Download INFLAMMATORY DISEASES OF FEMALE GENITALS

MINISTRY OF PUBLIC HEALTH OF UKRAINE
BUKOVINIAN STATE MEDICAL UNIVERSITY
“Approved”
on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 201_ year
protocol #
T.a.the Head of the department
Professor
________________ O.A. Andriyets
METHODICAL INSTRUCTIONS
for practical lesson
«Female urogenital inflammatory diseases.
Diagnostic, treatment and prophylaxis»
MODULE 4: Obstetrics and gynecology
CONTEXT MODULE 12: Gynecological diseases
Subject: Obstetrics and
Gynecology
6th year of studying
medical faculty № 2
Number of academic hours
– 5,5
Methodological instruction
developed by
assist.prof. A. Berbets
Chernivtsi – 2010
Objectives: to learn how to diagnose and prescribe special therapy for women with inflammatory
diseases of the female genitals.
Professional motivation: The rate of inflammatory diseases is over 60% of all gynecologic diseases
and about 30%patients of women’s hospitals have the inflammatory processes of the genital organs.
Especially the quantity of inflammatory diseases has enlarged because of an increased sexual activity
at young age, permissive sexual attitude, prostitution. Those at the highest risk are young unmarried
women with many sex partners. Primarily inflammatory diseases affect human fertility because of
infections of the female upper genital tract and their consequences. Women with persistent viral
infection are at particular risk for cervical dysplasia and intrauterine fetal death.
Basic level:
1.
Normal vaginal microflora.
2.
Vaginitis (colpitis).
3.
Acute endometritis.
STUDENTS’ INDEPENDET STUDY PROGRAM
1.
Objectives for Students’ Independent Studies
You should prepare for the practical class using the available textbooks and lectures. Special
attention should be paid to the following:
1.
Inflammatory diseases of the external female genitals
2.
Classification of diseases of the external female genitals
3.
Examination and urgency aid for a women with inflammatory processes
4.
Bacterial vaginosis
5.
Acute and chronic endometritis
6.
Salpingoophoritis
7.
Tuboovarian abscess
Key words and phrases: inflammatory diseases.
Summary
INFLAMMATORY DISEASES OF THE FEMALE GENITALS
The rate of inflammatory diseases is over 60% of all gynecologic diseases and about 30% patients of
female hospitals have the inflammatory processes of genital organs. Especially the quantity of the
inflammatory diseases has enlarged because of the increased sexual activity at the young age,
permissive sexual attitude, prostitution. Those at the highest risk are young unmarried women with
multiple sex partners. Primarily inflammatory diseases affect human fertility because of infections of
the female upper genital tract and their sequel. Women with persistent virus infection are at particular
risk for cervical dysplasia and intrauterine fetal death.
Normal flora has a significant role in defense against infection by genital pathogens. The female
genital tract, especially the vaginal secretions, contain from 108 to 109 bacteria per gram of fluid
examined. Lactobacilli produce lactic acid from glucose keeping the vagina at an acidic pH (3,8-4,2).
Glycogen is metabolized by vaginal epithelial cells to glucose, which then serves as a substrate for
Lactobacillus.
Normal vaginal microflora contains: Lactobacillus (70-90%), Staphylococcus epidermalis (30-60%>),
diphteroids (30-60%>), Hemolytic Streptococci (10-20%), nonhaemolytic streptococci (5-30%>),
Escherichia coli (20-25%), Bacte-roides (5-15%), Peptococcus (10-60%), Peptostreptococcus (1040%), Clostridium (5-15%).
Presence of pathogenic flora without inflammation isn't a sign of pathologic processes.
It is considered that normal vaginal flora is represented by Lactobacillus. But not only Lactobacillus
acidophilus provide the self-cleaning of the vagina. The normal vaginal ecosystem of reproductive age
women contains 7 kinds of Lactobacillus: L acidophilus (42,8%), L. Paracasei, L. Fermentum, L.
Plantarum (10-18,6%)), L.cateforme, L.corineformis, L. Brevis (2,5-5,7%), H202 producing Lactobacillus
may play an important role in acting as a natural microbicide within the vaginal ecosystem.
Variation in vaginal colonization by Lactobacillus and other organisms could relate to estrogen level
metabolism products of vaginal microflora, vaginal pH, and the type of Lactobacillus initially
colonizing the vagina. Many endogenic and exogenic factors may change the balance of the vaginal
ecosystem. Some vaginal microorganisms may cause the inflammation in certain conditions. Both
vaginal and cervical epithelial cells have the capacity to convert glycogen to glucose, which is further
metabolized to lactic acid. Vaginal acidity depends on adequate levels of estrogens as well as the
presence of lactic acid-producing bacteria such as Lactobacilli. Concentrations of lactobacilli are probably
important determinants of vaginal pH as well. The increased concentration of lactic acid producing
bacteria in the vaginal fluid may result in a lower pH which determines decreased susceptibility to
infection. Estrogens have a direct effect on the number of organisms and composition of the bacterial flora.
The mucosal surface provides protection from invading pathogens. Mucous may act to eliminate a
variety of pathogens or antigens. Mucous also serves for attachment of immunoglobulin A, lysozyme,
lactoferrin and other biologically active substances. Mucous in the female genital tract is under
hormonal control. Any abnormalities with low estrogen secretion and decreasing of estrogen level with
age may damage defense mechanisms of the female genital tract. Using of contraceptives, shower can
effect into vaginal ecosystem by changing vaginal pH, altering the vaginal fluid by direct dilution.
Bartholinitis
Bartholinitis is an inflammation of Bartholin's gland (large gland of vaginal vestibule). It may be caused
by Staphylococcus, E.coli and N. gonorrhea. Any type of the pathogen initiates ductal inflammation and
obstruction that can lead to Bartholin's abscess. There can be serous, serous-purulent, or purulent
inflammation.
Obstruction of the opening of the main duct into the vestibule leads to abscess formation. Infection of
Bartholin's glands can lead to secondary infections, abscess or cyst formation (fig 85). When the gland
becomes full and painful, incision and drainage is appropriate. Patients with abscess usually require
abscess incision with insertion of the catheter in abscess cavity. Recurrent infection from vaginal flora
and mucous cyst formation are common sequelae of bartholinitis. If the infection of gland is caused by
N. gonorrhea specific antibacterial treatment is prescribed.
Vulvitis
Vulvitis is a vulvar inflammation. It may be primary and secondary. Primary vulvitis is caused by local
irritants (including feminine hygiene sprays, deodorants, tight-fitting synthetic undergarments in
women with obesity or diabetes mellitus. Secondary vulvitis are caused by accompanying discharge
from vagina. Reduced estrogens levels in reproductive age women, and more frequent in girls and
menopause women may lead to vulvitis.
Clinic. Erythema, edema of vulva and skin ulcers are all indices of the infection.
Patient's complains are itching or burning. Excoriation caused by the patient's scratching of the skin of
vulva are often seen in vulvar irritation.
To relieve inflammation and itching the main suspected cause must be removed. The therapy includes
local application of boric acid solution or KMn04 solution. Candidasis is treated with Gyno-paveril
150mg in suppositories — 3 days, or Orungal lOOmg twice a day during 6-7 days orally, and then one
capsule per day every first day of menstrual cycle during 3-6 cycles. Treatment with local antibiotics
and steroids is successful.
Vaginitis (colpitis)
Vaginitis (colpitis) is an inflammation of vagina. It is the most frequent cause of visits to gynecologists.
It may be caused by Staphylococcus, Streptococcus, E.coli and other.
Excessive vaginal discharge is associated with an identifiable microbiologic cause in 80% to 90%of
cases. Hormonal or chemical causes account for most of the remaining cases. Vaginitis may be acute,
subacute and chronic. There are two forms of vulvitis: purulent and granulosa-diffusional.
The main symptom is the increased, gray-white or yellow discharge generally serous or purulent with
rancid odour. The patients complain of dysuria, vulvar itching, burning and dyspareunia. Examination
may reveal edema or erythema of vulva and vagina, petechia or patches in the upper vagina or on the
cervix. In case of chronic vaginitis all these signs are not so expressed.The cultures from vagina,
cervix,urethra, ductus of Bartholin's gland should be microscopically examined.
Treatment of nonspecific vaginitis is comlex:
• using of antiinflammatory medicines
• treatment of neuroendocrinologic and immunodificiency conditions
• treating of male sexual partner; patients should avoid sexual contacts while therapy
Local treatment includes using of syringing with antiseptic fluid (KMn04, furacilin, chlorhexidin) no
more than 3-4 days. In case of acute or chronic vaginitis laser therapy may be used.
Metronidazol (vaginal suppositories), chlorhinaldin, terginan, betadin, gyno-paveril may be prescribed.
For normalization of vaginal ecosystem solkotry-chovac, vagilak, Lactobacterin and Bifidumbacterin
are used.
Bacterial Vaginosis
10-25% of all gynecologic patients have this disease. Among sexually transmitted diseases, bacterial
vaginosis is diagnosed in 60-65%> of women. Bacterial vaginosis is a result of an overgrowth of both
anaerobic bacteria and the aerobic bacteria Gardnerella vaginalis. Anaerobes and G. vaginalis are normal
inhabitants of vagina, but these bacteria overgrowth dominant of the normal Lactobacillus flora results
in the appearance of a thin, fishy odor, gray vaginal discharge that adheres to the vaginal walls.
A small amount of vaginal discharge may be normal (2ml) particularly at the midcycle. Bacterial
vaginosis causes an increased vaginal discharge (15-20ml), vulvar irritation, pruritus, dysuria and foul
odour.
The diagnosis of bacterial vaginosis is based on the presence of the following characteristics of the
discharge:
• pH is higher than 4,5
• a homogeneous thin appearance
• a fishy amine odour produced by anaerobes when 10% KOH is added
presence of clue cells (vaginal epithelial cells to which organisms are attached).
Cultures aren't helpful because anaerobes and Gardnerella vaginalis can be recovered from normal
flora of healthy women, but the concentration of both bacteria is higher in patients with bacterial
vaginosis (fig. 86). Factors that lead to overgrowth of G.vaginalis and anaerobes have not been
identified.
Treatment includes elimination of anaerobic agent of microflora, inducement of local and general
immunity and then the normal microflora should be renewed.
Oral using of metronidazol (Flagyl) 500mg twice a day for 7 days or by intravaginal Metrogel 0,75%
cream twice a day for 5 days, 2% Clindamycin cream (Cleocin) once daily for 7 days.
For normalization of vaginal microflora the local bifidumbacterin insertion or 2-3%) solution of Lactic
acid is used. The treatment of the male parthner with Metronidazol can be advocated only when
bacterial vaginosis recurs, but effectiveness is not proven.
Endocervicitis
Endocervicitis is the inflammation of mucosa layer of the endocervix. Bacteria cause infection of the
columnar epithelium. Chlamidia trachomatis, Mycoplasma, Trichomonada vaginalis, N. Gonorrhoeae,
viruses, Candida, E.coli, Staphylococci cause endocervicitis.
Cervix is constantly exposed to trauma during childbirth, abortion.The abundant mucus secretion of
the endocervical glands both with the bacterial ascend from the vagina creates a situation that is
advantaging to infection.
The inflammatory process is chiefly confined to the endocervical glands. The squamous epithelium of
the exocervix may be involved into the process called acute exocervicitis. The extent of endocervical
involvement as compared with exocervical one appears to have some relation to the infecting agent.
Chronic cervicitis manifestation is cervical erosion. Erosion indicates the presence around the cervical
os a zone of infected tissue that has a granular appearance. It implies the loss of superficial layers of
the stratified squamous epithelium of the cervix and overgrowth of infected endocervical tissues.
The inflammatory process stimulates a reparative attempt in the form of an upward growth of
squamous epithelium, causing some of the ducts of the endocervical glands to be obstructed. Retention
of mucus and other fluid within these glands results in the formation of Nabothian cycts. These cysts
are endocervical glands filled with infected secretion. Their ducts become secondarily included into
the inflammation and reparative processes.
The most important in the diagnosis of chronic cervitis is the exclusion of the malignant process.
Before the begining of treatment, examination with colposcope should be carried out. The cervicitis
may appear as a reddish granulation raised above the surrounding surface, giving the impression of
being papillary.
A Papanicolaou smear should be obtained and suspicious areas should undergo biopsy.
Treatment Acute cervicitis is treated with appropriate antibiotics (it depends on bacterial agent). Local
treatment of acute phase is a real danger of dissemination of infection. Laser therapy is used in treatment
of acute and chronic cervicitis.
Electocautherization is the traditional treatment of chronic cervicitis, especially with erosion, cervical
ulcers or ectropion. Nowadays cryosurgery or laser surgery has replaced electrocautherization.
Acute endometritis
Acute endometritis is an inflammation of endometrium (mucus layer of uterine). It may occur in such
cases as: endometritis after uterine curettage or suction and puerperal endometritis. Endometritis is
caused by bacterias, viruses, mycoplasmas. The most frequent the associations of 3-4 anaerobic
bacteria and 1-2 aerobic are the main reason of endometritis.
Anaerobic bacteria compose apart of the normal cervicogenital flora. There are two known mechanisms
which cause anaerobic infection: antibiotic selection that preferentially inhibits aerobic bacteria and
tissual trauma that occurs after surgery which reduces the redox potencial. Anaerobes produce odorous
metabolic products.
Uterus has endometrium factors of local immunity. There are T-lymphocytes and other factors of cellular
imunity in endometrial stroma. Lymphocytes and :utrophiels normally appear in the endometrium in the
second half of menstrual 'cle; their presence does not necessarily constitute endometritis. The appearing
'plasma cells represents immune response, usually to foreign bacterial antigen. The organism should be
cultured before applying of antimicrobal therapy, s anaerobes compose a part of normal flora, deep
tissual cultures not mtaminated by surface bacteria are required. Forty eight or more hours are quired
for anaerobe recovery, and treatment usually is based on clinical signs, here are nonspecific and
specific endometritis. Specific endometritis is caused у М. Tuberculosis, N. Gonorrhea, Chlamidia
trachomatis, Actinomyces.
Clinic. Fever is the characteristic feature in the diagnosis of endometritis, nd it may be accompanied
by uterine tenderness. If the infection has spread to he parametrium and adnexa, tenderness may be
present there as well. Temperature :levation is probably proportionate to the extention of the infection
and when :onfmed to the decidua, the cases are mild and there is minimal fever. Chills nay accompany
fever. Women usually complain of abdominal pain. There is enderaess on one or both sides of the
abdomen and parametrial tenderness is ilicited upon bimanual examination. The uterus is lightly
enlarged.
A leukocytosis and increased erythrocyte's sedimentation rate is revealed n patient' blood test. In some
cases acute endometritis may become a chronic me;
Treatment Various choices of initial antibiotic therapy are used. Most of them are successful. Singleagent therapy has the benefit of easy administration; Cephalosporins such as Cefotetan and Cefoxitin
are commonly used. A combination of Ampicillin and Aminoglycoside is also popular. The
combination of Clindamycin with Gentamicin or Metronidasol with Unasyn (Ampicillin with
Sulbuctam) and Gentamicin is applied. It is desirable to provide additional antibiotic coverage if there has
been no responce within 48 to 72 hours. Intravenous antibiotic therapy is continued until the patient is
asymptomatic and afebrile period lasts for at least 24 hours.
Local uterine douching with antiseptic solution of chlorhexidin or furacilin has a good effect. In some
cases uterine curettage is performed after temperature normalization.
Chronic endometritis
Chronic endometritis is a sequale of untreated acute endometritis or nona-dequate treatment of
postabortion or purperal endometritis. The chronic endometritis sometimes is associated with the use of
intrauterine device (IUD). In some cases it may occur without acute stage.
Clinic. The chronic endometritis results from organisms that are normally in lower genital tract
(Protei, E. Coli, Staphylococcus, Mycoplasma). Bacteria that can be recovered are usually of low
pathogenicity, but more virulent intrauterine bacteria occasionally cause the serous purulent'
discharge, abnormal uterine bleeding and moderate uterine tenderness. Diagnosis is based on
anamnesis and clinical manifestation. It could not be diagnosed unless plasma cells are found in the
endometrium. Ultrasonography can identify gas vesicules in uterine cavity, hyperechogenic places
(local fibrosis, sclerosis) in basal layer of endometrium.
Treatment. A complex treatment is used. It includes a medicines for curing of accompaning deseases,
desensibilisative medicines and additional general health measures, vitamines.
Physiotherapy has an important role. It improves pelvic hemodynamics. Diathermy on lower
abdomen, electrophoresis with copper, zinc, ultrasound, inductothermy, laser radiation are used. If
during physiotherapy the process becomes strained antibiotic therapy is recomended. While remission
antibiotic using is not proved.
Physiotherapy promotes to activation of hormonal ovarian function. If effect is not enouph than a
hormonal therapy is used (taking into account the patient's age, term of deseases, degree of ovarian
hypofunction). Health resort treatment is effective (balneologic therapy, mudcure resort).
Salpingoophoritis
Salpingoophoritis is the inflammation of the uterine tubes and the ovaries. Salpingoophoritis is the
most frequent among all pelvic inflammatory deseases. Most cases of oophoritis are secondary to
salpingitis. The ovaries become infected by the purulent material that escapes from fallopian tube. If the
tubal fimbriae are adherent to the ovary, the tube and ovary together may form a large retort-shaped
tubo-ovarian abscess.
Most patients with salpingoophoritis have lower abdominal, adnexal tenderness (unilateral or
bilateral) purulent cervical exudate or purulent vaginal discharge (fig. 88).
Clinic. There are four stages of salpingoophoritis. The first — salpingitis without irritation
(inflammation), of the peritoneum, the second—with signs of peritonitis, the third with occlusion of
uterine tubes and tuboovarian abscess and the fourth is the rupture of tuboovarian abscess. During
bimanual examination adnexal inflammatory mass is revealed.
The diagnosis of salpingoophoritis is based on the history, physical examination and laboratory tests.
Besides that additional ultrasonography and laparoscopy can be used.
Laparoscopy provides the most accurate way to diagnose the inflammatory process and its stage. It
should be used in cases when the diagnosis is unclear, especially in patients with severe peritonitis, to
exclude a ruptured abscess and appendicitis. Besides diagnostic laparoscopy is used to provide
treatment procedures.
Ultrasound can be used to distinguish the presence of an abscess from an inflammatory mass within
the adnexal mass. It may also be helpful in defining mass in the obuse patient or if the bimanual
examination is unsatisfactory because of the excessive tenderness.
Treatment. All patients with acute salpingoophoritis should be hospitalized. Adequate therapy of
salpingitis includes the assessment of severity, antibiotic treatment, additional general health
measures.
Before the culture test performing the antibiotic therapy is provide with broad spectrum antibiotics. The
most effective is the combination of Clindamicin with Chloramphenicol, Gentamicin andLincomicin,
Doxycyclin, Clacid, Cefobid, Cyfran, Claforan, Dalacin С and Unasyn.
When anaerobic agents are suspected metronidazol should be used, in severe cases intravenously. After
temperature normalization and cessation of peritonitis signs antibacterial therapy is continued for 5 days.
Detoxycation is indicated and is provided by using of 5% glucose solution, polyglucin, reopolyglucin,
solutions of proteins, correction of pH balance by using of 4% solution of Sodium bicarbo-nates. Among
physical methods of treatment cold on the lower part of the abdomen is used. Appropriate antibacterial
treatment is combined with laparoscopy active drainage.
The tuboovarial abscess is drained of pus by puncture and rinsed with bacteriostatic solution and local
application of antibiotics. In subacute stage aloe, ultraviolet radiation, authohaemotherapy is used. They
prevent the chronic processes.
Chronic salpingoophoritis. In most cases chronic salpingoophoritis is the sequale of non treated acute
process. Chronic stage of the process is characterized by tubal occlusion with periovarial adhesions,
tubal dysfunction (fig. 89).
Clinic. The main complains of the patient are: mild tenderness in lower part of abdomen that becomes
severe during menstruation. Pelvic nerves have more painful sensitivity (pelvic plexitis, ganglionevritis
due to chronic inflammation). In some cases menstrual dysfunctions such as oligomenorrhea,
polymenorrhagia, algodismenorrhagia occur. Changing in uterine tubes and hypofunction of ovaries lead
to infertility or miscarriage. Secretory dysfunction like vaginal discharge or cervical exudate may be
observed as a clinical finding of colpitis or endocervitis. Some patients complain of low libido, painful
coitus, dysfunction of urinary bladder, liver tenderness.
Menstrual dysfunction (menorrhagia or metrorrhagia) is the most frequent symptom of chronic
salpingoophoritis as a sequel of disorders of neurohomoral regulation of menstrual function.
Metrorrhagia often occurs after cessation of menstruation and then the differential diagnosis should be
made in case of ectopic pregnancy.
Diagnosis. Correct history taking (reveal of inflammation after abortion, delivery or dilatation and
curettage) makes it possible to suspect the chronic inflammatory process. Primary chronic
salpingoophoritis is found in more than 60% of cases. Some information gives physical examination and
laboratory tests. Bimanual examination gives nonspecific information. Enlargement, consistency and
degree of adnexa mobility should be examined. Sometimes because of peritubal and periovarian
adhesions the sizes and mobility of adnexa are changed.
Additionally, ultrasound and laparoscopy, hysteroscopy should be held. Tomography or endoscopy
may be used. Laparoscopy is the most informative diagnostic method to differentiate
salpingoophoritis, external endometriosis, uterine myoma with inflammatory changes, cysts. Disorders
of adjacent organs (bladder, intestine) while serous inflammation is present without structural changes.
But women with disorders of urinary tract, gastro-intestinal tract must be additionally examined
(urography, irrigoscopy).
Treatment of chronic salpingoophoritis is provided with minding of pathogenesis and clinic. Antibiotics
are indicated in acute period, when there are signs of inflammation.
Nonsteroidal antiinflammatory drugs (Voltaren, Butadion) are prescribed. To stimulate immune system
immunomodulators are used: (Decaris, T-activin). FIBS, aloe, autohaemotherapy are also used.
Analgesia both by medicines and by reflextherapy is of great importance. Physiotherapy is conducted
in hospital while in case of acute process and remission it can be used in ambulatory conditions.
Ultrasound has analgetic and fibrinolityc influence and is prescribed in sinusoid and modulate of high
frequency. Laserotherapy is also used. To escape chronic salpingoophoritis the acute salpingoophoritis
must be treated in proper way and the quantity of abortion should be reduced.
Parametritis
Parametritis is an inflammation of parametrium. Inflammation of the whole pelvic cellular is called
pelviocellullitis. According to international statistics these diseases are classified as acute parametritis or
pelvic phlegmona.
Infection agents may be staphyloccocus, streptoccocus, E.coli, etc. It can be caused by one microbic
agent or microbe association. It occurs after pathologic delivery, abortion, operation on genitals. The
main way of infection spreading is lymphogenic. Morphologically parametritis is characterized by all signs
of inflammation: dilation of blood and lymphatic vessels, peripheral edema, exudation. There are 3
stages in course of parametritis (infiltration, exudation, firming). Exudation may be serous, and very
rarely it is purulent. Sometimes it undergo resorbtion and dissolves, sometimes a fibrose connective
tissue grows and leads to uterine dislocation to the side of previous inflammatory process.
Clinic. Moderate tenderness in lower parts of abdomen, in back, high body temperature (38-39°C),
tachicardia are found. Signs of peritoneal irritation and diminished or absent bowel sounds, especially
associated with ileus, indicate more serious infection, including the possibility of abscess formation.
Fever is a characteristic feature in the diagnosis of metritis and it is accompanied by uterine tenderness.
Bimanually before or behind on left or right side of the uterus infiltration may be palpated. It is firm
and immovable. Infiltration is classified into anterior, posterior and lateral.
Treatment begins from using antibiotic of broad coverage against a variety of common microorganisms
and is usually prescribed without cultures.
Various choices of initial antibiotic therapy are used. Most of them are successful. Cephalosporins such
as Cefotetan and Cefoxitin are commonly used. A combination of Ampicillin and Aminoglucoside and
also the combination of Clindamycin with Gentamicin are used.
A bottle with ice on the lower part of abdomen is used in case of infiltrative stage of disease. Bio
stimulators should be prescribed. Management of a persistent pelvic abscess includes drainage by
colpotomy, or laparotomy. Intraabdominal rupture of pelvic abscess is a surgical emergency. Sepsis may
occur in association with pelvic infection, with or without frank abscess formation. Phisiotheraputic
precedures are used for rehabilitation.
Tuboovarian abscess
Tuboovarian abscess (TOA) may occur as a complication of salpingoopho-ritis. It begins from acute
purulent salpingitis when all layers of uterine tubes are involved into the process. The tubes
characteristically become swollen and redde is the muscularis and serosa are inflamed. If exudate drips
from the fimbriated mds of the tubes a pelvic peritonitis is produced then it can give rise to peritoneal
idhesions. The swollen and congested fimbriaes may adhere to one another and produce tubal
occlusion. The fimbriae may occlude tubes producing permanent ubal infertility. The swollen and
congested fimbriae may adhere to ovary, trapping he exudate in the tube and giving rise to pyosalpinx or
if the ovary becomes nfected, a tuboovarian abscess (fig. 90). The mucosal folds may adhere to one
mother forming gland-like spaces that are filled with exudate. If the infection subsides after
agglutination of the fimbria and closure of the peripheral end of he tube, secretion accumulates and
distends the tube, forming pyosalpinx. Each •ecidive of chronic salpingoophoritis has more clinical
manifestation and is treated vith difficulty. TOA is associated with IUD, microbe association, chronic
salpingoophoritis.
Intoxication in case of TOA leads to liver disorders. Decreasing of albumin-globulin index is observed
while the level of general proteins is normal for a ong time. The degree of these disorders depends on
the time of duration of the process.
Clinic. Clinic of TOA depends on the volume of purulent damage of adnexa, duration of the process,
disorders of adjacent organs. There are some syndromes vhich are divided into local syndrome (pain,
purulent discharge, peritoneal symptoms and palpation of tuboovarian mass).
Inflammatory-intoxicative syndrome includes fever, tachycardia, nausea, vomiting. Luecocytosis,
decreasing of albumin-globulin index, C-reactive protein are observed in blood. Immune syndrome
(decreasing of lymphocytes and mono-cytis in blood) is found.
Syndrome of adjacent organs disorders (dysuria, urinary frequency, menstrual disorders) is also possible.
Severe lower abdominal pain occurs, pelvic peritonitis may be present. Pain can irradiate to back, pelvic
bottom, in the chest. In such cases the examinations should be performed to exclude pneumonia,
pancreatitis, cholecystitis. Musclar defance which prevents abdominal palpation in the lower quadrants,
adnexa are tender to various degrees and cervix movement may cause pain in case of bimanual
examination. The adnexa often are either adherent to the posterior aspect of the uterine or prolapsed in
cul-de-sac, which may pull the uterine into a retroverted position. TOA is characterized by pain and
tenderness, fever or chills, temperature rises up 39°C, blood pressure decreases. Abdomen takes part in
breathing, and it is painful in lower parts. In blood analysis elevated white blood count (9-10x107 1)
erythrocytes' sedimentation rate more than 30mm/hour, positive C-reactive protein, decreasing of
albumin-globulin index till 0,8 are observed.
Sometimes there can be urinary syndrome with proteinuria, leucocyturia. There may be disorders of
filtrative kidney' function, even unuria. Changing of albumin-globulin index and hypofybrinogenemia
characterizes the liver dysfunction.
Diagnosis is based on clinic, bimanual examination, laboratory analyses and additional methods of
investigation (ultrasound, laparoscopy).
Treatment Tuboovarian abscess is treated by antibiotics, desensibilisative and nonsteroidal
antiinflammatory medicines, detoxication and immunostim-mulation. Best of all one should combine
taking of penicillin with tetracyclins. When anaerobic infection is suspected metronidazole is used.
Daily punctions of tuboovarian abscesses are indicated to remove purulent containts.
Indications to surgical removal of tuboovarian abscess are:
• abscence of efficiency of complex treatment with usage of punctions during 2-3 days
• suspicion on tuboovarian abscess perforation; volume of surgical intervention depends on process'
spreading, woman's age and extragenital pathology
Peritonitis
Pelvioperitonitis is an inflammation of pelvic peritoneum.The polymicrobial infection such as
Escherichia coli and other aerobic, enteric, gramnegative rods, group of p-hemolytic staphylococci,
anaerobic, streptococci, Bacteroides species, aphylococci, mycoplasms cause the process.
Pelvioperitonitis occurs secon-ary. Primary process is in uterine tubes, ovaries, uterus and
parametrium. In lost cases purulent damage of uterine adnexa lasts with pelvioperitonitis. lfection can
be spread by limphogenic or blood vessels, and from uterine tubes l case of salpingitis, especially
gonococcial infection.
Clinic characterizes the acute inflammation. High temperature, severe lower bdominal pain, fever or
chills, tachycardia are common. There can be nausea nd sometimes vomiting. Muscular defence and
rebound tenderness are the ymptoms of peritoneal irritation. Anterior abdomen wall takes part in
breathing ct.Tender adnexa are present at bimanual examination. Cervical motion causes ain. Posterior
fornix is painfull.
Laboratory tests reveal increasing of white blood cell count and erythrocyte edimentation rate. Creactive protein levels may appear. Generall blood test hould be done 4-5 times per day to diagnose
transformation of pelvioperitonitis о peritonitis.
Treatment All the patients should be hospitalized. Ideally, the antibiotic hould be selected according to
the organism present in the fallopian tube or items, but in most cases empiric therapy must be used.
Treatment includes intravenous doxycycline and either cefoxitin or cefotetan or intravenous clindamycin
ind gentamicin for at least 4 days followed by oral clindamicin or tetracyclin for [0-14 days.
Hospitalized patients who have peritonitis but do not have adnexal ibscess usually respond rapidly to
the regimens. In the presence of an adnexal ibscess, even if the systemic manifestations are mild,
antibiotics which eliminate 3.fragilis should be selected because most pelvic abscesses contain this
organism. Clindamycin, Metronidazol, Cefoxitin, or Impinem should be used to treat pelvic ibscess. If
there is an intrauterine device it should be removed as soon as therapy s started. Surgery is indicated in
the case of ruptured pyosalpinx or ovarian ibscess. Colpotomy drainage usually is preferable when
unruptured midline cul-de-sac abscess is present. Laparotomy is required for such problems as unresolved
abscess or adnexal mass that does not subside, surgery should be limited to the most conservative
procedures that will be effective. Unilateral abscess respond to unilateral salpingoophorectomy.
Septic shock
Septic shock is associated with infection caused gram-negative aerobic coliform organisms those are
producing endotoxins. In gynecological practice it may occur in case of septic abortion, localized or
spreading peritonitis, thrombophlebitis. Septic shock is a special organism reaction that is expressed in
development of severe systemic disorders. It may be caused by using of broad spectrum antibiotic in high
doses, that results in releasing of great amount of endotoxin.
Endotoxin, a complex cell wall-associated lipopolysaccharide, is released into the circulation at the time of
bacterial death, resulting in multiple hemodynamic effects. The subsequent activation of lymphocytic Tcells and mass cells results in histamine and kinin activation as well as the activation of kallikrenin and
decrease in kallikreinogen and kallikrein inhibitor. These changes result in the release of bradykinin, a
potent arterial dilator. Early septic shock is a classic example of distributive shock, related to a systemic
maldistribution of relatively normal or even increased cardiac output. Clinical findings include
hypotension, fever and chills. Initial hemodynamic findings include decreased systemic vascular resistance
and high normal or elevated cardiac output. The continued maldistribution of cardiac output leads to local
tissue hypoxia and to the development of lactic acidosis and organ dysfunction. This decrease in systemic
vascular resistance is caused by the release of vasoactive substances, as well as by vascular endothelial
cell injury, which promotes capillary plugging secondary to complement induced leukocyte aggregation.
These factors lead to increased arteriovenous shunting.
If the process continues a second hemodynamic phase of septic shock is developed. The primary
importance in this late phase is the development and progression of myocardial dysfunction leading to
ventricular failure. Studies assessing stroke work index and ventricular ejection fraction have
demonstrated depressed intrinsic ventricular function even in the early stage of septic shock.
Pulmonary hypertension, another important hemodynamic alteration is often associated with septic
shock, may have additional profound hemodynamic consequences. As the sequalae of renal kidneys
filtration disorders — the shock kidney is formed and acute renal insufficiency is developed. Signs of
liver disorders are hyperbilirubinemia, lipid metabolism abnormalities.
Patients who recover from the initial hemodynamic instability of septic shock may suffer prolonged
morbidity secondary to endotoxin-mediated pulmonary capillary injury and noncardiogenic
pulmonary edema. Such lung failure is a major cause of death in patients whose hypotension was
prolonged and may experience acute tubular necrosis. Endotoxin mediated endothelial cell injury and
associated thromboplastine-like activity as well as prolonged shock from any other cause may also
lead to activation of the coagulation cascade and a clinical picture of disseminated intravascular
clotting syndrome (DIC).
Clinic and diagnosis. The clinical manifestation develops just after surgical operation on infected
organs. The body temperature rises till 39-40°C and is high during 1-3 days. Then the temperature
decreases, chills is a characteristic feature of the septic shock.
Among clinical findings there are hypotension without bleeding or nonade-quete to it, tachycardia, 120140 per minute. Decreasing of blood circulative volume leads to rising of shock index till 1,5 (normally
0,5). Skin is pale and wet because of perspiration, later akrocyanosis can appear. Breath disorders, like
tachypnoe till 30-60 per minute, is the sign of shock lungs. Skin may be colored in yellow, there may
be blood vomiting.
The most dangerous complication of septic shock is kidney insufficiency. Clinical manifestation at the
beginning is oligouria — less than 30 ml per hour. Later anuria is developed. All these changes in
organism appear in very short time in 6-8 or sometimes 10-12 hours.
Diagnosis is based on the following signs:
• septic organ
• low blood pressure, nonadequate to blood loss
• nervoues system disorders
• pain of different parts of body
• decreasing of diuresis
• rash on the skin
The blood temperature should be taken every 3 hours, blood pressure is measured every 30 minutes,
urine quantity must be measured. Bacterial culture from infected organ, blood analysis, coagulogram
and biochemical tests are performed.
Treatment of septic shock. The treatment of septic shock involves optimising preload relative intravascular
volume with crystalloid infusion as well as treating of the underlying infection. Although some
authorities advocate the use of colloid solutions for volume replacement, there is noconvincing evidence
that using of such solutions decreases the incidence of pulmonary edema or adult respiratory distress
syndrome. In most cases the infection is polymicrobial and broad spectrum coverage for gram-negative
and gram-positive aerobic and anaerobic organisms is most appropriate. If an abscess is involved,
promt surgical drainage after initial resuscitation is mandatory. Patients in septic shock should be treated
with dopamine hydrochloride. This agent in doses of less than 5mg/kg/minute improves renal blood
flow by means of dopaminergic mesenteric vasodilatation; in doses of 5 to 30 mg/kg/minute, a positive
inotropic effect is also seen. The hemodynamic manipulation of patients whose hypotension fails to
respond rapidly to volume infusion may be assisted by pulmonary artery catheterization, allowing the
clinician to achieve optimal preload before the institution of inotropic or vasoconstrictive therapy.
High-dose corticosteroids are advocated (60-120 mg of prednizolone or 8-16 mg of dexamethazone).
To renew Ph balance lactosol or bicarbonate natrii are indicated.
SPECIFIC INFLAMMATORY DISEASES
(Sexually transmitted diseases)
To specific inflammatory diseases of the female reproductive organs belong tuberculosis and sexually
transmitted diseases. According to the WHO's classification, there are 21 such diseases. Their
frequency has been risen for the last years.
SEXUALLY TRANSMITTED DISEASES
(the WHO's classification)
Classic venereal diseases
Nosology
Microorganism
1. Syphilis
Treponema pallidum
2. Gonorrhea
Neisseria gonorrhoeae
3. Chancroid
Hemophilus ducrei
4. Lymphogranuloma venereum
Chlamydia trachomatis
5. Donovanosis, or granuloma inguinale Callimmantobacteriumgranulomatis
3,4,5 are mostly in tropic countries
Other sexually transmitted infections
Nosology
Microorganism
A — that affect mostly genital tract
1. Syphilis
Treponema pallidum
1. Urogenital chlamydiasis
Chlamydia trachomatis
2. Urogenital trichomoniasis
Trichomonas vaginalis
3. Urogenital mycoplasmosis
Mykoplasma hominis
4. Candidosis vulvovaginitis
Candida albicans
5. Genital herpes
Herpes simplex virus
6. Genital warts
Papillomavirus hominis
7. Molluscum contagiosum
Molluscoviras hominis
8. Bacterial vaginosis
Gardnerella vaginalis та mini збудники
9. Urogenital shigellosis of homosexualistsShigella species
10. Pediculosis pubis
Phthyrus pubis
11. Scabies
Sarcoptes scabiei
В — With mostly affection of other organs
1. Infection, caused by HIV
2. Hepatitis В
3. Cytomegalovirus infection
4. Amebiasis
5. Lambliosis
Human immunodeficiency virus
Hepatitis В virus
Cytomegalovirus hominis
Entamoeba hystolytica
Giardia lamblia
Gonorrhea
Gonorrhea is a contagious disease caused by Neisseria gonorrhoeae. Among the specific inflammatory
diseases of the female genital tract gonorrhea takes the second place and is in 5-25% of cases of all
STDs.
Etiology and pathogenesis. Gonorrhea is caused by Neisseria gonorrhea (fig. 92). The causative agent
was found in 1879 by A. Neisser. Gram-negative N. gonorrhea is not stable in the outer surrounding and
dies quickly at the influence of antiseptic solutions, boiling, drying, but it is rather stabile in human
organism. In uncomfortable conditions they transform into L-forms, which can transform into the usual
form in the favourable conditions. In case of chronic gonorrhea, N. gonorrhoeae are situated mostly in
leukocytes and out of the cells, in case of the acutening of the process they are found in the leukocytes.
Fig. 92. An agent of gonorrhea —
gonococus
N. gonorrhea affects mostly those parts of urogenital tract, that are covered with cylindric epithelium:
mucosa of urethra, cervical canal, Bartholin's glands ducts, mucosa of uterine cavity, uterine tubes,
ovarian epithelium, peritoneum. During the pregnancy, childhood and menopausal period there can be
gonorrheal vaginitis.
The source of infection is a person with gonorrhea.
Ways of infecting:
• the disease is sexually transmitted
• homosexual contacts, orogenital contacts
• very rarely through sponges, towels, underwear
• during labour from mother (infected eyes, vagina in girls)
Incubational period lasts for 3-7 days, sometimes for 2-3 weeks.
According to the stage of spreading the process the gonorrhea of lowei part of genital organs
(gonorrheal urethritis, endocervicitis, Bartholinitis, vulvovaginitis) and gonorrhea of upper parts —
gonorrhea ascendens (endometritis, salpingitis, pelvioperitonitis) is classified.
According to duration there are such forms of gonorrhea:
• fresh gonorrheal infection with acute, subacute, torpid passing, which lasts less than two months
• chronic gonorrheal infection, lasting more than two months
• latent gonorrheal infection
In women the clinic of gonorrhea depends on the localization of the process, virulency of causative
agent, age of woman, organism's reactivity, stage of the disease (chronic, acute).
Fresh gonorrhea in acute forms has expressed clinical manifestations. Subacute form is characterized
by subfebrile condition, sometimes by expressed clinical symptoms, which appeared two weeks before.
Torpid gonorrhea in acute form has mild clinical manifestations or is asymptomatic, but N.
gonorrhoeae are found in the patient. Latent form is diagnosed when there is no bacteriologic and
bacterioscopic confirment, no symptoms, but person is a source of infection. Chronic gonorrhea lasts for
more than 2 months, or without establishing of the beginning.
Gonococcal urethritis. Clinical manifestation appears within 3-5 days after infection and is characterized
by dysuria. Variable degrees of edema and erythema of the urethral meatus, purulent or mucopurulent
discharge are present.
Gonococcal Bartholinitis. It may occur when N. gonorrhea with vaginal discharge infects the
Bartholin's gland. It is manifested by edema, erythema around the duct's os. When the occlusion
occurs, pseudoabscess or Bartholin's abscess which are accompanied by purulent process symptoms
can develop.
Gonococcal endocervicitis. Inflammatory process develops in mucosal layer of the cervical canal.
Examination reveals edema and erythema of vagina and part of the cervix. There is a red crown around
the cervical os and a mucopurulent cervical discharge.
Gonococcal proctitis occurs very rarely. Rectum is involved into the process in the result of contamination
with the infected genital discharge. Clinic includes tenesmus and rectal pain.
Gonococcal endometritis is the first stage of the ascendant gonorrhea with infection of basal and
functional layer of endometrium. It is manifested by lower abdominal pain, high body temperature,
sometimes nausea, vomiting. Pain often has spasmatic character. Discharge is sanguine-purulent or
mucopurulent. Uterus is painful at palpation. Chronic endometritis is characterized by menstrual disorders.
Gonococcal salpingitis is the infection of the fallopian tubes, mostly bilateral. In acute stage the pain
in lower part of abdomen is common. It becomes stronger, motion, nausea, vomiting. Menstrual
disorders can occur.
Smears must be taken on the 2-4th day of the menstrual cycle and after provocation in 24, 48, 72
hours, that allows to reveal N. gonorrhea.
Treatment is provided in special clinic. Sometimes the patient is treated by the venerologist in
ambulatory.
To reveal another sexually transmitted diseases clinical and laboratory examination must be
performed. While prescribing medicines the clinical form, complications and severity of the process
should be taken into consideration.
The main medicines in gonorrhea treatment are antibiotics. Gonococcal infection very often is
accompanied with trichomoniasis, chlamidiasis, candidiasis, mycoplasmosis.
Antibiotics that have influence on the following agents such as: Ciprofloxacin, Doxycyclin, Trobicyn,
Sumamed, Cephtriaxon, Afloxacin in combination with Metronidazol, Tiberal, Naxogyn should be
prescribed. The dose of antibiotics is taken according to the methodical instructions of the Ukraine МНР
and annotation of medicines.
Gonovaccine is used after ineffective antibiotic treatment and relapse in the latent fresh torpid and
chronic form of the disease (200-300 mln. of microbe bodies, in 2-3 days intramuscularly). During
pregnancy immunotherapy and antibiotics with negative influence on a fetus are not used.
For toilet of external genital organs 0,002% solution of Chlorhexidine, Re-cutan, Baliz-2 are prescribed.
Local treatment of chronic gonorrhea is conducted after disappearing of the signs of acute
inflammation. In chronic and subacute stages physiotherapeutic methods are used: laser radiation,
paraffinotherapy, mud-cure, diathermy, inductothermy, U.H.F-therapy.
The control of the results of treatment: disappearing of subjective signs and microbe agents in all the
infected organs and discharge. On the 7-10th day after medical therapy the bacterioscopic and
bacteriologic methods are used to confirm the results of treatment. If there is no N. gonorrhea in the
material, then the combined provocation is conducted: injection of Gonovaccine (500 mln. of microbe
bodies), instillation of 1% Lugol's solution in urethra, 0,5% solution of Argentum Nitrate into cervical
canal. Discharge from this organ should be examined during 3 days. Smears are taken during
menstruation and then after provocation in 24, 48, 72 hours. Such examinations are provided during 23 menstrual cycles. Women which have contacts or work with children are not allowed to work.
Prophylaxis. Using of condom is the most effective prevention method. If the sexual intercourse has
happened without it, then the external genital organs should be washed with water and soap, and after
urination syringing with 0,05% Chlorhexidin solution should be performed.
Urogenital trichomoniasis
Urogenital trichomoniasis is caused by Trichomonas vaginalis and is a result f their invasion into the
lower part of genital tract and urethra.
Ethiology. Trichomonas vaginalis is a flagellate protozoan (fig. 93, 94) and t is transmitted by sexual
intercourse. It is not stable in outer environment, dies n few seconds under the influence of antiseptic
solutions, in water it dies during 5-45 minutes, and also when they wash hands with soap, it is sensitive to
drying, n human organism Trichomonas vaginalis can exist in 3 forms: common one pear-shape form),
amebiform with the expressed phagocytosis action (it can ihagocytise mycoplasmas, N. gonorrhea and
other bacteria that caused the recur-ence of mycoplasmas or gonorrhea. This is the most spread disease
among all he sexually transmitted ones. Its frequency rate reaches 50-70% of sexually ictive women.
According to the WHO statistics, 10% of world population suffer rom trichomoniasis. Non-sexual
transmission is very seldom: when they use ;ponges, underwear, towels.
Incubation period lasts for 5-15 days, the main places of trichomonas >arasitizing are mucose
membranes of vagina, cervical canal, uterus cavity, uterine ubes, Bartholin gland's duct, urethra, urinary
bladder.
Inflammatory process develops in the infected mucous membrane: edema, lyperemia, exudation,
desquamation affects epithelial cells.
Clinical manifestations. Vaginitis, urethritis, endocervicitis, proctitis are he most common
manifestations, ascendant infection meets rarely.
Fig. 93. An agent of trichomoniasis — vaginal trichomonas
bodies. Practically they don't cause the infection. Microscopy allows to identify both kinds of bodies.
Chlamidia has a complicated antigenic structure. It is very sensitive to disinfectant substances. At 3537°C during 24-26 hours outcellular Chlamidia become nonvirulent, at temperature 95-1000C they die
during 5-10 minutes. In cotton material they can survive up to 2 days at temperature 19-20°C.
The source of infection is the ill person.
Ways of transmission:
• sexual
• intrapartum (passing through the infected birth canal)
• nonsexual way (polluted hands, instruments, underwear, toilet, etc.)
Besides infection of urogenital organs, Chlamidia trachomatis can cause pharyngitis, conjunctivitis,
perihepatitis, otitis, pneumonia, other diseases (Rei-ter's syndrome).
Clinical manifestations. Incubational period lasts from 5 to 30 days. The main primary form of
chlamidial infection is endocervicitis with mild symptoms or without any. In acute stage purulent or
mucopurulent discharge from the cervix, edema and erythema of the vaginal part of the cervix are
observed. In chronic stage there is the mucopurulent discharge and pseudoerosion of the cervix.
Chlamidial urethritis can be asymptomatic or it manifests itself by dysuria. There are no specific
symptoms for clinical diagnostics of chlamidiasis.
Salpingitis, caused by Chlamidia trachomatis, is characterized by the same symptoms like the process
caused by other bacteria.
The sequale of chlamidial salpingitis is infertility.
Diagnosis is based on the history (both partners are ill, there is the infertility). Residual diagnosis is
established after revealing chlamidias in the scrap from the cervix and vagina. The most exact are
immuno-enzyme and immuno-fluorescent methods.
Treatment. It is necessary to cure the woman and her sexual partner. The woman should avoid sexual
intercourses, alcohol, psychical and physical overload.
Medicines from the tetracyclin group are prescribed (Doxycyclin, Rondo-micyn, Morphocyclin),
Sumamed, Tarivid, Macrolids (Clacid, Erythromycin).
To prevent candidosis Diflucanum in dose 150 mg is used, Nistatin or Levorin (2.000.000 IU per day
during treatment) are prescribed. Fromilid (Clarythro-mycin), an acid-resistant antibiotic from
macrolid group is recommended. An important property of this drug is its possibility to cell
penetration, that's why Fromilid is 8 times more active, than Erythromycin. It doesn't suppress immune
system, activates phagocyto-macrophagal system and some enzymes, that take part in destroying of
pathogenic bacterias. The dose of fromilid is 500 mg twice a day during 7-14 days in case of fresh
incomplicated chlamidiosis. In chronic forms the treatment course must be elongated till 3-4 weeks.
At urogenital chlamidial infection medicines from ftorchinolon group, Ciprofloxacin (Ciprinol) are
used. Ciprinol is prescribed in the dose of 0,5g orally or 0,2g intravenously each 12 hours during 10-14
days. During treatment the ultraviolet irradiation including sun radiation are contraindicated.
Treatment of chlamidiasis demands from the doctor and patient accurate fulfilling of all the
indications (dose and duration of the therapy), especially at chronic, long-lasting forms of disease. At
the same time accompanying urogenital diseases should be treated. To reduce side effects of antibiotics
hepatoprotectors, antioxydants, polivitamins are used.
Urogenital mycoplasmosis
Ethiology. Microbal agents are Mycoplasma hominis, Mycoplasma genita-loum, Ureaplasma
urealiticum.
In the etiology of the inflammatory diseases of female genital organs the associaton of mycoplasmosis
with trichomoniasis, N. gonorrhea, Chlamidia trachomatis, anaerobes is of great importance.
Mycoplasmas are transmitted sexually and they are highly spread among the population.
Clinic. Mycoplasmas infection can occur in acute and chronic form, and has no symptoms, which are
specific for this agent. It is often found in healthy women. Mycoplasmosis is characterized by torpid
course, sometimes the latent forms of the reproductive system inflammation are observed. The agents
may be activated under the influence of menstruation, oral contraceptives, pregnancy, delivery.
Ureaplasma is identified in the patients with vaginitis, cervicitis, urethritis, in association with other
bacteria the symptoms are typically and described in the part "Nonspecific inflammatory diseases of
the female genital organs".
Diagnosis. To reveal ureaplasmas the bacteriological method is used. Material is taken from the
purulent discharge of Bartholin's glands, from uterine tubes at salpingitis, tuboovatian tumors at pelvic
inflammatory disease. Test on the urease is done (colour index). It is based on the property of
ureaplasms to product urease, that changes the pH and the colour of indicator. Serological diagnosis is
also used. Immunogram in diagnosis of mycoplasmosis and other infection (Chlamidia, gonorrhea,
trochomoniases, herpes simplex virus) is indicated.
Treatment. Using of antimicrobal medicines from macrolid group (Erythromycin, Sumamed,
Roxitromycin), Tetracyclin group (Tetracyclin, Doxycyclin), Fluorochinolones (Ciprofloxacin) is
etiotropic treatment. They are prescribed for not less than 10-14 days with the following laboratory
control. Another course of treatment is immunity stimulation (Immunoglobulin, Levamizol, T-activin,
Ginseng Tincture).
Prophylaxis. Examination of the risk group (prostitutes, women with infertility, inflammatory processes
of genital organs), and keeping to the same measures for preventing sexually transmitted diseases are
used.
Candidiasis vulvovaginitis (Monilia vaginitis)
Candidiasis is a polyorganic disease, caused by yeast fungi (Candida albicans, C. glabrata, С tropicalis)
(fig. 95). It can be transmitted sexually. The most frequent localization is in vagina, vulva, but there can
be candidiasis endocervi-citis, endometritis, salpingitis.
Predisposing factors:
• endogenous long lasting diseases, such as diabetes mellitus, avitaminosis
• exogenous factors, that predispose fungal colonization and decrease the general reactivity of the
organism (long treatment with antibiotics) and local immunity in vaginal mucosa high virulency of
Candidas.
There are such kinds ofcandididas vulvovaginitis:
Fig. 95. An agent of candidiasis — Candida albicans
• primary
• antibiotics-induced (as a result of antibiotic treatment)
• as a sequale of changes in different systems of the organism (diabetes, pregnancy, using of estrogens)
On the suppressed immunity of the organism fungi, that were previously saprophites, become
pathogenic. They adher to vaginal epithelial cells, causing superficial inflammation and desquamation
of vaginal cells. Genital candidiasis mostly doesn't cause a deep damage of mucosa and spreading of the
process, but if the agent has high virulence, it can penetrate into intra- and subepithelium parts. In
some cases there can be dissemination of candidiasis.
Clinical manifestations: Candidiasis vulvovaginitis is characterized by vulvar itching, pruritus,
cottage-cheese-like discharge.
Examination reveals edema and erythema of genital mucos with whitish adherent discharge, that
include pseudomicelium of fungi, exfoliated epithelial cells and leukocytes.
Diagnosis. Diagnosis is based on the clinical manifestations, vaginal examination, colposcopy,
bacterioscopic and bacteriological methods.
Treatment. Acute form is treated by Orungal 200 mg twice a day during 3 days; at chronic form they
use 100 mg twice a day during 6-7 days, then during 3-6 menstrual cycles 1 capsule on the first day of
menstrual cycle is taken. High effectiveness is observed while using Diflucan in dose 150 mg per 1
reception, and Gyno-pevaril — one suppository (150 mg) during 3 days. In case of relapse one
suppository (50 mg) twice a day for 7 days and application of Gyno-pevaril creme on glans penis during
10 days is recommended. The next step of treatment is normalization of vaginal ecosystem.
Prophylaxis: rational antibiotic treatment with keeping to optional doses and duration of the therapy
course, in-time using of antimycotic medicines with the preventive aim. Avoiding of premarriage and
extramarital relationships, condom using for preventing fungal colonization of the female genital tract.
Syphilis
Syphilis is an infective disease, that is transmitted sexually.
Etiology. The pathogene is Treponema pallidum. In microscopic examination it has spiral shape and is
movable. Optional temperature for reproduction of Treponema is 37°C. It is very sensitive to different
external conditions. It dies during boiling, drying, under the influence of different chemical agents and
90% ethanol. While working with the infected persons hands are cleaned with ethanol. It prevents from
infection at contact with syphilitic rash having Treponema pallidum on its surface. At 40°C
(temperature for keeping blood for transfusion in refrigerator) Treponema pallidum dies in 24 hours.
The source of infection is the infected person.
Ways of transmission:
• sexual perversion (oro-genital, homosexual contacts)
• transplacental — congenital syphilis, when a child is infected by transplacental transmission
• professional — while examining the ill person with wet surfaced rash
• transfusion (very rarely) — as a sequale of blood transfusion from the ill person
Clinical manifestations. 3-4 weeks pass from the moment of agent penetration into organism and till
the first manifestations of the disease. This is the so-caled incubational period. The microbe is already
in human organism, but there are no complications and signs of the disease.
After finishing of incubational period the first signs appear only in the area of agent inoculation. This is
the so-called primary lesion (ulcerated shancre) (fig. 96). It appears as a painless indurated papula on
skin or mucos with erosion or necrosis of the surface. Is a hard-based, wellFig. 96. Ulcerated shancre of labia major
circumscribed lesion. There is no inflammation around it and it has smooth surface with serous
discharge. Its
size is from several mm to few cm, and it can be coated with whitish discharge like old fat. On mucos
of genital organs or anus it is like fissure. Sometimes shancre can gangrenize. Indurative edema
belongs to the atypical forms of shancres. Labia major enlarges in size, they are firm and painless.
Chancre on pubis, thighs and cervix can occur rarely.
If the shancre is situated on the genital organs, then after nearly 7 days the inguinal lymphatic nodes
enlarge on one side (scleradenitis, bubo), rarely on both sides. They are firm, movable, painless. They
are not connected with skin and have no suppuration. This is the primary syphilis, that lasts for 6-8
weeks from the appearing of the shancre (the first 3-4 weeks is primary seronegative period, when
Wassermann reaction is negative, and next 3-4 weeks, when Wassermann test is positive). Diagnosis
in this period is based on the history taking (sexual contact, incubation period, examination of sexual
partner, revealing of Treponema pallidum on shancre surface, positive serological reactions (Wassermann's, immunofluorescence).
Without identification of the agent or positive serological reactions diagnosis of syphilis is not proved.
After 6-8 weeks of shancre development, the body temperature may rise, there is the night headache,
bone pain can appear. This is the so-called/?ro<iroma/ period. During this time the agents are
reproducted intensively, they appear in blood (treponems sepsis) and there is disseminated rash on
skin and mucosal layer. There appear the signs of secondary syphilis. Firstly roseolas (little red
macula 0,5-1 cm in size) appear on body skin. They disappear for a while after the finger pressure,
don't protuberate over the skin level. After some period papulas, very rarely pustulas or hair shedding
appear. In this time on skin and mucos of the female genitals papula (erosion nodes) can appear. They
are firm, without inflammation, up to 1 cm in diameter, with moist surface, rich in microbal agents
(Treponema pallidum), that make them very infectious. There are no subjective feelings. As a result of
irritation these nodes enlarge, indurate and transform into the so-called condyloma lata, 0,5-1 cm and
more in diameter, indurated, prominating above skin level, without signs of acute inflammation,
painless, with smooth or tuberous, sometimes with moist surface.
There are plenty of agents on the surface of condyloma lata and they are very contagious. They should
differ it from viral pointed condylomas (soft, on the pedicle, with lobular, like cauli-flower structure).
Diagnosis is confirmed by presenting erosional papulas and condyloma lata, positive serological
reactions (Wassermann's reaction, reaction of immobilization of Treponems).
Treatment of syphilis is provided by penicillin antibiotics (bicillin, retarpen, extencillin) in venerologic
dispensary, according to the instructions of the Ukrainian Ministry of Health Care.
Prophylactic measures: avoiding of extramarital relationships, using of condom. If coitus was without
condom or it has been torn, then the external genital organs should be washed with soap and warm
water, and during the first 2 hours the cleaning of genitals should be performed.
AIDS
Agent of AIDS is retrovirus, which affect immune system of organism.There are two types of Human
immunodeficiency virus, that caused acguired immunodeficiency syndrome (AIDS): HIV-1 and HIV2.
HIV-1 is spread in all the countries of the world. HIV (human immunodeficiency virus) is very
sensitive to heating, while at boiling it dies immediately, as well as after applying of 70% Ethanol,
0,2% solution of Natrii hypochlorate and other desinfective solution. But this virus survives in its
dried form during 4-6 days in 22°C temperature, in lower temperature even more. The source of
infection is the ill person or viral carrier. People with AIDS are infective all over the life.The quantity of
people with HIV in many times prevalents the quantity of ill person with AIDS. Infected person
becomes contagious in a very short time — 1 -2 weeks after infection.
The ways of infection:
• sexual, which insures natural viral transport from one person to another, as well as sequel of
homosexual contacts
• parenteral way of infection occurs when they break the sanitary rules making injections, especially
intravenous, when injections are made with one syringe, with changing only the needle
• professional way of infection of medical personnel occurs when blood of the person with AIDS
contacts with lesioned skin (microtrauma, fissure etc) or mucosal layer during manipulations
(injections and others)
• transfusional way occurs very rarely, when the infected blood is transfused to the healthy person
• transplacental — from the infected mother to the child
So, HIV infection can be transmitted from people to people in direct contact: "blood to blood" or "blood to
sperm". Transmission of virus through saline during kissing is less possible. The virus isn't transmitted
by insect stings.
Clinical manifestations of AIDS: Incubation period can last from 1 month to 10 months or even to
years. Clinical manifestations may vary, they can be divided into some periods. In 30-50% of the
inspected persons in 2-4 weeks an acute period can be observed: fever, tonsillitis, enlarging of neck
lymphatic nodes, liver, spleen. This lasts for 7-10 days, and then the disease becomes latent. The only
sign of illness at this time may be the enlarged peripheral lymphatic nodes. They are movable, not
connected with tissues, some of them are painful at palpation. Such enlarging of the nodes can
indicate to the AIDS, if it lasts for more than 1,5-2 months. Later the so-called AIDS-associated or
premorbid complex of symptoms is developed. It can last from 1 to 6 months during some years. In this
time many different symptoms and diseases which are not specific for AIDS (up to 200) are developed.
That is the long-term fever, generalized enlarging of peripheral lymphatic nodes, periodical diarrhea,
weight loosing (more than 10%), oral cavity candidiasis, leukoplakia of tongue, folliculitis, different
skin lesions.
This period lasts wave-likely while health becomes better till the clinic remission, when person
considers himself absolutely healthy.
The last period is AIDS. In such persons different infectious diseases occur (up to 170) on the base of
immunodeficiency, caused by HIV-infection. Nervous system is damaged (in 30-90% of patients), poor
orientation, bad memory and demention are develops. Pneumocystic pneumonia (lung inflammation)
occurs up to 60% with severe, sometimes with fulminant passing. In 60% of cases severe and long-termed
diarrhea is observed. Kaposhi's sarcoma very often progresses and becomes the reason of death at
young age In significant part of patients having AIDS, malignant processes like lymphoma and others
are developed as a result of virus influence on immune mechanism of human being. Skin and mucosa are
damaged with Candida fungi (candidiasis, Herpes simplex and Circular herpes virus with severe, relapsing
duration, they don't undergo to usual methods of treatment.
Diagnosis. In AIDS the following diagnosis are mentioned:
• epidemiological history (homosexualism, drug abuse, prostitution, intravenous injections etc.)
• a long-term enlargening of peripheral lymphatic nodes, loosing of body weight, long-term fever and
diarrhea
• revealing of antibodies to HIV in blood by immunofluorescent analysis and others. 5 ml of venous
blood is taken, and it is kept in refrigerator at the tempreature of+2 — +4°C. Serum is taken out after
appearing of the blood the clot and sent to the laboratory not later than in 1-3 days Treatment. There
are no medicines for treating AIDS. But remedies, that
inhibit development of the disease are used. Nowadays there is an effective preparation for treatment of
HIV infection and AIDS — Krixivan (protease inhibitor). Triple therapy of Krixivan base
(Krixivan+AZT+ZTS) has high effectiveness, decreases quantity of viruses in blood to lower level.
Immunostimu-lators, immunomodulators, symptomatic therapy depending on the pathology is used.
Prophylaxis:
• sanitary and educational work among inhabits
• avoiding of pre- and extramatrial relationships
• using of condoms (decrease the transmission in 200-500 times)
• prophylaxis of drug abuse, parenteral (subcutaneous or intravenous) injectons of medicines proper
sterilization of medical instruments, using syringes and needles of single use
• using special defence agents by medical workers contacting with patients' blood and other biological
substances (special closes, double gloves, goggles, masks)
• control of donor blood
VIRAL DISEASES
The quantity of viral diseases of genital organs has been significantly inc-increasing for the last time,
especially among young people.
Viral infections can occur in latent form, with less symptoms and with expressed clinical manifestation.
That's why it is very difficult to diagnose them. These diseases have especially negative influence on
the pregnancy. There is a risk of viral transmission to fetus.
They can cause fetus diseases or defects of development, leading to fetus death or miscarriage." Every
pregnant woman with miscarried fetus must be examined on these infections presence, because in the
majority of such women Cytomegalovirus, Gripp virus, Hepatitis A and В virus, Papillomavirus are
revealed. Besides the influence on fetus, according to the recent investigations, viral infection causes
malignant growth in the female genital organs.
Herpesvirus infection
Herpesvirus diseases of genital organs are caused by Herpes simplex virus, mostly of the second type
(HSV-2). Source of the infection are infected persons and carriers. It may be revealed in young sexually
active women. It can be transmitted during orogenital contact. The virus is located mostly in mucos
membranes of urogenital tract in men and cervical canal in women, also in the nervous ganglions of
lumbar and sacral parts of sympathetic nervous system. Genital herpes is transmitted sexually. During
pregnancy it may cause miscarriage and malformations.
Genital herpes is considered to be all-life persistant infection, that's why it has a relapsing passing.
Clinical manifestations. According to the clinical signs, the disease duration is divided into typical, nontypical, and asymptomatic one (viral carrier).
Typical passing of the disease is characterized by genital and extragenital signs. Extragenital signs:
rising tempreature, mialgias, headache, nausea, viral rash on face, bad sleep. Genital signs are present
on the lower parts of genital system — vulva, vagina, cervix, near urethra os perineum. Single or plural
vesicles up to 2-3 mm in size, with erythema and edema, which exist for 2-3 days appear in mucous
membranes. After vesicle rupture erosion with incorrect form, covered with yellow discharge appears.
The erosion re-epitheliazes without scars in 2-4 weeks.
Patients complain of pain, irritation, itching in area with viral lesions.
Clinical manifestations are in three forms:
• I — acute primary
• II — chronic recurrent
• III — atypic
Depending on the localization, genital herpes is divided into three stages:
• the first one — herpes lesions of external genital organs
• the second — herpes lesions of the vagina, cervix, urethra
• the third — herpes lesions of the uterus, adnexa, bladder
Diagnosis is based on history taking, complaints, objective examination, revealing of HSV-2 or its
antibodies in the patient's serum.
The most informative method of identification is isolation of the virus from discharge of the cervix,
vagina, uterine cavity, urethra. For express-diagnosis a method of fluoriscine antibodies and
immunoperoxydase method are used. There is electro-microscopic method of HSV-2 identification and
the method of viruses inoculation on tissue culture with the following studying of their properties.
Treatment is difficult because of the relapses of the disease and possibility of reinfection.
Antiviral medicines belong to three main groups (according to the action mechanism):
• replication inhibitors of viral nucleic acid
• interferon and compounds, that have interferon-inductive action
• compounds with other antiviral action
Difficulties of treatment are caused by virus peculiarities (they are obligate intracellular parasites).
As a result of investigation of virus nature on molecular level, new medicines were created. They have the
influence on viral growth and development of the virus. They are Zovirax (Acyclovir, Valacyclovir),
Alpizarin, Foscarnet, Valtrex, Herpevir. Acyclovir is used in dose of 600-1200 mg per day, orally or
intravenously.
Local therapy by 3% Megasin ointment, 3% Bonaphton or 3% Alpizarin is also used.
For treatment of the recurrent herpes antiviral medicines, herpal vaccines, antirecidive immunotherapy
are used.
Condylomas acuminata
Ethiology. Condylomas acuminata are caused by Human Papillomavirus of 16 and 18 types. They are
transmitted sexually (fig. 98). Resistant to disinfective agents viruses may be killed by high temperature
during sterilization. Incubational period of condyloma acuminata lasts from 1 to 9 months. The disease
often occurs in sexually active persons. Papillomavirus causes genital cancer. These patients have in 1-2
thousands times more chances to acquire a malignant process, than healthy people. Condylomas
acuminata can transform into cancer in 6-26% of cases.
Clinical manifestations: On the onset of disease single pink, sometimes grey warts, with thin pedicle,
rarely with wide base appears on skin surface of labia majora, perineal area and mucosal layer of
urethra, anus, vagina, cervix. Condylomas acuminatum can grow significantly and fuse (fig. 99). They
looks like cauliflower, with lobular structure, and have long-term duration. Some patients with longterm duration of the process can have big condylomas, like tumor. They can be complicated by
abnormal vaginal discharge, due to the secondary vaginal infection. Condylomas may cause some
difficulties at walking, intercourse. During pregnancy and delivery they can cause bleeding. In 15-17%
of patients regression may occur, especially during pregnancy.
Clinical diagnosis. Lobular surface, soft consistency, thin pedicle should be taken into consideration.
Differential diagnosis for genital warts includes condylomata latum, which have wide base, brown or
red colour, and no lobular structure. Also other manifestations of syphilis are present there.
Treatment If genital warts are large, laser vaporization is performed. It is more effective, than
criodestruction or surgical diathermy. For treatment of small condylomas 30% solution of Podophyllin,
Condilin or Resorcin are used. Modern effective remedy is Solcoderm.
Molluscum contagiosum
Ethiology. Molluscum contagiosum is caused by virus, that is transmitted by contact with the ill
persons or during using their things. In adults the main way of transmission is sexual contact. Children
are infected more often. Incubation period lasts from 2 till 9 months.
Clinical manifestations. On skin the small firm dome-shaped papules 5-7 mm in diameter, occasionally
enlarging to 1-3 cm conglomerates is appeared. The flesh-colored papules have specific central
umbilication (fig. 100). Lesions are located on the external genital organs, perineum, pubis, hips, face.
Molluscum contagiosum can persist for a long time.
Clinical diagnosis. After direct pressure by forceps white caseous material can be got.
Treatment. The lesions are pressed by forceps and cleaned by Iodine solution or Betadine, garlic juice or
cryotherapy.
Cytomegalovirus infection
Infectional agent is Human cytomegalovirus. The percentage of the infected women according to the
world literature is very high. In Western Europe it is from 50 to 85%. Among pregnant women with
usual miscarriage 70% are infected.
Fig. 100. Molluscum contagiosum (histological picture)
After invasion cytomegalovirus persists in organism for a long time, spreading by saline and sexual
contacts.
Clinical manifestations. The main signs of the infection are extragenital symptoms: CNS-lesions,
thrombocytopenia, liver disorders, pneumonia. Infecting of the fetus during pregnancy leads to intrauterine
development defects (microcep-falus, deafness), diseases of the newborn (cerebral paralysis,
miasthenia). It is manifested by cervicitis, cervical erosions, vaginitis, vulvitis and other inflammatory
diseases, that have subclinical passing.
Diagnosis: Blood and urine tests for virus presence are performed. Cytoscope analysis of saline and
urine sediments are based on the properties of Cytomegalovirus to penetrate into the cells and to make
big intranuclear inclusions. Infected cell becomes bigger, it is the so-called cytomegalovirus cell, "an
owl's eye".
Serological methods: indication of antibodies components to HCMV (1:8 and more is considered to
be positive).
Non-direct immunofluoriescence method and DNA-diagnostics (chain polymerize reaction) are used.
Treatment. The main purpose is the correction of the immune system disorders. Preparations for
immunity stimulation (Levamizol, T-activin, Immunoglobulin, Ginseng tincture) are used. Application
of ointment and injection of leukocyte interferon, immunoglobulin with high titred cytomegalovirus
antibodies ("Citotect") into cervix are used. Wide spectrum of antiviral preparations (Valtrex, Acyclovir,
Ribavirin, Gancyclovir, Bonaphton) are less effective.
Prophylaxis. Avoiding of pre- and extramarital sexual contacts, using of condom, keeping the rules of
personal hygiene.
Tuberculosis of genital organs
Genital tuberculosis is the secondary disease. Very often clinical focus is in lungs. The disease is caused
by Mycobacteria tuberculosis, which is transmitted hematogenically from lungs or intestine to genital
organs. Mostly women from 20 to 40 years of age become ill.
Tuberculosis infection is found in 5-8% of patients with inflammatory diseases of genital organs, and
in 1-3% of patients with salpongoophoritis.
Mycobacteria tuberculosis contaminate into genital organs mostly in childhood, but clinical
manifestations appear in the pubertyperiod, with the beginning of sexual life and after supercooling.
Tuberculosis damages uterine tubes (85-90%), rarely uterus and ovaries (fig. 101, 102), and more rarely
— the cervix, vagina, external genital organs.
According to Aburela E. and Petersuc B. (1975) classification, there are four main forms of specific
process in the female genital organs:
• tuberculosis of genital organs with microdamages mostly with productive character, and latent
duration
tuberculosis of genital organs with macrodamages mostly with exudative-proliferative or caseous
character, and lasts like salpingoophoritis and endometritis, accompanying with ascites or adhesive
peritonitis
• associative tuberculosis of genital organs and tuberculosis of other organs (lungs, kidneys) or
tuberculosis of genital organs, combined with the other gynecological diseases (endometriosis,
sclerocystic ovaries, uterine myoma)
• clinically curable genital tuberculosis with posttuberculosis changes (petrification, adhesions,
degeneration)
Fig. 102. Tuberculisis of uterus, fallopian tubes, ovaries, parametrial tissue
Pathomorphological examination reveals inflammatory changes. Morphological specificity of them is in
presence of tuberculous granuloma in productive phase of inflammation a focus of caseous
decomposition with exudative phase of the process. If antituberculosis medecines are used in exudative
inflammation phase, the exudate resolves with complete or almost complete renewing of tissue structure.
Destruction of the tissue is substituted by the connective tissue in productive phase of the process.
Separation of the focus from intact tissue take place in case of caseous damage resolvation of perifocal
infiltration and fibrose transformation of the destruction zone with the capsule. In such focus Mycobacterium tuberculosis can stay for a long time and in some cases it causes relapsing.
Clinical manifestation. At "small" forms of tuberculosis pain syndrome is absent. Dominant sign may
be menstrual dysfunction (hypomenorrhea or algo-dysmenorrhea). Pain appears in case of large
damage. Almost all the patients with genital tuberculosis suffer from reproductive disorders, i.e. primary
or secondary infertility, ectopic pregnancy.
If the changes in endometrium are significant, amenorrhea (uterine form) can develop.
General changes in the patient's organism are accompanied by the signs of tuberculosis intoxication:
disorders of general state, weakness, sweating, sub-febrile temperature.
Diagnosis. Diagnosis is based on the history data (contact with tuberculosis patients, previous
tuberculosis of bones, lungs, bronchitis, pneumonia, long-lasting subfebrile condition), objective
examination (tuberculosis changes in organs or their sequel), bacteriological examination, additional
methods of examination, including histological. For confirming the diagnosis of tuberculosis special tests
are used (Mantu, Koch's). The Mantu test identifies only the specific sensitization of the patient and has
less diagnostic value. For diagnosis the Koch's test is important. General, local and focal reactions
appear after subcutaneous injection of 20 IU of tuberculin in patients with tuberculosis. General one is
manifested by high temperature, headache, weakness. Focal reaction manifests itself in 48-72 hours by
enlarging of adnexal infiltration, they become more painful.
The Koch's test can be confirmed by changes in hemogram (high quantity of leukocytes at the expence
of the low amount of monocytes, eosinophiles and lymphocytes), proteinogram (low amount of
albumin and high amount of glo-bulines), immunogram. C-reactive protein and high level of sialic acid
appear in blood.
Bacteriological method is very important, it is in revealing of Mycobacterium tuberculosis in uterine and
adnexal tissue. Material for inoculation is discharge from uterus and vagina, punctate from ovarian
tumor or tissues taken during laparoscopy.
Laparoscopy is a valuable method, it allows to perform visual examination of abdominal cavity and to
take tissual samples for bacteriological and histological analysis.
roentgenological examination of genital organs and thoracic cavity are necessary, especially in
patients with first manifestations of the process in the uterus or adnexa (fig. 103).
Hysterosalpingography allows to estimate uterine cavity state, uterine tubes, their permeability and
other changes, caused by tuberculosis.
Histological examination of endometrium after uterine cavity curettage is important, too.
Ultrasonic echography for estimation of morphological changes in uterus and its adnexa is also used.
Treatment of genital tuberculosis is complex and includes rational regimen, dietotherapy, vitamins,
symptomatic therapy and climatic health-resort cure.
The main is the antibiotic therapy. Antituberculosis agents, being in nse now, are: Rifampicin, PAS A,
Ethambutol, preparations of Izonicotine acid. For preventing mycobacterium persistation, combination
of remedies (Izoniazide + Rifampicin) are used. If the process is revealed for the first time, or it has
acute or subacute passing, three preparations are prescribed: antibiotic, one preparation
Fig. 103. Calcificates in tuberculosis
of Izonicotine acid (Izoniazide, Saluzid) and PASA. The last one has not only bacteriostatic action,
but also prevents from development of microorganisms resistention to antibiotics and preparations of
izonicotine acid, that's why they can be used for a long time. Treatment lasts for 1,5-2 years, during the
first 3-6 months the combination of 3 medicines is used, and later on for 6-8 months 2 agents are
taken. After that supportive therapy is performed till 2 years.
Intramuscular and oral usage of medicines are combined with injection of some dose of medicine in
focus of lesion. Lidase with antibiotics and hydrocortisone are used for this purpose by means of
colpocentesis to the damaged organ. These medicines may be used during hydrotubations. 1 % solution of
chimo-tripsin is used through posterior fornix and by electrophoresis. In some cases surgical treatment
is used. In spring and autumn antirecidive therapy is performed.
Rehabilitation of such patients is provided in specialized health resorts (Odessa, Alupka). For
resolvation of residual affects after tuberculosis physiotherapy and pelotherapy are used.
Assignments for Self – assessment.
II. Multiple Choise.
Choose the correct answer / statement
1.
The most freguent type of inflammatory diseases is:
A.
Iron-deficiency amenia;
B.
Folate-deficiency amenia;
C.
Pain;
2.
Which of the following is Not characteristic of inflammatory diseases?
A.
Decreased factor VII;
B.
Pain;
C.
Family history of the diseases;
D.
Prolonged bleeding time.
3.
Infants bom to mother with inflammatory diseases are at higher risk for:
A.
Neonatal patology;
B.
Neonatal hypoglycemia;
C.
D.
Hypoglycemia;
Polycythemia.
III.Answers to the Self- Assessment.1.C, 2.A, 3.A.
Students must know:
1.
Normal vaginal microflora.
2.
Vaginitis (colpitis).
3.
Acute endometritis.
Students should be able to make:
1.
Plan of management of the patients with inflammatory diseases;
2.
Plan the treatment of the patients with inflammatory diseases;
3.
Plan the delivery of the patients with inflammatory diseases;
4.
Plan the postpartum care of the patients with inflammatory diseases;
References:
1. Obstetrics – edited by Professor I.B. Ventskivska, Kyiv “Medicine”, 2008.
2. Basic
2. Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993. -- P. 406412.
3. Obstetrics and gynecology. - Pamela S.Miles, William F.Rayburn, J.Christopher Carey. - SpringerVerlag New York, 1994. - P. 62-64.