Infections of the Genital Tract - Part III

Infections ofInfections of
the Genitalthe Genital
TractTract
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Doctors University College of Medicine
February 2016
@helenvmadamba CDUCM 2016

References

LECTURE OUTLINE
• Infections of the Vulva
• Bartholin’s gland abscess
• Ectoparasites
• Diseases characterized by Ulcers
• HPV and Anogenital Warts
• Infections of the Vagina
• Diseases Characterized by Vaginal Discharge
• Infections of the Cervix
• Diseases Characterized by Cervicitis

LECTURE OUTLINE
• Infections of the Upper Genital Tract
• Pelvic Inflammatory Disease
• Sexual Assault & STDs

The Five P’s
1. Partners
2. Practices
3. Prevention of
Pregnancy
4. Protection from
STDs
5. Past history of
STDs

INFECTIONS OF
THE CERVIX
PART III

Diseases
Characterized by
Urethritis and
Cervicitis
• Gonococcal infections
• Chlamydial infections

CERVIX
• The cervix acts as a barrier between the
abundant bacterial flora of the vagina
and the bacteriologically sterile
endometrial cavity and oviducts

Cervicitis
• Vaginal discharge, deep dyspareunia,
postcoital bleeding
• Cervix that is hypertrophic and
edematous
• Chlamydia trachomatis is the most
common etiologic agent

Cervicitis
• Vaginal discharge, deep dyspareunia,
postcoital bleeding
• Cervix that is hypertrophic and
edematous
• Majority of women who have
mucopurulent cervicitis are infected by
C. trachomatis or N. gonorrhoeae
• Many women harboring sexually
transmitted pathogens in the cervix are
asymptomatic.

Mucopurulent Cervicitis
• Gross visualization of yellow
mucopurulent material on a white
cotton swab

Mucopurulent Cervicitis
• Presence of 10 or more PMN
leukocytes per microscopic field on
Gram-stained smears obtained from
the endocervix
• Erythema and edema in an area of cervical
ectopy
• Associated with bleeding secondary to
endocervical ulceration
• Friability when endocervical smear is
obtained

Chlamydia
trachomatis
•most frequently reported
infectious disease
•prevalence is high among
persons aged 25 years or less
•most serious sequelae:
• PID
• ectopic pregnancy
• infertility

Chlamydia
trachomatis
•Diagnostics: urine or swab
specimens collected from
endocervix or vagina
•Others:
• culture
• direct immunofluorescence
• EIA

Chlamydia
trachomatis
This woman’s cervix has manifested signs
of an erosion and erythema due to
chlamydial infection.
• An untreated chlamydia infection can
cause severe, costly reproductive and
other health problems including both
short- and long-term consequences

CHLAMYDIAL CERVICITIS

Treatment for nonpregnant
women
Recommended Regimens
• Azithromycin 1g orally in a single dose OR
• Doxycycline 100mg orally twice a day for 7 days
Alternative Regimens
• Erythromycin base 500mg orally four times a day
for 7 days OR
• Erythromycin ethylsuccinate 800mg orally four
times a day for 7 days OR
• Ofloxacin 300mg orally twice a day for 7 days OR
• Levofloxacin 500mg orally once daily for 7 days

Treatment for pregnant
women
Recommended Regimens
• Azithromycin 1g orally in a single dose OR
• Amoxicillin 500mg orally thrice a day for 7 days
Alternative Regimens
for 7 days OR
for 14 days OR
times a day for 7 days OR
times a day for 14 days

CDC 2015 STD Guidelines

Neisseria gonorrhoeae
• second most commonly reported
bacterial STD.
• majority of urethral infections caused by
N. gonorrhoeae
• among women, several infections do not
produce recognizable symptoms until
complications (PID) have occurred.
• women aged 25 years or less are at
highest risk for gonorrhea infection.

Neisseria gonorrhoeae
• Risk factors include previous gonorrhea
infection, other sexually transmitted
infections, new or multiple sex partners,
inconsistent condom use, commercial
sex work, and drug use.
• Diagnostics: a Gram stain of a male
urethral specimen that demonstrates
polymorphonuclear leukocytes with
intracellular Gram-negative diplococci

Treatment
Ceftriaxone 250 mg IM in a single dose
OR
Cefixime 400mg orally in a single dose
OR
Single dose injectable cephalosporin
regimens
PLUS
Treatment for chlamydia if chlamydial
infection is not ruled out

INFECTIONS OF
THE UPPER
GENITAL TRACT
PART IV

Infections of the Upper
Genital Tract
• Pelvic Inflammatory Disease

Pelvic Inflammatory
Disease
• An infection in the upper genital tract
not associated with pregnancy or
intraperitoneal pelvic operations.
• Salpingitis – infection of the oviducts is
the most characteristic and common
component of PID.
Katz et al. 2007. Comprehensive Gynecology.

Pelvic Inflammatory
Disease
• A spectrum of inflammatory disorders
of the upper female genital tract,
including any combination of
endometritis, salpingitis, tubo-ovarian
abscess and pelvic peritonitis.
CDC. 2010 STD Treatment Guidelines.

Fitz-Hugh-Curtis

Acute PID
• ascending infection from the bacterial
flora of the vagina and cervix in >99%
of cases
• <1% of cases, from transperitoneal
spread of infectious material from
perforated appendix or intraabdominal
abscess
• Hematogenous and lymphatic spread
to the tubes or ovaries

Major Sequelae of PID
• Ectopic pregnancies: ↑6 to 10-fold
• Chronic pain: ↑4-fold
• Infertility: 6% to 60% depending on
severity of the infection, the number of
episodes and the age of the patient

Reduction of Impact of acute
PID
• Aggressive therapy for LGTI
• Early diagnosis and treatment of UGTI
• Primary prevention: safe sexual
practices
• Secondary prevention: screening for
gonorrhea, chlamydia and active
cervicitis, treatment of partners,
education to prevent recurrent
infection

Silent or asymptomatic
PID
• CDC emphasized: aggressively treat
women if there is any suspicion of the
disease, because the sequelae are so
devastating and the clinical diagnosis
made from the symptoms, signs and
laboratory data is often incorrect.

Neisseria gonorrheae
Chlamydia trachomatis
• These two organisms co-exist 25-50%
of the time
• Gonorrheal organisms frequently
cultured during first 24 to 48 hours of
the disease, but often absent later.

Minimum criteria:
Initiate empiric treatment in the presence of
any ONE of the three:
• Cervical motion tenderness
• Uterine tenderness
• Adnexal tenderness
• Predominance of leukocytes in vaginal
secretions, cervical exudates or cervical
friability increases specificity of diagnosis
CDC 2010 STD Treatment Guidelines

Additional criteria
• Oral temperature > 38.3 C◦
• Abnormal cervical or vaginal mucopurulent
discharge
• Presence of abundant numbers of WBC on
saline microscopy of vaginal fluid
• Elevated ESR
• Elevated C-reactive protein
• Laboratory documentation of cervical
infection with N. gonorrhoeae or C.
trachomatis

Most specific criteria
• Endometrial biopsy with histopathologic
evidence of endometritis
• Transvaginal sonography or MRI showing
thickened, fluid-filled tubes with or
without free pelvic fluid or tubo-ovarian
complex, or Doppler studies suggesting
pelvic infection
• Laparoscopic abnormalities consistent
with PID

Indications for
hospitalization
• 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 and
vomiting, or high fever
• The patient has tubo-ovarian abscess

• Cefotetan 2 g IV every 12 hours OR
• Cefoxitin 2 g IV every 6 hours PLUS
• Doxycycline 100 mg orally or IV every 12
hours

• Discontinue parenteral therapy 24
hours after clinical improvement:
 Doxycycline 100 mg every 12 hours to complete
14 days
• For tubo-ovarian abscess:
• Add oral clindamycin or metronidazole to
provide more effective anaerobic
coverage

Follow up
• Clinical improvement within 3 days
after initiation of therapy

Management of Sex
Partners
• Male partners of women who have PID
caused by C. trachomatis and/or N.
gonorrhoeae frequently are
asymptomatic.
• should be examined and treated if they
had sexual contact during the 60 days
preceding the patient’s onset of symptoms
• If >60 days, must be treated
• Abstain from sexual intercourse until
therapy is completed.

Management of Sex Partners
• Abstain from sexual intercourse until therapy is
completed.

SEXUAL
ASSAULT &
STDs
PART V

Adolescents and Adults
• Trichomoniasis, bacterial vaginosis,
gonorrhea, and chlamydial infection are
the most frequently diagnosed
infections among women who have
been sexually assaulted.
• Chlamydial and gonococcal infections in
women are of particular concern
because of the possibility of ascending
infection.

• HBV infection can be prevented through
postexposure vaccination.
• HPV vaccination is also recommended
for females through age 26 years.
• Reproductive-aged female survivors
should be evaluated for pregnancy.
Adolescents and Adults

These slides will be uploaded onto
http://www.slideshare.net/HelenMadamba

Infections of the Genital Tract - Part III

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