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Gynecological infections

Gynecological infections. Gebre K. Tseggay, M. D. Normal Vaginal Flora . Dominated by lactobacilli

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Gynecological infections

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  1. Gynecological infections Gebre K. Tseggay, M. D.

  2. Normal Vaginal Flora • Dominated by lactobacilli • Lactobacilli convert glucose to lactic acid, to maintain an acidic vaginal pH of 3.8 to 4.2. This acidic environment inhibits the overgrowth of bacteria and other organisms with pathogenic potential. • Some lactobacilli also produce hydrogen peroxide (H2O2), a potential microbicide. • After onset of sexual activity, increase in Gardnerella vaginalis, lactobacilli, mycoplasmas, ureaplasmas is seen.

  3. BACTERIAENDOGENOUSTOTHELOWERGENITALTRACT GRAM POSITIVEGRAM NEGATIVE Lactobacillus acidophilusEscherichia coli CorynebacteriumsppEnterobacter cloacae Gardnerella vaginalis Staphylococcus epidermidisKlebsiella Streptococci Morganella Enterococcus faecalisProteus Peptococcus Bacteroides Peptostreptococcus Fusobacterium Prevotella modified from Schlossberg,CTID 2001

  4. Vaginitis • Most common causes include: • Vulvovaginal Candidiasis (VVC) • Bacterial Vaginosis (BV) • Trichomoniasis • *In some cases the etiology may be mixed

  5. VAGINITISSYMPTOMS • Often non-specific: • Abnormal discharge • Vulvovaginal irritation • Vulvar itching • Odor

  6. VAGINITISDIAGNOSIS • History • Visual inspection • Appearance of vaginal discharge: color, viscosity, adherence to vaginal walls, odor • Collection of specimen • Diagnostictests: • Vaginal pH: determine vaginal pH with narrow-range pH paper • Whiff test: assessment of a fishy odor after application of 10% KOH to wet mount • KOH (wet mount): wet mount of discharge with 10% KOH • NaCl (wet mount): wet mount of discharge with 0.9% normal saline

  7. VAGINITIS DIAGNOSIS Other tests: • Cultures: not used routinely, but are available for both T. vaginalis and Candidaspp. • New tests for BV(commercially available) : • Fem Exam Test Card™: pH and amines • Fem Exam vaginalis PIP Activity Test Card™: detects enzyme breakdown from G. vaginalis • DNA probe for 3 organisms (T. vaginalis, C. albicans, and G. vaginalis): sensitivity, specificity, and clinical utility are under investigation.

  8. VULVOVAGINALCANDIDIASIS • Not considered to be STD • Caused by overgrowth of Candida species (Candida species are normal flora of vagina) • 80-90% caused by C. albicans. • Non-albicans candida play increasing role

  9. Uncontrolled DM Corticosteroid therapy Antimicrobial therapy (oral, parental, topical) Poor hygiene Estrogen therapy High-dose estrogen contraceptives Pregnancy IUD HIV infection Sponge Nonoxynol-9 (?) Diaphragm (?) Increased frequency of coitus "Candy binge“ Women frequenting STD clinics Tight-fitting synthetic underclothing But, most episodes of vulvovaginal candidiasis occur in the absence of a recognizable precipitating factors VULVOVAGINAL CANDIDIASIS RISKFACTORS

  10. VULVOVAGINAL CANDIDIASIS CLASSIFICATION UncomplicatedComplicated Sporadic, infrequent Recurrent Mild-to-moderate Severe Likely C albicans Non-albicans Non-immunocomprised Diabetes, pregnancy, immunosuppression

  11. VULVOVAGINALCANDIDIASISMANIFESTATIONS • Vulvar pruritis is most common symptom • Thick, white, curdy vaginal discharge ("cottage cheese-like") • Erythema, irritation, occasional erythematous "satellite" lesion • External dysuria and dyspareunia

  12. VULVOVAGINALCANDIDIASISDIAGNOSIS • Clinical • pHnormal (<4.5) • Whiff test negative • Fungal stain positive • 30% may have a negative fungal stain • Severity does not depend on No. yeasts present

  13. Regimens for the Treatment of Vulvovaginal Candidiasis • Intravaginal agents: • Butoconazole 2% cream, 5 g intravaginally for 3 days† • Butoconazole 2% sustained release cream, 5 g single intravaginally application • Clotrimazole 1% cream 5 g intravaginally for 7-14 days† • Clotrimazole 100 mg vaginal tablet for 7 days • Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days • Clotrimazole 500 mg vaginal tablet, 1 tablet in a single application • Miconazole 2% cream 5 g intravaginally for 7 days† • Miconazole 100 mg vaginal suppository, 1 suppository for 7 days† • Miconazole 200 mg vaginal suppository, 1 suppository for 3 days† • Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days • Tioconazole 6.5% ointment 5 g intravaginally in a single application† • Terconazole 0.4% cream 5 g intravaginally for 7 days • Terconazole 0.8% cream 5 g intravaginally for 3 days • Terconazole 80 mg vaginal suppository, 1 suppository for 3 days • Oral agent: • Fluconazole 150 mg oral tablet, 1 tablet in a single dose Note: The creams and suppositories in this regimen are oil-based and may weaken latex condoms and diaphragms. Refer to condom product labeling for further information. † Over-the-counter (OTC) preparations

  14. RECURRENTVULVOVAGINAL CANDIDIASIS • Four or more symptomatic episodes/year • Usually NOT from resistance to antifungals • Diabetes mellitus or immunosuppression should be considered in refractory/ recurrent cases • Simultaneous Rx of sex partners has no effect on recurrence (but 3-10% of sex partners may have balanitis) • Vaginal culture useful to confirm diagnosis and identify unusual species Treatment • Initial regimen of 7-14 days topical therapy • Fluconazole 150 mg (repeat 72 hrs) • Maintenance regimens- clotrimazole, ketoconazole, fluconazole, itraconazole • ForNon-albicans VVC: • Longer duration of therapy • Non-azole regimen may even be needed • 600 mg boric acid in gelatin capsule vaginally once a day for 14 days

  15. VULVOVAGINALCANDIDIASISTreatment in Pregnancy • Only topical intravaginal regimens recommended (usually for 7 days)

  16. VULVOVAGINALCANDIDIASISManagement of Sex Partners • Treatment not recommended • Treatment of male partners does not reduce frequency of recurrences in the female • But, male partners with balanitis may benefit from treatment

  17. BACTERIALVAGINOSIS • Not a classical STD • Overgrowth of vaginal normal flora with anaerobic bacteria and decrease or loss of protective lactobacilli (Disturbed vaginal ecosystem) • Gardrenella vaginalis (GV) & other microrganisms in high titers • But, GV found in 50% of vaginal cultures in asymptomatic women too. • BV linked to: premature rupture of membranes, premature delivery and low birth-weight delivery, acquisition of HIV, development of PID, and post-operative infections after gynecological procedures • Male sex partners may be colonized but asymptomatic

  18. BACTERIALVAGINOSIS • Gray, homogenous discharge w foul (fishy) odor reported mostly after vaginal intercourse and after completion of menses • Without obvious vaginal inflammation • Clue cells present • pH>4.5 • Positive Whiff test (KOH)

  19. NOT a clue cell Clue cells NOT a clue cell

  20. BV Diagnosis: Amsel Criteria

  21. BACTERIAL VAGINOSISOther Diagnostic Tools • Culture not recommended; Do not Rx a positive GV vaginal culture in asymptomatic women • Newer diagnostic modalities include: • FemExam™ • PIP Activity TestCard™ • DNA probe

  22. BACTERIALVAGINOSISTREATMENT • Metronidazole 500 mg twice daily x 7 days • Metronidazole gel 0.75%,5 g intravaginally once daily x 5 days • Clindamycin cream 5%, 5 g intravaginally qhs x 7 days Alternativeregimens • Metronidazole 2 gm in a single dose • Clindamycin 300 mg twice daily x 7 days • Clindamycin ovules 100 g intravaginally qhs x 3 days

  23. BACTERIALVAGINOSISTreatment in Pregnancy • Symptomatic pregnant women should be treated due to association with adverse pregnancy outcomes • Do not use of topical agents in pregnancy • Some experts recommend screening and treatment of asymptomatic women at high risk for preterm delivery (previous preterm birth) at the first prenatalvisit; optimal regimen not established

  24. BACTERIALVAGINOSISTreatment in Pregnancy Metronidazole 250 mg three times daily for 7 days or Clindamycin 300 mg twice daily for 7 days

  25. BACTERIALVAGINOSISManagement of Sex Partners • Not recommended • Woman’s response to therapy and the likelihood of relapse or recurrencenotaffected by treatment of sex partner

  26. Etiologic agent Trichomonas vaginalis – a flagellated protozoa TRICHOMONIASIS

  27. Trichomoniasis and other vaginal infections — Initial visits to physicians’ offices: United States, 1966–2003 SOURCE: National Disease and Therapeutic Index (IMS Health)

  28. TRICHOMONIASIS • Estimated 7.4 million cases annually in the U.S. • Almost always sexually transmitted • Causes urethritis in men (usu. asymptomatic) • Transmission between female sex partners has been documented • Fomite transmission rare • Possible association with • Pre-term rupture of membranes and pre-term delivery • Increased risk of HIV acquisition

  29. TRICHOMONIASISDIAGNOSIS • Copious, yellow-green or grayfrothy discharge, adherent to vaginal walls, w foul odor. • Vulvovaginal erythema • Punctate cervical microhemorrhages seen in 25%: ‘strawberrycervix’ • Saline smear 80% sensitive, highly specific (motile trichomonads) • Liquid culture, Diamond’s medium, done in persistent cases • Gram stain & Pap smear are not sensitive or specific • Whiff test (KOH) +/-

  30. TRICHOMONIASISTREATMENT Recommended regimen Metronidazole 2 gm orally in a single dose Alternative regimen Metronidazole 500 mg twice a day for 7 days Pregnancy Metronidazole 2 gm orally in a single dose

  31. TRICHOMONIASISTREATMENTFAILURE • Re-treat with metronidazole 500 mgtwice daily for 7 days • If above fails, Rx with metronidazole 2 gm single dose x 3-5 days • In repeated failure: • Confirm diagnosis with culture • consider metronidazole susceptibility testing through the CDC • Trial of tinidazole

  32. TRICHOMONIASISOther management issues • No alcohol for the duration of treatment and for at least 24 h after the last dose. • Trich is an STD, so: • GC and Chlamydia testing should be done, & • Syphilis, HIV, and hepatitis B serologic testing should be considered

  33. TRICHOMONIASISManagementofSexPartners • Sex partners should be treated, even if asymptomatic • Avoid intercourse until therapy is completed and patient and partner are asymptomatic .

  34. VAGINITIS DIFFERENTIATION

  35. NON-INFECTIOUS VAGINITIS • Vaginal foreign bodies, especially in prepubescent girls, may present with a heavy white discharge but would be unaccompanied by vulvar erythema or the microscopic appearance of hyphae. • Atrophic vaginitis is commonly found in postmenopausal women and is distinguished from candidal vaginitis by mucosal dryness, atrophy, dyspareunia, minimal discharge, and itching. • Contact dermatitis, local irritation secondary to tight-fitting underwear, and contact dermatitis from toiletry items, latex condoms, diaphragms, spermicides

  36. MUCOPURULENTCERVICITIS • Largely caused by Chlamydia trachomatis and Neiserria Gonorrheae

  37. Chlamydia trachomatis

  38. Chlamydia — Rates: United States, 1984–2003

  39. Chlamydia — Rates by sex: United States, 1984–2003 CDC

  40. Chlamydia trachomatis • Estimated 3 million cases in the U.S. annually • Women: bartholinitis, cervicitis, urethritis, PID, perihepatitis, conjunctivitis • Men: urethritis, epididymitis • M&W: LGV • Infants: conjunctivitis, pneumonia • Complications: PID, perihepatitis, Reiter’s syndrome, infertility, ectopic pregnancy, chronic pelvic pain, increased risk for HIV • Incubation period is 7-21 days.

  41. ChlamydiatrachomatisRiskfactors • Adolescence • Cervical epithelial cells are developmentally immature (ectopy) making them more susceptible to infection. • Risky behaviors also contribute to susceptibility. • New or multiple sex partners • History of past STD infection • Presence of another STD • Oral contraceptive use (contributes to cervical ectopy, & OCP users less likely to use barrier protection) • Lack of barrier contraception

  42. Chlamydiatrachomatis Cervicitis • Majority of cervical infections are asymtpomatic-70% to 80%. • When symptomatic, S+S may be non-specific: • spotting, or mucopurulent cervicitis, with mucopurulent endocervical discharge, edema, erythema, and friability w easily induced bleeding within the endocervix or any zones of ectopy. Urethritis • 50% of infected women yield chlamydia from both urethra and cervical sites • Usually asymptomatic • May cause the “dysuria-pyuria” syndrome mimicking acute cystitis. On urinalysis, pyuria present but few bacteria.

  43. ChlamydiatrachomatisDIAGNOSIS Culture: high specificity BUT • labor-intensive, expensive, • variable sensitivity (50%-80%), • not suitable for widespread screening Non-culture methods: • Serology: not very useful • EIA, DFA, DNA probe : less sensitive(50-75%), nonspecific • Nucleic acid amplification tests (NAAT): PCR, LCR: • more sensitive than culture (>80%-90%) • highly specific (>99%) • can use first void urine • can use self-obtained vaginal swab

  44. ChlamydiatrachomatisTreatment Azithromycin 1 gm single dose or Doxycycline 100 mg bid x 7d

  45. Chlamydia trachomatisAlternative regimens Erythromycin base 500 mg qid for 7 days or Erythromycin ethylsuccinate 800 mg qid for 7 days or Ofloxacin 300 mg twice daily for 7 days or Levofloxacin 500 mg for 7 days

  46. Chlamydia trachomatisTreatment inPregnancy Recommended regimens Erythromycin base 500 mg qid for 7 days or Amoxicillin 500 mg three times daily for 7 days Alternative regimens Erythromycin base 250 mg qid for 14 days or Erythromycin ethylsuccinate 800 mg qid for 14 days or Erythromycin ethylsuccinate 400 mg qid for 14 days or Azithromycin 1 gm in a single dose

  47. ChlamydiatrachomatisScreening • Annual screening of sexually active women < 25 yrs • Annual screening of sexually active women > 25 yrs with risk factors • Sexual risk assessment may indicate need for more frequent screening for some women • Screen pregnant women in the first trimester • Re-screen women 3-4 months after treatment due to high prevalence of repeat infection

  48. GONORRHEA

  49. Gonorrhea — Rates: United States, 1970–2003 and the Healthy People 2010 target Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

  50. GONORRHEA • Caused by Neisseria gonorrhoeae, a gram-neg intracellular diplococcus. • Estimated 700,00-800,000 persons infected annually in the US. • Manifestations in women may include: • cervicitis, PID, urethritis, pharyngitis, proctitis, disseminated (bacteremia,arthritis, tenosynovitis) • Accessory gland infection (Bartholin’s glands, Skene’s glands) • Fitz-Hugh-Curtis Syndrome (Perihepatitis)

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