Upper genital tract infection
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Pelvic inflammatory disease is a broad term used to cover infection of uterus, tubes,
parametrial tissues, ovaries and overlying pelvic peritone, sometimes infection
spread to reach hepatic capsule leading to perihepatitis
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 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
5) lymphatic spread
PID is a polymicrobial infection 80% of cases are triggered by sexually transmitted
infection
Chlamydia trachomatis:
It is the commonest bacterial sexually transmitted disease(STD). 10% of child bearing
age women are infected in UK, with highest prevalence among women<25 years,
50% of infected men and 80% of infected women are asymptomatic, if symptomatic,
in women it cause cervicitis and PID, in men it's most important cause of NGU(non
gonococcal urethritis) genital strains can infect the throat, conjunctiva and rectum.
Diagnosis:
Initially cell culture techniques were used
ELISA tests are used now more frequently, but there sensitivity is limited (it is
essential that samples are collected from the endocervix and areas of cervical
ectropion so that columnar cells harvested)
Nucleic acid amplification tests likePCR and ligase chain reaction(LCR) which can be
applied to urine or vaginal swabs samples are much more sensitive with detection
rate higher than ELISAtest done on cervical swabs and can be used as non invasive
screening for Chlamydia.
Direct fluorescent antibody test(DFA) done on cervical smear and is more
appropriate than ELISAwhen both are done on rectal or conjunctival swabs
Serological tests are not performed routinely in the diagnosis of Chlamydia
infections, micro
immunoflourescence can be used to detect serum antibodies which are not present
in all infected individual. highest antibody titre are found in women with PID or
disseminated infection, and 60% of women with tubal factor infertility. It's essential
that sex partners are screened fully for STI and treated for Chlamydia before sexual
intercourse is resumed.
The following treatment are effective for uncomplicated Chlamydia infection
Doxycycline 100mg twice/day for 7 days, azithromycin 1gm single dose,ofloxacine
400 mgfor 7 days, in pregnancy,azithromycin1 gm single dose, erythromycin500 mg
twice/D for 14 days
Gonorrhoea:
Gram negative diplococcic, colonize columnar or cuboidal epithelium, protective
immunity does not appeare to develop, there are no reliable serological test for N.
gonorrhea, resistant strain emerge rapidly. High level resistance to penicillin is
mediated by plasmid. Resisitance to quinolone antibiotic have emerged in
developing countries in the last 2 decades.
Prevelance, is less than 1% in women of child bearing age, chronic asymptomatic
infection is common, 50% of infected women are asymptomatic, 70% of infected
men are symptomatic, it cause urethritis, tonsillitis, conjunctivitis, and proctitis.
Diagnosis
Gram –staied smear of urethral, cervical and rectal swabs, it is fastidious M.O.,
requiring 7%co2 concentration, blood agar, antibiotic to inhibit the growth of
other organisms.
It may fail to grow on culture if transport to the lab. Was delayed, but culture is
necessary for antibiotic sensitivity.
DNAbased detection are available for screening.
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 always be prescribed for
gonorrhea patients and their partners.
Women should have 2 sets of culture performed following treatment as test of cure.
The following treatment are effectiveagainst sensitive strains of gonorrhea
Amoxycillin1g+probencid2g as single dose
Ciprofloxacine500mg as a single dose
Spectinomycin2 g as a single doseIM
Azithromycin 1g single dose
Ceftriaxone250mg single dose
Cefixim400mg single dose
Mycoplasma genitalium is propably STI implicated in PID in women and in
NGUin it's difficult to detect, require especial culture medium or PCR test.
Endogenous anaerobes, such as Bacteroides spp. Or mycoplasma
hominis, often come in as secondary invaders and are responsible for subsequent
tubal abscess formation.
Cervicitis:
Mucopurulent cervicitis is a clinical diagnosis based on detecting purulent mucus at
the cervical os and is often accompanied by contact bleeding.
It can be confused with a benign ectropion, but the latter does not usually bleed
heavily unless swabbed very vigorously.
Presentation is either with postcoital bleeding or complain of purulent vaginal
discharge , however it can be asymptomatic.
Aetiology often caused by STIs with male partner having NGU
Diagnosis tests for Chlamydia and gonorrhea should be performed. if ulceration is
present test for herpes simplex. Nabothian follicles are mucus containing cyst up to 1
cm in diameter, which are often present following chronic cervicitis which cause
scarring.
Pelvic inflammatory disease:
Infection ascends into the uterus, Fallopian tubes, ovaries, and parametrial tissues.
Clinical features:
Essential features
Pelvic pain, usually bilateral.
cervical excitation
adnexal tenderness on digital pelvic exam.
Supporting features:
Intermenstrual/ abnormal bleeding or postcoital bleeding(endomeritis, cervicitis)
Increased/ abnormal vaginal discharge
Deep dyspareunia
Vaginal discharge
Fever
Nausea vomiting
Right upper abdominal pain/tenderness
Generalized peritonitis
Differential diagnosis:
1-ectopic pregnancy
2-ovarian accident
3-acute appendicitis
4-irritable bowel syndrome
5-inflammatory bowel disease
6-UTI
7-bowel tortion
8-psychosomatic pain
Investigations:
Blood tests: (WBC,ESR, CRP-non specific-, pregnancy test-to exclude ectopic
pregnancy-)
Microbiological tests—endocervical swab for gonorrhea culture
---endocervical swab for chlamydiaNAAT
--Microscopy for cervical pus cell
If positive or patient at high risk for STI----offer microscopy /culture for T.vaginalis
------HIV ab test
---syphilis serology
Radiological investigations:
TVS(free fluid, exclude other diagnosis, detect tuboovarian abscess)
Power Doppler
MRI, CTscan , kept for cases with doubtful diagnosis.
Surgical diagnosis: definitive diagnostic procedure is laparoscopy, as an invasive
procedure it should be kept to cases with doubtful diagnosis
Or patient fail to respond to antibiotic within48-72hrs.
Treatment: most patients are treated as outpatient, the antibiotic should cover
Chlamydia, gonorrhea, and anerobes
Ceftriaxon 250mg im+doxycycline 100mgbd(14 days)+metronidazole 400 mg bd(5
days) or ofloxacine 400 bd(14 days)+metronidazole 400mg(5 days)
Inpatient care indicated if:
Patient is systemically unwell
Severe symptoms such as acute abdomen
Tubal abscess is suspected
And those should be treated with IV antibiotics initially iv
cephalosporines+metronidazole,2-3 days, then followed by oral doxycycline(14 days)
+metronidazole
e.g.cefxitin 2g QID+iv or oral doxycycline 100 mgBD followed by oral doxycycline+
metronidazole(BD)
It's essential that sexual partner is screened for STI and treated.
Surgery is indicated
To drain pelvic abscess
If doubtful diagnosis
Ultrasound guided aspiration is less invasive as effective as laparoscopy or
laparotomy.
Other complications of Chlamydia and gonorrhea
Periappendicitis and perihepatitis(Fitz-Hugh-Curtis syndrome)
Reiter's syndrome(sexually acquired reactive arthritis)
Septic oligoarthritis(disseminated gonorrhea infection)
Sequels of PID:
Recurrent PID
Ectopic pregnancy
Tubal factor infertility
Chronic pelvic pain
Female genital tract tuberculosis:FGTTB
Exact incidence is not accurately known-underreportedVaries from1% in USto 1-19% in various parts of india
FGTTB is almost always secondary to pulmonary(commonest) or extrapulmonary TB
Primary FGTTB in women who are partners of males had active genitor urinary TB
through infected semen
Fallopian tubes involvment100%
Endometrial TB50-80%
Ovarian TB is rare and often seen as part of TB peritonitis
Cervical TB5-15%
Vagina &vulva 1-2%
TB &infertility:
Infertility is the commonest presentation of FGTTB both primary and secondary
infertility may occur.
The reasons for infertility are:
Blocked damaged tubes, non receptive and damaged endometrium with Asherman's
syndrome, and ovarian damage.
Clinical presentation(symptoms and signs):
Systemic manifestations; fever, LAP, crackles on chest exam
Abdominal exam;mass,ascites
Vaginal exam;uterine enlargement(pyometra), adnexal tenderness, adnexal masses,
tubo-ovarian mass, fullness and tenderness in POD
Unusual signs;hypertrophic or ulcerative lesions in cervix, vagina or vulva
Gynecological fistulae.
Investigations
CBC, ESR
CXR
Mantoux-tuberculin test
Serology(HIV)
Endometrial biopsy, curettage or aspirate(in the premenstrual phase);for
histopathological testing for granuloma, specimen forAFBsmear and culture, PCR
Mycobacterial smear and Lowenstein-Jensen media culture of secretions from
vagina, cervix, peritoneal fluid or tubal biopsy,PCR
Imaging methods
US,CT, MRI,PET
Blood markers in genital TB, CA125(usually, the level in GTTBis only mildly
elevated<200 but could be very high in disseminted TB
Hysterosalpingography;is contraindicated in known cases of GTTB , but usually
diagnose GTTB retrospectively while investigating women for infertility
Hysteroscopy
Laparoscopy, macroscopically the tubes are thickened, with fibrosis and peritubular
adhesions, the fimberia remain everted retort-shape tube, the tubes are patent but
functionless.Yellow pus with caseations.
Treatment
9 monthsregimen
Rifampicin450-600 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 mo apart with 2
negative reports mean cure.