Infections in gynaecology pot

Chapter 15 Infections in gynaecology Prmcipksol management of se-ually Lrdri;ini;3ib e ml?clian^ Jn per gen itaUratf mis :ticns Genital uiDprdisen'ip Oilier viral ir leclions HIV infection Urinarylraclmtainn Table 15.1 Diffemi •Symptoms A\H\ Ilcbing i?i boreuesi Smell Colour P H Confirmed bv OVERVIEW women experience an irrfettion of Ihe urogeriilaltratt al some lime Ths incsl common sympicmaiic mlei;1inn& pre vulvn- V3glnaliandldla&i&(lhru£h)anaunnarylractinleHinn& Tim squally Iran&mlssibk Caclerlal InfeMicnsttJlamydia and snniiErriQea Can be earned asymptotically lor monlhs or evtn years Viral infections such Bshynanpapillnm^virusfHPVl and herpes simple* may pg;&isS lor Irfe. Upper genial trad Infection is a Ihrtal ID a we:man's future fertility The Irjng-lerm sequelae of to Hie Fallopian tobes include edn pic pregnancy and tobuladailor irifertility Worldwide, human Inmurmdtticiancy virus (HIV) infectignii predominantly acquired saxuaHyand in some parts ot I 1 * *^il(J as many a? 25-30 per cant of or^gnant \vcmen are =io« mlecleti Clinicians need la tp a™rnofthoxvayThat HIV allcnjlhs manl- festatlons of. andhoslsusceplibilrh/lp, gther t If Oau sexujlfy Ira then: may be olhers. shnuld be perfornm infection. 1 ; dni s ti,HI\"andhi ire nol avaibWe for si be referred to a genitoi To bre^k Ihe chd re-infection, it is ess inter t eniri,e until ihe been fiat-cned and n for incfivfdujf^ infect and are advisable for u ' Principles ol managemenl or sexually transmissible infections Many p'naecokigicjl iiifetiinni vrv it-xudlk lran&- iniuibk. Qlheis, ^uch a^ Candida and urinary iracl infection, are fretiucnlly In^cied by sexiuiJ inter- oourse although the organism is colonizing the beforehand. It take^ practice to be cottifofl- Caking n lexual histoirhom a patient. If (he clin- ician \s enibarrasse^ (his iiqukklj transmitted to the pa Hunt. II is also difGcull tn take a^eviifil history if (he patient's friends or r<:]ali^ r cb are piesent, 01 in a ward or cubicle in which there ij inadtquatt pmacv and soundproofing, It is sometimes netessarv, 10 pyitpont 1 becking a detailed history until tbe c can be provided. In order to as.se« the risk of an individual having acquired a sexually Irans- mitted disease fSJ'Dj, if isnetcssarj la find out: • when sexual intercourse last look place, • whclherthiiivai oral, vaginal or anal, • what contraception WB£ used, • when the woman last bad a differeni sexual partnj • a Cravtl history and knowledge about the origin of pjrLners ivhichmay indicate a ribk of a tropical intention seldom wen in I!K UK. • information concerning any previous pregnannies rind menMruailun. Enquire about intravenous drug use in ihe patiert and her partneis. Do not assume [bat a woman k hei«oseKuaI until TOU hare aBcertained the sec of !• partners. Lower genital Irac A.t birth j llu 1 neonale d of oesliogen dndprogi the v«t£ma is lined wit lium. Somenmes A bat fcalogous to a B^i"^vdn€%. it is be transmitted at hittb. In younjj femak-i tht tubnidal tpitbeJium. T 'inized by organisms; sim ihe iniluejiLie <>( oestroj nious epitheJium ihe pred.hminant pauici this cliange toil Following the inenopa Lone r gen i la I tract I n lecltons I 67 Table 15,1 Differential diagnosis uf vaginal discharge Symptoms and ngn:> Candidiasis Trichomonlasts CcrviuHs Itthing or soreness Smell < r>loLir Coribibtency PH Qmthmed by + + May he 'vea&ty' White Curdy <4.5 Microscopy and culture - Offensive, fishy \Vhireoryellaw Thin, homogeneous, 4.5-7.0 iVIkroscopv + -I-4- Kfav be offensive ftLow or green Thin, homogeneous 4.5-7.0 Microscopy and culture - - Ckaror coloured VI ii co id <4o Microscopy, tests [or CfriflJfiyifta and gonorrhoea nL In urder lo at-ess Uie a seyually trjns- u hn J outi last took place, iguial or anal, used, d a different serial pjirtntr, irfcdEeiiboul (he origin J kale a ri^k of a tropical • tbeUK, janv pievious pregnancies ions dmg use in [be 4 assume tbat a woman K ascertained |he bcs ot ly Iranwiusaibl* infeclion is present, there may bo others. Ideally, therefore, a full scrven should b<: performed for Chlamydiu, gonnrrboea, infei:tinns and yrolo-gjcdl tL L Sls for syphilis, s R. Hl\' and hep;nilii C if indicated. If facilities are not available fur such a screen, the patitnl should bt referred no agenftourinaiy medidnc ^GUMj clinic, lo break the chain jf infection and prcunl r?-infection, it is essential that the patient avoids iuttTcuLiric until fihe is sure that her parrner(s) baa been bcree-rnjd and received jippryprinle treatment, i'nllow-up e\ r aluat[on dnd l?sU n-f cure aie essential for individuals infected with Nsissena foi othci infections. Lower genital tract infections At birth, the neonate has btfn cspn.sed to high le\db of oestrogt-n and pro^esierone trom her mother and the vagina i' lined with stratilkd iquamourf epithe- lium. Soniennies a babi girl llsis ^ withdrawal bleed, k&Logous to a periml, a> ihr effect nf maternal cuiiro- gen waneb. 11 is possible for Trifhonivnia vanfiiirJri to bc-tran^illitTedatbirth, but the infection usuallyclcarb spontaneously. Tn vemng faiwl^ the wgina is. hnenii wilh J simple cuboidal epithelium The pH h neutral ;inil it is col- uni^ovlbyorpaniamsijmilartu bkin i:onnnensals. Under the influence of ueslro^en at pubem, itratilied squa- crioiii ^pHhelium develops and lacliibicilli become the predominant or^.anismb. A drop in the pH accum- (>aniM this change to it level ofippi'oxmiiiteli 3.5-4,5. Following the ine-nnpause, atrophic di-inges fn:cur, a relurn to bflclefial fln-ra similar to thjt of the sldo. The pH again rises to 7.0. Vaginal discharge can originate from anywhere in the upper or lower genital tract i, Table 15.1). Discharge arising from th$ \-agma itself tan be physio logical or due tu bacteiial vaginu^h. ;tfV; h candidiasii ur Trichawuis intcction (fi^ 15 1). Its presence LJITI be vety alarming for a woman, partieulHrly if she is concerned Llul she might have caught A serious .sexu- ally ir^nsniittedintectiun (yi'l). Physialogical discharge N'ormal vagina I tiwchirge is white, beuuni rig yellowish on cont-ict vvilh air, due to oxitldlion. It consists of de^uiiinHlraJ epithdiat cellb from ihe vagina and cersl\, mucus originating mainly from the cervical glands, thcvjginjl wall. More than 95 percent of the present are lactobatilli. 'Ibe acidic pH ib. hvthelactobddlliiind through the production nMac- tic acid by the viginal epithchum ineTdbolirnig glyco- gen. Phvsinlngicaldib-rhiiigi.' increases due to increased mucus production from the cervix. in mid-cycle. It also increases in pregnancy and &onKiime$ when women begin using a combined ur,i] contraceptive pill. Vaginal candidia&ls Over ibree-quarterb of ivomen have al least nne eifisode of vagindl ^andjdiiisis. A few women have frequent recurrences The organism is carried in the gut. under the nails, in the vnyina and on the &kin r 1 •• InlectioiiK in gyiUecQlKn Figure 15.1 Vaginal and cervical flora (all 1000 x magn-fiedi (a) Normal lartobaci'li - sean at large Gram-positive rods- p, r edaminat* Squamou 5 epithelial cells- are Gram negati'/e '•nth a large-amount rf cytoplasm (b] Dantfidiasis: Ihan? ;.w spsUJed Gram-positive spores and rung pse-udohyphae vision. There are numerous polymnrphs present and the bacterial Nora is abnormal resembling bacterial vaginnsij. (e) Bacterial vaglnasia there is an o'.'ergrowlh of anaerobic n'gaiisrris, including GanliersH,-, [smalHafam-vdnable CDCCIJ. and a decrease in Ibe numbers of lactobaclll- A'clue cell is seen. This is an epithelial cell covered uithsma I bacteria so that the edge of iheuall 13 obscured id) TrichomDnidsis an unstained 'wet mount 1 ol vaginal lluid from a woman with Trti.fioiifD.i3s rafwate Infection Ther? is a ccne-shapad flagellated organism m tlie centre, with a terminal spike and four NdgKlla visible In practice, the argjm&m is identified under the microscope by modernsnt. with amoeboid motion and its flags Ha vijinrm is implicated in more rhan raM, C. krusd& accnum \-ji must of the rest .Sexual it rarely unportant. dltbough the physical trauma ,>f interconriu maj be sufficient to trigger an attack in a predisposed individual. The class.ica.1 presenL^uoii ib ^ith itching and sorv- of tbt n ^'agina and vulra, with a cuidy, white dij- , x^hkh may smell yeasty, t>ul in som? causes may be itching anil rt-ilncib. with j thin, watery discharge. The pH of vaginal Jlnid ii iibiially normal, between 3.5 drd 4.5. M[cros.m>|>y and mlliirc of the Viigina] lluid can confirm a diagnosis. fT'ig. H> r lb]. Aii'mptomaiic women from whom Candida i*groivn on culture do not require treatment. Factors predisposing 1o vaginal candidiasis • HIV • ImmunQSUppresslveinerapy.Eg. • Diabetes mellltus • Vaginal douching, bubble bath shciver yel.tiyht cloth Ing. lights « Pregrincy • High-da&e combined .iral contraceptive pil • UndPhying dermatosis. e g. eczema » Broad-sptctr.,m antibiotic Iheidpy Recurrent Carttiu tre^lmcnl, is rcJativi be the cdsc, it is impi particularly herp« ulcerataon andsoren such AS c-L«md and As a general rule, iban a systemic in? of sy atomic side ftfe can be prescribed a I of treatment. For n dose treatment* sn adequjfe. IMHTH: wo therapy, particular!] lime of to C aibicanf needed when there; noi be eliminated, t rence^ ouur Ireijuci blood count In funiticni^ but cuns prestribc iitat month ti>r IS innnth.s Bacterial vaginas Racteri,]] v^ginosib is mal v-agriul dischdrg in antenatal a. preralencF of UK. It ib tummonc origin and in chose ' (IUD'. Higher prev women undtrgoingc It is. pi nhably comnif p«n repoited in vir [n lesbian v* mj; resolve spontaitf Whtn DV det-elop organ isms I ha I HIT us con cen nation in^rCii! sand -fold. This. Ls iff to between 4.3 jnd 7. may disappear '11'e r with BV are C spp., MA is Ai i ^. diarnatic i epithelial eel 1 :ovfir?d it vaginal tlu'.d from .mitli a terminal L witti amoeboid motion Recunent Caitdtdn, ur Carcjiiifii nut responding 10 treatment, ii relatively Liniomuion, If this appears to I": ihe !'£*£ i( is impn run r to consider other diagnoses particularly herpes simplex, which causes localized ulceiauon and sorenes*, and dennatolojn'tal conditions Kicb a& eczema and lichen sderwus et sttophiuis, As a general rule, il is better to use a topical rather than a systemic tieatment. Thib minimum:. Lhc risk 0f systemic aide effects Vaginal creanH jnd pessaries can l>e prescribed at a variety.' of doses and durations ol treatment. For uncomplicated Candida, a imglo do&e treatment, buth as clotttin^-ole 5GDnig, is. Uequale. Some women have a preference I'or oral therapy, particularly it' treatment ii required at the time of menstruation. A single 150 ing labler. of (lu- conazole i> usually efieclive but its activity is limited to C. alliicatts strains. Longer courses ol treatment are needed when there arc predisposing factors ilial can- not be eliminated, such as. sternid tberapy If recur rences. occur frequently, it is. worth pertoimmg a full blood couiic to check [or anaemia and checkup thvroid function, but usually Ihe&e arc normal. NUny clini- l^ prescribe treatment Ho he taken once or twice a month tor 6 months to suppress lecuircnccs. Bacterial vaginosis vaginosis is the commonest cause of abnoi mal vaginal discharge in women of cbildbfanng age. Studies in antenatal clmics and gynaecology dinics show a prevalence of rippiu-diiialely 12 per cent in the I'Kr ll is euntmuner in women of Afro-Caribbean origin and in those ivho have an intrauteime de'ice ilUD). Highei prevalence i> generally reported in women undergoing elective terminal ion of pregnancv. is pmhablv commoner in women with STls but has been repoited in viigins, and it mai be partn-iilarli 1 kitmmonmlcisbian women, IV condll ion often arises flfiOTiiHUiemisly around the time of menstiuauon and may lesoke spontaneously in mid-ci r cle. When BV develops, ihe predominantly anaerobic nisim ih.il ^re usually]? resent in the vagina at low concentration increase in concentlation up to a thou- sand-fold. Thi^s is accompanied b;. a rise in vaginal pi! 4.5 and 7 I), and ultimately the lactobacilh mav disappear. The organisms most commonly asso- ciated with BV aie GwdnereUn vagi'iala. Bill tertridt'S ) spp., MebiStwcw spp r and MycoplasiYta <J present we- do not know what triggers these dramatic changes in the vaginal ecology. Lnwer gemlal Iracl inleclions I •' 'I be principal symptom of BV jj an offensive fish\ smelling discharge; itib.ch-jrai - leri5liLrfllv lhin> liocno- gcneou& and adherent to the walls of the vagina and may be ivtlile or vellnw The smetl is particularly noticeable avound the time o f men jlni a lion or fi>l lov- ing mtcrcourse: however, semen itself can give off a weak fishy smell. The diagnosis is commonly made in clinical prac- tice usm;? the composite [j\msel) criteria: • vaginal pll "> 4.5, • release of a fisliy smell on addition of alkali (111% potassium hydroxide 1, • a iharaUeristic discharge on examination., • presence of'clue cells' on microscopy. "Clue cells' are vaginal epithelial tclli so he-nily coated with bacteria thai ihe border is obscured RVcan also bediagnnied fpini a Giam-stained vaginal smear. I .jrge numbers of Gram-positive an>l Crdm-iie^.itive cocci are s^en, with reduced ar absent large Gram- positivebaiJIli fl.ic:iobat:illi). Culture of a high vaginal iivab yidils mi\ed anaerobes and a high concentra- tion of GafdncrcUti mgin0li&. However, Gardeneua i-flfiuflJiicanbegiowB from culture;; taken tromupto !iO per cent of women with normal vaginal flora. ll& presence if, not, therefore:, diagnostic ofBV, The sunple^t and iheapest treatment for BV is inelronida^oliMOQrng: twice a day foil? days, or 2 gas d single dose. Topical preparations, are available in the formofmetionidaiok i gel0.7!>%ori:lindamyciiicream 2%. Initial Liirer.itesare over BO per cent, but up to .'0 percent of women relapse within I rnoath of treatment. It is now established thai women wilh tfV .ire at a greater risk of second trimester miscarriage and preterm delivery during pregnancy, which mai reiiilt in perinatal moitahtv or cerebral pals\, \Vonieti vvith a prior history of iccoud trimester IOSB or idiopathic preterm birlh jbould be screened tor BV and treated will] meti'onida7ole eaily in the second LrimeilCr. ll has also been demonstrated lhal Lie^lin^ women with BV ivith melronid^^le prinr to termination ot preg- nancy reduces the subsequent incidence ofendomelri- tis and pelvic mflammalori 1 disease IHIUJ. Women with BV are also al iricre.l^ed. risk of infections alter suiter; r In some women the vaginal flora is in a dynamic state, wi[hFV developing and remittingspontaneousli. Symptomalk women with lecurrcnt BV can become frustrated as the condition responds rapidly lo Irerit- ment with antibiotk& but may .liso rel.ip.se rapidly. Regular Irealmeiu once nr (ivice a month with oral or loyiCnil rnelrnnida/ole is ^^oinetimes helpful. . i Inlecllons in gynaecology Trichomoniasis This se-AUdllv transmissible infection can he carried ab.vmptomaiic.jllv for several monllii before causing symptoms The incidence hj& been falling in Ihe UK over the ksl 20 years In mm it is often carried urethrrtis (NCiUj In women it causes ,1 vulvoi'agimtis th.il ^an be -severe, accompanied by a purulent, some- times offensive, vaginal discharge. In many casts BV develops as well. examination shows ,< yellow or green v^ina! dis- charge *iiti inflammation someiime:, extending mil jnto Ihe vulva and adjacent skin, Punctate haemor- rhages can occur (jin theccivix, giving ibe appearance of a 'strawberry cervix - The diagnosis is confinned by culture, preferably in a specific medium such as Fineberj^-Whittington^ Microscopy ol vaginal setrt-tions mixed iviih saline bashtl per teni sensitivity for detec ling the organism. Is'umeious pohmorphonuclear cells. arc seen and the rnoliieoiganfsm is. identified nom its srupc and four moving (lamellae. Treatment is with melromda/ole, either 2g as asin- yk 1 dose 01 400 mg [win: a da} 1 foi 5 days. Ihe woman should be adiised to semi tin bt-xual partner^] fur ireatmeni Before resuming i nieri^iiriii: together. TrichomLiuiaiii^ h,u yecasionally been idunlified in the upper ^'Jiital trjct nf women with PID hulls prob- ably not an important cause of ^euiUil Irani pathology ll can be isolated from die bladder. OuabionaUy per- iiMcnltrichomoni^sfsiii &ccn. Thk iifavb^'ductopoor coinpliantL- with medioiiion, poor absorption ur a resistant o^Jiiiim. Review the hislor;' lo rule out re- infccflOd from an unlrealcd partner. The usual apprciat'Ji ib Co use higher dos^b of metronkfc/ole, ini- tially 4(111 my Ihrte times a djy, increasing to 1 g per reitrun 01 iiitrjv'fiiijiiili twice a day. Neurological tnx- iciiv may be encountered iMth higli dnfles, Unfoitu- natelv, alters Livt treatments jre [imittti, but include- ^rbphenjinine pessaries and dotrimazol«, ^-Jiich lias. an inhibitory effect on 7)iJwn»riflj Vaginal discharge in children Vaginal infections are common in childhood and mostly no I related lo sexual abuse. Stieptocoaal mlecticms arc Ihe commonest cauitr Slngst/a spp. can cause aJiaernurrhagiccbrcniievTigmnjs, oflen with no hi&tory of diarrhoea. Rtcuiient vaginal i gbould lead to suspicion uf a foreign body. \ i nation under anaesthesia may be necessary to Delude or remove the cause. Pmwoims [Eflteicbiits vermicularis) are cummun jnd "li^rjle num the anus a( mght^ cauanig intense irritation and inevitable scratching by the child The due to the diagnosis r& the nocturnal pattern. A ^elotape test can be |ierlbrmcd to look for eggs if Ihe worms ham not been witnessed ai night. If sexual .ibuie occurs leading to infection with Cfitofrtydia or gonorrhoea, a general i7ed v'ayinilis occurs. Adequate testing can thcrefuir be performed ftom vaginal iv.'abi, negating the- need to obseive the with the aid of n speculum. Other conditions affecting the vagina Other tsuscs of discharge include atmphic va^iditis, toxic shock ivndrome, Rartholiil 1 !. absce&s and LDreslationa. Atrophic vaginitis. is coincnon in pobtmenopjinsal women. (!>vtr Ihe S years fo]lniviiig die ceisation of inemti-uationj the vaginal epithelium atrophies and the lactobacilli are n nee Again replaced bvtvpifdlskiu cominensal organiims. This can kvd to iuperricial ik'ipareunia and vaginal ioreness. The trealment of choice is oestrogen repl^wmeiit witli either lopiudl diennes.lrol trcam or systemic iherapj. OttasionaJly n Irut bacterial v.iginilib i encountered <iue to a SfffpKfOCCUS or other organism, h rispandi to dppropnate antibiotic therapy. Tone shock syndrn me is a rare condition associated vniih the retention of Umpom 01 foreign bodies m the \-agina. An ovcr- growih of stapliylococti producing a tovin cau&a systemic bhockwith (ever, diarrhoea, vomiting and an civthematnus r^sh. There is a 10 per o;nt mortality rJtfr More frequenlly a foreign body or i tjni|ion merely causes an offensive discharge. Barthfll in 's abscess glands are situated on either side ol the vagina, opening into [he vestibule. Osts can develop if the npeiiing becomes blocked, theie present as swell ings, [flhey become infected, a Bartholms develops. I:\aniini3tion repeals a hot, abscess adjacent to Snrgic.ll li-calmenlisi marsup initiation. Ci organisms, including cocci, btaphylococci h I nle stations PubLc lice and scabies cojitatl. Pubic lice (P lo the base of pubic I thick body hair, so Eh ami eyelashes Infetic itchy papules, ornorj underwear. Lkearetr cal agi-Eti such as mal Tieatmem should h* supplied for partners . Scabies ( Sarcoptat a papular rash. If acifui beinitiallvionJinedtc Applications of nwlat -wmptoms may take up -*. dun, I vnfiiii •• i Isai hall ^1 tho&e Jtt^cted J» up^eryemtal tract rnfocl prcgnarcjf (TOP) section. be tr^tec 1 ID prevent re-i Upper genital trac fcivic inflamm^iory di ewer upper genital tra parametriiii, balpmgiti lionb usnaN^ iprc-ad through the uterijie t Upper genital IracUnfBcIirms 171 abscess adjacent to Ihe lower part of Ihe Surgical treatine ill is required. This is usually do lie by maisupiahzation Cult lire map yield a variety ot s, including Nei$-,&ia gonorrhoeas, strcpto- ykKucci, mixed anaerobic organ isms or Esche nchm cali. Infestations lieu and scabies aTe transmitted by Just bodily contact. Pubic lice [Phtbiixs pulm] attach their eggs lo the ba.se of pubic hair. 'Ibeir Jawi unlv attach to thick body hair, so they can also colonize thi 1 axillae and eyelashes. Infected, individuals may report small itchy papules, or nulke debris from the lice in their underwear. Lice are treated bv the application of topi cal ageiils such as maladiion, carbaryl or pcrmclhrin. Treatment should be repealed after 7 days, and he supplied tor partners, to use simultaneously. Scabies {Sarcopte* $cabn:t\ causes- an intensel.' itchy papuljr rush. If acquired during intercourse, it may be initially confined to (lie gemuljrca.lt responds, to applications of nialathion or pennelhrinj symptoms mav take up to 6 week.! to resnlve occur, cithei pariimetrijllyor aloiij; the surfatrof ihc ulerus. Although rare, ijlpin^uis has nciiurrei] in women who ll^.c been blerili^ed. Infection can al^o spread iroin the bowel or c^n be blood bume. Manj different organisms ha^'e heen cultured frorn ivomeii wiih I'll), but &D per >x n nt oi ta&cs are triggered by a .sexually transmissible infection - dlher Ojlamydia 01 gonorrhoea. Mycoplastui ycrbialiit'n is- probablj' icxualiy tranbmimi'd and ha^ been implicated in PID i 11 women and in NCjU in men. It is difficult to detect, rcquiiing special culture medium or a polymerase chain reaction (PCR) test. Endogenous anaerobes, such Hatimn,it.f spp. or MfOJpiasffm homiuis, often come in is secondary ijivatlers a ml -ire tesponsiblE for jubbequcnt tuba! abscess Inrniation. Pelvic Inflammatory disease is an mipoi'tant condi- tion because it results in Inbal damage leadmg to ectopic pregiiancj' and tuhal factor inferlilitv, Ab ni^ny di 20 per cent of women may he left with chronic pelvic pain. Fht symptoms and signs may be mild and subtle, with many women unaware of the significance of mild pelvic pain and possible fuluru fertility. On the other hand, many women are now aware of these complications, and seek rtdsburdnce about their future fertility when they receive 4 diag- nosis of PID. Vaginal r-nndidia&is 15 an opportunistic infection, nnt r.n STD Women with dbymptn malic candidal cclcnlzallon do not require treatment fecleflaf vagtnasb Is a common relapsing condition, v/lth harnf rhnge alerted being a&ymptrj mark fiaclerlal oaQinn^isiEassoDigted with preiErrn binh. and Chfamydia Irachomatis pregnancy [TOP), gynaecological surgery dnd section J^rmoiHs iflffflafJs fe sexuaflv <™isnillted. Partners must bp ueated to prE>/ent ra-lnlectlon Upper gemlal tract infections i' iilibmirntury dibease is a broad term used to cover upper genital tr*;( inlcctiun t i.e. cndometnti.s, ftjrametntis, salpingiti*, and oophoritis, Thise infec- tions usually bpread from the vagina or cervix through the uterine cjvuy. Lymphatic spread may tracli'miaiis is; the commonest bacterial 3TI in industrialiTed countries. As manv a& 1G per cent of womui of childbe^ung age are infected in inner cities in the UK. Women under 25 v^arsof age have the highest prevalence Many infections arc asymptomatic: approximately 50 per tent in men and SO per cent in women. In men it is the most import iint cause of \GL' In women \l au&es turviatii and PID, Genital strains can colonize the throat find dlsu cau« conjunctivitis It can infect the rectum, although only lympho^rajiulonu venerrum (LCV) strains uf Chiamydia cause a severe procti TII. Chlntnydw tr&cfaifm'tt.i*- is n small bacterium that is. an ohJipate intracellul.ir [irflho^un, Sciovars A-C cause trachoma, mtecting the conjUnOJva. Suro^vrb I>-K cause ^enil^l infctlioni. Specific LGV seiorars fLl-Li] cause LGV. The infectious pdrUtJi; die the dementai y bodies that infect columnarepitheli.il ^elk in ilie geiiildl Iracl. Thty gain intry to the cells, by binding to specific surface receplors. Ome uibide the \;l Infections in Gynaecology cell, inclusion bodies form, ^hidi eunt<un the metabolicallv active reticulate bod ie* J'hese divide bv binary fission. After a 4ft- hour life cycle, reticulate bodies GDzidease into elementary bodies which are released From the cell surface. He^iU- infected cells die but it is the inllammatoiv response to infection that tonlribules moil lo damaging ihe epithelial surface. Hunmral immunity may promt L from re-infection, but antibodies are serovar specific and [be protection \s snort lived. Cdl-medialed immunity, with activation ot .yloluMt T cells and prutluetion of inrerferon-gamma, is more important for oaitrolHng established infection. Chlamydiai infection is diagnosed by specific te.sts. Initially cell culture techniques were used. Enzyme- linked inrmuriosorbent as^ay (LLISA) (tits arc now used more commonly, hut their sensitivityk limited !t is essential that sampler are collected horn the endo cervix and ar&isof terMCiil et Iropion so tlul cohunnai epithelial cells are harvested Tests, that defect UNA, such as Ihc PCR and the ligase chain reaction fLCRI, arc much more icn&itiu'. They can be applied to urine sampkt or vaginal swi^saddhAvedneciioii rates supe- rior to ELTSA tests on ceivical swab,s. Tbi.s mean*, tbat nun- involve screening for Chlamydia is now possible. Unfortunately, higher cost taslrniiwd the at'ailabiliTy of .such tests in Ehe UK A direct fluorescent antibody (DFAl (ebt can be performed on ceivical smears lolled unlo a specific tulletling slide jntl fixtx] in altohol. ELTSA te^sts. cannnt be used reliably on rectul or con- luiiclivals^vabs, I'oi which DFA i&moreappropiiale. In Sesndiniwian countries, nationwide sciecnmg 11 is essential th-it six partners HR L st reunetl fulk for S I Is and presLribed tr^atmtnl for Chlamvdia before intercourse is. res-umed. Infection, with concomitant reductions in the inci- dence ol PLD and cctopic pregnancy. A national screening pro^nnimcii itartEng in ihe UK. Serolopical te^s are not performed routinely in the iliii^noijs of chlamidial infections. Micro- inimano fluort&anu: c^n be used lo detect scrum antibodies, which are not present in jll infecletl indivitlu^li. The highest antibody ntres are found in women with P1D or tlisseminatetl infection. These highest tltreb are present in 60 per cent of wamen with ruba] facior infertility. The following treatments are effective for uncom- plicated chlamydial infection: • doxv^cydine 100 mg. twice ;i tidy letr 7 tliiys • azithromycm 1 g as. a .single do.se • olloxntin 400m^dailv lor 7 days. niefolliiU'iii^jre used in preg;idiKv; • azithiomvcni 1 g a* a. single do.se » erylhiomycin 5UOmg twice a day lor 14 days. Gonorrlioea The incidence of gonanhoe.il hd> tkdined in devel- oped countries in theljst two decades. The r>re\ r alence is less than 1 pei cent in women of childbeanng age. Chronic asymptomatic infection is common; 50 pc[ ctnl of ^omenrwve no symplomi or jignj of infection. Appioxmiately 70 per cent ot men, however, aic symp- tomatic. Tn men, gonoirhoeacau 1 *: 1 , a severe urethiitib, \vith green unethial discharge jntl dysnria. In women, the tpectrtim ofdise^scii similar co that ctf Chlamydia. rui goriflrrhoeae may he carried in the throat or an exudative tonsillitis. 11 octabiurully causes in adults. It dbo causes procriti^ in women and homosexual men, who may present with purulent dischaige, bleeding and rectal pain. NctsfeTIC gumtfrhuene ib a Gram-nL'gJili^: tliplo^OC- cu*,, which coloni/e*, columnar or cuhoidal epithe- lium. In chronic infection there Is. a compk-x interaction »vilh thenobl immune iv item. The exprejbion of dnti- g,enic surface proteins cliang,e$ over lime in tliKf^cenf an effective antibody response. Protective inimumtv does not appeal lo develop. There are no reliable strologkdl tests fur gonyrrlioesir ^'liere antibiotic u« is not controlled adequately, resistant strains emerge rapidly. Chromosomal mutations, conferring reduced sensitivity lo penicillin emerge slowly in an incre- mental way. High-level rebus-tanee to penicillin is mediated by a plasm id; the fust one de&cubed encoded a panitilliaase enzyme fPPNG [peniallinrf&e- lirodticing jX'iTSierii? gonorrhoeas] ilrains) r Chrnmo so ma] mutations conferring resistance to quinolone anlibiotios have emerged in developing countnes \m ihe last tvu tlecntltj r In (iUM clinics, the dia^no^.i', fa made presuinp- lively byobsei^ng Apical Gram negative mlracellu- ]jr diplototci on Crjm-sljined smears of u cervical ,md rect.ll swabs (I'ig. 15-2J, It is. a fastidio» organism, requiring a carbon diovide concentration ol 7 per cent, specific media ^uch a^ bl<iod agar antibiotics to inhibit Ihe growth of other organi-snu. It may fail to grow on culture, parti cularJy it transport lu the laboralory is tickled. DXA-basetl dttec lesti ^re ^vdilnble for seriTniiig,, but culture essential to allow antibiotic sens.itivit FIU<irel5.2 Vacfral and A Gram -slamed ^mRarol polymniphs ^nd Gram-m nppe^'inee is highlysugi Tlie following trea strains nfgonurrhoe • amoK} r cillin 1 £ will • ciprofloj.acin 50On • spectiiioinyeJn2g, (mliamusculnrly). » a'llhromycin 1 g j' fintra muse nl jrly). • cefixime 4(JOmgas The dioice of treat ten ty patterns, a hisB eist'nlial tliat sex pail and [ircscribed trealn ual interixmrse is, resi Infected with l infection. menl is pit\scribed roi onhoea and fheirpar Because of the posa ctcasinnal tieatmenl ( Kts of cultures perfbn ofturc. Tliese iJiould i can spread to tlie rectu Mucopurulent cemci on delecting purulent Upper genital iract InfBritain . hgurellj 2 Vaginal a il cfimcal tiura (1QQO. magnified } A Gram-sUu til trndar nf cervical secrr-tions showing DO^/morpha and Gram-negative intracellulardiplQcuca This aopearance is highly supgtitive D! gnnnrrh™. J lie following Ire-dtmunti arc effective, for sensitive stiainsof onnnrrhoe.! InfcLlion: • anKJxyullin l£v.'ithpiobenecid2j:as a single ilose, • ciprofloy.ii; in SOOmgas asingledose, • specu 1 noniycin 2 g as a wngledosc ''intramuscularly!, 1 gas a single dose,. On-igasa single dose ', intramuscular ly I, • u'fi \irne dQOmgas a single dose. The din-ice of I real merit is dictated by local senai- Bvity pallerns, a history; of recent travd and cost, It is essential that its paitnevs ai'e screened full] 1 fur iTls and preitribcd treatment for gonorrboea before fiev- ual iiitei'caurse is. resumed Mure than 50 per cent of ivoirKn infected wilh gonnrrbnea h.iyeji coiicomiljnl •kmydial infection. Theretrn-e, chkmydij] ireal- men[ is prescribed routinci} lor all women witb gon- orrhoea and their partners. Because of the poBability of antibiotic r&sislenctand •ccasLonaJ ire^lrntnt fdilurcb, wo-men should luve nvo sets of cultures performed following treatment, as Ic&ts of cure. These sliouy include rectal ^in spread to the rectum from vaginal brvicitis •Bcopurulcnt ce/n.'icitii is a clinical diagnosis based on detecting pundent mucus al the ceirical os. and i.q Fig JIB 15 3 Cervicitis Thpce'vi' i= nflF.mflc! with er/lhem3 artd conlact bleeding tram trie columnar epithelium This ran h associated Hill gonorrhoea. Cl\!amydu or n orten accompanied by contact bleediiij? (l-ig. 15.3). It Can be H-unfuieil with j benign cctropion^ hut the lal- terdoe.3 nnt usually bleed heavily unless swabbed very vigorously Women wilh cervidtis ni.iy prcirin pDStcoital bleeding or complain of a puiulem discharge, Mdnv t howcvcTj are ,111 mptomaiac. Cervicitis is often caused by a sexually transmissible agent* mih iho male paitnei having NGU. Testa 101 Chlamydia diid ^unurrhuea ihoiilJ be perfbrmcd. If ulceration is pre.^ent^ te.31 fbrberpes ^insplc'. The treatment Is ihe same a*, for Chlomydlti Chronic ccrvialis producer scarring. Xahotbian fol- licle* are mucus-containing cvsls up tu 1cm in dianietei, which are often present folluwiug cl cervicitifl. Pelvic inflammEitory disease A.S infection ascends min the uterus, endometritis de.'elopi,. Pliiima cells are seen on endoniervial biopsy; Hnil germinal te-ntres ma^ develop with chronic cblamydial infection. It may be associaled ivithinter- meiistnial bleeding. llie fir&l iitdge e-f balpm^itis mvolvea mucosal in ^l,i ni nut inn wilh swelling, redneu anil dtahation. Polymorphonucleai celhs invade the subniucos.i, fol- bv mononuclcar cells and plasma cells. Inflani- exodatt fills (he lumen of the tube, and adhesions develop between mucosal foldd- Infldin- ni a I Ion SEfends t«.i th<: seiu^l surface and pus exudes from the iimbrisic lo Lhe ovaries and adnesae. At lapamscopi- the tubes are «. r olli!n,]ndr"S in mild irii.ei r In nioie ^serere cases, the tubes are fixed to idjace.nl 74 infections In aynaacDloin Figure 15,4 Lapaioscopic viev* of uterus rind ngbr lube. The lube is dllaredUiydrDsal pi nxnrpyc s^ lp inland Ihert ibR ome mum. Tne part is .1 • ri !i ••• Fallopian lube ibai is visible Table 15,2 Findings al Idpdruicxipj in women undergoing laparosoipv for binpeited pulvn.inlJamniatoivdisea.se (Pll)j 31 laparostopy SaLpingit is/Pi l> 65 Normal finding 22 Appendicitis 3 Endomecriosifi 2 Bleeding corpus luteuni 2 Lt tuple pregnancy 2 Miscellaneous 4 uf slruilureb b} fibrin eynd.ire and adh.jb.ions. With pelvic peritonitis all Ihe organs are congested, with niuliiple adhesions pudLiung an inflammatory mass, The omcntum usually conlinci the inaction lr> the pelvic, nicinleclion causes co ns.ider,ibl^ tissue destruc- tion; tiihal or lubo-ovariaa abbccsics may develop. scarring mdv k'dd lothc fimbnae beinft into the end^ of the ]-il]opian lubeb, adheiino; and se.iliny ihi: 'jndb. of Ine lubes I lie ulerub and uibeb-mayht pulled Isatkintu the pelvis by adhesions, becoming fixed and retroverted A hvdroialpinv is caused hy jctumuladon or lluid within (lie lube, v>'hich expands and svrlls. If Infected, a pvos.ilpim results. Pelvic apbesioD* urbanize, mailing cngeilier Ibe pelvic organs. Soine reonveff of the ciliated epiihelium wiibin (he lubes usually occurs. • In ninf'e sevcretH&^i. p^rtxia, a raised neulropbil count and a raised erythrflcyte sedinicnialion rjle (EbRl. » An adnenal ma&b mav be present in 20 per cell! of women, JSUidiy those who arc most systemically unwell- At heal, ihcdimcaJ diagnosis is 70-HIJ per cent accur- ate, Lapat^s^op-y is regarded ab ihc 'gold standard' for d[agnos[^ (Fig 1^.4), In Cdrli 1 &dlp[ngitii, howevei, the inlUmniiition may nol be visible from the sero&al sur- fiice of l)ie lubeb. The important diffeieiili.il diag- noses are shoivn in 'lablu 15.2. The most important di^gnosib to exclude acutely is ectapk pregnancy If there is -inv douLu dbout ihe possibility of pregnamJ j urine pre^r^nt-f ti:al should be performed. If carry pregnancy is established, -in ultrasound ican to look for evidence Of an intrauterine pregnancy is Clinical features As billion iiiccnds into rhe ulcrus. Fallopian lubes and ovaries, ptl\ic pain and deep dyspareunisi de^op. Intermensd'Lial hle^lin^mafbc caused b^^eci do rneiri- tk Ilia not uncommon for women lu havt an associ- ated urinary tract inlection An abnormal urini: d[psticktest*bould noUlibliactonefrom the dfagnoflia of P1D. The diagno^r^; yf FID ib based on the following. • AhisturvufptfMcpainanddeepdvip.ireunia. • On evaminalion; ttrvical motion tenderness {oflcn called cervical excilaiiOTi! with or without uterine, dntl adnexal tenderneBs r • Lower genital Irait infection: BV, t orccivicitis. PID are ai^ocialed \nlhtradilianglSTD pathugens CVitarnyrfi^and Nfitsswla $Qttti!ihG&!e Secondary Invasion with anaerobes is CDnmon, ^o Ili3l DDmbm^lion^ o( anlibiollcs are required ID ccvirth? spectrum ol likely palhngflns. Partner notificatinn is an importanl pan ol PID is associated v/llh tubal damage leadmp pregr'dncy ind tuba I f&ctor infertility. Musi cfilamydial Jind yonoDDccal mlectmns asympfamali&: safer ^e<' and ol pre';enliijn meaK nf women When PfD is suspected, endocervical swabs should be taken fur ihe tlelcciion of C. fradiQifiatis iind N. gtmofrhaeiK. A high vaginal swab should be token for the detecrion nf Ifttfiemonaf vaginali-, and RV Laparoscopy should be pertoimed it Ihe clinical diag- nosis is uniertam, drainage ol nn Hbiiuiti mighl bi: required, or thei'e is nn improvement after ?4-4tf hours of intravenous antibiotic treatment in a sys- U'niKaily unwell woman. Artib ul dill patients with mild symptoms can be treated as outpatients. The antibiotic regimen should cover bolh Chlnnfydia and gonorrhoea as well ,11 an anaerobic orgdiiiiin, II is usual to prescribe doxycy- clme UK) ing Iwice a day tor 14 days with J days of metronida7ole 41)11 ing twice a day. If gonorrhoea is juspeiled, prescribe tiprolloxnim 500 mg a> a jingk dose in addition, ^n alternative is in use oflovacin 401) nig daily tor 2 weeks with j days otmelionidazolc 4QOrn£ Iwke a day. Patients ^ho are sysiemkally unwellj nr i" wlioin a lub.il flbs^ess i^ suspecied, should be adinilled for intravenous antibiotic li'eaH- mentand mm require lapnioscopi definitely lo v:slab- lish the diagnosis, Entrj^enous cephalospoiin and metromdazole can be used milially^ bul it is essenlial thai a 2-week course of do^'orline is. prescribed lo crndii;ilt anv possible dildinvdiul infection, |[ Is essential that sexual partners are screened for Chitim'/dui and gonorrlio^a and prescribed appi opriate amibiolk InMlmenl before inlerconrse is resumed (Fig. 15,5), iii and Intra-ahdominal spread ol Chli\nryiitQ or gonorrhoea c^n LaiiM 1 p/Lii-jppL'ndKilis orpenhep;iiilis. The Utter is termed the I 'it?- Hugh Curtis svndrome \Voinen and, larely, men present wilh light hypochondrial pain and lendemejs and p> r re\[a. The. 1 are frequently nusdiagno&cd as having cholrcyslnjj. Careful indliyn lib nally dials signs of sal pingiti^. Atlajjamscopv, fine 'violin striiig adhesions are seen benveen ihe liver capsule and viscei al ptriloncurn. Penhepalilis is djrfd by a 3-week co urn 1 of upprupridl': ^nlibioiits, DLS^CITI!n^led infection with Chlaiwtlta may cause Reiter's s>nidiome or scxualli acquired rtacfht artbrilis (SAliA:, This probably ottiirb in less tben 1 p\:r cent of ^ases. 'Iliere is usually an asymmetrical nligoarlliritis, attettmp large joints ot Che lower lunb. In Reitei's syndrome, ihe arthritis Is accompanied by uveitis and A ruh That if florid m JV he similar to pso- rinisis- It is associated with Ihe presence of human leukocyte anligcn (H1A"\ ti27 hiipluivpe, and mere ifi overlap ivitholher seruntgaiive spondardiritidci, Dijss-TTiirirtied infeLiiLin with gonorrhoea occurs rarely {in ore often in women thiin men), bul presents as a scplic oli^uardirilit., usually affecting Ihe sniiill joints ol [he hand nr wrist, with a scanty papular rash. Pregnancy and vertical transmission See Obstetric by Ten Teadters, 18th edition, Chapter 15. Other causes of endometritis F|flui9l5.5 La'gehydrosalpirxcf left Fallopian lube wilh a hydrosalpiiix on the right side. Tuberculosis utfi tuberculosis ^dn spread through ihe tract via the blood or lymphatics. There I& nearly always tuberculosis clseivhcie, usuall;' pul- monaiy. Granuloninu Je'tlop in ihe FaLopian tobtt and bubscqueiilK the other genital organs. Inrection ni^v remain ^uhiilinica], presenting ultimately with amenorrnoea, mlertfhly or, in a similar lashion 10 FID, vvidi Jironio, bw-gr^de- pelvic pain. The endoinelriinn is involved in up to 8(J per cent of caica and the o^'aries in 20-30 per cent. Abnormal UtC[UK bleedmgis a presenting symptom rn 10—40pi:rcenl of patients. Eiamination findings are normal in many women, bul aiiadnexal mass orfiAin^ol (hi^ pclvii 1 organs, may bcdelecred, Diagnosis can be con firmed by obtaining endomecrial tissue Iroin biopsy 01 dilatation and curellage. The detection late ij greatest towards the end of Ihe menslrual cydt. Lvcn so, endometrial biopsy does not ha^'e 1011 percent sensitivity. Because die presentation, miiy be subtle, a high index of suspicion ibtMciUia]. AManlouxor Heaf test should be reacli^t in a woman ivith active tuberculosis anlei& she is immunosuppressed. A chc&t X-ray should be [...]... cj'&tourethruixk in w Urodyiuinii: i iind are Urinary incontinence in classified According lo cunctpli lather than symptobul Ihc fbllowing definitions of sj-mptoms are commonly used Introduction Urinary incnntinejuc ib tk-fincd aa the involuntary loss of urine that is objetlivdv demonatrabk and is a SOtiiil or hygienic problem Iti^ increasingly ^rcviik'nt a*, llie ^g^iiig popubfiun expands It afTeei*; an individual's... amenta! mvciligalion It involves siibullaneous abdominal pressure receding in addition to inlravtsicai pressure nionfinrin^ during bladder filling and voiding Electronic subtraction of abdominal detrusor pressure (Pip; 16 SI Cyitomctr; is indicated for the following • Previous unsuccessful continence suigery • Multiple sympioms, \.e ur£.e intonlincncc, inconlinence and trequeiicy • Voiding • Neuropath k... nmn in iiomc 'Vfrican cemnlnes, v«ilh a prevalarice of SO per cent ov greater Good control ofiTls should reduce the incidence of HI\' infection 1J Figura 15.11 _arqt miilhpl-; in a vinrruin "'ilh HIV irfprlion ^n 'ilcerlh^l for Tinrethan 1 month IR r;linii>nllyAIDS defining 1!)o Inleclions In gynaecology Although all HIV-infected ivurnen are urged to use condoms to prcveiil then transmitting the infection... estimated doubling lime of 20 hours Sustained tR'poneinicidal kvi-kuf-tnTibiotic are needed for a minirnum u f l ? days in eJily svphiJis The irt-itmenlot"choice is l^nicilhn Auirielyijfrcginiens is used (Table 15.3]: * prcnaine penicillin 1.2MUdaiU by idtrfltmuativ infection for 12 days, > ben zjthine penicillin 2A ML) by intramuscular iniLction, repeated after 7 days * do:iyc.ycline 11)11 ing two tinus n... developing in The nioulli or lips Wdrts are frequently multijjle and slowly increase in size inguinale (Dontwartfisis) Granuloma inpuinale is an infection caused by Kebsiella granulomaas 'previously known as Cal-fnimattibficlenum granulatf/am} It is endemic in India, Pa|>u,i Ne\s Guinej drill ioulhtrn j\friin It i& usually a slowly pmgie^s.ive infec[ion starring with diocrete (JHpulcb un (ht bkin or... carried lor 'ears, piobably litHong In oniL study, genital wirib dcvolopcd in nearly two-thirds of tunldtts of patients wllh vis.i|>legeni[al warts within 1 innn[hs of starting The relationship There is less information on the lole of asymptomatic shedding of ivart vinii in Tlio^t wiTh jubclinical lesions 'ITie virus tan infecTtbe skin of the vulva and perineum, the vagina, ccivix and lectum (Fig 15,fl);... ulcers, nj^mbling imall abraiioEi on ihe vulva • Localized clustcrb of vesicles- and ulcers over an ireaof 1-2 cm diameter • Widespread or chronic ulceiatkiD rc prinihir\ inlection cEinbe see-n in pregnant • [fa woman i&imiiiuimsuppici^d, lai^e at\-pical chronic ulcers inaydnTlop, Aherpeticulcer perbi&ting for innrethan 1 month 13 acquired ininiiinodefkn:n b>ndn>me fAIDSj d^finiuj? in an individual... counlnes, HIV is principally spread Lhrough vaginal inlcrcoui^e;, with approximatelv etfual number1; of men and isnmeii iufctied In developed countries, Ihe ina]onty of infections haveheen acquii^d ihrough horncMJtxnal S*K oi mtravenons drug use, although rlie incidtnct i>f hc-i^roievLial transmissioD i& increa.-iing Genital infections arcriiikfjcmri foi HIV transmission and acquisition, including genital... a rubber finger col to prevent laical blockage ii into Lhe recUnn lo mcajunL1 inlra-abdommal Mkrolip tranflducers.i^i|iht ust-d bill art more sive and fragile The hlJdder is filled {in silling and standing poiiliona) wtth a conlmuoub infusion ol noi'inal saline at rooin temptralurt The slandard lilhng late is between It! and JQQmL'min and is provocative for detrui,or instabilily During filling, the... (Ik' i n c o n t i n e n c e is due to a delect in die &phinncrk mechanism producing a lo^v-rrbi&lrfnce, poorly functioning, diainpipe uitlhrj.'Hie procedures to increase outllu^ itbibljncc i" Lhest circuinstances are the artificinll urinary sphincter and peri-urcthral inieclions, hut suburethrai &lingb jri1 a!iu ustd The jrlificial sphincier has been used since 1972 It is used where conventional smgeryhaa . [imittti, but include- ^rbphenjinine pessaries and dotrimazol«, ^-Jiich lias. an inhibitory effect on 7)iJwn»riflj Vaginal discharge in children Vaginal infections are common in childhood. prcnaine penicillin 1.2MUdaiU by idtrfltmuativ infection for 12 days, > ben zjthine penicillin 2A ML) by intramuscular iniLction, repeated after 7 days. * do:iyc.ycline 11)11 ing two tinus. 13 acquired ininiiinodefkn:n<;> b>ndn>me fAIDSj d^finiuj? in an individual willi HIV infection. A diagnosis of herpes can often be made by aivab- biny, small ulceri in women who