Adobe Systems Tvarožek S., Meixnerová I. Pelvic infection and STDs 2020 Department of Gynecology and Obstetrics Brno University Hospital and Masaryk University, Faculty of Medicine head: doc. MUDr. Vít Weinberger, Ph.D Obstetrics and Gynecology - lectures Adobe Systems Pelvic infection and STDs Risk factors •Age, parity •early sexual life, high risk: 15-39 yo. •Multiparous women 10x higher risk compare to nulligravid women •Promiscuity •IUS/IUD - 5-6x higher risk of inflamatory disease •Alcohol, drugs •Other •Iatrogenic factors (cervical dilatation, abrasion and curretage of the uterine cavity, hysteroscopy ...) Adobe Systems Pelvic infection and STDs Gynecological inflammatory diseases Localisation: •External female organs (vulvitis, colpitis) •Internal organs (cervicitis, metritis) •PID = pelvic inflammatory disease (oophoritis, salpingitis, pelveoperitonitis) Etiology: •Viruses, bacterias, fungi (?) protozoa (?) Adobe Systems Pelvic infection and STDs Vulvitis •Elderly women with skin damage (scratching, leakage of urine, sweat – obese people, menstrual blood) •Reduced skin resistens (diabetes, hepatopathy, anemia) •can occur concomitantly with other vaginal inflammatory diseases • Etiology : •bacteria, fungi, viruses Adobe Systems Pelvic infection and STDs Vulvitis Symptoms: •Bacterial : well-defined border (folliculitis, furuncle, abscess) or wihout sharply defined border (phlegmon), abrasions, skin defect with secretion, crusts •Fungal (Yeast) : itchy, burning, white patches •Viral (specific symptoms) : condylomata accuminata, herpes simplex genitalis • Adobe Systems Pelvic infection and STDs Vulvitis Diagnose: •Clinical symptoms, microbiological culture (bacterial inflammation) •Serological test (viruses) •Dermatologic examination • Therapy: depends on etiology •Antimycotics/local use of ATB/ATB systematic •Painkillers, antihistamines, corticosteroids •Surgical (abscess) incision/extirpation • Adobe Systems Pelvic infection and STDs Herpes simplex Etiology: DNA virus Herpesviridae (HSV1 a HSV2) •Latent infection – notably reside in neural ganglia, in case of stress or immunodeficiency can be reactivated •Transmitted by contact with infected person Symptoms: •Prodrome – red skin, itching 1-2 days before the onset of disease •Painful blisters - papules, vesikles, pustules, crusts •Tingling or burning in the genital area • Therapy: Acyclovir 200mg tablet five times a day • Adobe Systems Pelvic infection and STDs Condylomata accuminata (genital warts) Etiology: DNA Papillomaviridae, HPV low risk 6, 11 , sexually transmitted Symptoms and characteristics: •anogenital warts, located on vulva, perineum, perianal region, anus, vaginal wall, cervix •itching, bleeding •spread through direct skin-to-skin contact (oral, genital, or anal sex) •virus affect only squamous cells of the skin Therapy: •Topical agents: Podofylotoxin, Trichloroacetic acid, Imiquimod •Physical ablation: excision, electrocauterization, laser ablation Prophylaxis: HPV vaccination (low 6, 11 and high risk 16, 18 – cervical ca.) • Adobe Systems Adobe Systems Pelvic infection and STDs Diagnosis: 1. microscopic examination •vaginal wet mount – looking for: WBC, epithelia, bacteria, yeast cell, trichomonads, clue cells 2. Whiff test •several drops of a potassium hydroxide (KOH) solution are added to a sample of the vaginal discharge •a strong fishy odor from the mix means bacterial vaginosis is present 3. KOH slide •a sample of the vaginal discharge is placed on a slide and mixed with a KO •The KOH kills bacteria and cells from the vagina, leaving only yeast for a yeast infection Vaginal infections Adobe Systems Pelvic infection and STDs Vaginal infections Diagnosis: 3 . Vaginal pH •normal vaginal pH: 3–4,5 •pH 4,5–5,5 suggestive of bacterial vaginosis •pH higher than 5,5 may indicate bacterial vaginitis or trichomoniasis •in case of yeast infection is pH in normal range In case of unclear diagnose or recurrent infection perform microbiological culture • Adobe Systems Pelvic infection and STDs Bacterial vaginosis Definition: •overgrowth of bacteria naturally found in the vagina, or decrease in the abundance of lactobacilli in the vaginal microbiota •more common in women with IUD • Etiology: •facultative anaerobic Gardnerella vaginalis •overgrowth of other, predominantly anaerobic bacteria (Bacteroides, Mobiluncus (Vibrio), peptostreptococcus) Adobe Systems Pelvic infection and STDs Bacterial vaginosis Symptoms: •Thin, grey, white or green vaginal discharge •Foul-smelling "fishy" vaginal odor, mostly after sexual intercourse •Vaginal itching, burning •Sometimes no signs or symptoms • Diagnosis: Amsel criteria (2 out of 4 required for diagnosis) •Homogenous grey-white discharge •Increased pH 4,5–5,5 •Clue cells in microscopy (squamous epithelial cell with bacteria adherent on their walls) •Positive Whiff test Adobe Systems Pelvic infection and STDs Bacterial vaginosis Therapy: •In women with symptoms, I. trim. of pregnancy, before surgery •Metronidazol 500mg vag. 7 days, Clindamycin, Nifuratel (Macmiror) •Vaginal probiotics after ATB treatment as recurrence prophylaxis •treating the sexual partner is not necessary Complication : •metritis, cystitis, PID •Risk factor for preterm birth Adobe Systems Pelvic infection and STDs Bacterial colpitis (aerobic vaginitis) Etiology : colistreptococcus, staphylococcus, enterococcus and E. coli Symptoms: •Thick yellow vaginal discharge, dyspareunia, vaginal inflammation – red and swollen vaginal wall Diagnosis: •clinical symptoms •microbiological culture Therapy: vaginal application: Clindamycin, Nifuratel Adobe Systems Pelvic infection and STDs Candidiasis (yeast infection) Eriology: Candida albicans, C. tropicalis, C. glabrata •Vagina naturally contains a balanced mix of yeast including Candida •In case of disrupted vaginal balance, in immunodeficient patients, increased estrogen levels (pregnant, COC, estrogen therapy) Risk factors: •pregnancy (III. trimester) •Diabetes mellitus, increased sugar intake •ATB therapy, corticosteroids, estrogens •Impaired immune system •Synthetic underwear, promiscuity • Adobe Systems Pelvic infection and STDs Candidiasis (yeast infection) Symptoms: •itching, burning, especially during intercourse or while urinating •Thick, white, odour-free vaginal discharge with a cottage cheese appearance •redness and swelling of the vulva and vagina •Very often as a vulvovaginitis Adobe Systems Pelvic infection and STDs Candidiasis (yeast infection) Diagnosis: •Clinical symptoms •microscopic examination •microbiological culture •In recurrent infections – oGTT (DM exclusion) •Normal vaginal pH, negative whiff test • Therapy: •Azol antifungals – topical/vaginal (Clotrimazole) or systemic •therapy success rate is more than 90% • Adobe Systems Pelvic infection and STDs Trichomoniasis Etiology : Trichomonas vaginalis •STD, treatment of all sexual partners is necessary Symptoms: •50 % of women are without any clinical symptoms •frothy, greenish, foul-smelling vaginal discharge •vulval itching and soreness, Cervix may have a ‘strawberry’ appearance Diagnosis: •Positive Whiff test •pH > 4,5 •microscopy: flagellated moving protozoa (trichomonas vaginalis) • Výsledek obrázku pro Trichomonas vaginalis Adobe Systems Pelvic infection and STDs Trichomoniasis Therapy: •systemic use of Metronidazole 500mg tbl twice a day for 7-10 days Complications: •Preterm birth •Low birth weight •transmission of infection to the baby during delivery Adobe Systems Pelvic infection and STDs Cervicitis Etiology: •Chlamydia trachomatis, mycoplasma, Neisseria gonorrhoea Symptoms: •Asymptomatic in 30–50 % cases •large amounts of unusual vaginal discharge, dyspareunia, bleeding between periods, painful urination, lower abdomen pain •chronic cervicitis– dysmenorrhoea, dyspareunia, infertility •in men – urethritis, mostly asymptomatic – Asymptomatic carrier • Adobe Systems Pelvic infection and STDs Cervicitis Diagnosis: •a pelvic examination •A specimen collection – microbiological culture from the cervix •Antibody detection – RIA, ELISA, PCR •Cervical cancer exclusion (colposcopy, cytology, biopsy) Therapy: •Systemic targeted antibiotic therapy •Azithromycin 1000mg oral single dose (chlamydia) •Doxycyclin 200mg every twice a day for 7 day (chlamydia, Neisseria) Adobe Systems Pelvic infection and STDs Endometritis (endomyometriris) Etiology: •Ascendent infection - cervix •Surgical procedures (curettage, hysteroscopy, IUD insertion) •Neisseria, Chlamydia, rarely M. tuberculosis Symptoms: •acute: lower abdomen pain, fever, abnormal vaginal bleeding or discharge tender to bimanual palpation •chronic: hypermenorhoea, chronic lower abdomen pain Adobe Systems Pelvic infection and STDs Endometritis (endomyometriris) Diagnosis: •Symptoms •a pelvic examination •a specimen collection – microbiological culture from the cervix •The inflammatory markers: CRP, WBC) •Cervical cancer exclusion (colposcopy, cytology, biopsy) Therapy: •intravenous administration of antibiotics (empiricà targeted) •Symptomatic therapy: painkillers … • Adobe Systems Pelvic infection and STDs Pelvic inflammatory disease - PID •Inflammation of upper genital tract •fallopian tube or ovary (salpingitis, oophoritis) •Tubo-ovarian abscess (TOA) •Pelviperitonitis •Peritonitis Etiology: •ascendent infection from uterus or spreading from appendix •TOA can develop from the lymphatic system with infection of the parametrium from an intrauterine device (IUD) Adobe Systems Pelvic infection and STDs PID Symptoms: very variable •acute – almost 40% asymptomatic, lower (bilateral) abdomen pain, vaginal discharge, abnormal uterine (vaginal) bleeding, fever sometimes with chills, nausea, vomiting, dyspareunia, frequent or difficult urination •chronic – dyspareunia, chronic lower abdomen pain, infertility, irregular menstrual cycle Adobe Systems Pelvic infection and STDs PID Etiology : •Ch. trachomatis, N.gonorrhoeae, E.coli, mycoplasma, ureaplasma, Staphylococcus, Streptococcus, bacteroides, peptostreptococcus • Risk factors: •Being sexually active women younger than 25 yo. •Multiple sexual partners •Previous STDs •Uterine instrumentation – curettage, hysteroscopy, IUD insertion (very small risk) Adobe Systems Pelvic infection and STDs PID Diagnosis: •Symptoms •a pelvic examination •a specimen collection – microbiological culture from the cervix •The inflammatory markers: CRP, WBC) •Cervical cancer exclusion (colposcopy, cytology, biopsy) •Ultrasound – sacto/pyosalpinx Therapy: •intravenous administration of antibiotics (empyricà targeted) •Symptomatic therapy: painkillers … •Laparoscopy – ovariectomy, salpingectomy, adnexectomy,….. • Adobe Systems Pelvic infection and STDs ATB therapy PID •Combination of broad-spectrum antibiotics – intravenous preferably •Aerobic bacteria ATB •doxycyclin – 100 mg twice a day oral •azithromycin – 500 mg a day •Amoxicillin+Clavulanic Acid (Augmentin) – 1,2 g every 8 h. iv. •Anaerobic bacteria ATB •metronidazole – 500 mg every 8 h. iv. Adobe Systems Pelvic infection and STDs PID Complications •Acute: •Perihepatitis (4 - 28 %) •Rupture of TOA resulting in sepsis (life-threating) - mortality 6 - 15 % - immediate surgical intervention •Periappendicitis (2 - 10 %) Adobe Systems Pelvic infection and STDs PID Complications •Chronic: •Chronic lower abdominal pain (5 %) •Infertility (14 - 38 %) – from blocked fallopian tubes •Ectopic pregnancy 10 - 30 %) •FITZ-HUGH-CURTIS sy. – perihepatic adhesion (Chlamydia, Neisseria) • Adobe Systems Pelvic infection and STDs Pelvic actinomycosis Etiology: Actinomyces israeli •formation of painful abscesses and fibrosis in human body (lung, breast, pelvis...) •predominantly associated with the longstanding use of intrauterine device • Symptoms: abdominal pain, fever, vomitus, nausea, diarrhoea, obstipation Therapy •IUD extraction, ATB therapy PNC, Doxycycline •laparotomy/LSC (abscess drainage, lavage) (in unsuccessful ATB treatment) Adobe Systems Pelvic infection and STDs Thank you for your attention Adobe Systems Pelvic infection and STDs Questions 1.Which of the following is not the risk factor of pelvic infection? A)Promiscuity B)Alcohol C)Late sexual life D)Cervix dilatation E) 2.What two STDs cause PID when left untreated? A)Syphilis and gonorrhoea B)Genital herpes and genital warts C)Chlamydia and genital warts D)Gonorrhoea and chlamydia Adobe Systems Pelvic infection and STDs Questions 1.Which of the following is not the risk factor of pelvic infection? A)Promiscuity B)Alcohol C)Late sexual life D)Cervix dilatation E) 2.What two STDs cause PID when left untreated? A)Syphilis and gonorrhoea B)Genital herpes and genital warts C)Chlamydia and genital warts D)Gonorrhoea and chlamydia Adobe Systems Pelvic infection and STDs Questions 1.Which of the following is not the risk factor of pelvic infection? A)Promiscuity B)Alcohol C)Late sexual life D)Cervix dilatation E) 2.What two STDs cause PID when left untreated? A)Syphilis and gonorrhoea B)Genital herpes and genital warts C)Chlamydia and genital warts D)Gonorrhoea and chlamydia Adobe Systems Pelvic infection and STDs Questions 3.A normal vaginal pH level is? A)Between 3.8 and 4.5 B)Below or equal to 4.5 C)Above or equal to 4.5 D)Between 4.5 and 7 E) 4.Whiff test? A)may suggest either trichomoniasis or bacterial vaginosis B)strong fishy odour is indicative of a negative test result C)may suggest either trichomoniasis or bacterial colpitis D)All of the above answers are correct Adobe Systems Pelvic infection and STDs Questions 3.A normal vaginal pH level is? A)Between 3.8 and 4.5 B)Below or equal to 4.5 C)Above or equal to 4.5 D)Between 4.5 and 7 E) 4.Whiff test? A)may suggest either trichomoniasis or bacterial vaginosis B)strong fishy odour is indicative of a negative test result C)may suggest either trichomoniasis or bacterial colpitis D)All of the above answers are correct Adobe Systems Pelvic infection and STDs Questions 3.A normal vaginal pH level is? A)Between 3.8 and 4.5 B)Below or equal to 4.5 C)Above or equal to 4.5 D)Between 4.5 and 7 E) 4.Whiff test? A)may suggest either trichomoniasis or bacterial vaginosis B)strong fishy odour is indicative of a negative test result C)may suggest either trichomoniasis or bacterial colpitis D)All of the above answers are correct Adobe Systems Pelvic infection and STDs Questions 5.Symptoms of genital herpes are: A)Tingling or burning in the genital area B)Painful blisters in the genital area C)Vaginal discharge D)A and B E)A,B and C F) 6.The cytomegalovirus (CMV) can‘t be spread by: A)Kissing B)Sharing an office with an infected person C)Changing a child's wet diapers D)Childbirth Adobe Systems Pelvic infection and STDs Questions 5.Symptoms of genital herpes are: A)Tingling or burning in the genital area B)Painful blisters in the genital area C)Vaginal discharge D)A and B E)A,B and C F) 6.The cytomegalovirus (CMV) can‘t be spread by: A)Kissing B)Sharing an office with an infected person C)Changing a child's wet diapers D)Childbirth Adobe Systems Pelvic infection and STDs Questions 5.Symptoms of genital herpes are: A)Tingling or burning in the genital area B)Painful blisters in the genital area C)Vaginal discharge D)A and B E)A,B and C F) 6.The cytomegalovirus (CMV) can‘t be spread by: A)Kissing B)Sharing an office with an infected person C)Changing a child's wet diapers D)Childbirth Adobe Systems Pelvic infection and STDs Questions 7.Which of these is a health problem that can be caused by STIs in women? A)Pelvic inflammatory disease (PID) B)Ectopic pregnancy C)Higher risk for cervical cancer D)All of the above 8.What are symptoms of pelvic inflammatory disease? A)Abdominal pain B)Foul-smelling vaginal discharge C)Painful sexual intercourse (dyspareunia) D)Fever E)All of the above Adobe Systems Pelvic infection and STDs Questions 7.Which of these is a health problem that can be caused by STIs in women? A)Pelvic inflammatory disease (PID) B)Ectopic pregnancy C)Higher risk for cervical cancer D)All of the above 8.What are symptoms of pelvic inflammatory disease? A)Abdominal pain B)Foul-smelling vaginal discharge C)Painful sexual intercourse (dyspareunia) D)Fever E)All of the above Adobe Systems Pelvic infection and STDs Questions 7.Which of these is a health problem that can be caused by STIs in women? A)Pelvic inflammatory disease (PID) B)Ectopic pregnancy C)Higher risk for cervical cancer D)All of the above 8.What are symptoms of pelvic inflammatory disease? A)Abdominal pain B)Foul-smelling vaginal discharge C)Painful sexual intercourse (dyspareunia) D)Fever E)All of the above Adobe Systems Pelvic infection and STDs Questions 9.Which of the following HPV subtypes are linked to cervical cancer? A)6, 18 B)16, 11 C)6, 11 D)16, 18 E) 10.What are complications of pelvic inflammatory disease? A)Endometriosis B)Uterine fibroids C)Infertility D)Incontinence 1. Adobe Systems Pelvic infection and STDs Questions 9.Which of the following HPV subtypes are linked to cervical cancer? A)6, 18 B)16, 11 C)6, 11 D)16, 18 E) 10.What are complications of pelvic inflammatory disease? A)Endometriosis B)Uterine fibroids C)Infertility D)Incontinence 1. Adobe Systems Pelvic infection and STDs Questions 9.Which of the following HPV subtypes are linked to cervical cancer? A)6, 18 B)16, 11 C)6, 11 D)16, 18 E) 10.What are complications of pelvic inflammatory disease? A)Endometriosis B)Uterine fibroids C)Infertility D)Incontinence 1.