Download Pelvic Inflammatory

Genital Tract Infections
XU JIAN
[email protected]
The Normal Vagina
The normal vaginal flora is mostly aerobic, with an
average of six different species of bacteria
the most common of which is hydrogen peroxide (H2O2)
producing lactobacilli.
The pH level of the normal vagina is lower than 4.5, which
is maintained by the production of lactic acid.
The Normal Vagina
Vaginal self-purification
Estrogen-stimulated vaginal epithelial cells are rich in
glycogen.
Vaginal epithelial cells break down glycogen to
monosaccharides, which can then be converted by the
cells themselves, and lactobacilli to lactic acid.
Maintaining the pH level lower than 4.5.
The Normal Vagina
Against infection:
 Vaginal self-purification
 Immunity
 Vulva
 Uterine cervix
 Endometrium)
Trichomonas Vaginitis
Trichomonas Vaginitis
is caused by the sexually transmitted,
flagellated parasite, Trichomonas vaginalis.
The transmission rate is high; 70% of men contract the
disease after a single exposure to an infected woman,
The parasite, which exists only in trophozoite form, is an
anaerobe that has the ability to generate hydrogen to
combine with oxygen to create an anaerobic environment.
It often(60%) accompanies BV.
Trichomonas Vaginitis-Diagnosis
Vaginal discharge: thin, purulent, malodorous (when accompany BV).
Strawberry•cervix may be observed.
The pH usually higher than 5.0
Motile trichomonads.
Clue cells may be present (when accompany BV)
The whiff test may be positive (when accompany BV)
Trichomonas Vaginitis-Diagnosis
Women with this infection should be tested for other
sexually transmitted diseases (STDs), particularly
Neisseria gonorrhoeae
Chlamydia trachomatis.
Syphilis
Human immunodeficiency virus (HIV)
Trichomonas Vaginitis-Treatment
Metronidazole :first choice for treatment (cure rates 95%)
single-dose (2 g orally) OR
multidose (500 mg twice daily for 7 days)
The sexual partner should also be treated.
Metronidazole gel (effective for the treatment of BV) should
not be used for the treatment of TV.
Treatment of pregnancy women…
Trichomonas Vaginitis-Treatment
Not respond to initial therapy?
Treated again with metronidazole, 500 mg, Bib X 7 ds.
Repeated treatment not effective?
Treated with a single 2-g dose of metronidazole Qd
X5 ds or tinidazole, 2 g, Qd X5 ds .
Still not effective?
Exclude the possibility of reinfection
Expert consultation.
Culture of the parasite to determine its susceptibility
to metronidazole and tinidazole.
Vulvovaginal
Candidiasis(VVC)
Vulvovaginal Candidiasis(VVC)
Very common ：An estimated 75% of women
experience at least one episode of VVC.
Is usually endogenous
Candida albicans is responsible for 85% to 90% of
vaginal yeast infections.
Other species of Candida, such as C. glabrata and C.
tropicalis, can cause vulvovaginal symptoms and tend to
be resistant to therapy.
Vulvovaginal Candidiasis(VVC)
Candida are dimorphic
blastospores, responsible for transmission and
asymptomatic colonization
mycelia, result from blastospore germination and
enhance colonization and facilitate tissue invasion.
Vulvovaginal Candidiasis(VVC)
Factors that predispose women to the development of
symptomatic VVC include:
Long-term antibiotic use：Disequilibrium of of normal
vaginal flora.
Pregnancy: decrease in cell-mediated immunity
Diabetes : decrease in cell-mediated immunity
Vulvovaginal Candidiasis(VVC)
Classification of VVC
Uncomplicated
Complicated
Sporadic or infrequent in
occurrence
Mild to moderate
symptoms
Likely to be Candida
albicans
Immunocompetent women
Recurrent symptoms
Severe symptoms
Non-albicans Candida
Immunocompromised, e.g.,
diabetic women
VVC-Diagnosis
Symptoms:
Vulvar pruritus associated with a vaginal discharge that
typically resembles cottage cheese.
Others:Vaginal soreness, dyspareunia, vulvar burning,
and irritation.
Examination:
Erythema and edema of the labia and vulvar skin.
The vagina may be erythematous with an adherent,
whitish discharge.
The cervix appears normal.
VVC-Diagnosis
The pH is usually normal (<4.5).
Fungal elements, either budding yeast forms or mycelia,
appear in as many as 80% of cases.
The results of saline preparation of the vaginal secretions
usually are normal.
The whiff test is negative.
A fungal culture is recommended to confirm the diagnosis.
VVC-Treatment
Topically applied azole (吡咯) drugs are the most
commonly available treatment and are more effective than
nystatin (制霉菌素)
fluconazole (氟康唑), used in a single 150-mg dose (orally),
has been approved for the treatment of VVC.
Miconazole（咪康唑）200mg qd X 7ds
VVC-Treatment
Patients with complicated VVC :
an additional 150-mg dose of fluconazole given 72 hours
after the first dose.
or with a more prolonged topical regimen lasting 10 to 14
days.
Adjunctive treatment with a weak topical steroid, such as
1% hydrocortisone cream, may be helpful in relieving
some of the external irritative symptoms.
Recurrent VVC
Definition: four or more episodes in a year.
Symptoms :persistent irritative of the vestibule and vulva.
Burning replaces itching
Diagnosis: should be confirmed by direct microscopy of
the vaginal secretions and by fungal culture.
Many women with RVVC presume incorrectly they have a
chronic yeast infection. Many of these patients have
chronic atopic dermatitis or atrophic vulvovaginitis.
Recurrent VVC-treatment
A remission of chronic symptoms with fluconazole
(150 mg every 3 days for 3 doses).
Then be maintained on a suppressive dose of this
agent (fluconazole, 150 mg weekly) for 6 months.
On this regimen, 90% of women with RVVC will remain in
remission. After suppressive therapy, approximately one
half will remain asymptomatic. Recurrence will occur in
the other half and should prompt reinstitution of
suppressive therapy
Bacterial Vaginosis (BV)
Bacterial Vaginosis (BV)
BV has previously been referred to as nonspecific
vaginitis or Gardnella vaginitis.
The loss of hydrogen peroxide producing lactobacilli
Overgrowth of predominantly anaerobic bacteria, as well
as G. vaginalis and Mycoplasma hominis.
Bacterial Vaginosis (BV)
It is not known what triggers the disturbance of normal
vaginal flora.
Alkalinization of the vagina, which occurs with frequent
sexual intercourse or use of douches, plays a role.
After normal hydrogen peroxide producing lactobacilli
disappear, it is difficult to reestablish normal vaginal flora,
and recurrence of BV is common.
Bacterial Vaginosis (BV)
Sequelae:
Pelvic inflammatory disease (PID)
Postabortal PID
Postoperative cuff infections after hysterectomy ;
Abnormal cervical cytology ;
Premature rupture of the membranes ;
Preterm labor and delivery;
Chorioamnionitis;
Postcesarean endometritis
Bacterial Vaginosis-Diagnosis
A fishy vaginal odor
Vaginal discharge are present.
The pH is higher than 4.5 (usually 4.7 to 5.7).
Increased number of clue cells
Leukocytes are conspicuously absent.
The whiff test releases a fishy, aminelike odor.
Bacterial Vaginosis-Treatment
Ideally, treatment of BV should inhibit anaerobes but not
vaginal lactobacilli.
Metronidazole: is the drug of choice for the treatment of BV. 500
mg, orally twice daily for 7 days
Clindamycin, 300 mg, orally twice daily for 7 days
Treatment of the male sexual partner has not been
shown to improve therapeutic response
Bacterial Vaginosis-Differential Diagnosis
BV
VVC
TV
asymptomatic
vulvar pruritus &
burning
pruritus
gray , fishy odor
white, cottage
cheese
Yellow,purulent ,
malodorous
Vaginal wall
normal
Erythema, edema erythema
pH
>4.5(4.7 to 5.7)
<4.5
>5
whiff test
positive
negative
negative
microscopy
clue cells
budding yeast
forms or mycelia
trichomonads,
leukocytes
Symptoms
Vaginal
discharge
Acute Cervicitis
Acute Cervicitis
The cause of cervical inflammation depends on the
epithelium affected.
The ectocervical epithelium can become inflamed by
the same micro-organisms that are responsible for
vaginitis.
Trichomonas, candida, and HSV can cause inflammation
of the ectocervix.
Conversely, N. gonorrhoeae and C. trachomatis infect
only the glandular epithelium
Acute Cervicitis-Diagnosis
The diagnosis of cervicitis is based on the finding of a
purulent endocervical discharge, generally yellow or green
in color and referred to as mucopus
Acute Cervicitis-Diagnosis
Endocervical canal green or yellow color of the mucopus.
Cervix is friable or easily induced to bleed.
An increased number of neutrophils (30 per high-power field).
Intracellular gram-negative diplococci:gonococcal
endocervicitis?
negative for gonococci, chlamydial cervicitis?
Tests for both gonorrhea and chlamydia, preferably
using PCR, should be performed.
Acute Cervicitis -Treatment
Treatment Regimens for Gonococcal Infections
Neisseria gonorrhoeae endocervicitis:
or
or
or
or
Cefixime头孢克肟, 400 mg orally (single dose)
Ceftriaxone头孢曲松, 125 mg im (single dose),
Ciprofloxacin环丙沙星, 500 mg orally (single dose)
Ofloxacin, 400 mg orally (single dose)
Levofloxacin 250 mg orally (single dose)
Acute Cervicitis -Treatment
Treatment Regimens for Chlamydial Infections
Chlamydia trachomatis endocervicitis
or
or
or
Azithromycin, 1 g orally (single dose),
Doxycycline, 100 mg orally twice daily for 7 days,
Ofloxacin, 300 mg orally twice daily for 7 days,
Levofloxacin, 500 mg orally for 7 days
Acute Cervicitis -Treatment
It is imperative that all sexual partners be treated with a
similar antibiotic regimen.
Cervicitis is commonly associated with BV, which, if not
treated concurrently, leads to significant persistence of the
symptoms and signs of cervicitis.
Chronic Cervicitis
Chronic Cervicitis
Pathology:
Cervical erosion: three types and three degrees
Cervical polyp
Naboth cyst
Endocervicitis
Cervical hypertrophy
Chronic Cervicitis-Diagnosis
Symptoms
Discharge
Lower abdominal pain
Sourness
Infertility
Bleeding
Others
Signs
Chronic Cervicitis-Treatment
Physical treatment: the main way.
Electrocautery
Laser
Freezing
HIFU
Medicine
Operation?
Pelvic Inflammatory
Pelvic Inflammatory
PID is a clinical diagnosis implying that the patient has
upper genital tract infection and inflammation.
The inflammation may be present at any point along a
continuum that includes endometritis, salpingitis, and
peritonitis
Pelvic Inflammatory
PID commonly is caused by the sexually transmitted
micro-organisms N. gonorrhoeae and C. trachomatis
Endogenous micro-organisms found in the vagina,
particularly the BV micro-organisms, also often are
isolated from the upper genital tract of women with PID,
which include anaerobic bacteria such as Prevotella and
peptostreptococci as well as G. vaginalis.
Pelvic Inflammatory
BV often occurs in women with PID, and the resultant
complex alteration of vaginal flora may facilitate the
ascending spread of pathogenic bacteria by enzymatically
altering the cervical mucus barrier.
Less frequently, respiratory pathogens such as
Haemophilus influenzae, group A streptococci, and
pneumococci can colonize the lower genital tract and
cause PID.
Pelvic Inflammatory -Diagnosis
In the diagnosis of PID, the goal is to establish guidelines
that are sufficiently sensitive to avoid missing mild cases
but sufficiently specific to avoid giving antibiotic therapy to
women who are not infected.
Pelvic Inflammatory -Diagnosis
Traditionally, the diagnosis of PID has been based on a
triad of symptoms and signs.
It is now recognized that there is wide variation in many
symptoms and signs.
Some women may develop PID without having any
symptoms
.
Pelvic Inflammatory -Diagnosis
PID should be considered in women with any
genitourinary symptoms, including, but not limited to,
lower abdominal pain,
excessive vaginal discharge,
menorrhagia, metrorrhagia,
fever, chills,
urinary symptoms.
Pelvic organ tenderness, (uterine alone or uterine with
adnexal )
Cervical motion tenderness
Direct or rebound abdominal tenderness
Pelvic Inflammatory -Diagnosis
Evaluation of both vaginal and endocervical secretions is
a crucial part of the workup of a patient with PID .
An increased number of polymorphonuclear leukocytes
may be detected in a wet mount of the vaginal secretions
or in the mucopurulent discharge.
Pelvic Inflammatory -Diagnosis
More elaborate tests may be used,including
Endometrial biopsy to confirm the presence of
endometritis,
Ultrasound or radiologic tests to characterize a tuboovarian abscess,
Laparoscopy to confirm salpingitis visually.
Pelvic Inflammatory -Diagnosis
Clinical Criteria for the Diagnosis of PID
Symptoms
None necessary
Signs
Pelvic organ tenderness
Leukorrhea and/or mucopurulent endocervicitis
Additional criteria to increase the specificity
Endometrial biopsy showing endometritis
Elevated C-reactive protein
Elevated erythrocyte sedimentation rate
Temperature higher than 38°C
Leukocytosis
Positive test for gonorrhea or chlamydia
Elaborate criteria
Ultrasound documenting tubo-ovarian abscess
Laparoscopy visually confirming salpingitis
Pelvic Inflammatory -Treatment
Therapy regimens for PID must provide empirical, broadspectrum coverage of likely pathogens,including
N. gonorrhoeae,
C. trachomatis,
gram-negative facultative bacteria,
anaerobes, and
streptococci.
Pelvic Inflammatory -Treatment
Hospitalization is recommended only
when the diagnosis is uncertain,
pelvic abscess is suspected,
clinical disease is severe,
or compliance with an outpatient regimen is in question.
Pelvic Inflammatory -Treatment
Hospitalized patients can be considered for discharge
when their fever has lysed (37.5°C for more than 24 hs),
the white blood cell count has become normal,
rebound tenderness is absent,
and repeat examination shows marked amelioration of
pelvic organ tenderness.
Sexual partners of women with PID should be evaluated
and treated for urethral infection with chlamydia or
gonorrhea (Table 16.3). One of these STDs usually is
found in the male sexual partners of women with PID not
associated with chlamydia or gonorrhea (42,43).
Pelvic Inflammatory -Treatment
Sexual partners of women with PID should be evaluated
and treated for urethral infection with chlamydia or
gonorrhea.
One of these STDs usually is found in the male sexual
partners of women with PID not associated with
chlamydia or gonorrhea.
Pelvic Inflammatory –
Tubo-ovarian Abscess
Tubo-ovarian abscess, an end-stage process of acute
PID, is diagnosed when a patient with PID has a pelvic
mass that is palpable during bimanual examination.
The condition usually reflects an agglutination of pelvic
organs (tube, ovary, bowel) forming a palpable complex.
Occasionally, an ovarian abscess can result from the
entrance of micro-organisms through an ovulatory site.
Pelvic Inflammatory –
Tubo-ovarian Abscess
Tubo-ovarian abscess is treated with an antibiotic regimen
administered in a hospital.
About 75% of women with tubo-ovarian abscess respond
to antimicrobial therapy alone.
Failure of medical therapy suggests the need for drainage
of the abscess
Pelvic Inflammatory -Treatment
USA-CDC Guidelines
Outpatient Treatment
Regimen A
Cefoxitin, 2 g im, + probenecid, 1 g orally concurrently,
Or Ceftriaxone, 250 mg im,
Or Equivalent cephalosporin + Doxycycline, 100 mg bid x 14 ds
With or without: Metronidazole, 500 mg orally bid x 14 ds a
Regimen B
Ofloxacin, 400 mg orally bid x 14 ds
Or Levofloxacin, 500 mg orally once daily for 14 days
With or without: Metronidazole, 500 mg orally bid x 14 ds a
Pelvic Inflammatory -Treatment
USA-CDC Guidelines
Inpatient Treatment
Regimen A
Cefoxitin, 2 g iv q6h,
Or Cefotetan, 2 g iv q12h, + Doxycycline, 100 mg orally or iv q12h
Regimen B
Clindamycin, 900 mg iv q8h + Gentamicin,
loading dose iv or im (2 mg/kg of body weight)
followed by a maintenance dose (1.5 mg/kg) q8h
Use of metronidazole recommended in those cases in which BV is
diagnosed concurrently with PID.
Sequelae of PID
Diagnosis
Medical history
Chronic
Infertility
Recurrent acute PID
Ectopic pregnancy
Signs
Genital tuberculosis
Genital tuberculosis
Way of infection
Blood flow:
main way
Direct spread:
some times
lymph vesse：
less
sexually transmitted：very rarely
Genital tuberculosis
Pathology
Tuberculosis of fallopian tube: 90%-100%,bilateral usually
Endometrial tuberculosis: 50%-80%
Ovarian tuberculosis: 20%-30%
Tuberculosis of cervix: rarely
Pelvic peritoneal tuberculosis: common
Genital tuberculosis-Diagnosis
Symptoms
Infertility
Abnormal menstruation
Lower abdominal pain
Symptoms of tuberculosis
Signs
Genital tuberculosis-Diagnosis
Auxiliary diagnosis
Dilatation & curettage：frequent giant cells, caseous
necrosis, and granuloma formation (time, site, streptomycin)
X-ray
Laproscopy
Tubercle bacillus: microscopy, culturing, PCR
Tuberculin test：（-），(+) and (+++）
Genital tuberculosis-Treatment
Antitubercular agent
Isoniazid （H,异烟肼）
Rifampicin (R,利福平)
Streptomycin (S,链霉素)
Ethambutol (E,乙胺丁醇)
Pyrazinamide (Z,吡嗪酰胺)
Regimen A: 2SHRZ/4HR
or
2SHRZ/4H3R3
Regimen B: 2SHRZ/6HRE or 2SHRZ/6H3R3E3
谢
谢
联系我：
[email protected]