Pelvic Infections: Vulvovaginitis, Sexually Transmitted Infections, and

Pelvic Inflammatory Disease

Prepared by Mrs. Raheegeh Awni

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introduction

• Pelvic infections in women affecting the vulva, vagina, and cervix (lower reproductive tract) and the uterine corpus, fallopian tubes, and ovaries (upper reproductive tract) are common gynecologic problems.

• Many but not all of these infections are sexually transmitted and require partner treatment for effective immediate and preventive care.

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• Recently the term sexually transmitted infection (STI) has replaced sexually transmitted disease (STD) to emphasize the infectious nature of these frequently asymptomatic disorders and the need for screening, early recognition, and treatment.

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STIs

• The most common STIs are Chlamydia, genital herpes (GH), human papillomavirus infection (HPV), and gonorrhea, Trichomoniasis.

• Upper reproductive tract infection in the form of pelvic inflammatory disease (PID) is a serious consequence of unrecognized or inadequately treated lower tract disease.

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INVESTIGATION OF VAGINAL DISCHARGE

• Patients with a vaginal infection frequently complain of a nonbloody vaginal discharge.

• The characteristics of the discharge (e.g., color, texture, viscosity, and odor) are helpful in making the correct diagnosis.

• Normal vaginal fluid pH is <4.7 in ovulatory women.

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Common causes of vulvovaginitis

• Bacterial vaginosis • Yeast• Trichomoniasis

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Vaginitis – abnormal vaginal discharge

• This may include discharge from the upper genital tract, e.g. cervicitis,

• salpingitis.• Therefore, take swabs from the vagina and cervix for

possible• pathogens, e.g. Chlamydia, gonorrhoea and herpes

simplex • Organisms that cause vaginal discharge can occur as

an overgrowth, e.g. Candida and bacterial vaginosis.

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• Trichomonas is always sexually transmitted (except in theneonate, where vertical transmission occurs).

• Discharges may be caused by mixed pathogens, with mixed symptoms and clinical signs; requiring laboratory elucidation.

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BACTERIAL VAGINOSIS- odorous discharge

• Bacterial vaginosis (BV) is the most common cause of vaginal discharge, but is often without other symptoms.

• The commonest cause of vaginal discharge is an overgrowth of mixed organisms, mostly gut anaerobes, Gardnerella, Mobiluncus spp. in high numbers.

• There is a lack of lactobacilli and a rise in pH of the secretion from 5.0 to 7.0.

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Risk factors

• It is not sexually transmitted, but has been associated with

• increased sexual activity, • lesbian partners, • douching and • increased risk with intrauterine device (IUD)

insertion.

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Classic features of BV

• BV discharge include "profuse," "milky," non-adherent discharge that demonstrates an amine or fishy odor after alkalization.

• BV heightens a nonpregnant woman's risk for pelvic inflammatory disease (PID), postoperative infections (e.g., after hysterectomy or pregnancy termination), and HIV transmission.

• Partner treatment is generally not recommended

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Treatment

• Not indicated in asymptomatic women• Not indicated for sexual partners• Indicated before certain surgical procedures (e.g.

TOP)• The role of therapy in pregnancy to prevent preterm

labour is still under investigation (local clindamycin may have an adverse effect).

• Recurrent BV has been associated with altered anatomy, abnormal pooling of secretions, following

vaginal hysterectomy

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Candidiasis (thrush) – itchy discharge

• Candida albicans, a yeast, is causative in 90 per cent of cases and can produce pseudomycelium.

• Candida glabrata and Saccharomyces cerevisiae (Baker’s yeast)

are uncommon and more resistant to imidazoles.Candida albicans formerly caused over 90% of VVC

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• The majority of women acquire Candida at some stage with up to 20 per cent of women being asymptomatic carriers of Candida.

• Candida infection may result from the use of broad-spectrum antibiotics and may be worse in pregnancy because of the oestrogen

Levels and immunosuppression.

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Risk factors for recurrent VVC

• include high-dose oral contraceptives, • diaphragm use with a spermicide, • diabetes mellitus, • antibiotic use, pregnancy,

immunosuppression from any cause (HIV/AIDS, transplantation, alcoholism),

• tight occlusive clothing.

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Classic presentation of VVC

• includes vaginal itching, • burning, irritation,• and possibly post voiding dysuria. • The discharge is usually odorless, has a pH of

<4.7, and is thick or curdy with the appearance of cottage cheese .

• Examination often shows vulvovaginal erythema

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Complications of Chlamydia

• Upper genital infection includes ascending endometritis, salpingitis• chronic tubal disease that is immune mediated.• incidence of tubal factor infertility, • a 15 per cent incidence of ectopic pregnancy, • chronic pelvic pain and adhesions.• Fitz–Hugh–Curtis syndrome – perihepatitis – occasionally occurs• as a complication of PID, with severe subcostal pain sometimes• referred to the shoulder tip.• Reiter’s disease, a seronegative reactive arthritis affecting mostly• Adult is rare.• Transmission to the neonate may cause conjunctivitis

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RX.

• First line treatments include topical or oral antifungal (imidazole) agents.

• suppressive doses of topical imidazoles. • Boric acid (600 mg vaginal gelatin capsules)

three times daily for 1 week is an effective treatment for imidazole-resistant species.

• Although VVC is not thought to be sexually transmitted in most cases, male partners with diabetes sometimes reinfect their partners.

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TRICHOMONIASIS

• Trichomonias is caused by the protozoan Trichomonas vaginalis

• About 50% of cases in women and men are asymptomatic.

• Symptomatic infection is classically manifested by green-yellow, frothy vaginal discharge "musty" odor, dyspareunia, vulvovaginal irritation, and occasionally dysuria.

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• Male partners are often "asymptomatic" even though they demonstrate nongonococcal urethritis (NGU) on direct examination.

• The diagnosis of trichomoniasis in patients and their sexual partners should be followed by screening for other prevalent STIs and empiric treatment of partners.

• Diagnosis: is usually made on clinical findings • can be confirmed by seeing the characteristic motility of

trichomonads on a saline wet mount. • culture, • antigen testing

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• It is associated with upper reproductive tract symptoms, an increased risk of adverse pregnancy outcomes (prematurity, low birth weight), and increased transmission of HIV infection.

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RX• Metronidazole (2 g single oral dose) is the recommended

treatment (• Other nitroimidazoles (tinidazole, ornidazole)• Metronidazole is not teratogenic in recommended dosages

but has been traditionally avoided during the first 12 weeks of pregnancy.

• Prompt early treatment during pregnancy relieves symptoms, reduces the risk of HIV transmission, and may improve pregnancy outcomes.

• Trichomoniasis should be treated prior to vaginal surgical procedures.

• Tinidazole( for metronidazole resistant)

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OTHER COMMON SEXUALLY TRANSMITTED INFECTIONS (STIs)

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GENITAL HERPES

• Genital herpes (GH) is the most prevalent STI in the US, with an estimated 50 million adults infected with herpes simplex virus (HSV) and about 1.5 million new cases occurring every year.

• This infection may have devastating emotional and social consequences.

•

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• Unfortunately, only 10% to 20% of infected persons know that they are infected, and 70% of transmissions are from asymptomatic viral shedding from infected partners with no visible lesions.

• Individuals who are infected with HSV are at increased risk of acquiring and transmitting HIV.

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serotypes• HSV has two serotypes, HSV-1 and HSV-2. • HSV-1 is most commonly associated with oral lesions (cold

sores), • The virus enters the body through mucosa or microabrasions

in the skin and follows the sensory nerves to the dorsal spinal ganglion where it remains dormant until reactivated.

• Transmission occurs through intimate genital, oral or anal contact.

• An infected mother can transmit the virus to her infant during delivery resulting in significant fetal mortality and morbidity

• Regular condom use decreases transmission by about 50%, especially from men to women.

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DX.

• (1) viral culture that requires live cells from a lesion • (2) polymerase chain reaction (PCR), which is

expensive and very accurate, is not used routinely on genital lesions but is very useful for testing cerebrospinal fluid;

• (3) serologic tests for HSV-1 and HSV-2 antibodies are highly sensitive and specific tests that can identify individuals who are asymptomatic.

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treatment• The goals are symptom relief, acceleration of lesion

healing, and a decrease in frequency of recurrences. • Education and supportive counseling are also

important. • The antiviral agents (acyclovir, famciclovir, and

valacyclovir) are safe and effective for treating primary and episodic outbreaks, and suppressive therapy for patients with chronic disease.

• No treatment, however, completely eradicates the latent virus from the dorsal ganglia of the spinal cord.

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HUMAN PAPILLOMAVIRUS• (HPV) is a common viral STI with an estimated 20 million

infected persons in the US and 5 million new cases every year. • It is believed that about 75% of sexually active adults will be

infected sometime in their life. • The large majority of HPV cases are latent infections with no

visible lesions and are only diagnosed by DNA • Subclinical infections have lesions that are only visible during

colposcopy.• Clinical infections are characterized by readily visible "warty"

growths called condylomata acuminata on the vulva, vagina, cervix, urethra, and perianal area.

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• HPV infection usually clears spontaneously within 2 years, but recurrences are common.

• There are about 200 HPV genotypes. • Some have been strongly associated with genital neoplasia and cancers,

especially cervica.• Biopsies of atypical or persistent lesions are needed to rule out neoplastic

disease. • Because these growths may also mimic condylomata lata, syphilis must be

excluded if the lesions are atypical or do not respond to treatment. Transmission of HPV can occur even when there are no visible lesions.

• Regular condom use may provide some degree of protection. • During pregnancy, condylomata may increase in number and size. However, transmission from mother to infant is very rare.

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RX.

• visible genital warts are to relieve symptoms (pain and/or bleeding) and sometimes for cosmetic concerns of the patient.

• Provider-applied topical therapies include:• (1) podophyllin resin • (2) trichloroacetic acid (TCA) or bichloracetic acid

(BCA)• Patient-applied topical therapies include:• (1) podofilox 0.5% solution or gel and (2) imiquimod

5% cream.

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• Surgical therapies include:• (1) cryotherapy, • (2) manual excision,• (3) electrocautery, • (4) laser vaporization,• (5) intralesional interferon

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CHLAMYDIA• Chlamydia has the highest incidence of any bacterial

STI in the US, with 3 million new cases every year. • The majority of cases (75%) are found in individuals

who are <25 years old and about half of the cases are in teenagers.

• Chlamydia trachomatis is an obligate intracellular bacteria that grows in vitro only in tissue culture and in women infects the columnar epithelium of the endocervix, urethra, endometrium, fallopian tubes, and the rectum.

• This organism can persist for long periods in an asymptomatic carrier state.

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• Although Chlamydia antibodies are produced, they do not protect against reinfection.

• it is very difficult to diagnose and treat this "hidden" infection.

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the clinical manifestations

• symptoms of lower genital tract Chlamydia infection are

• (1) mucopurulent cervicitis or mucopus, which is a yellow discharge coming from a swollen, red, friable cervix that bleeds easily

• (2) acute urethritis and dysuria with minimal frequency/urgency and a negative urine culture.

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laboratory tests

• the diagnosis of Chlamydia: • (1) tissue culture• (2) antigen tests are inexpensive and rapid with a

high sensitivity and specificity; • (3) DNA hybridization tests and nucleic acid

amplification tests • These newer tests can be done on urine specimens

instead of cervical. • Selective screening should be performed at least

annually on sexually active females <25 years old.

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• Also test individuals with risk factors (unmarried, multiple partners, inconsistent use of barrier contraceptive methods, previous history of any STI) and all pregnant women.

• It is estimated that 30% of untreated chlamydial cervicitis will progress to PID.

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treatment guidelines• (1) presumptive treatment with appropriate antibiotics (e.g.,

azithromycin 1 g orally in a single dose or doxycycline 100 mg twice a day for 7 days);

• (2) treatment of all sexual contacts within the past 60 days prior to diagnosis;

• (3) testing for other STIs, including gonorrhea, syphilis, hepatitis B, and HIV;

• (4) abstinence from sexual contact for 7 days after last partner has started antibiotic therapy.

• Chlamydia infection during pregnancy can cause adverse outcomes for both mother and infant includi ng preterm labor, chorioamnionitis and postpartum endometritis. Intrapartum transmission to the infant can cause neonatal conjunctivitis and/or pneumonia.

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GONORRHEA

• Neisseria gonorrhoeae is the second most common bacterial STI in the United States with 600,000 new cases annually.

• The organism is a Gram-negative, bean-shaped diplococcus and it infects the same columnar epithelium as Chlamydia.

• It can infect the pharynx in about 10% of the cases. • It causes urethritis, cervicitis, and rarely pharyngitis

and vaginitis (prepubertal).

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• Most infected women, but only 5% of infected men, have no symptoms.

• If symptoms are present, the clinical manifestations of lower genital tract gonococcal infections are the same as for Chlamydia and include mucopurulent cervicitis, which involves a swollen, red, friable cervix, contact bleeding, and acute urethritis, producing dysuria with minimal frequency/urgency and a usually negative urine culture.

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Laboratory tests

• Gram's stain of the discharge or cervix, which is rapid and inexpensive. T

• the presence of gram-negative diplococci in the leukocytes.

• DNA hybridization test is inexpensive • These tests can be done on urine and/or cervical

swabs. • It is estimated that about 15% of untreated

gonococcal cervical infection will progress to PID.

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General treatment• guidelines for lower genital tract gonorrhea infection

include: (1) treatment with appropriate antibiotics (e.g., cefixime 400 mg orally in a single dose or ceftriaxone 125 mg IM in a single dose);

• (2) 1 g of azithromycin orally in a single dose) • (3) treatment of all sexual contacts within the past

60 days prior to diagnosis; • (4) abstinence from sexual activity for 7 days after

the start of antibiotic therapy; • (5) testing for other STIs, including Chlamydia,

syphilis, hepatitis B, HIV.

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• Gonococcal infection during pregnancy can cause adverse outcomes for both the mother and infant.

• These include preterm labor and delivery, chorioamnionitis, and postpartum endometritis.

• Intrapartum transmission to the infant can cause neonatal conjunctivitis (ophthalmia neonatorum).

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SYPHILIS (TREPONEMA PALLIDUM)

• Any positive syphilis serology in (Venereal Disease Reference Laboratory should be discussed immediately with an appropriate specialist genitourinary medicine or infectious diseases physician.

• Atypical genital ulcers require follow-up syphilis serology for up to 3 months to exclude a primary lesion.

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Secondary syphilis

• Secondary syphilis (6 weeks to 6 months after acquisition) has highly infectious mucous membrane lesions, i.e. oral cavity snail-tract

ulcers, genital area, flat wart-like areas, condyloma lata.

There may be a generalised maculopapular rash (including palms of hands and soles of feet), rubbery lymphadenopathy, etc.

This continues for 2 years (15 per cent up to 4 years) if untreated.

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PELVIC INFLAMMATORY DISEASE

• PID is a morbid and costly sexually transmitted bacterial upper-reproductive-tract infection affecting nonpregnant and occasionally pregnant women.

• Studies demonstrate the importance of pathogenic lower-reproductive-tract microorganisms ascending from the endocervix to mediate endometritis, salpingitis, and sometimes peritonitis.

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EPIDEMIOLOGY AND PATHOGENESIS

• More than 10% of reproductive-age women report a history of PID.

• PID is an expensive public health problem. • It has been estimated that the direct costs of

treating PID in the US exceed $6 billion annually.

• These costs do not include the indirect costs for treating sequelae such as infertility, ectopic pregnancy, and preterm birth.

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pathogens• causes of PID include C. trachomatis, N.

gonorrhoeae, and genital mycoplasmas (M. genitalium).

• Each of these is an STI with inoculation occurring most commonly during intercourse.

• MM. genitalium are widely recognized causes of nongonococcal urethritis (NGU) in males and females.

• Unlike gonorrhea, which occurs more frequently within inner-city and minority populations, chlamydial infections are broadly distributed among most racial, ethnic, and economic groups.

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• PID develops in 15% to 30% of women with inadequately treated gonococcal or chlamydial cervicitis.

• The highest rates of chlamydial cervicitis occur in sexually active adolescents and young adults between the ages of 20 and 25 years.

• The largely asymptomatic nature of chlamydial cervicitis in women and urethritis in men makes routine screening and treatment for Chlamydia necessary for the prevention of PID.

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COMPLICATIONS

• A seminal study of PID was performed in Lund, Sweden, where 2500 women were followed with their disease from 1960 to 1984.

• Women with clinical PID were six times more likely to have an ectopic pregnancy and 14 times more likely to have tubal factor infertility than women without PID.

• Women with a history of PID were 6 to 10 times more likely than healthy controls to have the diagnosis of endometritis, suffer from chronic pelvic pain, or require a hysterectomy.

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symptoms

• lower abdominal pain and tenderness (especially when walking or during coitus)

• abnormal vaginal discharge, chills, and fever.• Less common symptoms include irregular

vaginal bleeding, dysuria, nausea, and vomiting.

• No specific combination of symptoms is consistently associated with PID.

• Some women are asymptomatic.

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SIGNS

• Clinical signs are lower abdominal tenderness, with or without rebound tenderness; uterine and adnexal tenderness to palpation and motion; and findings of mucopurulent cervicitis.

• Fever is the least common finding

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INVESTIGATIONS• Confirmatory laboratory evidence includes leukocytosis,

increased erythrocyte sedimentation rate or C-reactive protein level,

• Pelvic ultrasonic studies may show enlarged fallopian tubes that are tender when approached with a vaginal probe,

• Laparoscopy for diagnosis of PID or tubo-ovarian abscess (TOA)

• Laparoscopy is generally not performed unless differentiation from other processes (e.g., appendicitis) is required.

• endometrial biopsy (

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• PID should be diagnosed and treated empirically in sexually active young women and women with risk factors who have uterine/adnexal or cervical motion tenderness.

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TREATMENT

• Therapeutic goals for treating PID are elimination of reproductive tract infection and inflammation, improvement of symptoms and physical findings, prevention or minimization of long-term sequelae, and eradication of causal agents from the patient and her sexual partner(s).

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• Women with severe infections or an inability to take and absorb oral antibiotics (nausea, vomiting, possible peritonitis, and ileus) should be hospitalized and treated until clinical improvement is evident.

• Similarly, women with a questionable diagnosis, pregnancy, or inability to be treated on an outpatient basis, should be admitted initially and treated with parenteral agents so as to ensure compliance and treatment efficacy, as should those who fail to respond to outpatient therapy.

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INPATIENT TREATMENT

• Cefoxitin2 g IV q6h Clindamycin 900 mg IV q8h or plus Cefotetan 2 g IV

• Doxycycline, 100 mg orally bid, to complete 14 days plus doxycycline 100 mg IV q12h until improved, followed by doxycycline 100 mg orally bid, to complete 14 days

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• Patients should be reevaluated 3 to 4 weeks after treatment.

• Pelvic examination should be done at that time to ensure adequacy of treatment. Counseling regarding preventative strategies for STIs and HIV infection, as well as contraceptive advice, should be repeated at the follow-up visit.

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(HIV 1 AND 2)

• Special considerations in HIV-women include:• Pelvic inflammatory disease may be more severe,

run• a more protracted course, be less responsive to

antibiotics and may require drainage if abscess formation develops.

• Prophylactic antibiotics for gynaecological surgery and procedures,

• including TOP, may have to be prolonged.

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• Recurrent and severe vaginal candidiasis is common and may require systemic antifungal therapy.

• Genital warts may have a poor response to the usual therapies and higher recurrence rates.

• cervical smear at diagnosis and repeat 6 months later, then yearly smears

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The history of (HIV)

• acquired immunodeficiency syndrome (AIDS) dates back to 1981, when homosexual men with symptoms of a disease that now are considered typical of AIDS were first described in Los Angeles and New York.

• The men had an unusual type of lung infection

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• The patients were noted to have a severe reduction in a type of cell in the blood (CD4 cells) that is an important part of the immune system.

• These cells, often referred to as T cells, help the body fight infections.

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the diagnosis of HIV

• The test used most commonly for diagnosing infection with HIV is referred to as an ELISA.

• Antibodies to HIV typically develop within several weeks of infection. During this interval, patients have virus in their body but will test negative by the standard antibody test, the so called "window period

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• MOST PATIENTS remain completely asymptomatic after as many as 20 years from the time of infection.

• Within weeks of infection, many people will develop the varied symptoms of primary or acute infection which typically have been described as a "mononucleosis" or "influenza" like illness but can range from minimal fever, aches, and pains to very severe symptoms.

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• The most common symptoms of primary HIV infection are

• fever,• aching muscles and joints• sore throat, • and swollen glands (lymph nodes) in the neck

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transmitted)?

• HIV is present in the blood and genital secretions of virtually all individuals infected with HIV, regardless of whether or not they have symptoms.

• The spread of HIV can occur when these secretions come in contact with tissues such as those lining the vagina, anal area, mouth, eyes (the mucus membranes), or with a break in the skin, such as from a cut or puncture by a needle.

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• The most common ways in which HIV is spreading include sexual contact, sharing needles, and by transmission from infected mothers to their newborns during pregnancy, labor (the delivery process), or breastfeeding.

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Thank you

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