Definition:: Pelvic Inflammatory Disease (Pid)
Definition:: 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:
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.
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
GENITAL HERPES
Definition:
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.
SYPHILIS
Definition:
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.
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
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:
Etiology:
Haemophilus ducreyi appears microscopically as a pleomorphic gram-negative rod
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
GONORRHEA
Essentials of diagnosis
General Considerations
1. Early symptoms
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
4. Anorectal inflammation
5. Pharyngitis
Acute pharyngitis and tonsillitis rarely occur; most infections are asymptomatic.
6. Disseminated infection
7. Conjunctivitis
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:
Precaution:
Definition:
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.
Treatment
GENITAL WARTS
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:
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.
Complications
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
Diagnosis
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:
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.
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
LYMPHOGRANULOMA VENEREUM/INGUINALE
Definition:
Etiology
Treatment
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:
Treatment