Infection of female genital tract 2

Upper genital tract infection pelvic inflammatory disease

Pelvic inflammatory diseases (PID) is broad term used to cover upper genital tract infection i.e. endometritis, parametitis, salpinigitis & oophoritis. These infections -usually spread from-vagina or cervix through –uterine cavity -lymphatic spread may occur. -Infection may be from the bowel or - can be blood borne

80% of cases is triggered bytransmissible infection: either chalmydia or gonorrhoea. Endogenous anaerobes as bacteriodes spp., or mycoplasma hominis usually came in as secondary invaders & cause tubal abscess PID is important condition because it result in tubal damage leading to ectopic pregnancy & tubal factor infertility, 20% of women left with chronic pelvic pain.

Aetiology -Neisseria gonorrhoeae and -Chlamydia trachomatis are the most important m.o., although -gardnerella vaginalis,anaerobes and -others like mycoplasma may be implicated and responsible for subsequent abscess formation.

Pathology of PID As infection ascend in to the uterus endometritis develops. In 1st stage of salpingitis i.e. the tubes involved in inflammation, swelling, redness & deciliation. Polymorphnuclear cells invade in submucosa followed by mononuclear cells & plasma cells

Inflammatory exudates fills the lumen of the tube & adhesions develop between mucosal dolds, inflammation extends to the serosal surface & pus exudes from fimbria to overies & adnexae, tubal or tubeorarian abscesses may develop. Subsequant scarring may lead to fimbriae being drawn into the ends of the fallopian tubes sealing the ends of tubes, the uterus & tubes may be pulled back into the pelvis becoming fixed & retroverted. A hydrosalpinx is caused by accumulation of fluid with in the tube which expands & swells. If infected, a pyosalpinx results. Plevic adhesions organize, matting together the pelvic organs

Predisposing factors Young age 15- 25 years. sexual activity Past history of STD. Termination of pregnancy. Insertion of IUCD in the past 6 months. Hysterosalpingography (HSG). In vitrofertilization. Postpartum endometritis. Bacterial vaginosis smoking

Clinical features *pelvic pain which also * present in menstruation (dysmenorrhoea), *deep dyspareunia & *pain during micturition (dysuria), * 35% may complain of irregular vaginal bleeding *many patients had increased vaginal discharge *In acute sever infection nausea, vomiting & fever with tachlycardia may occur

On examination -lower abdominal tenderness - with cervical excitation which is pain occur during moving the cervix on pelvic examination -Adnexal mass in 20%.of patients

Differential Diagnosis Salpingitis Appendicitis Endometriosis Bleeding corpus luteum Ectopic pregnancy

investigations 1-High vaginal and endocervical swabs and testing for gonorrhoeae and Chlamydia in the lower genital tract is important 2-ESR and c-reactive protein is elevated 3-Laparoscopy: should be performed if the clinical diagnosis is unceretain in mild cases the tubes are swollen and red. In severe cases the tubes adherent to the adjacent structures. In pelvic peritonitis, all the organs are congested and adhesion cause inflammatory abscess. 4- Endometrial biopsy and ultrasound

Management: -Pregnancy test -Appropriate analgesia -Rest -Pregnancy test -Appropriate analgesia -appropriate antibiotics Inpatient management in those with: *Sever condition *Failure of oral treatment *Suspicions of tubo-ovarian abscess *Those with immunodeficiency problem

treatment Ambulant patients with mild symptoms may be treated as out patients with antibiotic cover both Chlamydia & gonorrhoea as well as anaerobic organism. Doxycycline 100mg twice a day for 14 days with metronidazole 400mg twice daily, if gonorrhoea is suspected ciprofloxacin 500mg as a single dose in addition.

Inpatient management Intravenous cefoxitin 2g four times daily (I.V. cefotetan 2g twice daily) + I.V. doxycycline 100mg twice daily followed by oral doxycycline 1OOmgtwice daily with.oral metronidazole 500mg three times daily for 14 days

-Drainage of abscess is indicated if i. v -Drainage of abscess is indicated if i.v. treatment failed after 24-48 hours -Intra-abdominal spread of infection of Chlamydia and gonorrhoeae can cause peri-appendicitis or perihepatitis, which is called Fitz-Hugh Curtis syndrome. In this condition patient present with right hypochondrial pain and should be treated for 3 weeks with antibiotics

Chlamydia trachomatis -Is the commonest bacterial sexually transmitted infection - which is commonly a symptomatic. -It is small bacterium an obligate intracellular pothogen -Serovars A-C cause trachoma of conjuctiva, - serovars D-K cause genital infections, - specific LGV serovars (L1-L3) cause lymphogranuloma venerium.

Clinical features *80% asymptomatic *intermenstrual bleeding *Lower abdominal pain *Purulent vaginal discharge *Mucopurulent cervicitis & /or contact bleeding

complications 1-PID and subsequent Fitz-Hugh-Curtis syndrome 2-Tubal damage, ectopic pregnancy, infertility, and chronic pelvic pain 3-Transmission to the neonate causing conjunctivitis and pneumonia 4-Arthritis and Reiter's

diagnosis *Endocervical, urethral, and vaginal swab for culture but are not sensitive *ELIZA tests used commonly but with limited sensitivity, the samples are collcted from the endocervix & areas of cervical ectropion *Polymeraze chain reactin (PCR)& Ligase chain reaction are more specific. *Direct fluorescent antibody test

For uncomplicated chlamydia infection the treatment is :- Doxycyclin 100mg twice daily for one week. Ofloxacin 400mg daily for a week Erythromycin 500mg twice daily for 2 weeks. In pregnancy :- Azithromycin 1g single dose Erythromycin 500mg twice daily for 2 week The partner screened for transmitted infection & treated.

Gonorrhoea -It is a STD -Caused by gram negative diplococcus N.gonorrhoeae . -Sites of infection are mucous membrane of urethra, endocervix, rectum, pharynx, and conjunctiva -Vertical transmission from the mother to the fetus may occur during labour

Clinical features -50%asymptomatic -increased or altered vaginal discharge -lower abdominal pain -dysuria -Rarely intermenstrual bleeding or menorrhagia due to endometritis

Clinical signs -mucopurulent endocervical discharge and bleeding -pelvic or lower abdominal tenderness, -In the infant cause sever conjunctivitis (ophthalmia neonatorum)

complications *Spread of the micro-organism cause PID *Haematogenous spread causing - skin infection, - arthralgia, and arthritis -gonococcal septicaemia The incidence is declined in the last two decades

Diagnosis Diagnosis is made by observing typical Gram-negative intracellular diplococi on Gram-stained smears & cultures of urethral, cervical & rectal swabs.

The following treatments are effective for sensitive strains Amoxycillin 3g with probenecid 2gm single dose . Ciprofloxacin 500mg as single dose. Spectindmycin 2g as single dose ( in tramuscularly ) Azithromycin 1 g as a single dose. Ceftriaxone 250mg as a single dose ( in tramuscularly ) *More than 50% has concomitant chlamydial infection, therefore, treatment for the patient and partner should be done *The partner should be screened for the infection and treated

Other organisms cause PID are: Mycoplasma hominis & ureaplasma urealyticum Aerobic & Anaerobic organisms like coliforms, Group B& D streptococi staphylococci & Haemophillus, influenza & Anaerobic like peptococi, streptococci, clostridium & Bacteroides. Actinomyces israii Viral infections like coxakie B, echo 6 & herpes simplex.