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  2. 2. Sexually Transmitted Diseases • 1. 2. 3. 4. 5. The term denote disorders spread principally by intimate contact:Sexual intercourse, Close body contact, kissing, and anal intercourse. Transplacental spread, Passage through the birth canal, and Lactation during the neonatal period
  3. 3. Terminology • WHO recommends that the term STD be replaced by the term STI. • STI has been adopted since 1999 as it better incorporates asymptomatic infections. • Has also been adopted by a wide range of scientific societies & publications.
  4. 4. Introduction • the most common infectious diseases in the most parts of the world • five key points about all STDs today:
  5. 5. 1. STDs affect men and women of all backgrounds and economic levels. - They are most prevalent among teenagers and young adults. - Nearly two-thirds of all STDs occur in people younger than 25 years of age.
  6. 6. continued 2. The incidence of STDs is rising - Because in the last few decades, young people have become sexually active earlier yet are marrying later. - In addition, divorce is more common. - The net result is that sexually active people today are more likely to have multiple sex partners during their lives and are potentially at risk for developing STDs.
  7. 7. continued 3 Most of the time, STDs cause no symptoms, particularly in women. - When and if symptoms develop, they may be confused with those of other diseases not transmitted through sexual contact. - Even when an STD causes no symptoms, however, a person who is infected may be able to pass the disease on to a sex partner. - recommend periodic testing or screening for people who have more than one sex partner.
  8. 8. continued 4, STDs tend to be more severe and more frequent for women than for men, - because the frequency of asymptomatic infection many women do not seek care until serious problems have developed. - Some STDs can spread to cause PID, which in turn → infertility & ectopic (tubal) pregnancy. - may be associated with cervical cancer; HPV - causes genital warts - other genital cancers.
  9. 9. continued 5. STDs can be passed from a mother to her baby before, during, or immediately after birth; - When diagnosed and treated early, many STDs can be treated effectively. - Some infections have become resistant to the drugs used to treat them and now require newer types of antibiotics.
  10. 10. STD; microorganisms • Long list 1. Transmitted by sexual route (conventional STI) 2. Transmission described but less defined evidence
  11. 11. Cont’d; Organisms transmitted sexually • 1. 2. 3. 4. 5. 6. Bacteria N. gonorrhea C. trachomitis T. pallidum H. ducreyi C. granulomatis U. urealyticum • 1. 2. 3. 4. 5. Viral HIV HSV HBV HPV Molluscom contagiosum virus • Others 1. T. vaginalis
  12. 12. STDs; described but less defined for sexual transmission • Bacteria 1. M . hominis 2. G . vaginalis • 1. 2. 3. 4. • 1. 2. Viral CMV HCV HSV type 8 EBV Others C. albicans S. scabiei
  13. 13. Sexually transmissible 1. 2. 3. 4. 5. 6. Gonococci and Chlamydia infections Syphilis Genital herpes Papilloma virus infection LGV, Chancroid and GI Miscellaneous causes
  14. 14. Approaches to STD Dx & Rx Three approaches 1. Laboratory based 2. Clinical without laboratory support 3. Syndromic Approach
  15. 15. Background • Traditional approach to STD Dx and Rx relies on laboratory diagnosis to determine etiologic agents Expensive Involves delay in Dx and Rx Depends on technician and lab accuracy Often not available in resource poor settings Requires quality control procedures
  16. 16. …Background • Alternative approach – Clinical Dx Presumptive Dx of one etiology based on clinical findings Often inaccurate and incomplete • Similarities of Sn and Sx • Misses Co-infection • Atypical presentation - HIV
  17. 17. Definition • Syndromic Management is a management approach that uses clinical algorithms on an STD Syndrome, the constellation of patient symptoms and clinical signs to determine therapy. • Algorithms are adapted to local STD prevalence • Chooses antimicrobial agents to cover all the possible pathogens responsible for the syndromes in the specific geographic area.
  18. 18. Syndromic Management History  In 1991 WHO developed and started advocating the syndromic approach to address the limitation of aetiological (lab) & presumptive(clinical) Dx & Mx
  19. 19. …Syndromic Management Based On  Recognition of relatively consistent and characteristic combinations of easily elicited Sx and easily recognized Sn (Syndromes) with which STD commonly presents  Knowledge of the most common etiologies of different syndromes  Knowledge of antimicrobial susceptibility pattern  Knowledge of behavioral & demographic characteristics of people with STD
  20. 20. …Syndromic Management Components 1. Identification and Rx of the Syndrome 2. Education and counseling on - Rx compliance - Risk reduction including condom use 1. Partner notification 2. Provision of condoms 3. VCT for HIV
  21. 21. Advantages • Expedited care • Cost savings – less technically demanding • Increased client satisfaction • Treatment at first visit Decreases further transmission Decreases complication Eliminates need for return visit • Decrease incidence of HIV (by 42% in Tanzania)
  22. 22. …Advantages • Uses flow charts in case Mx which Standardizes Dx,Rx, referral and reporting Improves surveillance Improves programme Mx • High sensitivity • Gives emphasis to non-medical aspects of STD care
  23. 23. Disadvantages • Inevitable over treatment (multiple antimicrobials for single infection) • Does not address subclinical and asymptomatic STI • High sensitivity is at the cost of specificity • Doesn’t address poor health care seeking behavior for STD Sx • Works well with some syndromes (GU,UD) but not as well with others (VD)
  24. 24. …Disadv. • Rx with multiple drug might be expensive and • The recommended drugs may not be available • But, cost effectiveness increases further when  Applied to high STD prevalence areas  Long term cost of STD is considered  Increased HIV transmission and continued STD transmission is considered
  25. 25. Major STD Clinical Syndromes • • • • • • • Genital ulcer Urethral discharge Abnormal vaginal discharge Lower abdominal pain Bubo inguinale(INGUINAL LYMPHADENOPATHY) Scrotal swelling Neonatal conjunctivitis
  26. 26. Genital Ulcer Disease (GUD) • Algorithms for GUD try to identify presence of 1. Herpes, 2. Syphilis and/or 3. Chancroid • Frequency of causative agents differ in different parts • Review – syndromic treatment without lab support showed high cure rate  100% - Cote D’ivore  64% - Zambia
  27. 27. Herpes Simplex Virus – DNA virus • remain in latent form • other members of the family includes VZ, CMV ,EBV • there are different antigenic strains • but are divided in two:• Type1 = oral • Type2 = genital – primary infection occurs in child hood – latent infection resides in the sensory ganglion of trigeminal, sacral & vagal – 50 -100% of adults have serologic evidence of HSV1 – 20-80% type2
  28. 28. HSV Cont… • transmission = only by direct contact • clinical disease • painful papule followed by vesicle ,ulceration crusting & healing • more sever in women • Primary Vs Recurrent • primary episode – – – – more symptomatic incubation range 2-14 days there is fever & lymphadenities viral shedding & healing prolonged
  29. 29. HSV Cont… • recurrent episode – frequently have prodromal period signaling active viral replication, – lesions are often localized – shedding is shorter – recurrences is not usually from re infection but are reaction of latent viruses
  30. 30. • Diagnosis = mainly clinical – Tissue culture • best method but lengthy and costly – ELISA testing 70% – Direct immunofluoresent staining 75% sensitive = both the negative culture and smear don't exclude infection
  31. 31. Syphilis • organism characteristics & microbiology – By treponema pallidum – is tightly coiled a spirochete that can not be grown – can invade intact mucous membrane or area of abraded skin . • incidence and epidemiology – the incidence is rising – only 30% of patients exposed acquire the disease – in those infected patients not taking medication 60% do develop immune defense sufficient to control the infection – the remaining will go to late and tertiary syphilis
  32. 32. • Clinical diseases 1. EARLY SYPHILIS A = primary syphilis, • • • • painless chancre is the whole mark it occurs at the site of inoculation there is regional lymphadenopathy incubation period 10-90 days B = 20 syphilis - mucocutaneous skin lesion 6-8weeks after the original inoculation - alopacia, hepatitis & nephrotic syndrome
  33. 33. continued 2. Latent syphilis – characterized by serologic evidences but no clinical signs &symptoms – most patients are not infectious about 25% could have recent skin lesion – arbitrary division of this stage but has no clinical significance with regard to treatment – early latency (< 4 years from initial infection ) – late latency (>4 years )
  34. 34. continued 3. LATE SYPHILIS • 5-30 years after initial infection – there are three divisions 1. benign disease(gummas) - lesion occur in vital organs – can be life threatening if they compromise the organ 2. cardiovascular disease - involvement of the heart and the aorta are frequent dysfunction may cause serious problem 3. neurological diseases - three clinical syndromes of neurological involvement – asymptomatic disease no neurological manifestations but abnormal CSF – meningovascular disease the commonest manifestation is paresis , (tabis dorsalis) – parenchymatous disease →dementia the commonest manifestation
  35. 35. • Diagnosis A. Non treponemal specific test:• RPR (rapid plasma reagin) test, • standard VDRL slide test, B. Treponemal specific test; • FTA-ABS; fluorescent treponemal antibody absorbed (used commonly for adults ), • MHA_TP micro haemagglutination assay( for neonates) C. Dark field microscopy • the higher the titer the higher the inflammatory reaction • false +ve tests in chronic illnesses – e.g. leprosy - auto immune diseases( lupus) – pregnancy - drug addiction
  36. 36. Chancroid • Haemophilus ducreyi :- a gram negative bacteria • is a painful soft chancre ragged with raised borders • kissing ulcers do occur • unilateral lymphadenopathy that may suppurate • incubation period is 2-5 days • the organism is fastidious
  37. 37. …GUD Genital ulcers Patient complains of genital sore or ulcer Examine Ulcer present? Yes - Treat for syphilis and chancroid -Educate -Counsel if needed -Promote/provide condoms -Partner management -Advise to return in 7 days -Educate No Vesicular/recurrent lesion(s) present? Yes -Management of herpes -Educate -Counsel if needed -Promote/provide condoms No -Counsel if needed -Promote/provide condoms
  38. 38. …GUD • Syphilis  Recommended regimen Benzantine Penicillin 2.4miu im singledose Alternative regimen Procaine Penicillin 1.2miu im for ten days Penicillin allergy– TTC 500mg po qid/15d or doxycycline 100mg po bid/15d
  39. 39. …GUD • Chancroid Recommended regimen Erythromycin 500mg po qid/7days Alternative regimen Ciprofloxacin 500mg single dose or Ceftriaxone 250mg im single dose or Spectinomycin 2gm im single dose
  40. 40. …GUD • Herpes – to modify course of symptoms • 1st episode – acyclovir 200mg 5x per day /7 days(doesn’t appear to influence natural Hx of recurrent disease) • Recurrence – acyclovir 200mg tid continuously for frequently recurring outbreaks(>6 per year)
  41. 41. Inguinal Bubo • Inguinal adenopathy • LGV (L1,L2,L3), • Chancroid, • G I (donovanosis) is – Klebsiella granulomatis, formerly known as Calymmatobacterium granulomatis • Common in the tropics as a cause of genital ulcer • Men affected more than females • Prostitution is reservoir • Painful adenopathy
  42. 42. Inguinal Bubo, cont’d • Rare systemic symptoms except LGV • Common predisposing factor for the spread of HIV • Complications: – – – – – Abscess formation PID Lymphatic obstruction Stenosis Infertility
  43. 43. Differential Diagnosis • Infection in the lower limbs and perineum • Malignancy • Herpes genitalis • Syphilis
  44. 44. Inguinal Bubo Enlarged and/or painful inguinal lymph nodes? Examine Ulcer(s) present? Yes No - Treat for lymphogranuloma venereum -Educate -Counsel if needed -Promote/provide condoms -Partner management -Advise to return in 7 days Use genital ulcers flow chart
  45. 45. …Inguinal Bubo • Recommended regimen (LGV) Doxycycline 100mg po bid/14 days or TTC 500mg po qid/14 days • Alternative regimen Erythromycin 500mg po qid/14 days or Sulfadiazine 1gm qid/ 14 days • Aspirate fluctuant lymph nodes through normal skin • Incision and drainage or excision of nodes is contraindicated
  46. 46. Vaginal Discharge (VD) • Most difficult syndrome to diagnose • Either vaginitis or cervicitis • Cervicitis- N.gonorrhea - C.trachomatis • Vaginitis - Trichomonas vaginalis - Candida albicans - Bacterial vaginosis • Effective management of cervicitis is more important from patient point of view b/c of serious sequele
  47. 47. …VD • VD is not an adequate indicator of any particular STD making it a poor algorithm entry point • Use of risk assessment has shown to improve performance of syndromic management algorithms • The probability of correct Rx of STI relative to probability of overtreatment is increased
  48. 48. …VD • Risk scores use variables that are common risk predictors for STD Young age less than 21 Multiple partners Partner has urethral discharge New partner in the past three months Patient is single • Need adaptation to local,social and behavioral conditions and should be periodically updated
  49. 49. …VD Vaginal Discharge Patient complains of vaginal discharge (vaginal itching) partner symptomatic or specific risk factors positive? No Yes -Treat for cervical and vaginal infections -Educate -Counsel if needed -Promote/provide condoms -Partner management -Return if necessary -Treat for vaginal infection -Educate -Counsel if needed -Promote/provide condoms
  50. 50. …VD Vaginal Discharge (with speculum) Patient complains of vaginal discharge (vaginal itching) partner symptomatic or specific risk factors positive? No Yes Treat for cervical infection plus vaginal infection according to speculum examination findings Mucopus from Cervix? Profuse VD? Curd-like VD? - Treat for cervical & - Treat for trichomonas - Treat for vaginal infections & bacterial vagionosis Speculum and bimanual vaginal examinations No discharge? -Educate candida -Counsel if needed -Educate needed -Educate -Educate -Counsel if -Counsel if -Counsel if needed -promote/prov- needed Cervical motion tenderness present? Use flowchart for lower abdominal pain
  51. 51. …VD Treatment Cervicitis (Gonorrhea & Chlamydia) Recommended regimen Ciprofloxacin 500mg po single dose or Ceftriaxone 250mg im single dose or Cefixime 400mg po single dose or Spectinomycin 2gm im single dose Plus Doxycycline 100mg po bid/7 days or TTC 500mg po qid / 7 days or Erythromycin (pregnant)
  52. 52. …VD Vaginitis Recommended regimen metronidazole 2gm PO single dose or metronidazole 500mg PO bid/7 days plus Nystatin 100,000 IU intra vaginally once/14 d, or Clotrimazole 200mg once daily/3 days, or Clotrimazole 500mg single dose
  53. 53. Lower Abdominal Pain (LAP) Patient complains of lower abdominal pain Take history and examine (abdominal and vaginal) No Temp 38°C or Pain during examination (on moving cervix) No Missed/overdue or Vaginal discharge period or Yes Recent delivery - Treat for PID /abortion or -Educate Rebound -Counsel if tenderness or needed Guarding or -Promote/provide condoms Vaginal bleeding -Partner Follow up after 3 days or management Yes sooner if pain persists Refer No Refer Yes Continue Rx Improved? Follow up if pain persists
  54. 54. PID • PID refers to acute infection of the upper genital tract (above the internal cervical os) • community-acquired Vs Iatrogenic • USA - annually 2.5 million outpatient visits, • 200,000 hospitalizations, and • 100,000 surgical procedures • incurs an annual total expense of more than $5 billion
  55. 55. • Acute PID= attributed to an ascending spread of microorganisms from the vagina and endocervix. • Acute PID Vs Acute salpingitis – are often used interchangeably, – but PID is not limited to tubal infection only. • A more descriptive term = (UGTI). – Severity & Extent of disease • This is differentiated from (LGTI) because response to treatment appears to be different in these two entities.
  56. 56. • • • • • Etiology Neisseria gonorrhoeae and Chlamydia trachomatis serovars D-K common cause of PID = 1/3rd each; However, most = polymicrobial infection caused by ascending infection 15% of infections occur after procedures that break the cervical mucous barrier C. trachomatis etiologic role is very different from N. gonorrhea
  57. 57. • • • • • N. Gonnorrhea Gram-negative IC diplococcus rapid cycle 20 to 40 minutes to divide rapid and intense inflammatory response Less complication Early Rx • • • • • • C.Trachomatis is a slow-growing intracellular organism. lack of mitochondria growth cycle 48 to 72 hours does not induce a rapid or violent inflammatory response destruction by rupture Delayed Rx
  58. 58. Initial PID → • tissue damage provides fertile ground for the growth of secondarily infecting aerobic and anaerobic bacteria. • This necrotic tissue is an excellent growth medium, and • the epithelial damage enhances the breakdown of the surface defense mechanisms
  59. 59. • • • • • • Classification:Post STI / menustral Post abortal Post Partum Post Instrumentation IUD – Related Secondary PID
  60. 60. • Risk Factors 1. STI 2. Age – Adolescent 1:8 Vs 1:80 for a sexually active >24, b/c columnar epithelium 3. Contraceptives – – – – IUDs = threefold to fivefold Barriers = ↓ 60% OCP = ↓ risk, good Px fertility previous tubal ligation = 1/450; 4. Instrumentation ex. 1/200 induced abortion 5. Previous acute PID = 25 %, - partner treatment
  61. 61. Diagnosis:I. A minimal set of clinical criteria has been recommended by the CDC for empirical treatment of PID, including  Cervical motion tenderness or uterine or adnexal tenderness in the presence of lower abdominal or pelvic pain. The following additional criteria can also be used to support a clinical diagnosis of PID: 1. Oral temperature >101° F (>38.3° C) 2. Abnormal cervical or vaginal mucopurulent discharge 3. Presence of abundant numbers of white blood cells (WBCs) on saline microscopy of vaginal secretions 4. Elevated erythrocyte sedimentation rate 5. Elevated C-reactive protein
  62. 62. Diagnosis:II. Considered "confirmed" cases:  Patients with pelvic pain and tenderness and any one or more of the following are: 1. Acute or chronic (plasma cell) endometritis or acute salpingitis on histologic evaluation of a biopsy 2. Demonstration of N. gonorrhoeae or C. trachomatis in the genital tract 3. Gross salpingitis visualized at laparoscopy or laparotomy 4. Isolation of pathogenic bacteria from a clean specimen from the upper genital tract 5. Inflammatory/purulent pelvic peritoneal fluid without another source
  63. 63. Diagnosis:III. The "definitive" diagnosis of PID in symptomatic patients:  One or more of the following three findings are required: 1. Histologic evidence of endometritis in a biopsy 2. An imaging technique revealing thickened fluid-filled tubes/oviducts with or without free pelvic fluid or tuboovarian complex 3. Laparoscopic abnormalities consistent with PID (eg, tubal erythema, edema, adhesions; purulent exudate or cul-de-sac fluid; abnormal fibriae)
  64. 64. DDX:1. Gastrointestinal: Appendicitis, cholecystitis, constipation, gastroenteritis, inflammatory bowel disease 2. Renal: Cystitis, pyelonephritis, nephrolithiasis, urethritis 3. Obstetric/Gynecologic: Dysmenorrhea, ectopic pregnancy, intrauterine pregnancy complication, ovarian cyst, ovarian torsion, ovarian tumor
  65. 65. Laboratory tests — • • • • Pregnancy test Microscopic exam of vaginal discharge in saline Complete blood counts Nucleic acid amplification tests for chlamydia and gonococcus • Urinalysis • Fecal occult blood test • C-reactive protein (optional)
  66. 66. Investigations cont.... • Laparoscopy is limited as a method of diagnosing the early stages of PID, but it is important to rule out nonPID surgical emergencies, such as appendicitis, and other entities requiring different treatment modalities, such as endometriosis. • Endometrial biopsy is one alternative to laparoscopy. However, results may be delayed up to 2 to 3 days, making its clinical applicability limited. • Ultrasonography is of limited value for patients with mild or moderate pelvic PID. • Culdocentesis, with evidence of purulent peritoneal fluid, is helpful in the diagnosis of acute PID.
  67. 67. Recommendations — Despite this reservation about the  CDC criteria for the diagnosis of PID, it strongly agree  with the recommendation that "health care providers  should maintain a low threshold for the diagnosis of PID"  and that sexually active young women with the  combination of lower abdominal, adnexal, and cervical  motion tenderness should receive empiric treatment.
  68. 68. Complications: Early • Sepsis → MOF → Death( ruptured TOA = 10 %) • Surgical morbidity (TOA)  Late • Infertility = 20% ,if no Rx 50% to 70% • Ectopic Pregnancy = 6-10X higher; 12 %;                      ( due to interference of ovum transport through the tube or entrapment of  the ovum secondary to microscopic tubal damage). • Chronic pelvic Pain = 4x increases  (20% vs. 5%) • Chronic PID • Psychological consequences
  69. 69. Fitz-Hugh-Curtis syndrome, • Perihepatic inflammation and adhesions,  • 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). Thus, aminotransferases are also usually  normal  • develop in 1% to 10% of acute PID.  • RUQ- pain & tenderness, pleuritic pain,  • DDX =  acute cholecystitis or pneumonia.  • Develop from vascular or transperitoneal dissemination of either N.  gonorrhoeae or C. trachomatis to produce the perihepatic  inflammation. 
  70. 70. Treatment • based on the consensus that PID is  polymicrobial in cause.  • Empirical antibiotic protocols should cover  a wide range of bacteria  • Oral therapy can be considered for women  with mild to moderately severe acute PID 
  71. 71. Grading of severity Clinical system Grade I: Disease limited to the adnexae Grade II: PID with an inflammatory mass Grade III: Ruptured  tubo-ovarian abscess  Operative system Mild: Erythema and edema of the adnexae Moderate: Purulent exudate from fallopian tubes Severe: Pyosalpinx, inflamatory complex, TOA
  72. 72. CDC-Recommended Treatment Regimens for Oral  Therapy  • Regimen A - Levofloxacin 500 mg orally once daily for 14 days OR - Ofloxacin 400 mg orally once daily for 14 days WITH OR WITHOUT - Metronidazole 500 mg orally twice a day for 14 days • Regimen B - Ceftriaxone 250 mg IM in a single dose or Cefoxitin 2 g IM in a single dose or  (Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS - Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT - Metronidazole 500 mg orally twice a day for 14 days
  73. 73. Criteria for Hospitalization  • Surgical emergencies (such as appendicitis)  cannot be excluded.  • Pregnant.  • No response clinically to oral therapy.  • Unable to follow or tolerate oral regimen.  • Has severe illness, nausea and vomiting, or high  fever.  • The patient has a tuboovarian abscess. • Adolescents?? • HIV / Aids??
  74. 74. Criteria for Hospitalization  • Adolescents?? In the past, the CDC has suggested that all  adolescents with salpingitis be hospitalized because of their :  high noncompliance rate and to optimize treatment to prevent  damage to the reproductive tract, which could affect future fertility  and result in chronic pelvic pain. • HIV / Aids?? The microbiologic findings for HIV-positive and  HIV-negative women were similar, except for   (a) higher rates of concomitant M. hominis, candida, streptococcal,  and HPV infections and   (b) HPV-related cytologic abnormalities among those with HIV  infection.  Whether the management of immunodeficient HIV-infected women with  PID requires more aggressive interventions (e.g., hospitalization or  parenteral antimicrobial regimens) had not been determined.
  75. 75. CDC-Recommended Parenteral Treatment Regimen A - 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  Regimen B - Clindamycin 900 mg IV every 8 hours PLUS - Gentamicin  • D/C IV 24 hours after a patient improves clinically; • Continue oral therapy  – doxycycline 100 mg orally twice a day or  – Clindamycin 450 mg orally four times a day  • complete a total of 14 days of therapy 
  76. 76. • Male sex partners of women with PID should be  examined and treated • Education for the prevention of reinfection,  • Proper contraception   Surgical Mx • Laparascopy (helpful procedure for diagnosis, prognosis, and possibly  treatment of PID). • Laparatomy (for patients with surgical emergencies such as ruptured abscesses or  definitive treatment of failed medical management). • Colpotomy (posterior colpotomy is done to evacuate pus and to establish drainage from  a pelvic abscess that presents in the cul-de-sac). • Percutaneous drainage
  77. 77. Colpotomy There are three requirements for colpotomy drainage of a  pelvic abscess. 1. The abscess must be midline or nearly so. 2. The abscess should be adherent to the cul-de-sac  peritoneum and should dissect the rectovaginal septum  to assure the surgeon that the drainage will be  extraperitoneal and that pus will not be disseminated  transperitoneally. 3. The abscess should be cystic or fluctuant to ensure  adequate drainage.
  78. 78. Pelivic Tuberculosis • it is a frequent cause of chronic PID and  infertility in developing world • produced primarily by either: -  – Mycobacterium tuberculosis or  – Mycobacterium bovis  • The fallopian tubes = predominant site  • spread to the endometrium → ovaries.  
  79. 79. Female reproductive tract are usually  infected by:1. Hematogenous miliary spread from a primary  pulmonary lesion,  2. Hematogenous spread from a secondary  miliary site  3. Lymphatic spread from a primary pulmonary  site to intestinal lymph nodes and then to the  pelvis,  4. Direct extension from adjacent abdominal  organs  5. A venereal transmission  
  80. 80. Pathology of Pelvic Tuberculosis  • Both fallopian tubes are involved  • Tuberculous endometritis = 50%.  • Tuberculosis of cervix is present in 5%  • The vagina and vulva = 2% • Ovaries = only surface involvment.  • The mucosa of tubes may not be involved • 38% of women with genital tuberculosis had  previously had tuberculosis in other organs,  usually the lungs 
  81. 81. Clinical Features • most often = 20 and 40 years  • Chronic pelvic pain, • Inflammatory Pelvic Mass • General malaise, low grade fever  • Menstrual irregularity (50%), and infertility • Amenorrhea or oligomenorrhea = 27% • Failure of fever to subside with high doses of broad-spectrum antibiotic • 10-20 % of pts with pulmonary Tb have pelvic Tb  
  82. 82. Diagnosis • Mainly clinical • Biopsy – dilatation and curettage or endometrial biopsy  – From cervical ulcer • • • • • HSG Culture – menstrual blood, luteal phase Laparatomy / Laparoscopy Acid-fast stains of tissue  Other studies ex. CXR, Culture etc…
  83. 83. • Treatment  A. Medical • Daily INH, RIF, and PZA for 8 wk, followed by 16  wk of INH and RIF daily or 2 - 3 times/wk  • Other DOT regimens ex.:• Daily INH, RIF, PZA, and SM or EMB for 2 wk,  then administer the same drugs 2 times/wk for 6  wk (by DOT).  – Next, administer INH and RIF 2 times/wk for 16 wk  (by DOT). 
  84. 84. • B. Surgical 1. Persistence or enlargement of an adnexal  mass after 4 to 6 months of antituberculous  antibiotic therapy.  2. Persistence of pelvic pain or recurrence of  pelvic pain while on medical therapy 3. Primary unresponsiveness of the tuberculous  infection to antibiotic therapy  4. Difficulty in obtaining patient cooperation for  continued long-term therapy  
  85. 85. Thank You all