Genital Tract Infection - PDF

Genital tract infection DR.BANAV NAJEEB  Lactobacilli and a vaginal squamous Normal PH of the vagina is 3.5-4.5 (acidic) by the effect of lactic acid production of lactobacilli (Doderlline bacilli).  : Physiologic discharge(leukorrhoea ) is a normal condition, the disc...

Genital tract infection DR.BANAV NAJEEB  Lactobacilli and a vaginal squamous Normal PH of the vagina is 3.5-4.5 (acidic) by the effect of lactic acid production of lactobacilli (Doderlline bacilli).  : Physiologic discharge(leukorrhoea ) is a normal condition, the discharge is clear and doesn't smell bad, it increase: ▶at midcycle (ovulation) ▶pregnancy ▶using combined contraceptive pill ▶at intercourse  Classification of genital tract infection Venereal(STI) Non-venereal Bacterial Neisseria Gonorrheae Chlamydia Post-Partum Infections trachomatis, Treponema Pallidum, Haemophilus ducreyi Vulvovaginal Candidiasis  Protozoal Trichomonas vaginalis Bacterial vaginosis Viral : Human papiloma virus(HPV),Heprus simplex virus (HSV), Hepatitis B Virus HIV Arthropods Scabies mite Pubic louse Lower genital tract infection Candidiasis (fungal infection) It is caused by fungi the most commonly is candida albicans Symptoms: Itching of vulva Swelling and erythematous vulva Burning and vaginal soreness Thick whitish curdy vaginal discharge Painful urination and sexual intercourse Candida require estrogenated tissues, so VVC becomes more common after menarche and less common after menopause Risk factors of fungal infection ▶ diabetes ▶combined contraceptive pill user ▶pregnancy ▶antibiotics(prolonged use>10days) ▶ steroid and immunosuppressive drugs ▶immun-compromised disease like HIV ▶ poor eating habits, eating a lot of sugar ▶stress and lack of sleep High vaginal swap show The pseudohyphi of fungi under microscop  Treatment of Candida infection Topical: by Vaginal tablet, cream or pessaries in the form of clotrimazole or miconazole or imidazole or nystatin either for 3 to 7 days. Systemic: by fluconazole 150 mg (is contraindicated in pregnancy Patients with recurrent vulvovaginal candidiasis or chronic candidiasis should have tests of hepatitis and HIV. Those may benefit from weekly oral fluconazole for 6 months. Treatment would be an induction regimen to treat the acute episode followed by a maintenance regimen to treat further recurrences. Commonly fluconazole 150 mg is given in three doses orally every 72 hours followed by a maintenance dose of 150 mg weekly for six months.  Is there any need to treat asymptomatic partner?  General and supportive care  Avoid using soaps, perfumes and synthetic underwear. The high-dose oestrogen combined oral contraceptive pill should be changed to a lower- dose pill. If there are persistent or recurrent symptoms, consideration should be given to change to a progesterone-only contraception. Rule out undiagnosed diabetes mellitus and if present good glycaemic control should be the aim Avoid recurrent courses of broad spectrum  Trichomoniasis It is caused by protozoa trichomonas vaginalis It is transmitted by sex.(STI) It infect the vagina in women and the urethra of both sexs. women are more likely to have symptoms than men.  symptoms of TV: ♦ greenish-yellow frothy discharge ♦unpleasant oudor ♦itching of genitalia ♦discomfort during intercourse ♦dysuria ♦hemorrhagic spots on cervix (strawberry cervix)  Diagnosis of TV Take high vaginal swab for: Wet mount preparation and Gram stain & Culture  Treatment of Trichomoniasis ▶metronidazole 500 mg twice daily for 5-7 days or 2 gm as a single dose. ► Tinidazole 2 g single dose ▶The partner should be treated ►Abstain from intercourse during treatment  Bacterial Vaginosis(BV) Bacterial Vaginosis (BV) is caused by an imbalance in the “good” and “harmful” bacteria that are normally found in a woman’s vagina. In BV there is over growth of a complex microorganisms like gardenilla vaginalis, genital mycoplasm, and anaerobs. It is not a true vaginitis (no inflammation of vaginal wall) The most common symptom of BV is homogenous thin greyish-white discharge that has a strong fishy smell, particularly after intercourse BV is exacerbated: ∙around the time of menses, ∙those who have IUCD ∙It is more frequently found in sexually active women  of BV ◦ PH>4.5 ◦ Whiff test by adding KHO 10% cause fishy ouder ◦ High Vaginal Smear – Gram variable cocobacili and reduce numbers of lactobacilli ◦ Microscopic examination show clue cells It's also important to seek treatment if the woman is pregnant as there's a small chance that BV can increase the risk of second trimester abortion and preterm labour Treatment of BV metronidazole 500 mg twice daily for 5-7 days or 2 gm as a single dose or topical 0.75% metronidazole gel or 2% clindamycin cream Partner treatment is recommended or Upper genital tract infection is one of the commonest sexually transmitted disease(STD), it is an obligatory intracellular Chlamydia trachomatis bacterium. Symptoms: May be asymptomatic Mucopurulant vaginal discharge lower abdominal pain red, swollen and edematous cervix Postcoital bleeding or Intermenstrual bleeding They can cause serious, permanent damage to a woman's reproductive system, causing infertility or ectopic pregnancy. If the infected woman is pregnant and has Chlamydia,(rarely STDs occur in pregnancy. This could cause an eye infection (ophthalmia neonatorum) or pneumonia in here newborn. Reiter’s syndrome : reactive arthritis Adult conjunctivitis  Diagnosis of chlamydia oNucleic Acid Amplification test (NAAT) (gold standard) on first urine sample or vaginal discharge oligase chain reaction(LCR) oPCR on first urine sample oswab of urine and cervical discharge for culture, but it is expensive and not widely available, it is 100% specific, o ELISA tests there sensitivity is limited  Screening of CT Partners of patients diagnosed or suspected with infection History of chlamydia in the last year Patients with 2 or more partners within 12 months Women undergoing termination of pregnancy Treatment: General advice ⚫ A void intercourse until treatment of both partners is complete ⚫ Condom use ⚫ Retesting if any doubt about complete treatment, test of cure should be performed a minimum of 5 wks after initiation of treatment ⚫ Contact tracing if possible with multiple partner ⚫ Follow up interview with in 2-4 wks ⚫ If change partner, retesting between 3-12 months is recommended Antibiotics treatment The following treatment are effective for uncomplicated Chlamydia infection o Doxycycline 100mg twice/day for 7 days, o Azithromycin 1gm single dose o Ofloxacine 400 mg for 7 days, o Rrythromycin 500 mg 4 times/D for 7 days  Gonorrhoea: It is caused by Neisseria Gonorrhoea which is Gram negative diplococcic, colonize columnar or cuboidal (glandular)epithelium seen in the endocervical and urethral mucosa, it can infect oropharngeal and rectal mucosa. it cause cervicitis, urethritis, tonsillitis, conjunctivitis, and proctitis. Prevalence, is less than 1% in women of child bearing age, incidence is declining due to detection and earlier treatment, chronic asymptomatic infection is common  Signs and symptoms of NG ⚫Asymptomatic ⚫Vaginal discharge with lower abdominal ⚫Dysuria/urethral discharge ⚫Proctitis /Rectal bleeding, discharge and pain ⚫Endocervical discharge and contact bleeding ⚫Pelvic tenderness /cervical excitation  Diagnosi s Gram stained smear of urethral, cervical and rectal swabs(triple swab) Culture, It may fail to grow on culture if transport to the lab. was delayed, but culture is necessary for antibiotic sensitivity. DNA based detection(neucleic acids amplification tests/NA hybridization tests). Sex partners are screened fully for STIs and treated for gonorrhea before sexual intercourse resumed 50% of women treated for gonorrhea have concomitant Chlamydia infection and Chlamydia treatment should  Treatment Ceftriaxone250mg single dose IM Cefixim400mg single dose oral Azithromycin 1g single dose Spectinomycin2 g as a single dose IM Amoxycillin1g+probencid2g as single dose Ciprofloxacine500mg or Ofloxacin 400 mg as a single dose Pelvic inflammatory disease(PID) Infection arising from endocervix leading to infection of uterus, tubes, parametrial tissues, ovaries and overlying pelvic peritone, subsequently leading to tubo- ovarian and pelvic abscesses, sometimes infection spread to reach hepatic capsule leading to perihepatitis. PID is a polymicrobial infection 80% of cases are triggered by STI How infection can reach the upper genital tract? 1)ascend from the vagina or cervix through the uterine cavity. 2)introduced in to the upper genital tract while operating upon it's organs e.g. salpingitis following sterilization 3)blood borne e.g., pulmonary TB 4) spread from adjacent organs e.g. acute appendicitis What are the risk factors of PID????? Scarring and adhesion 139  Clinical features of PID: ⚫ Abdominal, Pelvic pain usually bilateral. ⚫ cervical excitation and adnexal tenderness on digital pelvic exam. ⚫ Intermenstrual/ abnormal bleeding or postcoital bleeding ⚫ abnormal vaginal discharge ⚫ Deep dyspareunia ⚫ Fever>38C ⚫ Nausea, vomiting ⚫ Right upper abdominal pain/tenderness ⚫ Generalized peritonitis , sepsis in severe systemic infections ⚫ Tubal damage, tubal occlusion, abscess and hydrosalpinx  Differential diagnosis: 1-ectopic pregnancy 2-UTI 3-Ovarian cyst complication 4-acute appendicitis 5-irritable bowel syndrome 6-inflammatory bowel disease 7-psychosomatic pain  Diagnosis Blood tests: (WBC,ESR, CRP)  pregnancy test-to exclude ectopic pregnancy  Microbiological tests— endocervical swab for gonorrhea cultur-endocervical swab for Chlamydia NAAT  Urine analysis  HIV Ab test  Syphilis serology  Ultrasound  MRI or CT scan  Laparoscopy Outpatient regimen for mild-to-moderate PID either Ceftriaxone (250 mg intramuscularly in a single dose),plus Doxycycline (100 mg orally twice daily for 2 wk) with or without metronidazole (500 mg orally twice daily for 2 wk) ofloxacine 400 bd (14 days) +metronidazole 400mg bd(14 days)  In patient treatment: if the patient is pregnant If she has human immunodeficiency virus infection If does not respond to oral medication If she is severely ill, nausea, vomiting, or high fever Inability to tolerate an outpatient oral medication regimen No clinical response to oral antimicrobial therapy Surgical emergencies (e.g., appendicitis) cannot be excluded Tubo-ovarian abscess  Long-term complications of PID  Recurrent PID  Ectopic pregnancy  Tubal factor infertility  Chronic pelvic pain  Hydrosalpinx  Tubo-ovarian abscess  Fitz-Hugh–Curtis syndrome violin-string adhesions.  Female genital tract tuberculosis: FGTTB is almost always secondary to pulmonary (commonest) or extra pulmonary TB Primary FGTTB in women who are partners of males had active genitor urinary TB through infected semen Fallopian tubes involvement 100% Infertility is the commonest presentation of FGTTB both primary and secondary infertility may occur. Vaginal exam;uterine enlargement(pyometra), adnexal tenderness, adnexal masses, tubo-ovarian mass or ulcerative lesions in cervix, vagina or vulva  Diagnosis Investigations:  CBC, ESR, CXR  Mantoux-tuberculin test  Serology(HIV)  Endometrial biopsy (in the premenstrual phase);for histopathological testing for granuloma  Mycobacterial smear and Lowenstein-Jensen media  culture of secretions from vagina, cervix, peritoneal fluid  Imaging methods US,CT, MRI  Laparoscopy and Hysteroscopy  Treatment 9 months regimen Rifampicin 450 - 600 mg Isoniazide300/day Ethanbutol 15mg/kg/day(in the 1st 2 months only with prophylactic pyridoxine 6 months regimen Rifampicin450-600 mg Isoniazide300mg/day Ethanbutol15mg/kg/day in the 1st 2 months only Pyrazinamide(20- 30 mg /kg/ day in the 1st 2 months only, with prophylactic pyridoxine Repeat endometrial sampling, negative bacteriological exam twice 6  In children the common causes of vaginal discharge are: poor hygiene foreign body sexual abuse The common micro-organism is streptococcus In postmenopause the vaginal discharge are due to: atrophic vaginitis malignancy(cervical or vaginal) Abnormal discharge may be a sign of something serious, like cervical cancer. Be sure to get pap smear at the recommended intervals  Herpes infection Genital Herpes infection is a chronic lifelong viral infection caused by herpes simplex virus, HSV has two serotypes, HSV-1 and HSV-2. HSV-1 is most commonly associated with oral lesions type 2 (HSV) is the cause genital herpes Causing the following symptoms: ♦ itching or tingling sensations in the genital or anal area ♦small fluid-filled blisters that burst leaving small painful Ulcer, the lesions heal without scarring within 14-21 days ♦pain when passing urine over the open sores. ♦retention of urine ♦flu-like symptoms, including fever. Diagnosis viral culture which is expensive PCR, which is expensive and very accurate type-specific serologic tests for HSV-1 and HSV-2 antibodies. These are highly sensitive and specific tests that can identify infected individuals who are asymptomatic Treatment: by bathing in salt water, analgesia, lignocaine and oral or topical Acyclovir (200mg orally five times daily orally for 5 days)  Genital warts Is caused by human papilloma virus (HPV). It is a common STI There are about 200 HPV subtypes, HPV 6, 11 associated with genital wart while HPV 16,18 linked to cervical ca Clinical presentation latent infection: no visible lesions , only diagnosed by DNA hybridization testing performed in the evaluation of an abnormal Pap smear. Subclinical infections have lesions that are only visible during colposcopy Clinical infections are characterized by visible “warty” growths called condylomata acuminata on the vulva, vagina, cervix, Transmission of HPV can occur even when there are no visible lesion Regular condom use may provide some degree of protection. During pregnancy, condylomata may increase in number and size, but transmission from mother to infant is rare.  Treatment of genital wart Surgical therapies include (1)cryotherapy (2)surgical excision (3)electrocautery (4)laser vaporization Patient-applied topical therapies include (1)podophyllin cream (2)trichloroacetic acid (TCA) or bichloracetic acid (BCA) 80% to 90%. (3) imiquimod 5% cream (4)podofilox 0.5% solution or gel The best treatment for genital wart in pregnancy?  HPV vaccin An HPV-like particle vaccine( Gardasil) is now available Quadrivalen that protects against four HPV serotypes (6, 11, 16, and 18), which together are responsible for 70% of cervical cancers and 90% of genital warts. This vaccin was used in female with age 9-26 years Another vaccine (Cervarix) act against HPV types 16 and 18 only.  Syphilis Is caused by Treponema pallidium. It is sexually transmitted infection, but can also be passed from an infected woman to her unborn child. Syphilis progresses through several stages: Primary syphilis the chancre, develops in locations close to where T. pallidum typically enters the body: Chancre is a painless ulcers on the genitalia with inguinal lymph node enlargement Secondary syphilis is a disseminated form Bloodborne spirochetes populate the dermis throughout the body causing a widespread papular rash over the trunk and extremities. Because the disease is systemic, fever, myalgias, lymphadenopathy, sore throat and headache are common, It can lead to arthritis, glomerulonephritis, nephrotic syndrome and uveitis. Untreated secondary syphilis One common manifestation is rough, reddish-brown spots on the bottoms of feet and on the palms of hands. tlatent period The subsequent months to years until the onset of symptoms of tertiary syphilis is known as the latent period. Tertiary syphilis usually appears many years after the disseminated stage. Tertiary syphilis can involve multiple organs, including the Vertical transmission to the fetus causing intrauterine death or congenital syphilis a(deafness, keratitis, abnormal teeth) Chancre Secondary syphilis  Diagnosis Detect the organism by sample taken from ulcer examine under dark field microscope Blood test (serology)to detect antibody like fluorescent treponemal antibody FTA (sensitive and specific test) VDRL and rapid plasma reagin test RPR(non specific) 3 serological test for syphilis including (FTA) test(most sensitive and specific test for syphilis, but time consuming to perform require skilled interpretation) In secondary syphilis VDRL positive , dark ground examination can be performed from mucosal lesions or condylomata lata  Treatment Penicillin is the first line treatment Procaine penicillin 1.2 MU daily i.m. 12 days Benzathine penicillin 2.4 MU i.m. repeated after 7 days Doxycyclin100 mg two times a day for 14 days doxycyclin or erythromycin in patients who have allergy to penicillin  HIV HIV is a retrovirus. The viral surface expresses a receptor called gp120 that binds specifically to receptors on lymphoid cells. it suppress the function of T- helper lymphocyte and macrophage Transmission: Viral transmission occurs through direct contact with bodily fluids, most often semen or blood. Viral spread can occur via sexual contact, via parenteral exposure (intravenous drug abuse and transfusions) or via perinatal transmission. The latter can occur during pregnancy (transmission across the placenta), at delivery or during breastfeeding. Only 25% of children born to untreated HIV-positive mother will aquire the infection although this rate can be decreased to less 1- 2% with aggressive antenatal and perinatal therapy Over 90% of HIV infections occur via heterosexual transmission.  Immunodeficiency syndrome (AIDS). Generalized lymphadenopathy diarrhoea Recurrent oral and vaginal Candidiasis Frequent oral or genital herpes and wart Opportunistic pathogens such as Pneumocystis carinii which cause atypical pneumonia tuberculosis Kaposi's sarcoma and non Hodgkin lymphoma Cervical carcinoma  Diagnosis of HIV& monitoring:  By finding antibodies to gp 120,(outer membrane protein binds to CD4 receptor) Normal lymphocyte CD4 in the peripheral blood is 0.5% the risk of AIDS development within one year if CD4 level drop to 0.2% CBC show lymphopenia and thrombocytopenia Treated by Antiretroviral drugs is reduce the level of viruses so the CD4 lymphocyte rises Other rare sexual transmitted infections which causing ulcers:  Chancroidis caused by Haemophilus ducreyi The lesions are painful and are usually accompanied by pelvic adenopathy. Diagnosis is made clinically and confirmed with cultures. Treatment is with azithromycin, 1 g orally in a single dose, or ceftriaxone 250 mg intramuscularly in a single dose. Granuloma inguinale (donovanosis) is caused by Calymmatobacterium granulomatis. The lesions are red and raised. Treatment is with doxycycline, 100 mg twice a day for a minimum of 3 weeks. Lymphogranuloma venereum is caused by C. trachomatis. Vesicles progress to bubo formation. Treatment is with doxycycline, 100 mg twice a day for at least 3 weeks. Donovanosis chancroid Thanks between the ages of 18 and 23 to investigate the pain; all were normal. At the age of 24, after the birth of her only child, she underwent a total abdominal hysterectomy at her own request, because her symptoms failed to resolve. The operative notes suggest that her pelvis was normal at the time. Subsequently she felt her symptoms had improved, although she remained on pain killers. Over the past two to three years, her pain has been increasingly difficult to control. It is constant, bilateral, and appears to be exacerbated cyclically, although it is worse at times of stress. Mrs Rana is requesting to have her ovaries removed, and her GP is supporting her request.  Consider possible physical and psychosexual causes of chronic pelvic pain. Analyse this patient’s history, considering the likelihood of organic disease.  Describe the effect of surgical menopause on women, with particular consideration to long-term health risks.  What approach to this patient’s management would you suggest  Discuss the ethical dimension of patient choice, when a procedure is requested that you, in your professional opinion, do not consider justifiable. …………………………………………………………………………… Mrs Najah is a 34 year old. She complains of vulval soreness for last 12 months and her symptoms had been getting worse of late. She had no other symptoms of note. On her first ever clinic visit two weeks ago, her vulval sores appeared to be herpetic, and the virus culture ordered was positive for Herpes Simplex Virus. She was given a short course of Aciclovir (200mg 5 times a day for 5 days). She underwent a sexual health check- up, and her blood test was found be positive for HIV-1. Other tests done as a part of STI screen were normal.  Suggest an empathetic way of telling the diagnosis of HIV to Mrs Najah.  What investigations would you recommend for this patient in the light of her newly diagnosed HIV and why? The Key results of the investigations performed on Mrs Najah are as follows: CD4 T-cells 180 cells/ml HIV Viral load 80,000 copies/ml HIV resistance test: No resistance to any anti-retroviral drug reported All other baseline investigations are normal. Outline a specific management plan you will suggest for this patient to deal with her HIV. Suggest how you would assess treatment efficacy. Mrs Najah is worried about impending death, and future of her children. How would you deal with her worries. Mrs Najah lives with her two children, aged 8 and 6 years. Her first daughter, passed away 11 years ago before her second birthday. Her husband has been healthy all his life, and he is in the clinic today with MrsNajah. It is recommended that both her children are tested for HIV. MrsNajah has got few questions before she agrees to this. Discuss the probability of her children having HIV. Why should she get her children to have HIV test, if they are well? pelvic pain. She is on the combined oral contraceptive pill, which she has been taking for the past six years. Her cycles were controlled on the COCP until about 18 months ago, when she split up from her long-term partner. In the last few months she has noticed that her periods are becoming longer, heavier, and more painful. She has also noticed increased vaginal discharge with some non cyclical, bilateral lower abdominal pain. her last menstrual period was 10 years ago; since then the pain has become severe What would be your differential diagnoses her last menstrual period was 10 years ago; since then the pain has become severe What other information would you like to obtain from the patient What would be your working diagnosis?  What are the long-term implications should your working diagnosis be correct?  pulse of 100 bpm and a temperature of 37.5oC. There is mild bilateral tenderness in the lower abdomen. On vaginal examination there is positive cervical excitation and bilateral adnexal tenderness. Describe the investigations you consider necessary in this case. How would you treat this patient should your working diagnosis be correct What other steps/interventions would you consider (including advice to patient) Miss Parker is now in a relationship with a new partner, however has not restarted the combined contraceptive pill. She attends the family planning clinic having had unprotected intercourse approximately 16 hours before presentation. What history would you need to take from her before providing emergency contraception? Outline two methods available for emergency contraception, with a description of their mechanism of action and contraindications to their use.