Vaginal infections & PID - PowerPoint Presentation

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Vaginal infections & PID

Yara

saleh

Slide2

outline

Approach

Bacterial vaginosis

Vulvovaginal candidiasis

PID

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Physiologic Discharge

• clear, white, flocculent,

odourless

discharge; pH 3.8-4.2

• smear contains epithelial cells, Lactobacilli

• increases with increased estrogen states: pregnancy, OCP, mid-cycle, PCOS, or

premenarchal

• if increased in

perimenopausal

/postmenopausal woman, consider investigation for other effects of excess estrogen (e.g. endometrial cancer).

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Vaginal discharge

 

1) History taking :

Discharge

( amount /consistency/

colour

/duration/

odour

)

first time and Associated symptoms(pain, itching, fever, bleeding ,

burnning

,

externl

dysuria,pain

during intercourse

)

Obtain history of the following

: 

•Prior similar episodes 

•Sexually transmitted infection 

•Sexual activities 

•Douching practice 

•Antibiotic use 

•General medical history 

•Systemic symptoms such as lower abdominal pain, fever, chills, nausea, and vomiting.

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Vaginal discharge

Visual inspection

: the gross characteristics of the vaginal discharge seen on

speculum

examination.

Vaginal pH

: Normal vaginal pH is an acidic

<4.5

.

Performed using pH-dependent Nitrazine paper. Normal vaginal discharge leaves the paper yellow, whereas an elevated pH turns the paper dark.

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Microscopic examination (Wet prep)

: For WBC, pseudo-

hyphae

,

trichomonads

, and clue cells.

Normal saline preparation

: microscopic examination of discharge ( clue cells of BV) 

KOH preparation

: dissolves cellular debris leaving pseudohyphae of candida.Whiff Test ; performed by adding several drops of 10% potassium hydroxide to a sample of vaginal discharge. A strong fishy odor is indicative of a positive test result. Such a result may suggest either

trichomoniasis

or bacterial

vaginosis

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Causes of vaginal discharge

Non infective

Infective causes

1-physiological

- menstrual cycle

- pregnancy

- sexual excitement

- emotional stress

- nutritional status

-Medications

2. Cervical polyps

3. Foreign bodies (Retained tampon)

4.

Valvular

dermatitis

5. Genital tract malignancy

6. Fistulae

A-Non-sexually transmitted

infections

- Bacterial vaginosis

candida vaginitis

b. Sexually transmitted infections

- chlamydia trachomatis

-

neisseria

gonorrhoeae

- trichomonas vaginitis

- Syphilis

- HSV

- HPV

- HIV

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Vaginitis differential

Bacterial

vaginosis

Candida

vaginitis

Trichomonas

vaginitis

-STD-

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Bacterial vaginosis

The

commonest cause

of abnormal vaginal discharge

While a definitive cause is

not

determined,

depletion of the lactobacilli

dominant in the healthy vaginal flora is observed

((Not a true infection, but alteration in concentration of normal vaginal bacteria (anaerobic species >lactobacilli))). Seen commonly in postmenopausal females due to decreased estrogen

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Risk factors

Douching

Black race

Smoking

Having a new sexual partner

Receiving oral sex.

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symptoms

Vaginal discharge typically

thin, grayish-white

with

no

obvious

inflammation

.

‘

fishy’ odorThe vaginal pH is elevated >4.5

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Wet prep

“

Clue cells

” on a

saline

preparation

A

positive “whiff ”test

is elicited when

KOH is placed on the discharge, releasing a fishy odor.

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treatment

Oral or intravaginal treatments with

metronidazole

or clindamycin

No need to treat partner

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Vulvovaginal candidiasis

This condition occurs when yeast of the Candida species, most frequently

C. albicans

, cause vulval and vaginal inflammation.

Risk factors

include:

diabetes mellitus

, systemic antibiotics,

pregnancy

, obesity, and decreased immunity.

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Clinical features

Itching and burning

On speculum:

Vaginal discharge

is typically

curdy and white

. The vaginal epithelium is frequently edematous and

inflamed

.

Wet mount: pseudohyphae on a KOH prep.Vaginal pH is normal <4.5.

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treatment

Up to

30-40% of asymptomatic

women may have

C. albicans

grown on a vaginal swab. These women

do not need treatment even if they are pregnant

.

A

single oral dose of fluconazole or vaginal “azole” creamsRecurrent infection (4/1y): treat the acute episode (3 days of fluconazole) followed by a maintenance regimen (fluconazole 150 mg weekly for 6 months) to treat further recurrences.asymptomatic sexual partner does not need to be treated.

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Pelvic Inflammatory Disease

It’s an

inflammation

of the female

upper genital tract

(uterus, tubes, ovaries, ligaments) caused mostly by

ascending infection

from the vagina and cervix.

The most common initial organisms are

chlamydia and gonorrhea. With persistent infection, secondary bacterial invaders include anaerobes and gram-negative organisms.The inflammation may be present at any point along a continuum that includes endometritis, salpingitis and peritonitis.

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Risk factors

Age <35 (especially in teens)

Multiple sexual partners

Unprotected intercourse

IUCD

Nulliparity

History of STD

Pregnancy is

protective

as it forms thick cervical mucous that occludes the way for the bacteria.

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Cervicitis

:

The initial infection starts with invasion of

endocervical

glands with

chlamydia

and gonorrhea. A

mucopurulent

cervical discharge or friable cervix may be noted. Cervical cultures will be positive, but symptoms are usually absent.

Acute

salpingo-oophoritis

:

Usually after a menstrual period with

breakdown of the cervical mucus barrier

, the pathogenic organisms ascend through the uterus causing an

endometritis

; then the bacteria enter the oviduct where acute

salpingo-oophoritis

develops.

Chronic PID

:

If the

salpingo-oophoritis

is not appropriately treated, the body’s immune defenses will often overcome the infection but at the expense of persistent adhesions and scarring.

Tubo

-ovarian abscess (TOA):

If the body’s immune defenses cannot overcome the infection, the process worsens, producing an inflammatory mass involving the oviducts, ovaries, uterus, bowel, and

omentum

.

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diagnosis

Minimal criteria

: Sexually active young woman, Pelvic or lower abdominal

pain

,

Tenderness

: cervical motion or uterine or adnexal

Supportive criteria

(but not necessary for diagnosis):

Fever

, Abnormal vaginal

mucopurulent discharge

,

Presence of abundant

WBC

on vaginal fluid saline microscopy,

Elevated ESR, Positive lab findings of cervical N. gonorrhoeae or C. trachomatis.

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Acute salpingo-oophoritis

Bilateral lower abdominal-pelvic

pain

Often after menses.

P/E

: Bilateral abdominal

tenderness

, cervical motion tenderness and

mucopurulent discharge

.Investigations: High WBC and ESR, positive culture, Normal U/S

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Differential diagnosis

Adnexal torsion

Ectopic pregnancy

Appendicitis

Endometriosis

Diverticulitis

IBD

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management

Outpatient treatment

:

Criteria: absence of inpatient criteria

Antibiotics:

Ceftriaxone

IM x 1 plus

doxycycline

po bid for 14 days with/without metronidazole po bid for 14 days

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management

Inpatient treatment

is essential with severe cases:

Criteria

: Appendicitis cannot be ruled out; failed outpatient therapy; unable to tolerate oral medications; severe illness, high fever, nausea/vomiting; tubo-ovarian abscess or pregnancy

Antibiotics

: (1)

Cefotetan

IV q12 h +

doxycycline po or IV q 12 h or (2)

clindamycin

+

gentamicin

IV q 8 h

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management

Hospitalized patients

can be considered for

discharge

when their

fever is less than 37.5° for more than 24 hours

, the

WBC count is decreasing

, rebound tenderness is absent, and repeat examination shows

marked improvement of abdominal tenderness.Sexual partners of women with PID should be evaluated and treated for urethral infection caused by Chlamydia or gonorrhea, treatment with doxycycline if sexual contact with partner in the last 6 days.

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Tubo-ovarian abscess

End stage

process of acute PID

Accumulation of pus in the adnexae forming an inflammatory mass

involving the oviducts, ovaries, uterus, or omentum

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TOA

Severe

bilateral pain (lower abdominal pain, back and rectal pain) , nausea, vomiting.

P/E

: septic patients, high fever, elevated heart rate, decreased blood pressure, peritoneal signs, grunting, rigidity, bilateral adnexal masses.

Investigations:

elevated WBCs and ESR, +ve cervical and blood culture

On CT: bilateral complex pelvic masses.

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Differential Diagnosis

Diverticular Abscess

Appendiceal Abscess

Adnexal Torsion

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management

Admit

IV

clindamycin + Gentamycin

75%

of women respond to ABs alone within 72 hours.

Failure of medical therapy

suggests the need for

drainage

of the abscess. Although drainage may require surgical exploration, percutaneous drainage, guided by imaging studies (U/S or CT) should be used as an initial option if possible.

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Chronic pid

Chronic bilateral pain

, infertility, dyspareunia, ectopic pregnancy, abnormal bleeding,

NO nausea or vomiting.

P/E

: cervical motion

tenderness

and bilateral adnexal tenderness,

no discharge, no fever or tachycardia.

Investigations: normal WBCs and ESR, -ve culture, - on US: hydrosalpinx. Diagnosis is by laparoscopy by visualization of pelvic adhesions

with

pus collection in cul de sac.

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management

It’s

difficult

but involves:

Analgesia

and

adhesion lysis

which might be helpful in

fertility.

If severe and unresponsive pain: TAH-BSO with ERT (estrogen replacement therapy)

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complications

Infertility

Ectopic pregnancy

Fitz-Hugh Curtis syndrome

Dyspareunia

Abnormal bleeding.

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Thank you!