doxycycline 100mg twice daily for 14 days . Ceftrixone 250 mg single IM injection with oral azithromycin 1gm metronidazole 400 mg twice a day per week for 2weeks.If one sexually transmissible infection is present, there may be others. So a full screen should be performed for Chlamydia, gonorrhea, syphilis. To break the chain of infection and prevent re-infection, the husband should received appropriate treatment. Follow-up evaluation and tests of cure are essential for Neisseria gonorrhea and Chlamydia