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PELVIC INFECTIONS & URINARY TRACT INFECTION DR. AKINWUNMI L. AKINWUNTAN MBBS (Ibadan), MHS Pop. & RH (Ibadan), FMCOG (Nig), FWACS OBSTETRICIAN & GYNAECOLOGIST INTRODUCTION • Pelvic inflammatory disease (or disorder) (PID) is a term for inflammation of the uterus, fallopian tubes, and/or ovaries • It progresses to scar formation with adhesions to nearby tissues and organs • PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections 5/23/2017 2 Acute Salpingitis 5/23/2017 3 • STI or STD is often the cause, many other routes are possible, including lymphatic, postpartum (miscarriage or abortion) or intrauterine device (IUD) related, and hematogenous spread 5/23/2017 4 • The term "sexually transmitted diseases" is used to denote disorders spread principally by intimate contact • Although this usually means sexual intercourse, it also includes close body contact, kissing, cunnilingus, anilingus, fellatio, mouth–breast contact, and anal intercourse 5/23/2017 5 EPIDEMIOLOGY • In the United States , more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers • PID causes over 100,000 women to become infertile in the US each year • About 2% of young women in the UK give a history of PID if asked, and about 1 in 50 consultations with general practitioners made by young women relate to PID 5/23/2017 6 EPIDEMIOLOGY • RISK FACTORS: – – – – – – Young age Multiple sex partners Lack of condom use Low Socio-economic class Blacks/Caribbean origin Genetics- HLA subtype A31 compared with HLA DQA 0501 and DQB 0402 – ??? Bacterial Vaginosis – Indiscriminate/Improper use of antibiotics 5/23/2017 7 Organisms associated with Pelvic inflammatory disease Aerobic • • • • • • • • • • • Neisseria gonorrhoeae Chlamydia trachomatis The big two Ureaplasma urealyticum Mycoplasma genitalium Gardnerella vaginalis Strep. pyogenes Escherichia coli Haemophilus influenzae Mycoplasma hominis Strep. pneumoniae Mycobacterium tuberculosis 5/23/2017 8 Anaerobic • Bacteroides sp. • Peptostreptococcus sp. • Clostridium bifermentans • Fusobacterium sp. Viruses • Herpes simplex • Echovirus • Coxsackie 5/23/2017 9 NEISSERIA GONORRHOEAE • Neisseria gonorrhoeae is a gram negative diplococcus • Can be seen on microscopy as pairs of red kidneyshaped organisms mostly sitting within polymorphs • Isolated in 40–60% of women with acute salpingitis • It initially infects the cervix but ascends the upper genital tract in 10 -20% of untreated cases 5/23/2017 10 SYMPTOMS & SIGNS • Most women with gonorrhea are asymptomatic • When symptoms occur, they are localized to the lower genitourinary tract and include: – vaginal discharge, urinary frequency or dysuria, and rectal discomfort – Vulva/Vaginal itching • The incubation period is only 3–5 days • Bartholinitis • Acute Pharyngitis/Tosillitis 5/23/2017 11 • Purulent vaginal discharge. • Urinary frequency and dysuria • Recovery of organism in selective media • May progress to pelvic infection or disseminated infection • The organism may be recovered from the urethra, cervix, anal canal, or pharynx 5/23/2017 12 • Polyathralgia • Tenosynovitis • Dermatitis • Conjunctivitis 5/23/2017 Opthalmia Neonatorum 13 Male Urethral Discharge • Discharge coming from the urethral meatus • May be frank pus, mucopurulent, or serous (clear) • Occasionally discharge will be white in colour 5/23/2017 Gonococcal urethral discharge 14 DIAGNOSIS • Discharge – Urethral, Cervical, Anal, Pharynx • Thayer-Martins Media • Gram Negative Diplococci in leucocytes • ELISA • Nucleic Acid Amplification Test (NAATs) 5/23/2017 15 CHLAMYDIA TRACHOMATIS • Is estimated to be the cause in about 60% of cases of salpingitis which may lead to PID • Chlamydiae are obligate intracellular microorganisms that have a cell wall similar to that of gram-negative bacteria • They are classified as bacteria and contain both DNA and RNA • Like viruses they grow intracellularly 5/23/2017 16 CLINICAL PRESENTATION • • • • • • • • • ASYMPTOMATIC FEVER ABNORMAL VAGINAL DISCHARGE LOWER ABDOMINAL PAIN PAINFUL INTERCOURSE IRREGULAR MENSTRUAL BLEEDING PAINFUL MENSTRUATION CERVICAL MOTION TENDERNESS COMPLICATION ie Infertility 5/23/2017 17 DIAGNOSIS • Based solely on lab test • Cell Culture isolation: sensitivity= 70-90% • Complement Fixation Methods • Immunofluorescence • DNA Probe 5/23/2017 18 Genital Ulcer Disease Syphilis 5/23/2017 Chancroid Herpes Simplex 19 Genital herpes vesicles 5/23/2017 20 Typical vaginal discharge caused by trichomoniasis 5/23/2017 21 “Strawberry cervix” due to T. vaginalis 5/23/2017 22 PHYSICIANS’ ROLE 1. Understand the microbiology of STDs in order to appropriately diagnose and treat patients 2. To alleviate the symptoms and prevent future sequelae 3. To prevent the transmission to others including health care professionals 4. To do all of the above combined with patient education and counseling 5/23/2017 23 5/23/2017 26 Essential Steps In STI Care Management* Syndrome Assessment Contact tracing (diagnostic tools) Diagnosis Treatment (screening tests) Compliance 5Cs Confidentiality Condom use Counseling Risk Assessment 5/23/2017 27 ANTIBIOTIC Rx • CEPHALOSPORINS – Cefuroxime – Ceftriaxone – Cefpodoxime eg Orelox • MACROLIDES – Azithromycin • TETRACYCLINS – Doxycycline • FLUOROQUINOLONES – Ciprofloxacin, Levofloxacin, Ofloxacin 5/23/2017 28 URINARY TRACT INFECTION • A urinary tract infection (UTI) is a bacterial inflammation in the urinary tract • Urethritis - Urethra • Cystitis – Bladder • Pyelonephritis - Kidneys 5/23/2017 29 Risk factors • Women – Anatomy – Sexual intercourse – Pregnancy • • • • • • Catheterization Bladder/Kidney stones Immunosuppression Stroke/Bedridden Family history Diabetes Mellitus 5/23/2017 30 CAUSES • • • • • • E. Coli - 80 – 85% Klebsiella Pseudomonas Proteus Enterobacter Rarely – Viruses and Fungi 5/23/2017 31 SYMPTOMS & SIGNS • Lower Tract – Burning sensation on micturition – Frequency – Urgency • Upper Tract – Flank Pain – Fever – Haematuria/Pyuria – Nausea and Vomiting 5/23/2017 – Plus symptoms of the lower tract 32 SYMPTOM & SIGNS….. • In the Elder Post-menopausal – Incontinence – Altered sensorium – Fatigue – Sepsis – Plus earlier symptoms 5/23/2017 33 DIAGNOSIS • HISTORY • LAB: – Urinalysis – Nitrites, Leucocytes, Leucocyte Esteraces – Urine m/c/c – WBCs, RBCs, Bacteria, Colony count ≥ 10,000/colony forming unit Asymptomatic bacteriuria : No symptom plus significant count 5/23/2017 34 TREATMENT • UNCOMPLICATED – Oral Antibiotics – Cephalosporins eg Cefuroxime (Axacef) – Quinolones eg Ciprofloxacin (Cyplox) – Usually a 3-5 day course is sufficient • PYELONEPHRITIS – Requires prolonged medication – Parenteral – Ceftriaxone – Amoxicillin/Clavulanate 5/23/2017 35 5/23/2017 36