1. PELVIC INFECTIONS AND SEXUALLY TRANSMITTED DISEASES
Dr Dora Milman
Kaplan Medical Center
Rehovot

2. The Normal Vagina
Vulvar secretions from sebaceous, sweat, Bartholin, Skene glands
Transudate from vaginal wall
Exfoliated vaginal & cervical cells
Cervical mucus
Endometrial & oviductal fluids
Micro-organisms and their metabolic products

3. The Normal vagina
The type, amount of cells, mucus and fluids are determined by biochemical processes that are influenced by hormone levels
Vaginal secretions may increase in the middle cycle due to increase in the amount of cervical mucus
These cycle variations do not occur when oral contraceptives are used

4. The Normal Vagina
The vaginal desquamative epithelial cells are responsive to amounts of estrogen and progesterone:
Superficial cells – the main type in the reproductive age, predominate when estrogen stimulation is present
Intermediate cells – during the luteal phase – stimulation by progesterone
Parabasal cells – absence of either hormone, in postmenopausal without HRT

5. The NormaVagina The normal vaginal flora – mostly aerobic
An average of six types of bacteria
The most common – Hydrogen peroxide-producing lactobacilli
Normal vaginal pH is lower than 4.5 (due to production of Lactic acid by lactobacilli and vaginal epithelial cells)
Normal vaginal secretions are floccular, white, usually located in the posterior fornix

6. The Normal Vagina Microscopy of normal vaginal secretions:
Many superficial epithelial cells
Few white blood cells
Few, if any, Clue cells (superficial vaginal epithelial cells with adherent bacteria, usually Gardnerella vaginalis, wich obliterates the crisp cell border)

7. Bacterial Vaginosis - BV
An alternation of normal vaginal flora: loss of lactobacilli, overgrowth of predominantly anaerobic bacteria
The most common form of vaginitis
Anaerobes, G. vaginalis, Mycoplasma hominis – ,000 times higher than in normal women
The possible triggers: repeated alkalinization of the vagina (frequent sexual intercourse or use of douches)

8. Bacterial vaginosis - BV
Increased risk for:
Pelvic inflammatory disease (PID)
Postabortal PID
Postoperative cuff infections after hysterectomy
Abnormal cervical cytology
In pregnancy:
PROM
Preterm labor and delivery
Chorioamnionitis
Postcesarean endometritis

9. BV - diagnosis A fishy vaginal odor, particularly following coitus
Vaginal secretions – gray, thinly coat the vaginal wall
The pH higher than 4.5
Microscopy: increased number of clue cells and leukocytes
The addition of KOH to the vaginal secretions releases a fishy, aminelike odor (the “whiff” test)

10. BV – Clue cells

11. BV - Treatment Inhibition of anaerobes but not vaginal lactobacilli.
Metronidazole – orally 500 mgX2 for 7 days or vaginal gel 0.75% for 5 days
Clindamycin – 100 mg ovules intravaginally for 3 nights or 2% vaginal cream for 7 nights or 300 mg X2 for 7 days
No need of treatment of male sexual partner (no improvement of therapeutic results)

12. Trichomonas Vaginalis

13. Trichomonas Vaginitis
Sexually transmitted flagellated parasite Trichomonas vaginalis
High transmission rate
An anaerobe, with ability to generate Hydrogene to combine with Oxygen to create an anaerobic environment
Often accompanies BV (as many as 60% of cases of trichomoniasis)

14. Trichomonas Vaginitis - Diagnosis
Local immune factors and inoculum size influence the appearance of symptoms
Profuse, purulent, malodorous vaginal discharge, vulvar pruritus
A patchy vaginal erythema and colpitis macularis (“strawberry” cervix)
The pH of vaginal secretions higher than 5.0
Microscopy: motile trichomonads, increased number of WBC
Clue cells may be present
The whiff test may be positive

15. Trichomonas Vaginitis
Morbidity (in association with BV) – postoperative cuff cellulitis after hysterectomy, P-PROM, preterm delivery Tests for other STD: Neisseria gonorrhoeae, Chlamydia trachomatis Serologic testing for Syphilis and HIV should be considered

16. Trichomonas vaginitis - Treatment
Metronidazole – the drug of choice: a single-dose (2 g orally) or 500 mg twice daily for 7 days - a cure rate 95%
The sexual partner should be treated!
Vaginal treatment is not effective

17. VVC – Candida albicans

18. Vulvovaginal Candidiasis - VVC
An estimated 75% of women experience at least one episode of VVC during lifetimes Candida albicans – 85-90% of vaginal yeast infections C. glabrata, c. tropicalis – rare, tend to be resistant to therapy Predisposing factors: antibiotic use, pregnancy, diabetes Decrease in cell-mediated immunity (pregnancy, diabetes) leads to higher incidence of candidiasis

19. VVC - Diagnosis
Vulvar pruritus, vaginal discharge – “cottage cheese” or watery, or homogeneously thick
External dysuria, vulvar burning, dyspareunia
Erythema and edema of the vulva, vagina. The cervix appears normal
The pH of the vagina is usually normal (<4.5)
Fungal elements appear in as many as 80% of cases
The whiff test is negative
A fungal culture

20. VVC - Treatment Topically applied azole – 80-90% relief of symptoms
Oral fluconazole in a single 150-mg dose
Complicated VVC – an additional 150-mg dose of fluconazole 72 hours after the first dose or days of topical treatment
Ajunctive treatment – a weak topical steroid – 1% hydrocortisone cream – for relieve of external irritation

21. Recurrent VVC 4 or more episodes in a year – a small number of women
Persistent irritative symptoms of the vestibule and vulva
Diff. diagnosis with chronic atopic dermatitis or atrophic vulvovaginitis
Fluconazole 150 mg every 3 days for 3 doses and supression with 150 mg weekly for 6 months
One half – recurrence of the symptoms

22. Atrophic Vaginitis
In Menopause – naturally or secondary to oophorectomy
Inflammatory vaginitis
Increased purulent vaginal discharge
Dyspareunia
Postcoital bleeding
A result of atrophy of the vaginal and vulvar epithelium
Topical Estrogen – cream or tablets, or systemic HRT

23. Cervicitis

24. Cervicitis
Two types of cervical epithelium: squamous – ectocervical – an extension of vaginal epithelium, and glandular - in endocervix
the ectocervical infections – as in the vagina – Trichomonas, Candida, HSV
The endocervical infections –N. gonorrhoeae, C. trachomatis

25. Cervicitis - Diagnosis
A purulent endocervical discharge, yellow or green – “mucopus”
Gram stain
Increased number of neutrophils
Intracellular G- diplococci (gonorrhea)
If negative for gonococci, the presumptive diagnosis is chlamydial cervicitis
Nucleic acid amplification tests for gonorrhea and chlamydia
The etiology of 50% of endocervicitis is unknown

26. Cervicitis - Treatment
Treatment of Gonorrhea and Chlamydia
Treatment of sexual partners!
Treatment of BV, commonly associated with cervicitis
Fluoroquinolone resistance is common in N. gonorrhoeae
N. gonorhoeae – Ceftriaxone, 250 mg IM – single dose
C. trachomatis – Doxycycline, 100 mg X2 for 7 days
Azithromycin, 1 g orally as single dose

27. PID

28. Pelvic Inflammatory Disease - PID
Acute infection of the upper female genital tract – uterus, oviducts, ovaries, often involvement of neighboring pelvic organs
Endometritis,salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, perihepatitis
N. gonorhoeae, C. trachomatis are often implicated
Vaginal flora (BV micro-organisms)
Haemophilus influenzae, group A streptococci, pneumococci

29. PID – Long-term complications
Chronic pelvic pain – as many as one-third of women with PID.
Infertility - injury to fallopian tube – loss of ciliary action, fibrosis, occlusion - hydrosalpinx (in IVF – negative consequences on the rates of pregnancy, implantation, early pregnancy loss, preterm birth, and live delivery)
Ectopic pregnancy % after laparoscopically- confirmed PID versus 1.3% without PID at laparoscopy.

30. PID - Diagnosis
Lower abdominal pain– may be subtle, worsens during coitus, may onset during or shortly after menses, usually bilateral
Abnormal uterine bleeding – in one-third of patients with PID
New vaginal discharge
Fever, chills
Non of these signs is neither sensitive nor specific

31. There is NO single diagnostic gold standard
PID - diagnosis
There is NO single diagnostic gold standard

32. PID – Risk factors Previous episode of PID Sex during menses
Vaginal douching
Bacterial vaginosis
Intrauterine device
Age less than 25 years
Young age at first sex
Nonbarrier contraception
Oral contraception
New, multiple, or symptomatic sexual partners

33. PID - diagnosis Fever – only about one-half
Diffuse tenderness greatest in the lower quadrants
Rebound
Right upper quadrant tenderness – Fitz-Hugh-Curtis syndrome – perihepatitis – 10% of patients with PID
Purulent endocervical discharge
Cervical motion and adnexal tenderness
Low-grade fever, weight loss, abdominal pain – susp. Actinomycosis (IUD?)

34. PID - Diagnosis Leukocytosis Elevated CRP or ESR
Positive test for Gonorrhea or Chlamydia
Ultrasound documenting tubo-ovarian abscess
Laparoscopy visually confirming salpingitis

35. Tubo-ovarian abscess Sonographic image

36. Fitz-Hugh-Curtis Perihepatitis

37. PID - Treatment
Empirical, broad-spectrum coverage of likely pathogens, including N. Gonorrhoeae C. Trachomatis M. Genitalium Gram-negative facultative bacteria Anaerobes Streptococci

38. PID - treatment Mild – outpatient regimen Hospitalization – when:
- the diagnosis is uncertain
- pelvic abscess is suspected
- clinical disease is severe
- poor compliance
Evaluate sexual partners for gonococcal and chlamydial urethritis

39. Tubo-ovarian abscess An end-stage process of acute PID
A palpable pelvic mass - agglutination of pelvic organs
Hospitalization!
About 75% respond to antimicrobial therapy alone
Failure to respond to antimicrobial therapy after 72 hours – the need for drainage – percutaneous, transvaginal or surgical exploration (laparoscopy)

40. Genital Ulcer Disease Infectious:
Herpes simplex – HSV – type 1, type 2
Syphilis – Treponema pallidum
Chancroid – Haemophilus ducreyi
Lymphogranuloma Venerum – Chlamydia trachomatis serovars L1-3
Granuloma Inguinale (Donovanosis) – Klebsiella granulomatis

41. Genital Ulcer disease Noninfectious: Fixed drug reactions
Behchet’s disease
Neoplasms
Trauma

42. Genital Ulcer - infectious
HSV
Type-2, type-1
Multiple small grouped vesicles - ulcers; erythematous base
Usually painful
Occasionally single lesion/fissures
Can be painless or pruritic
Reactive lymphadenopathy

43. Genital ulcer - infectious
Syphilis:
Ulcer – usually a single, indurated, with smooth firm borders
Usually painless
Inguinal lymphadenopathy

44. Genital ulcer - infectious
Chancroid:
Begin as papules that go on to ulcerate
Sharply circumscribed or irregular, ragged undermined edges
Multiple ulcers
Not indurated
Base with gray or yellow exudate
Very painful
50% with inguinal adenopathy

45. Genital ulcer - infectious
Granuloma inguinale:
One or more nodular lesions that ulcerate
Usually painless
Slowly enlarge friable ulcers, with raised, rolled margins
Granulation-like lesions
“kissing” lesions
Lymphadenopathy – less common, though nodular lesions may appear as pseudobuboes

46. Genital ulcer – infectious
LGV – Lymphogranuloma venerum:
Often begins as a single papule or a small and shallow ulcer
Usually painless
Rapid spontaneous healing
Tender lymphadenopathy
Suppuration of the lymph nodes
A painful “buboe”

47. Genital ulcer - summary
Infectious or noninfectious
Sexual and medical history
Ulcer - single or multiple? Recurrent? Painful? Indurated or no? Suppurative? Lymphadenopathy?
Underlying HIV infection? (oropharyngeal thrush, significant concomitant inguinal, cervical, axillary lymphadenopathy)
Supportive laboratory testing (the appearance of genital ulcers may vary and overlap)

48. Genital ulcer - summary
Tests for STD’s – C. trachomatis, N. gonorhoeae, HIV, Hepatitis B, Hepatitis C
Atypical presentation in the immunocompromised host
Follow-up
To exclude non-infectious causes