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Definition:: Pelvic Inflammatory Disease (Pid)

Pelvic inflammatory disease (PID) is caused by the ascent of microorganisms from the vagina and cervix into the upper female genital tract. Chlamydia trachomatis and Neisseria gonorrhoeae are common causes, along with other bacteria. Risk factors include young age, multiple sexual partners, and history of STDs. Symptoms range from abdominal pain to fever and vaginal discharge. Treatment involves antibiotics to cover common causative organisms. Syphilis is a systemic infection caused by Treponema pallidum that progresses through primary, secondary, latent, and tertiary stages if left untreated. Genital herpes is caused by herpes simplex virus types 1 and 2, presenting

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0% found this document useful (0 votes)
26 views20 pages

Definition:: Pelvic Inflammatory Disease (Pid)

Pelvic inflammatory disease (PID) is caused by the ascent of microorganisms from the vagina and cervix into the upper female genital tract. Chlamydia trachomatis and Neisseria gonorrhoeae are common causes, along with other bacteria. Risk factors include young age, multiple sexual partners, and history of STDs. Symptoms range from abdominal pain to fever and vaginal discharge. Treatment involves antibiotics to cover common causative organisms. Syphilis is a systemic infection caused by Treponema pallidum that progresses through primary, secondary, latent, and tertiary stages if left untreated. Genital herpes is caused by herpes simplex virus types 1 and 2, presenting

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Malueth Angui
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© © All Rights Reserved
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PELVIC INFLAMMATORY DISEASE (PID)

Definition:

 PID is a clinical syndrome caused by the ascent of microorganisms from the vagina
and endocervix to the endometrium, fallopian tubes, ovaries, and contiguous
structures
 PID is a broad term that includes a variety of upper genital tract infections, unrelated
to pregnancy or surgical procedures, such as salpingitis, salpingo-oophoritis,
endometritis, tubo-ovarian inflammatory masses, and pelvic or diffuse peritonitis.

Etiology:

 Bacteriology - multiple organisms act as etiologic agents in PID and most cases are
polymicrobial.
 Chlamydia trachomatis, Neisseria gonorrhoeae, and a wide variety of aerobic and
anaerobic bacteria are recognized as etiologic agents
 Mycoplasmas have also been implicated but their role is less clear.
 The most common anaerobes include Bacteroides, Peptostreptococcus, and
Peptococcus species.
 The organisms involved in bacterial vaginosis are similar to the nongonococcal,
nonchlamydial bacteria often found in the upper genital tract of women with PID

Risk factors:

 Sexually active, reproductive age


 Most common in adolescents
 Multiple sexual partners
 Use of an IUD, greatest risk in first few months after insertion
 Previous history of PID; 20-25% will have a recurrence
 Chlamydial or gonococcal cervicitis; 8-10% will develop PID
 Gonococcal salpingitis occurs commonly within 7 days of onset of menses

Pathogenesis:

 The precise mechanism by which microorganisms ascend from the lower genital
tract is not known.
 One possibility is that chlamydial or gonococcal endocervicitis alters the defense
mechanisms of the cervix allowing ascent of the vaginal flora with or without the
original pathogen.
 Other possibilities suggest that polymicrobial infection can occur without N.
gonorrhoeae or C. trachomatis.
 Factors that predispose to the ascent of bacteria include the use of an intrauterine
device (IUD) and the hormonal and physical changes associated with menstruation.

Signs and symptoms:

 May be asymptomatic
 Lower abdominal pain
 Fever and malaise
 Vaginal discharge
 Irregular bleeding
 Urinary discomfort, proctitis
 Nausea and vomiting
 Abdominal tenderness
 Tenderness with cervical motion
 Adnexal tenderness
 Unilateral or bilateral tender adnexal mass

Treatment

 Several antibiotic regimens are highly effective with no single regimen of choice, but
coverage should include chlamydia, gonorrhea, anaerobes, gram-negative rods, and
streptococci.
 The CDC regimens that follow are recommendations and the specific antibiotics
named are examples.

Parenteral; regimen A
 Cefoxitin 2 g IV every 6 hours or cefotetan IV 2 g every 12 hours (or other
cephalosporins such as ceftizoxime, cefotaxime, and ceftriaxone) plus doxycycline
100 mg orally or IV every 12 hours
 Therapy for 24 hours after clinical improvement and doxycycline continued after
discharge for a total of 10-14 days

Parenteral; regimen B
 Clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg
of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours
 Therapy for 24 hours after clinical improvement with doxycycline after discharge as
above, or clindamycin 450 mg orally qid for a total of 14 days

Outpatient treatment; regimen A


 Ofloxacin 400 mg orally bid for 14 days or levofloxacin 500 mg orally once daily for
14 days with or without metronidazole 500 mg orally bid for 14 days

Outpatient treatment; regimen B


 Cefoxitin 2 g IM plus probenecid, 1 g orally, concurrently or ceftriaxone 250 mg IM
or equivalent cephalosporin plus doxycycline 100 mg orally bid for 10-14 days with
or without metronidazole 500 mg orally bid for 14 days

GENITAL HERPES

Definition:

 Herpes simplex virus (usually HSV-2) infection involving the genitals

Classification:

1. Primary genital herpes: genital herpes due to HSV-1 or HSV-2 with absence of
antibody to HSV-1 or HSV-2 at time of infection
2. Non-primary first episode genital herpes: genital herpes due to HSV-2 with existing
antibody to HSV-1 or genital herpes due to HSV-1 with existing antibody to HSV-2
3. Recurrent genital herpes: reactivation of latent genital herpes with existing antibody
to the same HSV type recovered from the lesion

Etiology:

 Herpes simplex virus (HSV) causes genital ulcers and must be differentiated from
syphilis and chancroid
 Most HSV genital infections are due to type 2.
 Most often, intimate contact with someone shedding the virus leads to infection.
 The incubation period is 5 to 7 days, after which small vesicles appear.
 During the initial infection, the HSV ascends the peripheral nerves to the sacral
plexus, where it resides permanently.

Signs and symptoms

 The initial infection is usually associated with malaise, regional lymphadenopathy,


and fever, which resolve in 1 wk.
 Burning genital pain
 Dysuria (female)
 Dyspareunia
 Lesions are extremely tender and heal in about 21 days.
 Recurrent infections, which tend to be milder and localized, are preceded by a
prodrome of numbness or tingling at the site.
 Viral shedding from recurrent lesions lasts 4 days, and lesions heal in about 10 days.
Treatment

 Antiviral treatments shorten viral shedding by 1 day.


 For the initial infection, treatment is traditionally acyclovir 200 mg po 5 times/day
for 10 days.
 Recurrences can be treated with 200 mg 5 times/day, 400 mg tid, or 800 mg bid.
 New oral antiviral drugs for the treatment of recurrent infections include famciclovir
125 mg bid for 5 days and valacyclovir 500 mg bid for 5 days.
 About 70% of women have a recurrence within 1 yr.
 Long-term suppression with acyclovir 400 mg bid for 1 yr (after which it is stopped
and recurrences are assessed) should be considered for women with multiple
recurrences.

SYPHILIS

Definition:

 Syphilis is a complex infectious disease caused by Treponema pallidum, a spirochete


capable of infecting almost any organ or tissue in the body and causing protean
clinical manifestations

Etiology & progression:

 Transmission occurs most frequently during sexual contact, through minor skin or
mucosal lesions; sites of inoculation are usually genital but may be extragenital.
 The risk of developing syphilis after unprotected sex with an individual with early
syphilis is approximately 30-50%.
 The organism is extremely sensitive to heat and drying but can survive for days in
fluids; therefore, it can be transmitted in blood from infected persons.
 Syphilis can be transferred via the placenta from mother to fetus after the tenth
week of pregnancy (congenital syphilis).
 The natural history of acquired syphilis is generally divided into two major clinical
stages: early (infectious) syphilis and late syphilis.
 The two stages are separated by a symptom-free latent phase during the first part of
which (early latency) the infectious stage is liable to recur.
 Infectious syphilis includes the primary lesions (chancre and regional
lymphadenopathy), the secondary lesions (commonly involving skin and mucous
membranes, occasionally bone, central nervous system, or liver), relapsing lesions
during early latency, and congenital lesions.
 The hallmark of these lesions is an abundance of spirochetes; tissue reaction is
usually minimal.
 Late syphilis consists of so-called benign (gummatous) lesions involving skin, bones,
and viscera; cardiovascular disease (principally aortitis); and a variety of central
nervous system and ocular syndromes.
 These forms of syphilis are not contagious.
 The lesions contain few demonstrable spirochetes, but tissue reactivity (vasculitis,
necrosis) is severe and suggestive of hypersensitivity phenomena.

Clinical stages of syphilis

1. Primary Syphilis

Essentials of Diagnosis

 Painless ulcer on genitalia, perianal area, rectum, pharynx, tongue, lip, or elsewhere
2-6 weeks after exposure
 Nontender enlargement of regional lymph nodes

General consideration:

 The typical lesion is the chancre at the site or sites of inoculation, most frequently
located on the penis, labia, cervix, or anorectal region.
 The chancre starts as a small erosion 10-90 days (average, 3-4 weeks) after
inoculation that rapidly develops into a painless superficial ulcer with a clean base
and firm, indurated margins, associated with enlargement of regional lymph nodes,
which are rubbery, discrete, and nontender.

Treatment

 Benzathine penicillin G, 2.4 million units intramuscularly in the gluteal area, is given
once.
 For the nonpregnant penicillin-allergic patient, doxycycline, 100 mg orally twice daily
for 2 weeks, or tetracycline, 500 mg orally four times a day for 2 weeks, can be used.
 There is more clinical experience with tetracycline, but compliance is probably better
with doxycycline.
 Ceftriaxone and azithromycin can be used in the penicillin-allergic patient.

2. Secondary Syphilis

Essentials of Diagnosis

 Generalized maculopapular skin rash.


 Mucous membrane lesions, including patches and ulcers.
 Weeping papules (condylomas) in moist skin areas.
 Generalized nontender lymphadenopathy.
 Fever.
 Meningitis, hepatitis, osteitis, arthritis, iritis

General Considerations

 The secondary stage of syphilis usually appears a few weeks (or up to 6 months)
after development of the chancre, when sufficient dissemination of T pallidum has
occurred to produce systemic signs (fever, lymphadenopathy) or infectious lesions
at sites distant from the site of inoculation.
 The most common manifestations are skin and mucosal lesions.
 The skin lesions are nonpruritic, macular, papular, pustular, or follicular (or
combinations of any of these types), though the maculopapular rash is the most
common. The skin lesions usually are generalized; involvement of the palms and
soles is especially suspicious.
 Specific lesions-condylomata lata-are fused, weeping papules on the moist areas of
the skin and mucous membranes
 Meningeal (aseptic meningitis or acute basilar meningitis), hepatic, renal, bone, and
joint invasion may occur, with resulting cranial nerve palsies, jaundice, nephrotic
syndrome, and periostitis.
 Alopecia (moth-eaten appearance) and uveitis may also occur.

CHANCROID

Definition:

 Chancroid is an infectious, painful, ragged venereal ulcer at the site of infection by


Haemophilus ducreyi, beginning after an incubation period of 3-7 days; seen more
commonly in men; Gram-negative streptobacilli may be identified by staining
material from the ulcer. SYN: soft chancre, soft sore, soft ulcer, venereal sore,
venereal ulcer
 Chancroid is a sexually transmitted disease caused by the organism Haemophilus
ducreyi.
 The illness is characterized by painful genital ulcers and tender inguinal adenopathy
that may suppurate.
 Also known as "soft chancre," venereal sore, chancroid is one of the three major
causes of genital ulcer disease; the other major causes are genital herpes and
syphilis.

Etiology:
 Haemophilus ducreyi appears microscopically as a pleomorphic gram-negative rod

Signs and symptoms

 Typically, the first lesion noted is a small inflammatory papule surrounded by a zone
of erythema.
 Within 2 or 3 days a pustule forms that soon ruptures, leaving a sharply
circumscribed ulcer with ragged undermined edges without induration.
 The base of the ulcer usually has a granular appearance and is always painful.
 In males, the most common sites for the ulcers are on the distal prepuce, the
mucosal surface of the prepuce on the frenulum, or in the coronal sulcus.
 In females, the majority of lesions are at the entrance to the vagina.
 Painful tender inguinal adenopathy is present in as many as 50% of patients and is
usually unilateral.
 The involved lymph nodes may rapidly become fluctuant and rupture, with the
formation of inguinal ulcers.
 The combination of a painful ulcer with tender inguinal adenopathy is suggestive of
chancroid, and when accompanied by suppurative inguinal adenopathy is almost
pathognomonic

Diagnosis

 Gram stain of purulent material may reveal gram-negative rods in the characteristic
"school-of-fish" pattern, but this appearance is probably more characteristic of in
vitro propagated organisms.

Treatment

 Successful antimicrobial treatment of genital ulcers caused by Haemophilus ducreyi


cures infection, resolves clinical symptoms, and prevents transmission to others.
 The Centers for Disease Control and Prevention currently recommend one of four
antibiotic regimens for treatment of chancroid:
a) Azithromycin: 1 g orally in a single dose;
b) Ceftriaxone: 250 mg intramuscularly in a single dose;
c) Ciprofloxacin: 500 mg orally twice a day for 3 days; or
d) Erythromycin base: 500 mg orally 4 times a day for 7 days.
 All four regimens are effective for treatment of chancroid in patients with HIV
infection.
 A successful response to therapy is usually evident within 48 to 72 hours, as
evidenced by decreased ulcer tenderness and pain.
 Complete healing of ulcers may take up to 28 days, but is often achieved in 7 to 14
days.
 Healing of fluctuant adenopathy is slower than that of the ulcers and may require
needle aspiration through adjacent intact skin even during successful therapy.

GONORRHEA

Essentials of diagnosis

 Most affected women are asymptomatic carriers.


 Purulent vaginal discharge.
 Frequency and dysuria.
 Recovery of organism in selective media.
 May progress to pelvic infection or disseminated infection.

General Considerations

 Sites of infection include the cervix, urethra, rectum, and pharynx.


 In addition, gonorrhea is a cause of PID.
 Humans are the natural reservoir.
 Gonococci are present in the exudate and secretions of infected mucus membranes.
 Neisseria gonorrhoeae is a gram-negative diplococcus that forms oxidase-positive
colonies and ferments glucose.
 The columnar and transitional epithelium of the genitourinary tract is the principal
site of invasion.
 The organism may enter the upper reproductive tract, causing salpingitis with its
attendant complications.
 It has been estimated that after exposure to an infected partner, 20-50% of men
and 60-90% of women become infected.
 Without therapy, 10-17% of women with gonorrhea develop pelvic infection.
 N gonorrhoeae is often present with other sexually transmitted diseases.
 Traditionally, women with gonorrhea are considered to be at risk for incubating
syphilis.
 It has been shown that 20-40% also has Chlamydia infection.

Symptoms and Signs

1. Early symptoms

 Most women with gonorrhea are asymptomatic.


 When symptoms occur, they are localized to the lower genitourinary tract and
include vaginal discharge, urinary frequency or dysuria, and rectal discomfort.
 The incubation period is only 3-5 days
 Ninety-five percent of males with gonorrhea are symptomatic, with a yellowish-
green urethral discharge and burning on urination.
 Both males and females can develop gonococcal proctitis and pharyngitis after
exposure.

2. Discharge

 The vulva, vagina, cervix, and urethra may be inflamed and may itch or burn.
 Specimens of discharge from the cervix, urethra, and anus should be taken for
culture in the symptomatic patient.

3. Bartholinitis

 Unilateral swelling in the inferior lateral portion of the introitus suggests


involvement of Bartholin's duct and gland.
 Enlargement, tenderness, and fluctuation may develop, signifying abscess formation

4. Anorectal inflammation

 Anal itching, pain, discharge, or bleeding occurs rarely

5. Pharyngitis

 Acute pharyngitis and tonsillitis rarely occur; most infections are asymptomatic.

6. Disseminated infection

 Asymptomatic carriers can develop systemic infection.


 Commonly, a triad of polyarthralgia, tenosynovitis, and dermatitis is seen or
purulent arthritis without dermatitis.

7. Conjunctivitis

 In adults, ophthalmic infection is usually due to autoinoculation.


 Ophthalmia neonatorum may result from delivery through an infected birth canal.

Complications

 The major complication in the female is salpingitis and the complications that may
arise from salpingitis
 It is important to note that asymptomatic carriers can also develop tubal scarring,
infertility, and increased risk of ectopic gestations.
 Gonorrhea is complicated occasionally by perihepatitis and rarely by endocarditis or
meningitis.
Treatment

 Any patient with gonorrhea must be suspected of also having other sexually
transmitted diseases (e.g. syphilis, HIV, and chlamydial infection) and managed
accordingly.
 Treatment should cover N gonorrhoeae, Chlamydia trachomatis, and incubating
syphilis.
 Dual therapy has contributed greatly to the declining prevalence of chlamydial
infections.
 Therefore, if chlamydial infection is not ruled out, the regimens below should be
given with doxycycline (for nonpregnant patients) or azithromycin.

A. Uncomplicated Infections

 Guidelines issued by the Centers for Disease Control (CDC) for therapy of
uncomplicated infection in adults are as follows:

(1) Recommended regimens:

a) Ceftriaxone, 125 mg intramuscularly once, plus doxycycline, 100 mg orally twice


daily for 7 days (for nonpregnant patients), or azithromycin 1 g orally in a single dose
if chlamydial infection is not ruled out;
b) Cefixime 400 mg orally once, plus doxycycline or azithromycin as above; and
c) Ofloxacin 400 mg, levofloxacin 250 mg, or ciprofloxacin 500 mg, orally once in
nonpregnant, nonlactating patients over 17 years of age, plus doxycycline or
azithromycin as above.

(2) Alternative regimens:

a) Spectinomycin, 2 g intramuscularly once, followed by doxycycline or azithromycin as


above, for patients who cannot take cephalosporins or quinolones (not reliable for
pharyngeal infection);
b) Ceftizoxime, 500 mg, cefotaxime 500 mg, or cefoxitin 500 mg, intramuscularly once
with probenecid 1 g orally, plus doxycycline or azithromycin as above; and
c) Gatifloxacin 400 mg, norfloxacin 800 mg, or lomefloxacin 400 mg orally once in
nonpregnant, nonlactating patients over 17, plus doxycycline or azithromycin as
above.

Precaution:

 Pregnant women should not be treated with quinolones or tetracyclines.


 They should be treated with a recommended or alternate cephalosporin.
 If cephalosporins are not tolerated, spectinomycin 2 g IM should be given along with
treatment for diagnosed or presumptive C. trachomatis.
GENITAL CANDIDAL INFECTION

Definition:

 Symptomatic overgrowth of commensal yeasts on the mucosa of the vagina or


penis
 Fungal or yeast infections account for 30 to 35% of vaginal infections; most of
them are due to Candida albicans.
 Yeast colonizes 15 to 20% of nonpregnant and 20 to 40% of pregnant women.

Etiology

 Yeast infections of the genital tract, usually caused by Candida albicans, are very
common in women but usually are not acquired sexually

Risk factors:

 Diabetes,
 Use of IUDs,
 Oral contraceptives
 Pregnancy,
 Recent use of an antibiotic (e.g. tetracycline for acne)
 Use of corticosteroids regularly,
 Immunodeficient.

Symptoms and Signs

 Typical symptoms include vaginal pruritus--with or without vulvar itching


 Burning, or irritation (which may be worse with intercourse)
 A thick, white (cottage cheese-like) vaginal discharge that clings to the vaginal
walls
 The vulva may be inflamed, with excoriation and fissures
 Symptoms increase the week before menses.
 Erythema, edema, and excoriation are common.
 pH is < 4.5 and budding yeast, pseudohyphae, or mycelia are seen on a wet
mount, especially the potassium hydroxide preparation.
 Men often are asymptomatic carriers, but may occasionally notice a slight
urethral discharge.
 They may complain of irritation and soreness of the glans penis and prepuce,
especially after intercourse
 The glans penis and prepuce may be inflamed, and white cheesy material,
vesicles, or erosions may be present.
 In severe cases, the prepuce may be edematous, causing phimosis (constriction
of the foreskin).

Treatment

 Topical or oral drugs are highly effective


 Frequent episodes of infection require long-term suppression with oral drugs
(fluconazole or ketoconazole).
 Vaginal candidiasis can be treated locally with
1. clotrimazole one 100-mg tablet/day intravaginally for 6 days or 200 mg/day for 3
days,
2. miconazole 200 mg/day intravaginally for 3 days,
3. butoconazole 2% cream 5 g/day intravaginally for 3 days,
4. terconazole one 80-mg suppository/day for 3 days or 0.4% cream 5 g/day for 7
days, or
5. econazole 1% vaginal creme or 100-mg suppositories for 3 days.
 All of these agents are used once daily at bedtime.
 Fluconazole 150 mg po once is also effective but may be more expensive.
 Candidal balanoposthitis is treated by washing the genitalia with soap and water,
drying with a clean towel, and applying nystatin cream or another topical agent bid for 7
to 10 days.

GENITAL WARTS

Human Papillomavirus: Genital Warts (Condylomata acuminata)

 Genital warts are the most common viral STD


 Genital warts, are usually caused by HPV types 6 and 11, but may also be caused by
16, 18, and 30s, 40s, 50s, and 60s groups
 HPV subtypes primarily infecting vulvar epithelium include types 6 and 11.
 Types 16, 18, 31, 33, 35, 39, 41, 42, 43, 44, 51, 52, and 56 are less common in vulvar
disease but are involved in cervical dysplasia and invasive cervical cancer, in which
they play a pathogenic role.
 Many patients with HPV also have other sexually transmitted infections.

Treatment

 Treatment of the warts is determined by the site and extent of wart growth.
 Self-administered topical drugs include imiquimod 5% applied 3 times/wk until
resolution for up to 16 wk (for recurrence, treatment can be repeated for an
additional 16 wk) and podofilox 0.5% applied bid for 3 days followed by 4 days of no
therapy (this sequence can be repeated 3 more times).
 Trichloroacetic acid 75 to 90% can be applied by a health care practitioner weekly.
 Standard treatment is to cover the wart with bichloroacetic or trichloroacetic acid
every week until the wart is gone.
 Alternative forms of treatment include cryosurgery, electrosurgical destruction,
excision, and laser vaporization
 If no resolution is apparent after six applications, cryotherapy, electrocautery, or
laser therapy may be used.
 These options require anesthesia.
 Biopsy is appropriate if resolution is delayed.
 A Papanicolaou smear should be obtained to rule out cervical dysplasia.
 Warts recur in 65% of patients.

Pregnancy:

 Trichloroacetic or bichloracetic acid, 80 to 90 percent, applied topically once a


week, is an effective regimen for external warts.
 Some clinicians prefer cryotherapy or laser ablation of lesions in pregnancy
 Condylomatous warts may grow rapidly during pregnancy.
 Podophyllin resin, 5-fluorouracil cream, imiquimod cream, and interferon therapy
should not be used in pregnancy because of concerns about maternal and fetal
toxicity

CHLAMYDIAL INFECTIONS

Essentials of diagnosis

 Mucopurulent cervicitis.
 Salpingitis.
 Urethral syndrome.
 Nongonococcal urethritis in males.
 Neonatal infections.
 Lymphogranuloma venereum.

General Considerations

 Genital infection with this organism is the most common sexually transmitted
bacterial disease in women.
 Chlamydiae are obligate intracellular microorganisms that have a cell wall similar to
that of gram-negative bacteria
 Chlamydiae attach only to columnar epithelial cells without deep tissue invasion
 As a result of this characteristic, clinical infection may not be apparent
 Infections of the eye, respiratory tract, or genital tract are accompanied by
discharge, swelling, erythema, and pain localized to these areas only.
 C trachomatis infections are associated with many adverse sequelae due to chronic
inflammatory changes as well as fibrosis (e.g. tubal infertility and ectopic
pregnancy).
 The proposed mechanism for the pathogenesis of chlamydial disease is an immune-
mediated response.
 Sexually active women younger than 20 years of age have chlamydial infection rates
2-3 times higher than those of older women.
 The numbers of sexual partners, and in some studies lower socioeconomic status,
are associated with higher chlamydial infection rates.
 Women who use oral contraceptives may have a higher incidence of cervical
infection than women not using oral contraceptives.

Symptoms and Signs

 It is not uncommon for women with chlamydial infection to be asymptomatic.


 Women with cervical infection generally have a mucopurulent discharge with
hypertrophic cervical inflammation.
 Clinical infection in females manifests as dysuria, urethritis, vaginal discharge,
cervicitis, or PID.
 The presence of mucopus at the cervical os (mucopurulent cervicitis) is a sign of
Chlamydia or gonorrhea.
 Salpingitis may be unassociated with symptoms.
 In males, Chlamydia may be asymptomatic or manifest as dysuria, urethritis, or
epididymitis.
 Fifty percent of male patients complain of urethral discharge; in an additional 30% a
clear white discharge is revealed after milking the penis.

Complications

 Adverse sequelae of salpingitis, specifically infertility due to tubal obstruction and


ectopic pregnancy, are the most dire complications of these infections.
 Pregnant women with cervical chlamydial infection can transmit infections to their
newborns; there is evidence that up to 50% of infants born to such mothers will
have inclusion conjunctivitis
 This pathogen may also cause otitis media in the neonate.
 Whether or not maternal cervical infection with Chlamydia causes significantly
increased fetal and perinatal wastage by abortion, premature delivery, or stillbirth
remains uncertain.
 Increasing evidence exists that chlamydial infection in pregnancy is a risk marker for
premature delivery and postpartum infections.
 It is hypothesized that asymptomatic cervicitis predisposes to mild amnionitis.
 This event activates phospholipase A2 to release prostaglandins, which cause
uterine contractions that may lead to premature labor.
 Chlamydial infection is associated with higher rates of early postpartum
endometritis as well as a delayed infection from Chlamydia that often presents
several weeks postpartum.

Treatment

 In most cases, Chlamydia can be eradicated from the cervix by doxycycline, 100 mg
orally twice daily for 7 days (for nonpregnant patients), or azithromycin, 1 g orally as
a single dose.
 Erythromycin base, 500 mg, or erythromycin ethylsuccinate, 800 mg, orally 4 times a
day should be given for a minimum of 7 days as an alternate regimen
 Patients who cannot tolerate erythromycin should consider ofloxacin, 300 mg twice
daily or levofloxacin 500 mg orally once daily for 7 days
 Pregnant women are advised to take erythromycin base, 500 mg, 4 times per day for
7 days, or amoxicillin, 500 mg, 3 times a day for 7 days.
 Alternate regimens include erythromycin base 250 mg orally 4 times daily for 14
days, erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days, or
Azithromycin 1 g orally as a single dose.

BACTERIAL VAGINOSIS

Definition:

 The term bacterial vaginosis refers to the intricate changes of vaginal bacterial flora
with a loss of lactobacilli, an increase in vaginal pH (pH > 4.5), and an increase in
multiple anaerobic and aerobic bacteria.
 The concentration of anaerobic pathogens (Bacteroides sp, Peptostreptococcus sp,
Gardnerella vaginalis, Prevotella, genital mycoplasmas and G. mobiluncus) increases
tenfold to a hundredfold.
 Bacterial vaginosis represents 60% of all vulvovaginal infections.

Risk factors

 STDs
 Multiple sexual partners
 Use of an intrauterine device (IUD).
 Douching

Symptoms and Signs


 The most common complaint is a malodorous discharge; itching and irritation are
common.
 The amine (fishy) odor often becomes stronger when the discharge is more alkaline-
after coitus and menses.
 Redness and edema are uncommon.

Diagnosis

 Clinical criteria for diagnoses include:


1. Homogeneous white, noninflammatory discharge;
2. Microscopic presence of > 20% clue cells;
3. Vaginal discharge with pH > 4.5;
4. Fishy odor with or without addition of 10% KOH
 Diagnosis is made during pelvic examination.
 The clinician inspects the vagina, measures the pH and, using a water-lubricated
speculum, and obtains a specimen with a cotton-tipped applicator.
 A gray, homogeneous discharge and a pH of > 4.5 are the initial clues.
 Saline and potassium wet mounts are prepared:
 The specimen is divided between two slides and diluted with 0.9% sodium chloride
on one slide and with 10% potassium hydroxide on the other; the latter specimen is
checked for fishy odor (whiff test).
 On microscopic examination, the presence of clue cells (bacteria adherent to
epithelial cells obscuring their cell margins) suggests bacterial vaginosis.
 The presence of three of four criteria (gray discharge, pH > 4.5, fishy odor, and clue
cells) is diagnostic.
 The presence of WBCs on a wet mount suggests a concomitant infection, such as
gonorrhea or chlamydial infection, and cultures should be performed.

Treatment

 Oral metronidazole 250 mg tid or 500 mg bid for 7 days is effective and was the
standard therapy for years.
 However, metronidazole vaginal gel 0.75% daily for 5 days or clindamycin 2% vaginal
cream daily for 7 days has less systemic adverse effects and equal efficacy.
 Women who use clindamycin cream cannot use latex products (i.e. condoms or
diaphragm) for contraception because the drug weakens latex, possibly increasing
the likelihood of pregnancy
 Although bacterial vaginosis used to be considered an inconsequential infection, it is
increasingly associated with pelvic inflammatory disease, postabortion endometritis,
posthysterectomy vaginal cuff infection, chorioamnionitis, postpartum endometritis,
premature rupture of the membranes, preterm labor, and preterm birth.
 Preoperative prophylaxis decreases the incidence of postabortion endometritis.
TRICHOMONAS VAGINALIS INFECTION

Definition:

 Trichomoniasis is an infection of the vagina or male genital tract with trichomonas


vaginalis

Etiology:

 T. vaginalis is a flagellated protozoan found in the GU tract of both men and women
 Trichomonas vaginalis is a pear shaped protozoan which is a facultative anaerobe.
 It is usually sexually transmitted although a non-venereal route is possible as the
organism survives for several hours in a moist environment.
 The organism is more common in women, affecting about 20% during the
reproductive years and causing vaginitis, urethritis, and possibly cystitis.

Signs and symptoms:

Female
 About 50% of women who harbor the organism are asymptomatic
 Symptoms typically begin or worsen at time of menstrual period
 Vaginal discharge (75%, usually copious, which may be frothy, yellowish green and
alkaline, watery and pooling)
 Vulvovaginal irritation (50%)
 Dysuria (50%)
 Vaginal odor (10%)
 A "strawberry cervix" from punctate hemorrhages (5% of cases)
 Vaginal hyperemia
 Dyspareunia
 Suprapubic discomfort
 Cervical erosion

Male
 Most are asymptomatic
 Symptomatic (20%)
 Urethral discharge
 Dysuria
 Epididymitis (rare)

Diagnosis
 Trichomoniasis in women is diagnosed by microscopic examination of a fresh
sample of the vaginal discharge mixed in one to two drops of normal saline.
 Motile protozoans are usually easily identified.

Treatment

 Metronidazole 500 mg bid for 7 days or a single dose of 2 g po (acceptable as


treatment in pregnant women according to the CDC) may be used.
 Effectiveness of single-dose regimens in men is less clear, so men may be treated
with 500 mg bid for 7 days, especially if a single dose is not curative.
 Clinical and microbiologic resistance to metronidazole occurs and may require high-
dose IV or topical therapy.
 Adverse effects include nausea and a metallic taste; severe nausea with vomiting is
more common with the single dose.
 The patient's sexual partner should be treated.
 Some strains of T. vaginalis have diminished susceptibility to metronidazole but
respond to higher doses.
 Treat patients with repeated treatment failures with metronidazole (Flagyl) 2 g po
once a day for 3 to 5 days

LYMPHOGRANULOMA VENEREUM/INGUINALE

Definition:

 A sexually transmitted chlamydial disease characterized by a transitory primary


lesion followed by suppurative lymphadenitis and lymphangitis and serious local
complications.

Etiology

 Lymphogranuloma venereum (LGV) is caused by several immunotypes of Chlamydia


trachomatis
 Three of fifteen known strains of C. trachomatis described as serovars L1, L2, and L3
are responsible for LGV.

Symptoms and Signs

 After an incubation period of 3 to = 12 days, a small, transient, nonindurated


vesicular lesion forms, ulcerates rapidly, heals quickly, and may pass unnoticed.
 The first symptom usually is unilateral, tender enlargement of the inguinal lymph
nodes, progressing to form a large, tender, fluctuant mass that adheres to the deep
tissues and inflames the overlying skin.
 Multiple sinuses may develop and discharge purulent or bloodstained material.
 Healing eventually occurs with scar formation, but the sinuses can persist or recur.
 The patient may complain of fever, malaise, headaches, joint pains, anorexia, and
vomiting.
 Backache is common in women, in whom the initial lesions may be on the cervix or
upper vagina, resulting in enlargement and suppuration of perirectal and pelvic
lymphatics.
 Chronic inflammation obstructs the lymphatic vessels, leading to edema,
ulcerations, and fistula formation.
 Large polypoid masses develop, and chronic lymphatic obstruction may eventually
result in genital elephantiasis.
 Rectal strictures may be found in women and homosexual men.

Treatment

 Doxycycline 100 mg po bid, erythromycin 500 mg po qid, or tetracycline 500 mg po


qid, each for 21 days, rapidly heals the early stages of disease

MOLLUSCUM CONTAGIOSUM

Definition:

 Common, benign viral skin disorder consisting of small umbilicated papules which
tend to occur on the face, trunk and extremities in children and on the groin and
genitalia in adults
 Molluscum contagiosum is a cutaneous viral infection caused by a poxvirus

Causes:

 DNA virus of the poxvirus group


 Molluscum contagiosum is a cutaneous viral infection caused by a poxvirus,
Molluscipoxvirus
 Humans are the only known source of the virus, which is spread by direct contact,
including sexual contact, autoinoculation, or from contaminated fomites

Signs and symptoms:

 Discrete pearly to flesh colored firm papules


 Diameter 2 to 6 mm (rarely giant nodules up to 3 cm occur)
 Usually grouped in one or two areas
 Centrally umbilicated with erythematous base
 Lesions can be pruritic or tender
 Beneath umbilicated center is white curd-like core
 Distribution: Anywhere. Predilection for face, trunk and extremities in children and
groin and genitalia in adults.

Treatment

 Molluscum contagiosum infection is usually self-limited, with the disease duration


quite variable, lasting several weeks to several years.
 Lesions can regress spontaneously, but treatment may prevent autoinoculation and
spread to other individuals.
 Chemical or physical destruction is commonly used to treat molluscum.
 Chemical treatments include cantharidin (0.7% in collodion), salicylic acid, lactic
acid, and tretinoin.
 Physical destruction using liquid nitrogen cryotherapy or removal of the central core
of each lesion usually results in resolution.
 EMLA (eutectic mixture of local anesthetics) cream, a topical anesthetic, may be
applied 60+ minutes to 2 hours prior to needle extraction or curettage.
 Scarring is rare, but may occur spontaneously or secondary to treatment.
 Cantharidin 0.9% solution with equal parts acetone and flexible collodion: apply
topically one to three treatments every 7 days or until resolution
 Podophyllin (podofilox 0.5%): apply topically q 12 hrs for 3 days, withhold for 4 days;
repeat 1 week cycle up to four times until resolved
 Trichloroacetic acid (50-80%): apply and cover with bandage 5-6 days
 Tretinoin 0.1%: topically q12h for 10 days or until resolution of lesions
 Imiquimod cream - 1% or 5% applied topically 1 or 2 times daily 3 times a week for
4-16 weeks
 Podophyllotoxin cream - 0.5% applied topically daily for up to 4 weeks
 Potassium hydroxide - 5% or 10% applied topically twice daily for up to 6 weeks

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