1. Genital infections in gynaecology
Dr. Alyaa Abdul-monem

2. Vaginal discharge
Causes of increased vaginal discharge Physiological • Oestrogen related—puberty, pregnancy, COCP. • Cycle related—maximal mid-cycle and premenstrual. Pathological Infection • Non-sexually transmitted (BV, candida). • Sexually transmitted (TV, chlamydia, gonorrhoea). Non-infective • Foreign body (retained tampon, condom, or post-partum swab). • Malignancy (any part of the genital tract). • Atrophic vaginitis (often blood-stained). • Cervical ectropion or endocervical polyp. • Fistulae (urinary or faecal).

3. Physiological discharge:
• Normal vaginal discharge is white, becoming yellowish on contact with air. • It consists of desquamated epithelial cells from the vagina and cervix, mucus originating mainly from the cervical glands. bacteria and fluid, which is formed as a transuedate from the vaginal wall. More than 95 per cent of the bacteria present are lactobacilli. • The acidic pH is maintained by the lactobacilli and through the production of lactic acid. • It increases due to increased mucus production from the cervix in mid-cycle, pregnancy and sometimes when women begin using a combined oral contraceptive pill.

4. Normal: lactobacilli – seen as large Gram-positive rods – predominate
Normal: lactobacilli – seen as large Gram-positive rods – predominate. Squamous epithelial cells are Gram negative with a large amount of cytoplasm.

5. Lower genital tract infections:
Vulvovaginal Candidiasis ( thrush ): Epidemiology • It is a mycotic disease, caused by the dimorphic Yeast-like fungus (90%Candida albicans, remainder other species,e.g. C.glabrata ). • About 75% of women will experience at least one episode, and 10–20% are asymptomatic chronic carriers (increasing to 40% during pregnancy). • It is not sexually transmitted

6. Predisposing factors are those that alter the vaginal micro-flora and include:
• immunosuppression
• antibiotics
• pregnancy
• diabetes mellitus
• HIV.
• Steroids.
• Vaginal douching, tight clothing.
• Cocp

7. Diagnosis
Symptoms: May be asymptomatic, but usually presents with: • Vulval itching and soreness. • Thick, curd-like, white vaginal discharge. • Dysuria. • Superficial dyspareunia. Signs: • Characteristic appearance of: • vulval and vaginal erythema • vulval fissuring, oedema, excoriation • typical white plaques adherent to the vaginal wall. • Normal vaginal pH. Investigations: • Culture from HVS or LVS. • Microscopic detection of spores and pseudohyphae on wet slides.

8. Candidiasis: there are speckled Gram-positive spores and long pseudohyphae visible. There are numerous polymorphs present and the bacterial flora is abnormal, resembling bacterial vaginosis.

9. Treatment
Uncomplicated infection • candidiasis should only be treated if it is symptomatic. • Azoles/imidazoles are the mainstay of the treatment. •The commonly prescribed medication is clotrimazole, which can be taken as single 500 mg pessary or a course of a 100 mg pessary over 6 days. • Oral imidazoles, such as fluconazole, are given as a single dose at 150 mg or itraconazole 200 mg twice a day for 1 day. However, these are contraindicated in pregnancy. • Other simple measures may help to decrease recurrent attacks, e.g.: - Wearing cotton underwear. - Avoiding chemical irritants, e.g. soap and bath salts.

10. Recurrent infection • Recurrent infection is defined as at least four episodes of infection per year and/or a positive microscopy of moderate to heavy growth of C. albicans. • The principle of 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. • Oral imidazoles cannot be used in pregnancy but a topical imidazole can be used for 2 weeks for induction followed by a weekly dose of Clotrimazole pessary 500 mg for possibly 6–8 weeks.

11. Complicated infection Commonly seen in acute severe infection in pregnancy, women with diabetes mellitus or with immunosuppression conditions or therapy. The topical treatment in such cases can be extended to up to 2 weeks. Implications in pregnancy • It is very common in pregnancy with no apparent adverse effects. • Topical imidazoles are not systemically absorbed and are therefore safe at all gestations.

12. Trichomonas vaginalis
Epidemiology • Trichomonas vaginalis —flagellated protozoan can cause severe vulvovaginitis and UTI . • Found in vaginal, urethral, and para-urethral glands. • It is usually sexually transmitted and commonly recurrences occur if the male partner is not simultaneously treated. Signs & Symptoms Asymptomatic in 10–50%, but may present with: • Frothy,yellowish green, offensive smelling vaginal discharge. • Vulval itching and soreness. • Dysuria. • Cervix may have a ‘strawberry’ appearance from punctate haemorrhages (2%).

13. Trichomoniasis: an unstained ‘wet mount’ of vaginal fluid from a woman with Trichomonas vaginalis infection. There is a cone-shaped, flagellated organism in the centre, with a terminal spike and four flagella visible. In practice, the organism is identified under the microscope by movement, with amoeboid motion and its flagella waving.

14. Diagnosis • Direct observation of the organism by a wet smear (normal saline). (sensitivity 40–70% cases). • Culture media are available and will diagnose up to 80% cases. • NAATs have been developed and sensitivities and specificities approaching 100% have been reported. Complications There is some evidence that trichomonal infection may enhance HIV transmission.

15. Management • Both partners should be treated and both should be screened for other sexually transmitted infections. • Metronidazole 2g orally in a single dose. • Metronidazole 400 bd for 5–7 days. • Tinidazole in a single oral dose of 2 g is equally effective, but can cost more. Implications in pregnancy • Trichomonas is associated with: • preterm delivery • low birth weight. • Trichomonas may be acquired perinatally, occurring in 5% of babies born to infected mothers.

16. Bacterial vaginosis
Epidemiology • BV is a common condition caused by an overgrowth of mixed anaerobes, including Gardnerella vaginalis, Mycoplasma hominis, Bacteroides spp. and Mobilincus spp., which replace the usually dominant vaginal lactobacilli causing an increase in the vaginal pH making it more alkaline. • Not sexually transmitted. • About 12% of women will experience BV at some point in their lives, but what triggers it remains unclear.

17. Signs and Symptoms • May be asymptomatic, but usually presents with a profuse, whitish grey, offensive smelling vaginal discharge. The characteristic ‘fishy’ smell is due to the presence of amines released by bacterial proteolysis and is often distressing to the woman. • More prominent during and following menstruation Diagnosis (Amsel criteria—3 out of 4 required for diagnosis.) • Homogenous grey-white discharge. • Increased vaginal pH >4.5. • Characteristic fishy smell. • ‘ Clue cells’ present on microscopy (squamous epithelial cells with bacteria adherent on their walls).

18. Bacterial vaginosis: there is an overgrowth of anaerobic organisms, including Gardnerella vaginalis (small Gram-variable cocci), and a decrease in the numbers of lactobacilli. A ‘clue cell’ is seen. This is an epithelial cell covered with small bacteria so that the edge of the cell is obscured

19. Complications Increased risk of pelvic infection after gynaecological surgery. Treatment May resolve spontaneously and if successfully treated has a high recurrence rate. However, most women prefer it to be treated. • Metronidazole 400mg orally bd for 5 days; or • Metronidazole 2g (single dose). • Alternatively, it can be used as a local intravaginal gel (0.75 per cent) usually applied at night for between 5 and 7 days. • Clindamycin 2% cream vaginally at night for 7 days. Lifestyle factors—avoidance of vaginal douching/overwashing which can destroy natural vaginal flora.

20. Implications in pregnancy Associated with an increased risk of: • Late mid-trimester miscarriage. • Preterm rupture of membranes. • Preterm delivery. Women with a previous history of second trimester loss or preterm delivery should have a vaginal swab performed in early pregnancy and if bacterial vaginosis is detected, it should be actively treated in the early second trimester of pregnancy. Metronidazole is safe to use in pregnancy, however, large or prolonged doses should be avoided.

21. Gonorrhoea
Epidemiology • Neisseria gonorrhoeae: intracellular Gram –ve diplococcus. • It is a STD. • It has affinity to infect the mucous membranes of the genital tract infecting cuboidal and columnar epithelium seen in the endocervical and urethral mucosa. It can also infect the rectal and oropharyngeal mucous membrane • > 35% of strains are resistant to ciprofloxacin, 70% to tetracyclines. • Sexually transmitted coinfection with Chlamydia and Trichomonas are common

22. Signs & Symptoms • Asymptomatic • Increased vaginal discharge with lower abdominal/pelvic pain • Dysuria with urethral discharge • Proctitis with rectal bleeding, discharge and pain • Endocervical mucopurulent discharge and contact bleeding • Mucopurulent urethral discharge • Pelvic tenderness with cervical excitation.

23. Diagnosis:
• Gram staining: visualization of Gram-negative intracellular diplococci
• Culture medium using an agar medium containing antimicrobials to reduce growth of other organisms
• Nucleic acid amplification tests (NAATs)
• Nucleic acid hybridization tests
Endocervical swabs should be taken and if symptomatic, swabs from the rectum and pharynx should also be included.

24. A Gram-stained smear of cervical secretions showing polymorphs and Gram-negative intracellular diplococci. This appearance is highly suggestive of gonorrhoea.

25. Complications of gonococcus infection • PID • Bartholin’s or Skene’s abscess. • Disseminated gonorrhoea may cause: - fever - pustular rash - migratory polyarthralgia - septic arthritis. • Tubal infertility. • Risk of ectopic pregnancy.

26. Treatment Cephalosporins are the mainstay of treatment.
• Contact tracing and treatment of partners.
• Single oral dose of cefixime 400 mg
• Single intramuscular dose of ceftriaxone 250 mg
• Single intramuscular dose of spectinomycin 2 g
• Single oral dose of ciprofloxacin 500 mg or ofloxacin 400 mg
• Azithromycin 1 g as single dose
• Ampicillin 2 g or amoxycillin 1 g with probenecid 2 gm as a single oral dose.
In pregnancy, it is safe to use the penicillins and cephalosporins, but tetracycline and ciprofloxacin/ ofloxacin should be avoided.

27. Implications in pregnancy • Gonorrhoea associated with: - preterm rupture of membranes and premature delivery - chorioamnionitis. • The risks to the baby are of ophthalmia neonatarum (40–50%).

28. Genitourinary Chlamydia
Epidemiology • Chlamydia trachomatis: obligate intracellular bacterium affecting the columnar epithelium of the genital tract. • Is the commonest bacterial sexually transmitted infection which is commonly a symptomatic. • Serovars D-K cause genital infections • An important cause of tubal infertility. SIGNS & Symptoms Dysuria with urethral discharge, vaginal discharge and lower abdominal pain, Mucopurulent cervical discharge ,or irregular bleeding (IMB or PCB), but 70% of cases are asymptomatic.

29. Complications of Chlamydia infection • Pelvic inflammatory disease (10–40%). • Perihepatitis (Fitz–Hugh–Curtis syndrome). • Reiter’s syndrome (more common in men): • arthritis • urethritis • conjunctivitis. • Tubal infertility. • Risk of ectopic pregnancy.

30. Diagnosis • Vulvovaginal or endocervical swab for nucleic acid amplification test (NAAT). Requires specific medium. • Real-time polymerase chain reaction(PCR). • Endocervical, urethral, and vaginal swab for culture but are not sensitive • ELIZA test on endocervical smear. Old method Screening and opportunistic testing • Partners of patients diagnosed or suspected with infection • History of chlamydia in the last year • Patients attending GUM clinics • Patients with two or more partners within 12 months • Women undergoing termination of pregnancy • History of other sexually transmitted infection and HIV.

31. Treatment General advice
• Avoid intercourse, before treatment of both partners is complete.
• Use of condoms should be encouraged to prevent reinfection and other STIs.
• Retesting if any doubt about complete treatment. Test of cure should be performed a minimum of 5 weeks after initiation of treatment.
• Test of cure should be routine in pregnancy.
Antibiotic treatment
- Doxycycline 100 mg twice a day for 7 days
- Azithromycin 1 g as single dose
- Ofloxacine 400 mg daily for 7 days
- In pregnancy:
o Azithromycin 1 g as single dose
o Erythromycin 500 mg twice a day for 14 days
- Partner should be fully screened and treated

32. Implications in pregnancy • Association with preterm rupture of membranes and premature delivery.The risks to the baby are of: • Neonatal conjunctivitis (30% within the first 2wks). • Neonatal pneumonia (15% within the first 4mths).

34. Upper genital infection
Pelvic inflammatory disease: Definition: PID is infection of the upper genital tract. - Pelvic inflammatory disease is characterized by inflammation and infection arising from the endocervix leading to endometritis, salpingitis, oophoritis, pelvic peritonitis and subsequently formation of tubo-ovarian and pelvic abscesses.

35. Causes • Most commonly caused by ascending infection from the endocervix, but may also occur from descending infection from organs such as the appendix. • There are multiple causative organisms: • 25% of cases estimated to be caused by Chlamydia trachomatis and Neisseria gonorrhoeae • anaerobes and endogenous agents, either aerobic or facultative, may be responsible for the remainder.

36. Pathophysiology • First stage of salpingitis is mucosal Inflammation with swelling, redness and deciliation. • Submucosal invasion with polymorph nuclear cell, mononuclear and plasma cell. • Inflammatory exudates fills the lumen. • Inflammation extends to the serosal surface, and pus exudes from the fimbriae to the ovaries and adnexia. • Omentum usually confines the infection to the pelvis, however, infection may cause tissue damage end with tubo-ovarian abscess . • Subsequent scarring made the fimbrial end adherent to the tube and sealing the end of the tubes .

37. • The-uterus fixed by adhesion and becomes retroverted
• The-uterus fixed by adhesion and becomes retroverted. • Hydrosalpinx, and if infected pyosalpinx results • Chlamydia and gonorrhoea can also cause perihepatitis leading to adhesions between the liver and the peritoneal surface. This gives a typical violin string appearance at laparoscopy and is known as the Fitz–Hugh–Curtis syndrome.

38. Fitz Hugh Curtis Syndrome showing perihepatic adhesions (typical violin string appeareance).

39. Peritubal adhesions of the left Fallopian tube.

40. Left Fallopian tube with terminal hydrosalpinx

41. Left Fallopian tube hydrosalpinx.

42. Large hydrosalpinx of the left Fallopian tube with a smaller hydrosalpinx on the right side

43. History and examination • A full gynaecological history including sexual history. • An abdominal examination to elicit the site and severity of the pain. • Speculum and vaginal examination to assess for adnexal masses, vaginal discharge, or cervical excitation. Risk factors for PID • Age <25. • Previous STIs. • New sexual partner/multiple sexual partners. • Uterine instrumentation such as surgical termination of pregnancy and intrauterine contraceptive devices. • Post-partum endometritis.

44. Protective factors These include the use of barrier contraception, the levonorgestrel (LNG)(Mirena IUS) and the COCP. DIAGNOSIS: Signs & symptoms -PID may be relatively asymptomatic, the diagnosis only being made retrospectively during investigation of subfertility. -Symptoms may include some or all of the following: • Pelvic pain (may be unilateral), constant or intermittent. • Deep dyspareunia. • Vaginal discharge (usually due to concurrent vaginal infection).

45. • Irregular and/or more painful menses. • IMB/PCB
• Irregular and/or more painful menses. • IMB/PCB. • Fever (unusual in mild/chronic PID). -Signs (at least one of which should be present when making a PID diagnosis) are: • Cervical motion pain (cervical excitation). • Adnexal tenderness (commonly bilateral, but may be unilateral). • Elevated temperature (unusual in mild/chronic infection).

46. Investigations • High vaginal swab for tricomonas and vaginosis and endocervical swab for gonorrhea and Chlamydia. • WCC, ESR and CRP may be elevated. • USS may be indicated if a tubo-ovarian abscess is suspected. • Laparoscopy is the gold standard test; however, it is invasive and only used where diagnosis is uncertain. Complications of PID • Tubo-ovarian abscess. • Fitz-Hugh–Curtis syndrome. • Recurrent PID. • Ectopic pregnancy. • Infertility.

47. Diffrential diagnosis: • Ectopic pregnancy. • Acute appendicitis
Diffrential diagnosis: • Ectopic pregnancy. • Acute appendicitis. • Endometriosis. • Complicated ovarian cyst. • Constipation.

48. Treatment
Early empirical treatment is recommended. Multiple antibiotic regimes are required to cover all potential causative organisms.
• pregnancy test should be done in all cases to rule out ectopic pregnancy.
• Most patients can be treated in an outpatient setting.
• Review after 72h to ensure adequate response.
• Contact tracing and treatment of partners is essential.
• Inpatient treatment may be required if symptoms are severe, fail to respond, or abscess is suspected.
• If there is USS evidence of a tubo-ovarian abscess, drainage may be required either by ultrasonic guided aspiration or at laparoscopy.

49. There are several differing antibiotic regimes that are used; Mild/moderate infection (outpatient treatment) • Oral ofloxacine 400mg bd + oral metronidazole 400 mg bd daily for 14 days or • IM ceftriaxone 500 mg + oral doxycycline 100 mg bd 14 days + oral metronidazole 400 mg bd 14 days.

50. Principles of inpatient treatment • Adequate supportive care • Strict watch on fluid balance • Parenteral antibiotics: I.V. ceftriaxone 2g od + I.V. doxycycline 100mg bd followed by oral doxycycline 100mg bd 14 days + oral metronidazole 400mg bd for 14 days. •Drainage of abscess is indicated if i.v. treatment failed after hours & sometimes the affected tube/ovary may have to be removed.

51. Thank you