3.0 Infections in Gynaecology-1yisitityix.pptx

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1. Gynaecological Infections Dr E. Kaunda OBG MBChB Junior Clerkship Lecture 1 March 2024

2. Objectives To understand gynecological infections [Including Sexually Transmitted Infections (STIs) and PID] and their treatment. To review the syndromic approach to management 2

3. Introduction Many gynaecological infections are sexually transmissible Others, such as Candida and UTI, are frequently triggered by sexual intercourse although the organism is colonizing the woman before hand STIs associated with risky sexual behavior Inflammatory STIs & genital ulcers lead to increased risk of HIV acquisition by: Reducing physical/mechanical barriers (disruption of epithelium) Increasing HIV in genital lesions, semen or both Increasing the number of receptor cells or the density of receptors per cell 3

4. Who Gets STIs? Anyone having unprotected sex regardless of their age, gender, race etc is at risk Inner city, low income communities have higher incidence Higher risk seen in women, teens and young adults & substance users 4

5. Importance of STIs Common & cause significant morbidity Incurable viral STI are increasing Are preventable Chlamydia & Gonococcus have major adverse upper genital tract sequelae Both ulcerative and non-ulcerative STI facilitate HIV transmission Most people with STIs are seen outside of STI clinics 5

6. Morbidities attributable to STIs Cancer (HPV, HBV, HCV) Immunodeficiency (HIV) Chronic Pelvic Inflammatory Disease (PID)/ Chronic Pelvic Pain (CPP) Infertility (Chlamydia, Gonorrhea) Ectopic Pregnancy (Chlamydia, Gonorrhea) Chronic Liver disease (HBV, HCV) Perinatal complications (pre-term; LBW; stillbirth; occular , respiratory, and systemic disease) 6

7. STIs: Largely Asymptomatic 75% of Chlamydia in women Most gonorrhea in women 33-50% of Hepatitis B in adults 75% of Hepatitis C in adults Almost all carcinogenic HPV types (low risk types cause visible genital warts) Two-thirds HSV-2 infected adults have no recollection of an episode of genital herpes HIV for most of its clinical course 7

8. STI Case Management Etiologic Lab isolation of the causative organism Clinical Assessment based on clinical appearance Syndromic Clinical symptoms, signs, risk assessment, rapid and cost-effective tests Mixed All of the above 8

9. Etiologic Case Mx Advantages Screening for asymptomatic infection Definitive diagnosis to guide accurate Mx Antimicrobial susceptibility testing Disadvantages Current tests often expensive and unreliable Require sophisticated equipment and training Often require clients to return days later 9

10. Syndromic Case Management Types of Syndromes Vaginal discharge Genital ulcer disease Inguinal Bubo Genital growths/ warts Lower Abdominal Pain 10

11. Syndromic Case Management (SCM) Advantages Identifies and treats by signs & symptoms Syndromes are easily recognized clinically Tx given for majority of organisms Simple and cost-effective Valid, feasible, immediate Tx 11

12. Syndromic Case Management (Cont’d) Disadvantages Tendency to over treat – justifiable in high prevalence settings ( > 20%) Decreased specificity Overuse of expensive drugs Asymptomatic cases not identified & treated. 12

13. Syndromic Case Management (Cont’d) Requirements Adequate medical history Good sexual history Complete STI clinical examination Management guidelines Good supply of effective drugs 13

14. 14 Essential Steps In STI Care Management* Syndrome Assessment Risk Assessment Diagnosis Treatment 5 C s C ontact tracing C ompliance C onfidentiality C ondom use /abstinence C ounseling (screening tests) (diagnostic tools) * Adapted from Holmes & Ryan-modified

15. Vaginal Discharge Syndrome Can be normal (physiological) or pathological Normal Vaginal Discharge Is whitish, becoming yellowish on contact with air due to oxidation Components: Desquamated epithelial cells Mucous from the cervical glands Bacteria Fluid formed as a transudate from vaginal wall 15

16. Vaginal Discharge Syndrome Normal Vaginal Discharge (Cont’d) Physiological discharge increases In mid cycle due to increased mucous Pregnancy Sometimes when woman is on COCs More than 90% of the bacteria in the vagina is lactobacilli Lactobacilli breaks down glycogen to produce lactic acid 16

17. Vaginal Discharge Syndrome Pathological Vaginal Discharge Infectious Candidiasis Bacterial Vaginosis Tichomoniasis Cervicitis Other causes Cancers (eg Ca cervix) 17

18. Vaginal Discharge Syndrome Vulvovaginal Candidiasis Causes: C. albicans (80%), C. glabrata, C. krusei and C. tropicalis Distinguish between two syndromes: Uncomplicated: sporadic; mild-mod sx , usually albicans complicated: recurrent; severe sx ; non- albicans ; altered host (DM, pregnancy, immunodeficiency) 18

19. Vaginal Discharge Syndrome Vulvovaginal Candidiasis (Cont’d) Clinical Features Itchness and soreness of vulva and vagina Curdy whitish discharge that may smell of yeast Normal vaginal pH (3.5-4.5) Diagnosis Microscopy and culture to confirm diagnosis 19

20. Vaginal Discharge Syndrome Vulvovaginal Candidiasis: Treatment Uncomplicated Clotrimazole 200mg OD X 3-6/7 or Fluconazole 150mg PO stat (Only for C. albicans strains) or Nystatin PV pessaries 100,000 units nocte X14/7 Complicated Treat once or twice a month for six months to suppress recurrence 20

21. Vaginal Discharge Syndrome Bacterial Vaginosis (BV) Introduction Overgrowth of anaerobic/facultative anaerobic flora Organisms: Gardnerella vaginalis Bacteroides spp Mobilincus Mycoplasma hominis Clue Cell 21

22. Vaginal Discharge Syndrome Bacterial Vaginosis Clinical Features Principal symptom is a PV discharge: Offensive fishy smell Thin Homogeneous Adherent to vaginal walls White or yellow Diagnosis Gram stain findings (Nugent scale): based on number of lactobacilli and other bacterial morphotypes Clinical findings (Amsel criteria): 3 of the following must be present: homogeneous discharge pH >4.5 clue cells (>20%) amine odor on addition of KOH (+whiff test) 22

23. Vaginal Discharge Syndrome BV – Adverse Outcomes Non-Pregnant Women PID Post-hysterectomy infection May enhance HIV transmission In Pregnancy postabortal infections preterm labor and delivery premature rupture of membranes chorioamnionitis postpartum endometritis spontaneous abortion in first trimester 23

24. Vaginal Discharge Syndrome Management: BV Metronidazole 400 mg TDS PO X 5days or Metronidazole 2 g PO stat Metronidazole gel 0.75% Clindamycin cream 2% Initial cure rates are at 80% 30% have a relapse within 1 month of treatment 24

25. Vaginal Discharge Syndrome Trichomonas Vaginalis Introduction Sexually transmissible infection Causes Vulvovaginitis that can be severe Accompanied by purulent, offensive discharge Punctate haemorrhages occur on the cervix i.e. strawberry Cervix Discharge 25

26. Vaginal Discharge Syndrome Trichomonas Vaginalis (Cont’d) Strawberry Cervix Microscopy 26

27. Vaginal Discharge Syndrome Trichomonas Vaginalis (Cont’d) Diagnosis Wet mount microscopy of vaginal secretions -Has 60% sensitivity for detecting the organism Culture in a specific medium such as Fineberg -Whittington. Treatment Metronidazole 2 g PO stat OR Metronidazole 400mg TDS PO for 5 days Partner (s) should treated as well 27

28. Vaginal Discharge Syndrome Chlamydia trachomatis Organism: intracellular bacteria Transmission: penile, vaginal, anal, perinatal Sites infected: urethra, cervix, rectum (eyes, resp tract-neonates/infants) Incubation: approx 1-3 weeks though most cases are asymptomatic ( F>M) Symptoms: Men-dysuria, clear or cloudy urethral discharge, rectal pain &/or bleeding 28

29. Vaginal Discharge Syndrome Chlamydia trachomatis (Cont’d) Symptoms: women- vaginal discharge, dysuria dyspareunia, spotting or postcoital hemorrhage, lower abdominal pain Diagnosis: culture, antigen detection, DNA amplification tests Treatment: Azithromycin 1gm PO stat or , Doxycycline 100m BD X 7/7 or Erythromycin 500mg QID X 7/7 Prevention: abstinence - barriers - monogamy High re-infection rate 29

30. Vaginal Discharge Syndrome Gonorrhea (Top G - ve diplococci, bottom Gonococcal cervicitis) Organism: bacteria (Neisseria Gonorrhoea ) Transmission: penile, vaginal, pharyngeal, perinatal, rarely anal Sites infected: urethra, cervix, pharynx (eyes-neonates/infants), rectum 30

31. Vaginal Discharge Syndrome Gonorrhea (Cont’d) Most non-urethral infexns are asymptomatic (F>M) Symptoms: Men- dysuria, purulent urethral discharge, rectal discharge pain and /or bleeding Symptoms: women-vaginal discharge, dysuria, dyspareunia, spotting or postcoital hemorrhage, lower abdominal pain 31

32. Vaginal Discharge Syndrome Gonorrhea Diagnosis: gram stain, culture, antigen detection, DNA amplification tests Treatment: Ceftriaxone 500mg IM stat or Cefixime 400mg PO stat Prevention: abstinence - barriers - monogamy high re-infection rate 32

33. Syndromic Case Management: Vaginal discharge syndrome Treat for Gonorrhoea Treat for Chlamydia Treat for Trichomoniasis Treat for Bacterial Vaginosis Treat for Candidiasis Drug combinations as highlighted under etiologic management 33

34. Genital Ulcer Disease (GUD) Syphillis Chachroid Herpes Simplex Lymphogranuloma venereum Granuloma inguinale (Donovanosis). 34

35. Genital Ulcer Disease: Syphilis Organism: bacteria (Treponema pallidum) Transmission direct contact with an infected site, perinatal Sites infected: sex organs, blood, body tissue, all organ systems Incubation: approx. 10-90 with average of 21days. Symptoms: primary- chancre, often painless secondary- rash, mucus patch, alopecia tertiary/latent- with no obvious symptoms for 5-20+years destructive lesions targeting bones, heart, CNS etc 35

36. Genital Ulcer Disease: Syphilis – Chancre 36

37. Genital Ulcer Disease: Secondary Syphilis 37

38. Genital Ulcer Disease: Syphilis (Cont’d) Diagnosis : physical exam Darkfield microscopy CSF and serology tests VDRL TPHA FTA(abs) 38

39. Genital Ulcer Disease: Syphilis (Cont’d) Treatment: penicillin (Benzathine Penicillin 2.4 MU IM stat or Erythromycin 500mg QID X 14/7) Prevention: abstinence - barriers - monogamy Serious outcome: increased risk of HIV infection severe organ damage severe illness or death in newborns. 39

40. Genital Ulcer Disease: Herpes Simplex Herpes simplex viruses are ubiquitous, host-adapted pathogens that cause a wide variety of disease states Two types exist: herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) HSV-1 is traditionally associated with orofacial disease HSV-2 is traditionally associated with genital disease 40

41. Genital Ulcer Disease: Herpes Simplex (Cont’d) 41

42. Genital Ulcer Disease: Herpes Simplex - Laboratory Studies Herpes simplex virus (HSV) infection is best confirmed by isolation of the virus in tissue culture (the criterion standard for diagnosis) Immunofluorescent staining of the tissue culture cells can be used to quickly identify HSV and can distinguish between types 1 and 2. 42

43. Genital Ulcer Disease: Herpes Simplex - Treatment The goals of pharmacotherapy are to reduce morbidity and to prevent complications Initial treatment: Acyclovir 400 mg PO TDS for 7-10 days Intermittent treatment for recurrence: 200 mg PO q4hr while awake (5 times daily) for 5 days; initiate at earliest sign or symptom of recurrence 43

44. Genital Ulcer Disease: Granuloma Inguinale or Donovanosis Caused by Klebsiella granulomatis Single /multiple slightly elevated lesions under the skin at the site of infection Become heaped ulcers, painless & enlarge slowly into open sores. May form abscesses 44

45. Genital Ulcer Disease: Donovanosis - Treatment Trimethoprim/sulfamethoxazole Doxycycline Ciprofloxacin Erythromycin 45

46. Inguinal Bubo/GUD: Chancroid Caused by a bacteria Haemophilus Ducreyi Painful ulcers on the genitals. May cause lymph nodes in the groin Swollen lymph nodes which are filled with pus are referred to as " buboes" 46

47. Inguinal Bubo/ GUD: Chancroid- Treatment Azithromycin - 1 g orally (PO) as a single dose  or Ceftriaxone - 250 mg intramuscularly as a single dose  or Erythromycin base - 500 mg PO 3 times daily for 7 days or Ciprofloxacin - 500 mg PO twice daily for 3 days 47

48. Inguinal Bubo: Lymphogranuloma Venerium (LGV) LGV is an uncommon STD caused by Chlamydia trachomatis Characterized by self-limited genital papules or ulcers followed by painful inguinal and/or femoral lymphadenopathy 48

49. Inguinal Bubo: LGV - Treatment Erythromycin 500mg 4 times a day for 21 days 49

50. Genital Ulcer Disease Syndrome Treat for Syphilis Treat for Chancroid Treat for Lymphogranuloma Venerium Treat for Genital Herpes Treat for Donovanosis 50

51. Genital growths/ warts Human Papilloma Virus Transmission: direct contact with an infected site, low rate of perinatal/neonatal trans. Infects the vulva, perineum, the vagina, cervix, rectum, urethra, oral, anal area Cause warts & cervical cancer 51

52. Genital growths/ warts Human Papilloma Virus (Cont’d) Types 6 & 11 causes warts Types 16 and 18 causes cervical cancer Incubation: 30 days - 22 months Symptoms: painless warts on infected area, most people are asymptomatic and unaware 52

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54. Lower Abdominal Pain Pelvic Inflammatory Disease (PID) A bacterial infection of the female upper genital tract , including the uterus, fallopian tubes and ovaries. It is commonly an ascending infection from the vagina or cervix. leading to endometritis, salpingitis, parametritis , oophoritis, pelvic abscess & peritonitis 54

55. Lower Abdominal Pain PID (Cont’d) Commonly develops in sexually active women between the ages of 15 and 24. In presence of HIV infection, PID may be more common and more severe Many more women with PID experience few or no symptoms 55

56. Lower Abdominal Pain PID (Cont’d) Clinical feature -Fever >38.3°C, Abnormal PVD, LAP & tenderness Different types of bacteria, mainly chlamydia or  gonorrhoea Prognosis is good if treated adequately on time 56

57. Lower Abdominal Pain: PID - Acute Salpingitis 57

58. Lower Abdominal Pain: PID - Long Term Complications Chronic PID Tubo-ovarian abscess Peri-Hepatitis (Fitz- Hugh-Curtis Syndrome) Ectopic pregnancy Infertility Chronic Pelvic pain 58

59. Lower Abdominal Pain: PID - Treatment Outpatient treatment (Mild cases) Regimen consists of the following: Ceftriaxone 500 mg intramuscularly (IM) once as a single dose  plus Doxycycline 100 mg orally twice daily for 14 days Metronidazole 400 mg orally TDS for 14 days 59

60. Lower Abdominal Pain: PID – Treatment (Cont’d) In-Patient treatment (Severe cases) Regimen consists of the following: Ceftriaxone 1 BD IV for 5-7 days then oral cephalosporin or quinolone for a total duration of 14 days Doxycycline 100 mg orally twice daily for 14 days plus Metronidazole 500 mg TDS IV for 5-7 days then orally for a total duration of 14 days 60