Gynaecological infections
- If one STI is present, there may be others
Lower Genital Tract
- Prior to puberty, the vaginal epithelium is cuboidal and the pH is neutral
- After puberty under the influence of oestrogen, stratified squamous epithelium develops and lactobacilli become the predominant commensals. This results in a drop in vaginal pH to 3.5-4.5
- After menopause the vaginal epithelium become atrophic and the bacterial flora becomes similar to that of the skin. pH rise to neutral again
Physiological discharge
- Normally white, turns yellow with oxidation
- Consists of desquamated epithelium, mucus, bacteria and vaginal transudate fluid
- Discharge increases midcycle due to increased mucus production
- Also increases during pregnancy and sometimes if the woman is on the contraceptive pill
Vaginal Candidiasis
- Over ¾ of women have had at least one episode
- Opportunistic infection, not an STI
- Presents are itching and soreness of the vagina and vulva with a white, curdy, yeasty smelling discharge
- pH of vagina is normal
- Predisposing factors
- Immunosuppression
- Diabetes
- Increased oestrogen
- Pregnancy
- High dose oral contraceptive pill
- Broad-spectrum antibiotic therapy
- Vaginal douching, tight fitting clothes etc.
- Treatment
- Topical clotrimazole 500mg
- Oral fluconazole 150mg (only affective against candida albican – cause 80% of cases)
Bacterial Vaginosis
- Commonest cause of abnormal discharge in women of childbearing age
- Commoner in women of Afro-Caribbean origin or those with an IUD
- Often arises spontaneously around the time of menstruation and then resolves spontaneously mid-cycle
- Causes by anaerobic bacteria e.g. Gardnerella vaginalis, Bacteroides
- Results in a rise in vaginal pH to between 4.5 and 7 and a disappearance or reduction in lactobacilli
- Associated with an offensive fishy smelling discharge
- Fishy smell due to the production of polyamines and trimethylamine by bacteria
- Diagnostic criteria
- Vaginal pH >4.5
- Release of a fishy smell on addition of alkali
- Characteristic discharge on examination
- Presence of ‘clue cell’ on microscopy – vaginal epithelium cells which are so coated in bacteria that there borders are obscured
- Cultures taken from high vaginal swabs – should see increase gram-positive and gram-negative cocci in the absence of with reduced numbers of gram-positive bacilli
- Treatment
- Metronidazole
- Women with BV are at increased risk of second trimester miscarriage and preterm delivery during pregnancy
- Also at increased risk of infection following surgery
- Treated women with metronidazole prior to termination reduces subsequent incidence of PID and endometriosis
Trichomoniasis
- Caused by a protozoan parasite, Trichomonas vaginalis
- STI which may be carried asymptomatically for several months prior to the development of symptoms
- Often carried in men asymptomatically but may present as a urethritis
- In women causes severe vulvovaginitis and a yellow/green purulent vaginal discharge
- Punctuate haemorrhages occur on the cevix, ‘strawberry cervix’
- Diagnosis is via culture of vaginal secretions. Causative organism has 4 flagella. PMNs may also be present
- Treatment
- Metronidazole
- Sexual partners should also be treated
Upper genital tract infections
- 80% of PID caused by gonorrhoea and Chlamydia
- PID results in tubule damage leading to ectopic pregnancy and infertility as well as chronic pelvic pain
Non-specific cervicitis
- Diagnosis is based on detecting purulent discharge at the cervical os
- It is often accompanied by bleeding
- Can be confused with a benign ectropion but this doesn’t generally bleed so readily
- Symptoms include
- Postcoital bleeding
- Purulent vaginal discharge
- Associated with;
- Gonorrhoea
- Chlamydia
- Herpes simplex (ulceration present)
- Nabothian follicles are mucus containing cysts which are often presnt following chronic cervicitis
Chlamydia trachomatis
- Commonest STI in industrialised countries
- Highest prevalence in women under 25
- Asymptomic in 80% of women and 50% of men
- In men it causes a urethritis
- In women it causes cervicitis and PID
- Intracellular bacterium, infects columnar epithelium in the genital tract
- Samples must be taken from the endocervix and diagnosis is via ELISA or PCR
- PCR can also be done on urine samples
- Treatment
- Doxycycline
- Azithromycin
- Ofloxacin
- During pregnancy
- Azithromycin
- Erythromycin
- Essential that sexual partners are also treated
Gonorrhoea
- Prevalence of around 1% in women of child-bearing age
- 50% of women are asymptomatic
- 70% of men are symptomatic, symptoms include;
- Urethritis
- Green urethral discharge
- Dysuria
- Can be carried in the throat and cause exudative tonsillitis
- Can also cause conjunctitis and proctitis
- Neisseria gonorrhoeae is a gram-negative diplococcus which colonises the columnar epithelium of the genital tract
- Diagnosis made by observing gram-negative diplococci, intracellularly or urethral, cervical and rectal swabs
- Treatment – will depend on culture sensitivity. Mostly only requires a single dose
- Amoxicillin
- Ciprofloxacin
- Spectinomycin
- Azithromycin
- Ceftriazome
- Cefixime
- Sexual partners must be also screened and treated
- More than 50% of women with gonorrhoea also have Chlamydia, therefore treat together
Pelvic Inflammatory Disease
- As infection ascends into the uterus endometritis develops which is associated with inter-menstrual bleeding
- Salpingitis;
- Mucosal inflammation, initially involving PMN, then mononuclear cells followed by plasma cells
- Inflammatory exudates fills the tube and adhesions can develop
- Inflammation extends over the serosal surface and pus exudes from the fimbriae over the ovaries and adnexae
- Tubes can become fixed
- Can result in pelvic peritonitis
- Tubes can become blocked
- Uterus can become fixed and retoverted
- Hydrosalpinx is caused by accumulation of fluid within the tubes resulting in swelling
- Pyosalpinx is infection within the tube
- Clinical features
- Pelvic pain
- Deep dyspareunia
- Intermenstrual bleeding
- O/E cervical excitiation
- Lower genitial tract infection, BV, trichomoniasis or cervicitis
- Pyrexia, raised CRP and neutrophil count
- Adnexal mass
- Laproscopy is regarded as the gold standard for diagnosis
- If PID is suspected, endocervical swabs should be taken for C. trachomatis and N. gonorrhoeae. A high vaginal swab should be taken for Trichomonas vaginalis and BV
- Treatment – should cover both Chlamydia and gonorrheoea and well as anaerobics
- Doxycycline and ciprofloxacin along with metronidazole or;
- Ofloxacin with metronidazole
- In patients who are systemically unwell;
- I.V. cephalosporin and metronidazole along with a 2 week course of doxycycline
- Intra-abdominal spread of Chlamydia and gonorrhoea can cause peri-appendicitis or peri-hepatitis
- Peri-hepatitis is called Fits-Hugh Curtis syndrome
- May present with right upper quadrant pain
- May be misdiagnosed as cholecystitis
- Disseminated infection with Chlamydia may cause Reiter’s syndrome or sexually acquired reactive arthritis
- Occurs in less than 1% of cases
- Asymmetrical oligoarthritis affecting the large joints of the lower limb
- In Reiter’s syndrome there is also uveitis and rash
- It is associated with HLA-B27
- Disseminated infection with gonorrhoea is rare but can present as a septic oligoarthritis in the small joints of the wrist and hands. Also associated with a popular rash.
Genital Ulcer Disease
Herpes Simplex
- Mostly associated with herpes simplex virus Type II
- Present for life
- Reports however that up to 50% of cases might be caused by Type I
- May be subclinical for many years prior to presenting features developing
- Diagnosis is made by extracting vesicular fluid from the ulcer and demonatrating viral particles via EM or culture on a tissue monolayer
Primary Herpes
- Presents up to 3 weeks after infection
- Widespread involvement of the vagina and vulva
- Cervix may also be affected
- Primary pharyngeal and rectal infections can also present
- Painful vesicles can coalesce to form ulcers
- Urinary retention can develop due to pain and involvement of the sacral nerves
- Generally looks much worse than recurrent infection
- Treatment
- Bathing in salt water
- Lignocaine local anaethetic gel
- Antiviral treatment – acyclovir
Recurrent Herpes
- Following a primary infection, herpes colonises the neurons of the dorsal root ganglion therefore establishing a latent infection
- Recurrent disease can vary from asymptomatic shedding or virus to large ulcers which can develop if the patient is immunosuppressed
- Antiviral treatment is usually ineffective at treating established recurrent infection
- Advice is the bath in salt water and to avoid intercourse until vesicles have cleared up
- Some individuals experience a prodrome prior to development of the vesicles. This may involve tingling or pain in the thigh or perineum
- Some patients develop frequent reoccurrences which are quite debilitating. In these circumstances it might be appropriate to prescribe long term suppression with acyclovir.
- Virus can be transmitted in the absence of clinical signs it is therefore important that the patients uses condoms for intercourse
Syphilis
- Systemic STI caused by Treponema pallidum
- First manifestation is a painless ulcer (chancre) at the site of inoculation – in women most common on the cervix
- Usually arises 3-6 weeks post infection
- Usually associated with enlargement of the inguinal lymph nodes
- Following the chancre, secondary syphilis can arise, this is associated with a non-itchy maculopapular rash mostly involving the palms and soles of the feet
- Warts can be seen peri-anally
- Mucus patches and linear ulcers can be seen on the mucosal surfaces
- May be generalised lymphadenopathy
- Sensorineural deafness can occur early in infection due to destruction of the inner ear hair cells
- Alopecia, arthritis and meningitis can also develop
- Diagnosis is made via microscopy and serological tests
- Following resolution of secondary syphilis a period of latency occurs whereby there are no clinical manifestations of disease
- Primary and secondary syphilis are not life threatening but late tertiary syphilis is
- 5-10% can develop neurosyphilis
- 20% will develop cardiovascular syphilis – aortic aneurism, aortic regurgitation
- Risk of vertical transmission
- This can cause intrauterine death
- Prevention of vertical transmission requires mother to be treated before 20 weeks gestation
- Treatment
- Penicillin
Human papillomavirus
- More than 70 different types have been decribed
- Some strains (6 and 11) can cause genital warts
- These are sexually transmitted
- Can affect the skin of the vulva, perineum, vagina, cervix and rectum
- HPV 16 and 18 cause flat warts and have been linked to cervical carcinoma
- Smoking is a strong risk factor
- Treatment of genital warts
- Cyotherapy
- Application of podophyllin
- Surgical treatment for intractable cases, laser, electrocautery or scissor excision
Molluscum contagiosum
- Causes by pox virus
- Painless pearly lesions up to 5mm in diameter
- STI
- Fluid from vesicles is infectious
- Large confluent lesions can develop in patients who are immunosuppressed
- Untreatable, cleared by own immune response
- Can be treated with cyotherapy and application of phenol