GENITAL TRACT

INFECTIONS
 CONTENTS
Vulval infection
 Vulvitits due to specific infection
1. Bacterial
2. Viral
3. Fungal
4. parasitic
 Infections of Bartholin’s gland
 Bartholin’s Abscess
CONTENTS
 Bartholin’s Cyst
Vaginitis
• Vulvovaginitis in childhood
• Trichomonias
• Moniliasis
• Vaginitis due Chlamydia trachomatis
• Atrophic vaginitis
• Non-specific vaginitis
• Toxic shock syndrome
CONTENTS
Cervicitis
Acute cervicitis
Chronic cervicitis
Endometritis
Acute
Chronic
Atrophic endometritis
Pyometra
Salpingitis
Acute salpingitis
chronic salpingitis
CONTENTS
Oophoritis
Parametritis
Pelvic abscess
 Nursing management of female genital tract infections
 Bibliography
GENERAL OBJECTIVE
At the end of the class students gets adequate knowledge regarding
genital tract infection and apply this knowledge in their clinical settings
SPECIFIC OBJECTIVES
• At the end of the class students can able to
1. Define Vulval infection
2. Describe Vulvitits due to specific infection
3. Explain Infections of Bartholin’s gland
4.Describe Bartholin’s Abscess
5. Describe Bartholin’s Cyst
6. Define Vaginitis
SPECIFIC OBJECTIVES
• At the end of the class students can able to
6. Explain Oophoritis
7. Describe Parametritis
8. Explain Pelvic abscess
9. Apply Nursing management of female genital tract infections
 VULVAL INFECTION
vulval and perineal skin is usually resistant to common
infection. But the defence is lost following constant irritation
by the vaginal discharge or urine. Furthermore there may be
atrophy or degenerative changes either in disease or following
menopause when the infection is more likely.
 CLASSIFICATION
• Due to specific infection
• Due to sensitive reaction
• Due to vaginal discharge or urinary contamination
VULVITIS DUE TO SPECIFIC INFECTION
1. BACTERIAL
• Pyogenic(non-gonococcal)
• Sexually transmitted diseases
Gonorrhoea
Syphilis
Chancroid
Lymphogranuloma venereum
Granuloma inguinale
• Tubercular
VULVITIS DUE TO SPECIFIC INFECTION
2. VIRAL
• Condyloma acuminata
• Herpes genitalis
• molluscum contagiosum
• Herpes zoster
VULVITIS DUE TO SPECIFIC INFECTION
3. FUNGAL
• Moniliasis
• Ringworm
4. PARASITIC
• Pediculosis
• Scabies
• Threadworm
 1. PYOGENIC INFECTION
1. Vulval cellulitis
- Causative organism Staphylococcus aureus
- Vulva- Swollen, red and tender
- Profuse exudation
- Limited inflammation, up to the labiocrural fold
- Intense pain, itching and problem in micturition
- Excoriation of the skin due to scratching and laceration
- Treatment – Systemic antibiotics
- Local hot compress and analgesics
 1. PYOGENIC INFECTION
2. Furunculosis
- Affects the hair follicles of the mons and labia majora
- Folliculitis  furunculitis
- Causative organism- staphylococcus aureus
- Treatment – systemic and local antibiotics
- local cleanliness
 1. PYOGENIC INFECTION
3. Infections of sebaceous and apocrine glands
• Present the features of a boil
• If recurs- excision at quiescent state
 1. PYOGENIC INFECTION
4. Impetigo
- Pustular infection
- Causative organism – Staphylococcus aureus or streptococcus
- May localised to vulva or spread to other parts of the body, face or
hands
- Treatment- systemic and local antibiotic
 1. PYOGENIC INFECTION
5. Erysipelas
- Rare
- Spreading cellulitis
- Caused by invasion of the superficial lymphatics by beta haemolytic-
Streptococcus
- Systemic constitutional symptoms
- Treatment- systemic broad spectrum antibiotic
 1. PYOGENIC INFECTION
6. Intertrigo
- Irritation and infection of retained secretions in the skinfolds
- Seen in obese patients
- Occurs due friction of the undergarments or sanitary towels
- Treatment – local hygiene
- Local antibiotics
- Systemic antibiotics
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
‒ Causative organism- Neisseria gonorrhoeae.
‒ Incubation period- 3-7 days
‒ Site of invasion- columnar and transitional epithelium of genitourinary
tract
‒ Primary sites of infection - endocervix, urethra, Skene’s gland, and
Bartholin’s gland
‒ Localised in the lower genital tract to produce urethritis, bartholinitis
or cervicitis.
‒ Other sites of infection – oropharynx, anorectal region, conjunctiva
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Clinical features
• Local
• Distant or metastatic
• PID
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Clinical features
1. Local features
Symptoms
⁻ Urinary symptoms –dysuria(25%)
⁻ Excessive irritant vaginal discharge(50%)
⁻ Acute unilateral pain and swelling over the labia due to involvement of
Bartholin’s gland
⁻ There may be rectal discomfort due to associated proctitis from genital
contamination
⁻ Others: pharyngeal infection, intermenstrual bleeding
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Clinical features
1. Local features
Signs
• Labia may be swollen and looks inflamed
• Mucopurulent vaginal discharge
• Congested external urethral meatus and opening of the Bartholin’s gland
• Enlarged Bartholin’s gland with tenderness
• Speculum examination- congested ectocervix, mucopurulent cervical
secretions.
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Clinical features
2. Distant or metastatic features
• Features of perihepatitis and septicemia
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Diagnosis
• NAAT (Nucleic acid amplification testing )
• Culture and sensitivity
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Preventive Treatment
• Adequate therapy for gonocaoccal infection and meticulous follow up
are to be done till the patient is declared cure
• To treat adequately the male sexual partner adequately and
simultaneously
• To avoid multiple sex partners
• To use condom till both the sexual partners are free from disease
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Curative Treatment
Specific treatment- single dose regimen
• Ceftriaxone – 125 mg IM
• Ciprofloxacin – 500 mg PO
• Ofloxacin – 400 mg PO
• Cefixime 400 mg PO
• Levofloxacin 250 mg PO
2. SEXUALLY TRANSMITTED DISEASES
1. Gonorrhoea
Follow up
• Culture and sensitivity 7 days after therapy
• Repeat monthly following menses for 3 months
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Causative organism- Treponema pallidum
Transmission through abraded skin or mucosal surface
Clinical features
• Incubation period 9-90 days
• Primary lesion
• Single/ multiple located in labia
• Other sites of lesions-fourchette, anus, cervix, and nipple
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Clinical features
• A small papule is formed which is quickly eroded to form an ulcer
• Ulcer is painless without any surrounding inflammation
• Inguinal glands are enlarged and painless
• Primary lesion heals spontaneously in 1-8 wks.
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Secondary syphilis
• With in 6wks. To 6 months from the onset of primary lesion
• Condyloma lata
• Coarse, flat topped, moist, necrotic lesions and teeming with treponemes.
• Systemic symptoms
• Maculopapular rashes in palms and soles
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Latent syphilis
• Quiescence phase after the secondary syphilis hs resolved,
• Duration 2-20 years
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Tertiary syphilis
• Damage to CNS, CVS and musculoskeletal system.
• Cranial nerve palsies, hemiplegia, tabes dorsalis, aortic aneurysms and
gummas of skin and bones
• Endarteritis and periarteritis
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Diagnosis
1. History of exposure to infected persons
2. Identification of organism
3. Serological test
a. VDRL
b. Specific test
- Treponema pallidum haemagglutination test
- Treponema pallidum enzyme immunoassay
- Treponema pallidum immobilisation test
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Treatment
Primary, secondary and latent syphilis less than 1 year duration
• Benzathine penicillin G 2.4 million units IM single dose half to each
buttocks
• Tetracycline 500 mg 4 times a day/doxycycline 100 mg PO for 14
days
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Treatment
Primary, secondary and latent syphilis less than 1 year duration
• Benzathine penicillin G 2.4 million units IM single dose half to each
buttocks
• Tetracycline 500 mg 4 times a day/doxycycline 100 mg PO for 14
days
2. SEXUALLY TRANSMITTED DISEASES
2. Syphilis
Treatment
Late syphilis
• Benzathine penicillin G 2.4 million unit is given IM weekly for 3
weeks.
• Doxycycline 100 mg PO twice daily / tetracycline 500 mg orally 4
times a day for 4 weeks
2. SEXUALLY TRANSMITTED DISEASES
3. Chlamydial infections
• Causative organism – chlamydia trachomatis
• Incubation period – 6- 14 days
• Affect columnar and transitional epithelium of the genitourinary tract.
• Infection is localised in the urethra, Bartholin’s gland and cervix
2. SEXUALLY TRANSMITTED DISEASES
3. Chlamydial infections
Clinical features
• Non specific and asymptomatic (75%)
• Dysuria
• Dyspareunia
• Post coital bleeding
• Intermenstrual bleeding
2. SEXUALLY TRANSMITTED DISEASES
3. Chlamydial infections
Diagnosis
• NAAT and PCR (specific 95%)
• ELISA testing – detection of chlamydial antigen
• Tissue culture
2. SEXUALLY TRANSMITTED DISEASES
3. Chlamydial infections
Treatment
• Azithromycin 1gm orally single dose
• Doxycycline 100 mg orally bid for 7 days
• Ofloxacin 200 mg orally bid for 7days
• Erythromycin 500 mg orally bid for 7 days
2. SEXUALLY TRANSMITTED DISEASES
4. Chancroid
• Causative organism- Haemophilus ducreyi
• Incubation period 3-5 days
• Lesion starts as multiple vesicopustules over the vulva, vagina, or
cervix
• Slough to form shallow ulcers circumscribed by inflammatory zone.
• Lesion is tender with foul purulent and haemorrhagic discharge
2. SEXUALLY TRANSMITTED DISEASES
4. Chancroid
Diagnosis
• Syphilis must be rule out first
• culture method
2. SEXUALLY TRANSMITTED DISEASES
4. Chancroid
Treatment
• Ceftriaxone 250 mg IM single dose is effective .sexual partner also
treated.
• Azithromycin 1 gm buy mouth single dose.
• Erythromycin 500 mg by mouth every 6hrs for 7 days can also be
given
2. SEXUALLY TRANSMITTED DISEASES
5. Lymphogranuloma Venereum(LGV)
• Causative organism- Chlamydia trachomatis( L Serotypes)
• Incubation period- 3-30 days
• Painless papule, pustule or ulcer in the vulva, urethra, rectum or the
cervix
• The inguinal nodes are involved.
• Acute lymphangitis and lymphadenitis
• Glands become necrosed and abscess forms
• Groove sign- depression between the groups of inflamed nodes
2. SEXUALLY TRANSMITTED DISEASES
5. Lymphogranuloma Venereum(LGV)
Complications
• Vulval elephantiasis
• Perineal scaring
• Dyspareunia
• Rectal stricture
• Sinus and fistula formation
2. SEXUALLY TRANSMITTED DISEASES
5. Lymphogranuloma Venereum(LGV)
Treatment
• Prevention
Use condom or to avoid intercourse with a suspected infected partner
• Definitive treatment
Doxycyline 100 mg bid for 21 days
Alternatively azithromycin 1 gm PO weekly for 3 weeks
2. SEXUALLY TRANSMITTED DISEASE
6. Bacterial vaginosis
- Anaerobic vaginitis / Gardnerella vaginitis
- An alteration in the normal vaginal flora, rather than a specific
infection
- Causative organism- Gardnerella vaginalis, Mycoplasma hominis,
Mobilincus, Peptostreptococcus and Bacteroides species
- Not definitely proven to be sexually transmitted.
2. SEXUALLY TRANSMITTED DISEASE
6. Bacterial vaginosis
Clinical features
• Fishy odour
• Thin grey or white adherent vaginal discharge, which may be frothy
• No associated inflammation
• Majority are asymptomatic
2. SEXUALLY TRANSMITTED DISEASE
6. Bacterial vaginosis
Diagnosis
Amsel criteria for diagnosis of bacterial vaginosis
• Thin homogeneous discharge
• pH more than 4.5
• Whiff test ( addition of a drop of KOH(10%) to a drop of secretion
releases fishy odour
• Clue cells ( wet film microscopy shows masses of small bacteris
coating epithelial cells)
2. SEXUALLY TRANSMITTED DISEASE
6. Bacterial vaginosis
Diagnosis
Nugent score for diagnosis of bacterial vaginosis
Large gram- positive rods(lactobacillus)
Small gram – variable rods(Gardnerella vaginalis or Bacteriodes)
Curved Gram- variable road(Mobilincus)
2. SEXUALLY TRANSMITTED DISEASE
6. Bacterial vaginosis
Tratment
• Metronidazole 500mg orally twice a day for 7 days
OR
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally, once
a day for 5 days
OR
• Clindamycin cream 2%, one full applicator (5g) intravaginally, at bed
time for 7 days
2. SEXUALLY TRANSMITTED DISEASE
7. Trichomonas vaginitis
Causative organism- Trichomonas vaginalis
Clinical features
1. Profuse greenish yellow mucopurulent vaginal discharge
2. Pain may be predominant- dysuria and vulval soreness
3. Pruritus vulva may accompany
4. Strawberry spots over vaginal and cervix
5. pH usually more than 5
2. SEXUALLY TRANSMITTED DISEASE
7. Trichomonas vaginitis
Diagnosis
Wet mount microscopy of vaginal discharge – motile flagellate
trichomonads and abundance of pus cells
2. SEXUALLY TRANSMITTED DISEASE
7. Trichomonas vaginitis
Management
• Other STI are to be tested for
• Drug of choice -metronidazole
( 500 mg twice daily orally for 7 days or Tinidazole single 2 g dose
orally)
2. SEXUALLY TRANSMITTED DISEASE
8. Genital herps
Causative organism- herpes simplex virus types 1 and 2
Clinical features
• Severe pain
• Dysuria
• Excess discharge
• Lesion- erythematous plaques which later form vesicles and then then
small ulcers with an erythematous halo and yellow base
2. SEXUALLY TRANSMITTED DISEASE
8. Genital Herpes
Complications
1. Secondary bacterial infection
2. Sacral radiculomyelopathy
3. Acute urinary retention
4. Meningitis
5. Encephalitis
6. Disseminated HSV infection in pregnancy can rarely occur
7. Neonatal herpes by infection of the fetus in labour
2. SEXUALLY TRANSMITTED DISEASE
8. Genital Herpes
Diagnosis
• Tissue culture
• ELISA
• PCR test
2. SEXUALLY TRANSMITTED DISEASE
8. Genital Herpes
Management
• Rest ,systemic and local analgesics
• Antibiotics
• Frequent saline bath
• Acyclovir 200 mg 5 times daily for 5 days
2. SEXUALLY TRANSMITTED DISEASE
9. Genital warts
• Caused by human papilloma virus
• Vertical transmission occurs leading to juvenile laryngeal
papillomatosis in neonate
• Occur any where over external genitalia or anus
• Treatment- podophyllin application or trichloroacetic acid
 3. VIRAL INFECTION
1.HERPES ZOSTER
• Causative organism- varicella zoster virus
• Inflammatory painful eruption of groups of vesicles distributed over
the skin corresponding to the course of peripheral sensory nerves
(dermatome).
• It is commonly unilateral but may extend to the thigh or buttock of the
same side.
• The vesicles may rupture or become dry with scab formation.
• It resolves spontaneously in 3 weeks time
 3. VIRAL INFECTION
1.HERPES ZOSTER
Treatment
• Analgesics to relieve pain and antibiotics to prevent secondary
infection.
• Acyclovir 800 mg orally five times daily for 7 days is recommended.
• Acyclovir cream (5%) may be used locally for less severe infection.
 FUNGAL INFECTION
Ringworm
• The causative organism is Tinea cruris.
• The lesions look bright red and circumscribed.
• The fungus can be detected microscopically from scraping of the
lesion.
Treatment
• Imidazole (clotrimazole or miconazole) cream.
 PARASITIC INFECTION
Threadworm:
• The causative organism is Oxyuris vermicularis.
• It is common in children.
• Nocturnal perineal itching with evidences of perianal excoriation is
observed.
• The parasite is detected in the stool.
• Anthelmintic drugs such as mebendazole and local application of
gentian violet cures the condition.
INFECTIONS OF BARTHOLIN’S GLAND
Bartholin’s glands are the two pea sized (2 cm) glands, located in the
groove between the hymen and the labia minora at 5 O’Clock and 7
O’Clock position of the vagina.
INFECTIONS OF BARTHOLIN’S GLAND
• Causative Organisms:
Escherichia coli, Staphylococcus, Streptococcus, or Chlamydia
trachomatis or mixed types (polymicrobial)
Pathology
• Both the gland and the duct are involved.
• The epithelium of the gland or the duct gets swollen.
• The lumen of the duct may be blocked or remains open through which
exudates escape out.
INFECTIONS OF BARTHOLIN’S GLAND
• The gland becomes fibrotic.
• The duct lumen heals by fibrosis with closure of the orifice → pent up secretion of
the gland → formation of bartholin cyst.
Clinical Features:
• Initially, there is local pain and discomfort even to the extent of difficulty in
walking or sitting.
• Examination reveals tenderness and induration of the posterior half of the labia
when palpated between thumb outside and the index finger inside the vagina .
• The duct opening looks congested and secretion comes out through the opening
when the gland is pressed by fingers.
• The secretion should be collected with a swab for bacteriological examination
INFECTIONS OF BARTHOLIN’S GLAND
Treatment:
• Hot compress over the area and analgesics to relieve pain are
instituted.
• Systemic antibiotic like ampicillin 500 mg orally 8 hourly
BARTHOLIN’S ABSCESS
• Bartholin’s abscess is the end result of acute bartholinitis.
• The duct gets blocked by fibrosis and the exudates pent up inside to
produce abscess. If left uncared for, the abscess may burst through the
lower vaginal wall. A sinus tract may remain with periodic discharge
through it.
BARTHOLIN’S ABSCESS
Clinical Features
• The local pain and discomfort become intense.
• The patient cannot walk or even sit.
• Fever.
• On examination, there is an unilateral tender swelling beneath the
posterior half of the labium majus expanding medially to the posterior
part of the labium minus.
• The overlying skin appears red and edematous.
BARTHOLIN’S ABSCESS
Treatment:
• Rest is imposed.
• Pain is relieved by analgesics and daily sitz bath.
• Systemic antibiotic— ampicillin 500 mg orally 8 hourly or
tetracycline in chlamydial infection is effective.
• Abscess should be drained at the earliest
 BARTHOLIN’S CYST
• There is closure of the duct or the opening of an acinus. The cause may
be infection or trauma followed by fibrosis and occlusion of the lumen.
Pathology
• It may develop in the duct (common) or in the gland.
• Commonly, it involves the duct; the gland is adherent to it
posterolaterally.
• Cyst of the duct or gland can be differentiated by the lining epithelium.
The content is glairy colorless fluid—secretion of the Bartholin’s
gland.
BARTHOLIN’S CYST
Treatment:
Marsupialization is the gratifying surgery for Bartholin’s cyst.
• An incision is made on the inner aspect of the labium minus just
outside the hymenal ring. The incision includes the vaginal wall and
the cyst wall. The cut margins of the either side are to be trimmed off
to make the opening an elliptical shape and of about 1 cm in diameter.
The edges of the vaginal and cyst wall are sutured by interrupted
catgut, thus leaving behind a clean circular opening.
 BARTHOLIN’S CYST
The advantages of marsupialization over the traditional excision
operation are:
(i) Simple.
(ii) Can be done even under local anesthesia.
(iii) Shorter hospital stay (24 hours).
(iv) Postoperative complication is almost nil.
(v) Gland function (moisture) remains intact.
VAGINAL INFECTION (VAGINITIS)
• Vulvovaginitis in childhood.
• Trichomoniasis.
• Moniliasis.
• Vaginitis due to Chlamydia trachomatis.
• Atrophic vaginitis.
• Non-specific vaginitis.
• Toxic shock syndrome.
VULVOVAGINITIS IN CHILDHOOD
• Inflammatory conditions of the vulva and vagina are the commonest
disorders during childhood. Due to lack of estrogen, the vaginal
defence is lost and the infection occurs easily, once introduced inside
the vagina.
VULVOVAGINITIS IN CHILDHOOD
Etiology
• Non-specific vulvovaginitis.
• Presence of foreign body in the vagina.
• Associated intestinal infestations—threadworm being the commonest.
• Rarely, more specific infection caused by Candida albicans or
Gonococcus may be implicated.
VULVOVAGINITIS IN CHILDHOOD
Clinical Features:
• The chief complaints are pruritus of varying degree and vaginal
discharge.
• painful micturition.
• Inspection reveals soreness of the vulva.
• The labia minora may be swollen and red.
• If a foreign body is suspected, a vaginal examination with an aural or
nasal speculum may help in diagnosis.
VULVOVAGINITIS IN CHILDHOOD
Investigations:
• The vaginal discharge is collected with a platinum loop and two
smears are taken, one for direct examination and the other for Gram
stain. A small amount may be taken with a pipette for culture in
Stuart’s media. To exclude intestinal infestation, stool examination is
of help.
• Vaginoscopy is needed to exclude foreign body or tumor in a case with
recurrent infection.
VULVOVAGINITIS IN CHILDHOOD
Treatment:
• Simple perineal hygiene will relieve the symptoms.
• In cases of soreness or after removal of foreign body, estrogen cream
is to be applied locally, every night for two weeks.
CANDIDA VAGINITIS (MONILIASIS)
• Moniliasis is caused by Candida albicans, a gram positive yeast-like fungus
PREDISPOSING FACTORS
• Diabetes : ↑ Glycogen in the cells, glycosuria
• Pregnancy : ↑ Vaginal acidity, glycosuria ↑ Glycogen in the cells
• Broad spectrum antibiotics : ↓ Acid forming lactobacillus
• Combined oral pills
• Immunosuppression– HIV
• Drugs–steroids
• Thyroid, Parathyroid disease: Obesity
CANDIDA VAGINITIS (MONILIASIS)
Clinical Features
• The patient complains of vaginal discharge with intense vulvovaginal
pruritus.
• The pruritis is out of proportion to the discharge.
• dyspareunia due to local soreness.
On examination:
• (a) The discharge is thick, curdy white and in flakes, (cottage cheese
type) often adherent to the vaginal wall
CANDIDA VAGINITIS (MONILIASIS)
(b) Vulva may be red and swollen with evidences of pruritus.
(c) Vaginal examination may be tender. Removal of the white flakes
reveals multiple oozing spots.
CANDIDA VAGINITIS (MONILIASIS)
• Diagnosis: Wet Smear of vaginal discharge is prepared. KOH solution
(10%) is added to lyse the other cells.
• Filamentous form of mycella, pseudohyphae can be seen under the
microscope
• Culture in Nickerson’s or Sabouraud’s mediA
CANDIDA VAGINITIS (MONILIASIS)
Treatment:
• Local fungicidal preparations commonly used are of the polyene or
azole group.
• Nystatin, clotrimazole, miconazole, econazole are used in the form of
either vaginal cream or pessary.
• One pessary is to be introduced high in the vagina at bedtime for
consecutive 2 weeks
• Single dose oral therapy with fluconazole (150 mg) or itraconazole
 ATROPHIC VAGINITIS (SENILE
VAGINITIS)
• Vaginitis in postmenopausal women is called atrophic vaginitis.
• The term is preferable to senile vaginitis.
• There is atrophy of the vulvovaginal structures due to estrogen
deficiency.
• The vaginal defence is lost.
• Vaginal mucosa is thin and is more susceptible to infection and
trauma.
• There may be desquamation of the vaginal epithelium which may lead
to formation of adhesions and bands between the walls.
 ATROPHIC VAGINITIS (SENILE
VAGINITIS)
Clinical Features
(a) Yellowish or blood stained vaginal discharge.
(b) Discomfort, dryness, soreness in the vulva.
(c) Dyspareunia.
On examination
(a) Evidences of pruritus vulvae.
(b) Vaginal examination is often painful and the walls are found
inflamed.
 ATROPHIC VAGINITIS (SENILE
VAGINITIS)
• Diagnosis: Senile endometritis may co-exist and carcinoma body or
the cervix should be excluded prior to therapy
 ATROPHIC VAGINITIS (SENILE
VAGINITIS)
Treatment
• Improvement of general health and treatment of infection if present
should be done.
• Systemic estrogen therapy may be considered if there is no
contraindication. This improves the vaginal epithelium, raises
glycogen content, and lowers vaginal pH.
• Intravaginal application of estrogen cream by an applicator
 TOXIC SHOCK SYNDROME (TSS)
• TSS is commonly seen in menstruating women between 15 and 30
years of age following the use of tampons (polyacrylate).
• Other condition associated with TSS is use of female barrier
contraceptives (diaphragm).
TOXIC SHOCK SYNDROME (TSS)
FEATURES
• Fever >38.9°C.
• Diffuse macular rash, myalgia.
• Gastrointestinal:Vomiting, diarrhea.
• Cardiopulmonary:Hypotension, adult respiratory distress syndrome.
• Platelets: < 100,000/mm3 .
• Renal : ↑ BUN (> twice normal).
• Hepatic : Bilirubin, SGOT, SGPT rise twice the normal level.
• Mucous membrane (vaginal, oropharyngeal) : Hyperemia.
• The pathological features are due to liberation of exotoxin by Staphylococcus aureus.
• It may lead to multiorgan system failure.
TOXIC SHOCK SYNDROME (TSS)
Treatment
• Supportive therapy
• Correction of hypovolemia and hypotension with intravenous fluids and dopamine
infusion is done in an intensive care unit.
• Parenteral corticosteroids may be used.
• Blood coagulation parameters and serum electrolytes are checked and corrected.
• Infection is controlled by b-lactamase resistant antistaphylococcal penicillin
(cloxacillin, clindamycin and oxacillin) for 10–14 days.
• The tampon should be removed.
• Cotton tampons are the safest.
• Mortality following TSS is 6–10 percent.
 CERVICITIS

The term cervicitis is reserved to infection of the endocervix including

the glands and the stroma. The infection may be acute or chronic.
 ACUTE CERVICITIS
• The endocervical infection usually follows childbirth, abortion, or any
operation on cervix.
• common pathogens are : Gonococcus, Chlamydia trachomatis,
Trichamonas bacterial vaginosis, Mycoplasma and HPV,
 ACUTE CERVICITIS
The organisms gain entry into the glands of the endocervix and produce
acute inflammatory changes. The infection may be localised or spread
upwards to involve the tube or sidewards involving the parametrium
ACUTE CERVICITIS
Clinical Features:
• The vaginal examination is painful.
• The cervix is tender on touch or movements.
• Cervix looks edematous and congested.
• Mucopurulent discharge is seen escaping out through the external os.
ACUTE CERVICITIS
Treatment:
• High vaginal and endocervical swabs are taken for bacteriological
identification and drug sensitivity test.
• Appropriate antibiotics .
• General measures are to be taken as outlined in acute pelvic infection
 CHRONIC CERVICITIS
• Chronic cervicitis is the commonest lesion
• It may follow an acute attack or usually chronic from the beginning.
• The endocervix is a potential reservior for N. gonorrhoeae,
Chlamydia, HPV, mycoplasma and bacterial vaginosis.
CHRONIC CERVICITIS
Pathology:
• The mucosa and the deeper tissues are congested, fibrosed, and infiltrated
with leukocytes and plasma cells.
• The glands are also hypertrophied with increased secretory activity. Some
of the gland mouths are closed by fibrosis or plugs of desquamated
epithelial cells to cause retention cyst— nabothian follicles.
• ectocervix is protected by the overlying stratified squamous epithelium.
• There is associated lacerated and everted endocervix, the so-called eversion
or ectropion..
CHRONIC CERVICITIS
Clinical Features:
• There may not be any symptom as it may be accidentally discovered
during examination.
• Excessive mucoid discharge, at times mucopurulent, is the
predominant symptom.
• History of contact bleeding may be present
CHRONIC CERVICITIS
• On examination:
(a) The cervix may be tender to touch or on movement.
(b) Speculum examination reveals—mucoid or mucopurulent discharge
escaping out through the cervical os. There may be enlargement,
congestion, or ectropion of the cervix. Associated ectopy may be present
CHRONIC CERVICITIS
Treatment
• Cervical scrape cytology to exclude malignancy is mandatory prior to
any therapy.
(i) There is no place of antimicrobial therapy except in gonococcal or
proved cases of chlamydial infection or bacterial vaginosis.
(ii) The diseased tissue may be destroyed by electro or diathermy
cauterization or laser or cryosurgery.
The ectropion is corrected by deep linear burns and the coincidental
ectopy may be coagulated
ENDOMETRITIS
• During childbearing period, infection hardly occurs in the
endometrium except in septic abortion or puerperal sepsis and acute
gonococcal infection.
• Endometrium is protected from infection due to vaginal and cervical
defence and also due to periodic shedding of endometrium.
 Acute Endometritis
• It almost always occurs after abortion or childbirth
• Treatment of acute endometritis is similar to acute salpingitis for 14
days.
 Chronic Endometritis
• chronic endometritis occur during reproductive period even following
acute PID and endometritis.
• This is because of cyclic shedding of endometrium.
• The infection can gain foothold, however, when there is persistent
source of infection in the uterine cavity.
• Such conditions are IUCD, infected polyp, retained products, uterine
malignancy, and endometrial burns due to radium.
 Chronic Endometritis
• Tubercular endometritis is chronic from the beginning.
• Women often presents with purulent or seropurulent vaginal discharge.
• Diagnosis is made by cervical smear, culture of the discharge,
transvaginal ultrasonography and histology, of the endometrium.
• Treatment: The offending cause is to be removed or eradicated.
Levofloxacin 500 mg PO daily for 14 days with Metronidazole 400
mg PO twice daily for 14 days are given.
 ATROPHIC ENDOMETRITIS (Senile
endometritis)
• Following menopause, due to deficiency of estrogen, the defense of the
uterocervicovaginal canal is lost.
• There is no periodic shedding of the endometrium. As a result, organisms
of low virulence can ascend up to infect the atrophic endometrium.
• There is intense infiltration of the endometrium with polymorphonuclear
leukocytes and plasma cells.
• The endometrium becomes ulcerated at places and is replaced by
granulation tissues.
• The purulent discharge either escapes out of the uterine cavity or may be
pent up inside producing pyometra
 ATROPHIC ENDOMETRITIS (Senile
endometritis)
Clinical Features:
The postmenopausal women complain of vaginal discharge, at times
offensive or even blood-stained.
Pelvic examination reveals features of atrophic vaginitis.
Purulent discharge may be seen escaping out through the cervix.
In presence of pyometra, the uterus is enlarged; feels soft and tender.
 ATROPHIC ENDOMETRITIS (Senile
endometritis)
Diagnosis
The diagnosis is confused with carcinoma of the endometrium which
must be excluded prior to treatment.
In fact, pyometra may be present both in atrophic endometritis and
endometrial
Ultrasonography (TVS) is helpful to the diagnosis.
Diagnostic curettage should be done and the endometrium is subjected
to histological examination
 ATROPHIC ENDOMETRITIS (Senile
endometritis)
• If however, pyometra is present, drainage of pus by simple dilatation
should be done first.
• After 1–2 weeks, diagnostic curettage is to be done under cover of
antibiotics.
Treatment:
• In women with recurrent attacks, hysterectomy should be done and the
specimen should be subjected to histological examination
 PYOMETRA
Collection of pus in the uterine cavity is called pyometra.
The prerequisites for pyometra formation are :
• Occlusion of the cervical canal.
• Enough sources of pus formation inside the uterine cavity.
• Presence of low grade infection.
 PYOMETRA
Causes
• Obstetrical—The only condition is following infection of lochiometra.
• Gynecological—The conditions which are associated with pyometra are:
(a) Carcinoma in the lower part of the body of uterus
(b) Endocervical carcinoma
(c) Senile endometritis
(d) Infected hematometra following amputation, conization or deep
cauterization of cervix
(e) Tubercular endometritis.
 PYOMETRA
Pathology:
• There is abundant secretion of pus from the offending sites. T
• he cervical canal gets blocked due to senile narrowing by fibrosis or
due to debris.
• The accumulated pus distends the uterine cavity.
• The postmenopausal atrophic myometrium fails to expel the collected
pus.
• The uterus gets enlarged more and more with thinning of its wall. The
lining epithelium is lost at places and replaced by granulation tissue..
PYOMETRA
• The organisms responsible are coliforms, streptococci or
staphylococci.
• Rarely, it may be tubercular.
• Except in tubercular (caseous), the fluid is thin, offensive, at times
purulent or blood stained.
• The pus may be sterile on culture or the offending organism can be
detected.
PYOMETRA
• Clinical Features:
• The patient complains of intermittent blood stained purulent offensive
discharge per vaginam.
• There may be occasional pain in lower abdomen.
• Systemic manifestation is usually absent
 PYOMETRA
Per abdomen:
• An uniform suprapubic swelling may be felt of varying size.
• It is cystic with well-defined margins but lower pole is not felt.
• It may be tender.
Internal examination reveals:
• The swelling is uterine in origin.
• The offensive discharge is seen escaping out through the cervix.
• Pelvic ultrasonography reveals distended uterine cavity with accumulation of
fluid within.
• Diagnosis is confirmed by dilatation of the cervix when pus escapes.
PYOMETRA
• In every case, all types of investigations are to be made to exclude
malignancy of the body of the uterus and endocervix.
• Diagnostic curettage should be withheld for about 7–14 days
following dilatation and drainage of pus.
• This will minimize such complications such as perforation of the
uterus and spreading peritonitis.
• During the interval period, antibiotics should be prescribed.
PYOMETRA
Treatment:
• Once malignancy is excluded, the pyometra is drained by simple
dilatation of the cervix.
• Even in non-malignant cases or in cases of recurrence, hysterectomy
may be indicated.
• Definite surgery for malignancy is to be done following drainage of
pus.
 SALPINGITIS
Infection of the fallopian tube is called salpingitis.
• The infection is usually polymicrobial in nature
• Both the tubes are usually affected.
• Ovaries are usually involved in the inflammatory process and as such,
the terminology of salpingooophoritis is preferred.
• Tubal infection almost always affects adversely the future
reproductive function.
Organisms responsible for salpingitis
Sexually transmitted:
• Gonococcus Chlamydia trachomatis
• Mycoplasma (rarely)
Pyogenic:
• Aerobes – Streptococcus, Staphylococcus, E. coli
• Anaerobes – Bacteroides fragilis, Actinomycosis (rarely), Peptococcus
Tubercular: Mycobacterium tuberculosis
SALPINGITIS
• Etiology
I. Ascending infection from the uterus, cervix and vagina
Pyogenic organisms
Sexually transmitted infections (STIs)
II. Direct spread from the adjacent infection
One or both the tubes are affected in appendicitis, diverticulitis, or
following pelvic peritonitis.
ACUTE SALPINGITIS
Pathology:
• Pyogenic
• Gonococcal
 ACUTE SALPINGITIS
• Acute pyogenic The pathological changes in the tubes depend on the virulence of
the organisms and the resistance of the host.
• There is intense hyperemia with dilated vessels visible under the peritoneal coat.
• The enlargement of the tube is greater than gonococcal infection because of
interstitial involvement.
• The wall is enormously thickened and edematous.
• The mucopurulent or purulent exudate can be expressed out through the
abdominal ostium.
• Microscopically, the epithelium looks normal or the mucosa slightly edematous.
• The muscularis shows marked edema and acute inflammatory reaction. As the
outer coat is involved, adhesions are likely and are dense.
ACUTE SALPINGITIS
• Complications of acute salpingitis:
(i) Pelvic or generalized peritonitis
(ii) Pelvis cellulitis
(iii) Pelvic thrombophlebitis
(iv) Pelvic abscess
(v)Tubo-ovarian abscess.
CHRONIC SALPINGITIS
Pathology
• Hydrosalpinx.
• Pyosalpinx.
• Chronic interstitial salpingitis.
• Salpingitis isthmica nodosa.
CHRONIC SALPINGITIS
• Hydrosalpinx
Collection of mucus secretion into the fallopian tube is called
hydrosalpinx
CHRONIC SALPINGITIS
Pathogenesis:
• It is usually due to the end result of repeated attacks of mild
endosalpingitis by pyogenic organisms of low virulence but highly
irritant.
• The organisms involved are Staphylococcus, E. coli, Gonococcus,
Chlamydia trachomatis, etc.
CHRONIC SALPINGITIS
• During initial infection, the fimbriae are edematous and indrawn with
the serous surface, adhering together to produce closure of the
abdominal ostium.
• The uterine ostium gets closed by congestion.
• The secretion is pent up to make the tube distended.
• The distension is marked on the ampullary region than the more rigid
isthmus.
• As the mesosalpinx is fixed, the resultant distension makes the tube
curled and looks ‘retort’-shaped. The wall is smooth and shiny
containing clear fluid inside, which is usually sterile
CHRONIC SALPINGITIS
• The uterine ostium is not closed anatomically, thus favors repeated
infection.
• At times, there is intermittent discharge of the fluid into the uterine
cavity (intermittent hydrosalpinx or hydrops tubal profluens).
• Hydrosalpinx is also considered as the end stage of pyosalpinx when
the pus becomes liquefied to make the fluid clear.
CHRONIC SALPINGITIS
Complications The following may happen :
(i) Formation of tuboovarian cyst
(ii) Torsion
(iii) Infection from the gut
(iv) Rupture
CHRONIC SALPINGITIS
• Pyosalpinx: The pyogenic organisms, if become virulent, produce
intense inflammatory reaction with secretion of pus.
• The tube becomes closed at both ends; the abdominal ostium by
adhesions of the fimbriae and the uterine end by exudate.
• Because of intense inflammatory reaction and/or escape of pus into
the peritoneal cavity, there is dense adhesions with the surrounding
structures like ovaries, intestines, omentum, and pelvic peritoneum.
• Thus, a tuboovarian mass is formed. The inner wall of the tube is
replaced in part by granulation tissue
CHRONIC SALPINGITIS
• Chronic Interstitial Salpingitis
• The tube enlarges mainly due to great thickness of the wall. The
distension of the tube by the exudate is unusual.
• The abdominal ostium may be closed or partially open.
• The adjacent organs are adherent to the tube. Microscopically, there
is extensive infiltration of plasma cells and histiocytes in all the layers.
• The epithelium is usually intact.
• There is intense fibrosis of the muscle coat along with inflammatory
changes.
Salpingitis Isthmica Nodosa

• Pathogenesis: The exact nature still remains unclear.

(i) It is related to tubercular infection, although it may be the residue
of any form of chronic interstitial salpingitis.
(ii) There is infiltration of the tubal mucosa directly into the muscularis
resembling adenomyosis of the uterus.
(iii) It is one form of endometriosis of the tube. Absence of endometrial
stroma, however, points against it.
Treatment of acute Salpingitis/ Peritonitis
Outpatient therapy:
• (i) Ofloxacin 400 mg PO twice daily for 14 days plus metronidazole 500 mg PO twice daily
for 14 days are given.
• Patient is admitted for inpatient therapy if there is no response by 72 hours.
Inpatient therapy
• (Temp >39°C, toxic look, lower abdominal guarding, and rebound tenderness).
• Clindamycin 900 mg IV 8 hourly, plus gentamicin 2 mg/kg IV, then 1.5 mg/kg IV every 8
hours are given.
• This is followed by doxycycline 100 mg twice daily orally for 14 days. IV fluids to correct
dehydration and nasogastric suction in the presence of abdominal distension or ileus are
maintained.
• Laparotomy is done if there is clinical suggestion of abscess rupture.
OOPHORITIS
• Isolated infection to the ovaries is a rarity. The ovaries are almost always affected
during salpingitis and as such the nomenclature of salpingo-oophoritis is preferred.
• The affection of the ovary from tubal infection occurs by the following routes:
• Directly from the exudates contaminating the ovarian surface producing
perioophoritis.
• Through lymphatics of the mesosalpinx and mesovarium producing interstitial
oophoritis.
• Blood borne—mumps.
• Through the rent of the ovulation producing interstitial oophoritis.
• If the organisms are severe, an abscess is formed and a tubo-ovarian abscess
results.
OOPHORITIS
• ovaries may be adherent to the tubes, intestine, omentum, and pelvic
peritoneum producing tuboovarian mass (TO mass). Such a mass is usually
bilateral.
• Direct affection of the ovaries without tubal involvement may be due to mumps
or influenza.
• In mumps, there is no sterilizing effect on the ovaries unlike testes.
• This is because the capsule of the ovary is elastic and as such, ischemic injury to
the graafian follicles is not likely.
• Even if some follicles are damaged, many are left behind to carry on the
reproductive function.
• The symptomatology and treatment are like those of salpingitis.
Parametritis
Inflammation of the pelvic cellular tissue is called parametritis
Aetiology of Parametritis
• Delivery and abortion through placental site or from lacerations of the
cervix, vaginal vault or lower uterine segment
• Acute infections of the cervix, uterus and tubes
• Caesarean section or hysterectomy
• Secondary to pelvic peritonitis
• Carcinoma cervix or radium introduction
Parametritis
Causative organisms
• Anaerobic streptococcus
• Staphylococcus
• E.Coli
Clinical features of parametritis
• Acute:
• The onset is usually insidious and appears about 7–10 days following initial infection.
• The temperature rises to about 102°F.
• Pain is not a prominent feature, may be dull aching deep in the pelvis.
On examination,
• the pulse rate is raised proportionate to the temperature.
• There is generalized deep tenderness on lower abdomen.
• Rigidity is absent because the lesion is extraperitoneal. Pelvic examination reveals hot
and tender vagina.
• There is an indurated tender mass usually unilateral, which extends to the lateral pelvic
wall and to which the uterus is firmly fixed.
• The uterus is pushed to the contralateral side
Clinical features of parametritis
• Chronic
The clinical features vary, as it is often associated with chronic salpingo-
oophoritis and as such, the symptoms and signs are overshadowed by
the latter condition.
The chief complaint is chronic deep seated pelvic pain, may be localized
to one side.
There is deep dyspareunia.
Clinical features of parametritis
• Chronic
Pelvic examination
reveals the uterus fixed to an indurated and tender mass.
The uterus is also drawn to the affected side because of scarring.
Movement of the cervix produces pain.
Ultrasonograhy can localize the abscess with its site and extent.
• Treatment
• Acute: The outline of management protocol is the same like that of
acute salpingitis of pyogenic origin. Only when an abscess is pointing
and easily accessible that it should be drained surgically.
• Chronic: The treatment is the same as for chronic salpingo-oophoritis.
Deep pelvic short wave diathermy may be tried to relieve pain and
dyspareunia. Too often, all the measures fail, hysterectomy decision
may have to be considered even at an early age specially in women
whose family is completed.
 Pelvic abscess
Encysted pus in the pouch of Douglas is called pelvic abscess
Aetiology of pelvic abscess
• Postabortal and puerperal sepsis
• Acute salpingitis
• Perforation of an infected uterus such as attempted uterine curettage in
septic abortion or pyometra
• Infection of pelvic haematocele usually following disturbed tubal
pregnancy
• Post operative pelvic peritonitis following abdominal or vaginal
operations
• Irritant peritonitis following contamination of urine, bile, vernix caseosa,
meconium
Aetiology of pelvic abscess
Extra pelvic causes
• Appendicitis
• Diverticulitis
• Ruptured gall bladder
• Perforated peptic ulcer
Clinical features of pelvic abscess
Symptoms
Spiky rise of high temperature with chills and rigor
Rectal tenesmus
Pain lower abdomen
Urinary symptoms
Clinical features of pelvic abscess
Signs
General the face is flushed with anxious look
Tachycardia
Per abdomen
Tenderness and rigidity in lower abdomen
Mass in the supra pubic region
Per vaginum
The vagina is hot and tender
Uterus pushed anteriorly
Boggy, fluctuant and tender mass is felt in the pouch of Douglas
A separate mass may be felt through the lateral fornix
Investigations
• Blood
• High leucocytosis with increased polymorphs
• Bacteriologoical study
• Confirmation of diagnosis - culdocentesis
Treatment
• General
• Systemic antibiotics
• Surgery
• Posterior colpotomy
• laparotomy
 Nursing management
Sexually Transmitted Infections
• Nursing assessment
Subjective data
• Past health history
Contact with individual with STIs, multiple sexual partners, pregnancy
Medications: use of oral contraceptives, allergy to any antibiotics
• Functional health patterns
 Health perception- health management shared needles during IV drug use
 Nutritional
 Elimination
 Cognitive
 reproductive
Nursing diagnosis
• Risk for infection related to lack of knowledge about mode of
transmission, inadequate personal and genital hygiene
• Anxiety related to impact of condition on relationships, disease
outcome, and lack of knowledge
• Ineffective health maintenance related to lack of knowledge about
disease process.
 Nursing implimentation
• Health promotion activities
• Measures to prevent infection
• Screening programme
• Psychological support
• Compliance and follow up