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Gynecologic Infections- Pelvic Inflammatory Disease (PID), Bacterial Vaginosis (BV)

  • Gynecological infections
    • Sexually transmitted disease, or
    • Unrelated to a sexually transmitted disease.
    • Two major gynecological infections affect a woman, mostly during her childbearing years:
    • Pelvic inflammatory disease (PID):
      • General:
        • Sexually transmitted,
        • Infectious,
        • Affects the upper part of the female reproductive tract, including the ovaries, uterus, fallopian tubes, and other pelvic structures.
        • Multiple bacterial species linked as causative agents
        • Can be confined to the pelvis or can include the liver (then called Fitz-Hugh-Curtis syndrome).
      • Incidence:
        • US: 800,000 cases of PID are reported every year. Underreporting problem: CDC: Per year: about one million PID in the US per year, about 150,000 hospitalizations
      • Predisposing factors:
        • Multiple sexual partners,
        • History of sexually-transmitted diseases,
        • History of sexual abuse in the past,
        • Frequent vaginal douching may
        • Dilatation and curettage,
        • Hysteroscopy, or endometrial biopsy: ascending PID,
        • Female under the age of 25 years using oral contraceptive pills,
        • Intrauterine device: about nine-fold risk for having PID, and
        • Genetic predisposition: abnormalities in the immune system: increased risk of getting an infection with Chlamydia trachomatis.
      • Signs and Symptoms:
        • Lower abdominal or pelvic pain,
        • Cervical motion tenderness,
        • Uterine tenderness, and
        • Fever of greater than 101 degrees Fahrenheit.
        • Physical exam:
          • Rebound tenderness in the abdomen,
          • Foul-smelling vaginal discharge, and
          • Right upper quadrant abdominal pain and tenderness may increase the chance that the patient has Fitz-Hugh-Curtis syndrome. (Incidence rate:4%).
        • Etiology:
          • Organisms isolated in cultures of the cervical and vaginal discharge include Neisseria gonorrhea and Chlamydia trachomatis—both of which are exclusively sexually-transmitted.
          • The most common agent: Chlamydia with gonorrhea being the second most common organism.
          • 10-20 percent of untreated STDs from either of these organisms will lead to PID.
          • 30-40 percent of cases are considered polymicrobial, with more than one organism isolated.
          • Inflammation of the upper reproductive tract seems to facilitate the involvement of other types of bacteria, particularly anaerobic bacteria. Viruses, such as cytomegalovirus and herpes simplex type.
        • Pathology:
          • Starts with a vaginal infection in the vagina and cervix
          • Ascends into the upper reproductive tract.
          • Most common organism: Chlamydia and Gonorrhea infections,
          • Haemophilus influenzae, Gardnerella, Bacteroides and Peptococcus and other anaerobes can be part of the polymicrobial picture,
          • Best diagnostic tool: Laparoscope.
          • Elevated ESR and C-reactive protein in most cases,
          • Cultures and/or DNA probes for Chlamydia and gonorrhea should be done.
          • Unclear to be evaluated with ultrasound, MRI scan, or CT scan of the pelvis.
          • Two stages of PID:
            • First stage: Actual vaginal or cervical infection,
            • Second stage: Ascent of the organisms from the lower reproductive tract to the upper reproductive tract.
            • Hormonal changes in the cervical environment during the menstrual cycle predispose a woman to have ascending disease.
            • Infection may spill out of the fallopian tubes to affect the nearby bowel or may include peri-hepatic area (Fitz-Hugh-Curtis syndrome).
            • Lymphatic spread of infection is believed to be behind the extra-pelvic involvement.
            • Acute peritonitis can be seen in severe cases.
          • Treatment and Management:
            • Pain management,
            • Treatment of infection:
              • Aggressive antibiotic use is recommended: Eradicate the offending organisms: success rate: up to 75 percent of cases.
              • Surgery: Laparotomy: Irrigation of the pelvis, drainage of abscesses, release of adhesions or even the unilateral removal of an involved tube and ovary.
            • Reduction of complications.
              • Tube-related infertility:
                • Implantation failure occurs in up to 25 percent of patients who later have IVF.
                • Surgery: Lysis of adhesions,
              • Ectopic pregnancy, and
              • Chronic pelvic pain.
            • Complications:
              • Ectopic pregnancy
                • The risk of ectopic pregnancy is increased by up to 50 percent in women who have had PID
              • Tube-related infertility
                • Up to half of all women with known tube-related infertility will have scarring consistent with a previous PID infection and positive antibodies indicating a past Chlamydia infection.
                • The number of episodes of PID correlates positively with the risk of scarring and infertility.
              • Chronic pelvic pain:
                • About 25 percent of women with PID will have chronic pelvic pain later.
              • Tubo-ovarian abscess:
                • Low risk but life-threatening: rupture associated with peritonitis.

 

  • Bacterial vaginosis (BV):
    • General:
      • Not usually sexually transmitted,
      • nonspecific vaginitis,
      • lack of real inflammatory response.
      • Causative agent: Gardnerella vaginalis: main bacterial species.
    • Incidence:
      • One-third of all women will have BV in their lifetime: US: ten million cases seen per year on an outpatient basis. 80 percent of men who have a sexual partner with BV grow out Gardnerella in urethral cultures.
    • Predisposing factors:
      • Recently used antibiotics,
      • Decreased levels of estrogen,
      • Vaginal douches,
      • Intrauterine device, and
      • New sexual partner (as some aspects of getting Gardnerella vaginalis is sexually-transmitted).
    • Signs and Symptoms:
      • Fishy vaginal odor,
      • Increased vaginal discharge,
      • Irritation of the vulva and
      • Pain with urination or with intercourse (which is the least common symptom).
    • Etiology:
      • Polymicrobial in nature, Gardnerella vaginalis: most common organism cultured.
        • Facultative anaerobe grows in patients who may or may not have a sexual partner.
      • Disruption in the normal vaginal flora triggers the chance that BV can occur.
      • Other anaerobic organisms also are cultured of the vaginal discharge in patients with BV.
    • Pathology:
      • The presence of clue cells on a saline smear of the vaginal discharge is the most specific criterion for the disorder.
      • pH of the discharge of greater than 4.5 is seen in up to 90 percent of patients.
      • Seventy percent will have a fishy odor to the discharge with a gray, thin, and homogeneous nature.
      • The culture will grow out Gardnerella, Lactobacillus species, or Mobiluncus species.
    • Treatment and Management:
      • Antibiotic coverage for Gardnerella vaginalis,
      • Pregnant women with known BV should be treated,
      • Treat BV before IUD insertion,
      • Douching and bubble baths should be avoided,
      • Any over-the-counter vaginal cleansing products should be avoided, and
      • Hypoallergenic soap should be used to wash the genitalia.
    • Complications:
      • Urinary tract infection caused by Gardnerella vaginalis,
      • Endometritis,
      • Chorioamnionitis (in pregnancy),
      • Cervicitis, and
      • Pelvic inflammatory disease.
      • Rare cases if untreated result in bacteremia with the causative agent.
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