2. Objectives
1. To discuss the different lower and
upper genital tract infections
2. To discuss the treatment of choice of
the different genital tract infections
3. To discuss the complications of the
different genital tract infections
4. 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
6. The Five P’s
1. Partners
2. Practices
3. Prevention of
Pregnancy
4. Protection from
STDs
5. Past history of
STDs
7. VULVA
• Stratified squamous epithelium with hair
follicles and sweat, sebaceous and
apocrine glands
• Also contains Bartholin’s and Skene’s
glands
• Vulvar skin is sensitive to hormonal,
metabolic and allergic influences
• Sensory nerve endings are more
numerous in the vulvar skin than in the
vagina
9. Signs & Symptoms of
Vulvar Infection
• Vulvar itching and burning
• Erythema
• Edema
• Superficial skin ulcers of the vulva
• Skin fissures
• Excoriation
10. BARTHOLIN’S
GLANDS
• Located at entrance of
the vagina at 5 o’clock
and 7 o’clock
• most common cause:
cystic dilation of the
Bartholin’s duct
secondary to
nonspecific
inflammation or
trauma.
• women are usually
asymptomatic.
11. Infections of the
Bartholin’s Glands
• Cystic dilation of Bartholin’s duct
• Abscess of Bartholin’s gland
• Adenocarcinoma of Bartholin’s gland
12. INFECTIONS OF THE
BARTHOLIN’S GLANDS
• the cysts may vary from 1 to 8 cm in
diameter
• they are usually unilateral, tense, and
nonpainful.
• Signs of classic abscess:
• erythema, acute tenderness,
edema and occassionally
cellulitis of the surrounding
subcutaneous tissue.
13. Treatment:
• asymptomatic cysts in women under the
age of 40 do not need treatment.
• for a symptomatic cyst or abscess →
development of a fistulous tract from
the dilated duct to the vestibule.
• Classical surgical treatment – develop a
fistulous tract to “marsupialize” the duct
16. Pediculosis Pubis
• Pediculosis pedis is an infestation of the
crab louse, Phthirus pubis
• transmitted by close contact, towels or
beddings
• lice in pubic hair is the most contagious of
all STDs: 90% single exposure
• Confined to hairy areas of the vulva
• Major nourishment is human blood
17. Pediculosis Pubis
• Lifecycle: egg (nit), nymph, adult
• Diagnosis: microscopic slide by scratch
technique, place crust under drop of
mineral oil
18. Treatment of Pediculosis
Pubis
• permethrin (Nix Crème) 1% cream rinse, applied
to affected areas and washed off after 10
minutes
• Lindane (Kwell) 1% as shampoo, applied for 4
minutes then thoroughly washed off
• Side effect: Seizures when applied immediately after a
bath
• Not recommended for pregnant or lactating women
or children less than age 2
• pyrethrins with piperonyl butoxide applied to
affected areas and washed off after 10 minutes
20. Scabies
• Scabies is a parasitic infection of the itch
mite, Sarcoptes scabiei, transmitted by
close contact, widespread over the body
without a predilection for hairy areas
• Itch mite travels rapidly over skin, able to
survive only ew ha fours away from
warmth of skin
• Severe but intermittent itching,
predominantly at night when skin is
warmer and mites are more active
21. Scabies
• Scabies present as papules, vesicles, or
burrows (pathognomonic), termed the
“great dermatologic imitator”
• Most commonly infected areas: hands,
wrists, breasts, vulva, buttocks, examine
under handheld magnifying lens
• Microscopic slides: scratch technique,
under mineral oil
23. Treatment of Scabies
• Permethrin 5% applied to all areas of the
body from neck down and washed off
after 8 to 14 hours
• Ivermectin 0.2 mg/kg orally, repeated in
two weeks if necessary
• Lindane 1% 1 oz of lotion or 30g of cream
applied thinly to all areas of the body
from neck down and thoroughly washed
off after 8 hours.
• Antihistamine for pruritus
25. Pediculosis Pubis and
Scabies
• Treatment prescribed for sexual
contacts within previous 6 weeks and
other household contacts
• Clothing and bedding should be
decontaminated
• Permethrin 1% cream rinse for pubic lice
• Permethrin 5% cream for scabies
26. Molluscum
contagiosum
• Asymptomatic viral disease primarily of
the vulvar skin
• Caused by the poxvirus and is spread by
close contact. Poxvirus does not grow on
mucous membranes.
• Common generalized skin disease in
adults with immunodeficiency,
especially HIV infection.
27. Molluscum contagiosum
• Characteristic skin lesion –
umbilicated papule.
• Small nodules or domed
papules - 1 to 5 mm in
diameter.
• “Water wart”
• Incubation period is 2 to 7
weeks
28. Molluscum contagiosum
• Infected women = 1 to 20 solitary
lesions randomly distributed over the
vulvar skin.
• Diagnosis
• simple inspection
• white waxy material from inside the nodule
should be expressed in a microscopic slide
• Findings: intracytoplasmic molluscum
bodies (Wright’s or Giemsa stain)
29.
30. Molluscum contagiosum
• Major complication: bacterial
superinfection
• A self limiting infection
• Treatment of individual papules:
• Decrease transmission
• Autoinoculation of the virus
31. Molluscum contagiosum
• Injection of LA – subdermal wheal,
evacuation of caseous material and the
nodule excised with a sharp dermal
curet.
• Chemically treated with either ferric
subsulfate (Monsel’s solution) or 85%
trichloroacetic acid – base of papule.
• Alternative: cryosurgery or
electrocautery
33. Condyloma
Acuminatum
• Most common viral STD due to Human
Papillomavirus (HPV) infection
• Non-oncogenic, or low-risk HPV types 6
and 11 are the cause of genital warts
and recurrent respiratory
papillomatosis.
• More than 50% of sexually active
persons become infected at least once
in their lifetime.
34.
35.
36. Prevention
•Two HPV vaccines:
• a bivalent vaccine (Cervarix)
containing HPV types 16 and 18
• a quadrivalent vaccine (Gardasil)
containing HPV types 6,11, 16
and 18.
37. Prevention
• Both vaccines offer protection
against HPV types that cause 70%
of cervical cancers.
• QHPV protects against HPV types
that cause 90% of genital warts
(approved for use in males and
females 9-26 years)
44. Counseling
• A diagnosis of HPV in one sex partner is
not indicative of sexual infidelity in the
other partner.
• Sexually active persons can lower their
chances of getting HPV by limiting their
number of partners.
• Genital warts commonly recur after
treatment, especially in the first 3
months.
CDC 2010 STD Treatment Guidelines
45. Counseling
• Women should get regular Pap tests as
recommended, regardless of vaccination
or genital wart history.
• If one sex partner has genital warts,
both sex partners benefit from getting
screened for other STDs.
• Refrain from sexual activity until the
warts are gone or removed.
CDC 2010 STD Treatment Guidelines
46. Cervical cancer
screening
• Current guidelines from USPSTF and
ACOG recommend that cervical
screening begin at age 21 years.
• ACS recommends that women start
cervical screening after 3 years of
initiating sexual activity but by no later
than age 21 years.
47. Hayden, a 23-year-old videographer is the next patient you see in the
clinic. Under the chief complaint, the nurse has written, “Wants a general
checkup.” You enter the room and greet a generally healthy-appearing
young, Filipino man, who seems anxious. He appears to have difficulty in
maintaining eye-to-eye contact with you.
Hayden tells you, “I have an ulcer…but not in my stomach.” He finally
admits that he has been worried about a lesion on his penis. He denies
pain or dysuria. He has never had any sexually transmitted diseases (STDs)
and has an otherwise unremarkable medical history.
Hayden is afebrile, and his examination is notable for a shallow clean ulcer
without exudates or erythema on the shaft of his penis, which is nontender
to palpation, and has a cartilaginous consistency. There are some small,
nontender, inguinal lymph nodes bilaterally.
50. Chancroid
• Painful genital ulcer
• Tender suppurative inguinal
adenopathy
• Diagnosis: identification of H. ducreyi
51. • Probable diagnosis
• Patient has one or more painful genital
ulcers
• No evidence of T. pallidum infection by
darkfield exam
• Clinical presentation, appearance of genital
ulcer and +/- regional lymphadenopathy
• Test for HSV on ulcer is negative
57. • Type specific serologic test
• Recurrent genital symptoms or atypical
symptoms with negative HSV culture
• Clinical diagnosis of genital herpes without
laboratory confirmation
• A partner with genital herpes
58. MANAGEMENT OF
GENITAL HERPES
• Antiviral chemotherapy offers clinical benefits
to most symptomatic patients and is the
mainstay of management.
59. Suppressive Therapy
for Recurrent Genital Herpes
•Suppressive therapy reduces the frequency of genital herpes
recurrences by 70%–80%
•many persons receiving such therapy report having experienced
no symptomatic outbreaks
60. Episodic Therapy
for Recurrent Genital Herpes
Effective episodic treatment of recurrent herpes requires
initiation of therapy within 1 day of lesion onset or during
the prodrome that precedes some outbreaks.
62. • Severe HSV disease
• Acyclovir 5-10mg /kg IV every 8 hours for 2-
7 days until with clinical improvement then
PO antiviral therapy to complete at least 10
days
63.
64. Granuloma Inguinale
• Klebsiella granulomatis
(Calymmatobacterium granulomatis)
• Painless, slowly progressive ulcerative
lesions on genitals or perineum
• No regional lymphadenopathy
84. VAGINA
• Normal vaginal pH approx 4.0 in pre-
menopausal women
• Estrogen stimulates glycogen content of
vaginal epithelial cells.
• Lactobacillus
• aerobic gram positive rod
• found in 62% to 88% of asymptomatic women
• regulator of normal vaginal flora
• 60% vaginal lactobacilli strains make hydrogen
peroxide which inhibits the growth of bacteria
• destroys HIV in vitro
85. VAGINA
• Lactic acid, pH 3.8 – 4.5
• maintains normal vaginal
• inhibit adherence of bacteria to vaginal
epithelial cells
• Normal physiologic vaginal discharge
• Epithelial cells
• Normal bacterial flora
• Water
• Electrolytes
• Other chemicals
89. • Vaginal discharge is the most common
symptom in gynecology
• The clinical diagnosis of the etiology of
vaginitis depends on:
• Measurement of the vaginal pH
• KOH test
• Examination of the vaginal secretion under
the microscope
90. Common Vaginal Infections
Symptoms signs Examination
Findings
disharge present in
dependent portions
of vagina
pH Wet mount
Normal White floccular or
curdy, odorless
3.8 – 4.5
Bacterial
vaginosis
Increased white thin
discharge, increased
odor
Thin whitish gray
homogenous
discharge sometimes
frothy
Thick curdy
discharge, vaginal
erythema
Yellow frothy
discharge with or
without vaginal or
cervical erythema
>4.5
basic
Clue cells >20%
shift in flora,
amine odor after
KOH smear
Hyphae or
spores
Candidiasis Increased white thick
discharge, pruritus,
dysuria, burning
Increased yellow
frothy discharge,
increased odor,
pruritus, dysuria
<4.5
Acidic
Trichomonas >4.5
Basic
Motile
trichomonads
Increased white
cells
91. BACTERIAL VAGINOSIS
(BV)
• polymicrobial clinical syndrome
resulting from replacement of the
normal H2
02
-producing Lactobacillus sp
in the vagina with high concentrations
of anaerobic bacteria (e.g., Prevotella
sp. and Mobiluncus sp.), G. vaginalis,
and Mycoplasma hominis.
• most prevalent cause of vaginal
discharge or malodor.
92. BACTERIAL VAGINOSIS
(BV)
• Associated with:
• multiple male or female partners
• A new sex partner
• Douching
• Lack of condom use
• Lack of vaginal lactobacilli
• Women who have never been sexually active can
also be affected
• Women with BV are at increased risk for the
acquisition of some STDs (HIV, N gonorrhoeae,
C trachomatis and HSV-2)
93.
94. Amsel’s Criteria:
3 of the following symptoms or signs
• Homogeneous, thin, white discharge that
smoothly coats the vaginal walls;
• Presence of clue cells on microscopic
examination;
• pH of vaginal fluid >4.5; and
• A fishy odor of vaginal discharge before or
after addition of 10% KOH (i.e., whiff test).
95. Nugent criteria
• Gram stain morphology score (1-10) based on
lactobacilli and other morphotypes
• A score of 1-2 indicates normal flora
• A score of 7-10 bacterial vaginosis
• High interobserver reproducibility
96. Acceptable diagnostic tests for
BV
• DNA probe-based test for high concentrations of G.
vaginalis (Affirm VP III, Becton Dickinson, Sparks,
Maryland)
• A prolineaminopeptidase test card (Pip Activity
TestCard, Quidel, San Diego, California)
• OSOM BVBluetest
• PCR (for research purposes)
101. TRICHOMONIASIS
• caused by Trichomonas vaginalis
• a unicellular protozoon that inhabits the
vagina and lower urinary tract, specially
the Skene’s gland in females.
• a highly contagious sexually transmitted
disease.
• Incubation period: 4-28 days
102. TRICHOMONIASIS
• It is a hardy organism and will survive for
up to 24 hours on a wet towel and up to
6 hours on moist surface.
• Primary symptom:
• profuse frothy vaginal discharge with an
unpleasant odor
• diffuse, malodorous, yellow-green vaginal
discharge with vulvar irritation
103.
104. High Risk for infection
• Women who have new or multiple
partners
• Have a history of STDs
• Exchange sex for payment
• Use injection drugs
105. Diagnosis
• Microscopy of vaginal secretions,
with sensitivity of 60% to 70%
requires immediate evaluation of
wet preparation slide for optimal
results
• OSOM Trichomonas Rapid Test (Genzyme Diagnostics,
Cambridge, Massachusetts)
Affirm VP III (Becton Dickenson, San Jose, California)
APTIMA T. vaginalis Analyte Specific Reagents (ASR, Gen-
Probe, Inc)
Culture of vaginal secretions
Liquid-based Pap test
•
•
•
•
106. CDC 2015 STD Guidelines
Sex partners of patients with T. vaginalis should be
treated.
107. VULVOVAGINAL
CANDIDIASIS
• caused by Candida albicans and
occasionally by other Candida species or
yeasts
• associated with normal vaginal ph (<4.5)
• At least 75% of women will have at least
one episode of VVC and 40-45% will have
two or more episodes within their
lifetime.
108. VULVOVAGINAL
CANDIDIASIS
• Symptoms : pruritus, vaginal soreness,
dyspareunia, external dysuria and
abnormal vaginal discharges
• Signs : vulvar edema, fissures,
excoriations or thick curdy vaginal
discharges
• On the basis of clinical presentation,
microbiology, host factors, response to
therapy: uncomplicated or complicated.
111. Miconazole 1,2000 mg vaginal
suppository, one suppository for
1 day
Fluconazole 150 mg oral tablet,
one tablet in single dose
@helenvmadamba CDUCM 2016
115. CERVIX
• The cervix acts as a barrier between the
abundant bacterial flora of the vagina
and the bacteriologically sterile
endometrial cavity and oviducts
116. Cervicitis
• Vaginal discharge, deep dyspareunia,
postcoital bleeding
• Cervix that is hypertrophic and
edematous
• Chlamydia trachomatis is the most
common etiologic agent
117. 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.
119. 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
120.
121. Chlamydia trachomatis
•most frequently reported
infectious disease
•prevalence is high among
persons aged 25 years or less
•most serious sequelae:
• PID
• ectopic pregnancy
• infertility
123. 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
125. 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
126. 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
• Erythromycin base 500mg orally four times a day
for 7 days OR
• Erythromycin base 250mg orally four times a day
for 14 days OR
• Erythromycin ethylsuccinate 800mg orally four
times a day for 7 days OR
• Erythromycin ethylsuccinate 400mg orally four
times a day for 14 days
128. 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.
129. 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
130. 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
133. 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.
134. 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.
136. 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
137. Risk factors
● Menstruating teenagers.
● Multiple sexual partners.
● Absence of contraceptive pill use.
● Previous history of acute PID.
● IUD users.
● Area with high prevalence of sexually transmitted dise
138. Protective factors
Contraceptive practice
● Barrier methods, specially condom, diaphragm
with spermicides.
● Oral steroidal contraceptives have got two
preventive aspects.
○ Produce thick mucus plug preventing
ascent of sperm and bacterial penetration.
○ Decrease in duration of menstruation,
creates a shorter interval of bacterial colo-
nization of the upper tract.
● Monogamy or having a partner who had
vasectomy.
Others
● Pregnancy
● Menopause
● Vaccines: hepatitis B,
HPV
139. 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
140. 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
141. 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.
142. Microbiology
Acute PID is usually a polymicrobial infection caused by
organisms ascending upstairs from downstairs.
➔ The primary organisms are sexually
transmitted and limited approximately to:
◆ N. gonorrhoeae in 30%
◆ Chlamydia trachomatis in 30%
◆ Mycoplasma hominis in 10%.
143. Microbiology
➔ The secondary organisms normally found in the
vagina are almost always associated sooner or later.
These are:
◆ Aerobic organisms—non-hemolytic streptococcus.
E. coli, group B streptococcus and staphylococcus.
◆ Anaerobic organisms—
Bacteroides species –
fragilis and bivius,
peptostreptococcus and
peptococcus.
144. Mode of infection
● The classic concept is that the gonococcus ascends up
to affect the tubes through mucosal continuity and
contiguity. This ascent is facilitated by the sexually
transmitted vectors such as sperm and trichomonads.
● Reflux of menstrual blood along with gonococci into
the fallopian
tubes is the other possibility.
● Mycoplasma hominis probably spreads across the
parametrium to affect the tube.
● The secondary organisms probably affect the tube
through
lymphatics.
● Rarely, organisms from the gut may affect the tube directly.
13
145. Pathology
the ostia results in pent up of the exudate inside the tube.
14
● The involvement of the tube is almost always bilateral
and usually
following menses due to loss of genital defence.
● The pathological process is initiated primarily in the
endosalpinx.
● There is gross destruction of the epithelial cells, cilia
and microvilli and may becomes edematous and
hyperemic (in severe infection).
● The exfoliated cells along with the exudate pour into the
lumen of the tube and agglutinate the mucosal folds.
The abdominal ostium is closed by the indrawing of the
edematous fimbriae and by inflammatory adhesions.
The uterine end is closed by congestion. The closure of
both
146. Pathology
producing ovarian abscess.
15
● Depending upon the virulence, the exudate may be
watery producing hydrosalpinx or purulent
producing pyosalpinx.
● The purulent exudate then changes the microenvironment
and favors growth of other organisms resulting in deeper
penetration and more tissue destruction.
● There will be adhesions of the tube with the surrounding
structures.
● On occasions, the exudate pours through the abdominal
ostium to
produce pelvic peritonitis and pelvic abscess or may affect the
ovary
147. Differential diagnosis
The clinical condition may be confused with:
(1)Appendicitis
(2) ) Disturbed ectopic pregnancy
(3)Torsion of ovarian pedicle,
haemorrhage or rupture of ovarian
cyst
(4) ) Endometriosis
(5) Diverticulitis
(6) Urinary tract infection
The two conditions—acute appendicitis and disturbed
ectopic pregnancy
must be ruled out, because both the conditions require urgent
laparotomy whereas acute salpingitis is to be treated conservatively.
27
149. Investigations
● A pregnancy test should always be performed to
exclude the important differential diagnosis of ectopic
pregnancy.
● High vaginal and endocervical swabs (high vaginal for
Trichomonas vaginalis, Candida and bacterial vaginosis,
endocervical for gonorrhoea and endocervical for Chlamydia)
should be taken, paying attention to using the correct
technique.
● Midstream specimen of urine should be sent for
microscopy and culture.
● Full blood count and C-reactive protein are important if
the woman is systemically unwell, and urea and electrolytes
should be analysed if she is vomiting.
● Serological test for syphilis should be carried out for both
the partners in
all cases.
150. Investigations
● Ultrasound scan will exclude a large tubo-ovarian
collection, but is usually normal with PID except for
possible free peritoneal fluid, which is a non- specific
finding.
● Culdocentesis: Aspiration of peritoneal fluid and its
white cell count, if exceeds 30,000 per mL. is
significant in acute PID. Bacterial culture from the fluid
is not informative because of vaginal contamination.
● Investigations are also to be extended to male partner
and smear and
culture are made from urethral secretion.
● Laparoscopy is indicated if the diagnosis is
unclear or there is no response to treatment
after 48 hours.
151. Steps in the evaluation of
women suspected with PID
1. Abdominal Examination
2. Vaginal Speculum exam
3. Bi-manual examination
4. Collection of samples of cervico-vaginal
discharge (for microscopy, and NAAT)
157. Best marker of Tubal Inflammatory disease =
presence of incomplete septum of the tubal wall
Thick wall + cogwheel sign = Acute
Thin wall + beads on string = Chronic
158. Tubo-ovarian Complex
Ovaries inflamed
Ovaries adherent to the
fallopian tube but still
visualized as a discrete
structure
Dilated tube with
hypoechoic fluid
Hyperemia of tubal walls
and adhesions
167. Laparoscopy
24
● Laparoscopy is considered the "gold
standard".
● While it is the most reliable aid to support the
clinical diagnosis but it may not be feasible to
do in all cases.
● It is reserved only in those cases in which
differential diagnosis includes salpingitis,
appendicitis or ectopic pregnancy.
● Laparoscopy helps to aspirate fluid or pus for
microbiological study from the fallopian tube,
ovary or pouch of Douglas.
● Nonresponding pelvic mass needs
laparoscopic clarification.
168. Laparoscopy
25
Laparoscopic findings and severity of
PID:
● Mild: Tubes: edema, erythema, no
purulent exudates and mobile.
● Mod: Purulent exudates from the
fimbrial ends, tubes not freely
movable.
● Severe: Pyosalpinx, inflammatory
complex, abscess.
● ‘Violin string’ like adhesions in
the pelvis and around the liver
suggests chlamydial infection.
169.
170. Treatment
To prevent reinfection.
03
To prevent infertility and late sequelae.
02
To control the infection energetically.
01
THE PRINCIPLES OF THERAPY ARE:
171. Indications for
hospitalization
• Surgical emergencies cannot be excluded
• The patient is pregnant
• The patient does not respond clinically
to oral antimicrobial therapy for 72
hours
• 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
CDC 2010 STD Treatment
Guidelines
172. • 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
CDC 2015 STD Treatment Guidelines
176. • 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
CDC 2010 STD Treatment Guidelines
177. Treatment
Indications of surgery:
The indications of surgery are comparatively
less. The unequivocal indications are:
● Generalized peritonitis.
● Pelvic abscess.
● Tubo-ovarian abscess which does not
respond (48–72 hours) to antimicrobial
therapy.
179. 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.
CDC 2010 STD Treatment Guidelines
180. Management of Sex Partners
• Abstain from sexual intercourse until therapy is
completed.
CDC 2015 STD Treatment Guidelines
182. 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.
183. • 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
