upper and lower genitourinary infections

it is a topic of gynaecology

1. UPPER AND LOWER GENITAL TRACT INFECTIONS   M.MAAZ HAMEED SAMI UL HASSAN ALI HASSAN YOUSAF KHAN

2. CLINICAL SCENARIO A 23 years old patient ,presents to the emergency department with a 3-day history of lower abdominal pain , which she describes as dull and crampy, worsening with movement. She also reports experiencing unusual vaginal discharge with an unpleasant odor, fever (38.5°C), nausea, and vomiting.She gives a history of use of IUCD and pharyngeal infection. On Examination, there is Lower abdominal tenderness , especially in the pelvic region, with rebound tenderness, there is also Cervical motion tenderness , uterine tenderness , and adnexal tenderness. Her Investigations showed, Raised WBCs, ESR :19mm / hrs and elevated CRP, Her ultrasonography showed thickened fallopian tubules and fluid in pelvis.

3. DIAGNOSIS: PELVIC INFLAMMATORY DISEASE

4. CLINICAL CRITERIA FOR DIAGNOSIS: LOWER ABDOMINAL , ADENEXAL(UTERINE) TENDERNESS AND CERVICAL MOTION TENDERNESS (Chandelier`s sign). ORAL TEMPERATURE> 101°F A BNORMAL VAGINAL AND SALINE MOUNT SECRETIONS ESR> 15mm/ hr ELEVATED CRP LABORATORY DOCUMENTATION OF CERVICAL INFECTION WITH N.gonorrhea or C.trachomatis

5. RISK FACTORS INVESTIGATIONS MANAGEMENT Sexual Activity Clinical Diagnosis Hospital Admission Previous PID CBC : Leukocytosis Resusication (severe pain , sepsis, poor compliance) Multiple Sex Partners CRP: raised 2 week duration of antimicrobial therapy Lack of barrier protection Culture Sensitivity Macrolide + Metronidazole+ 3rd generation cephalosporins ( parentral ) IUCD use Ultrasound Contact tracing of partner Septic abortion Nucliec acid Amplification test Treatment of partner

6. COMPLICATIONS Chronic pelvic pain sub fertility ectopic pregnancy pelvic Abscess Fitz Hugh Curtis syndrome- right upper quadrant pain due to peri hepatitis- violen string appearance

7. LOWER GENITAL TRACT INFECTIONS THESE ARE INFECTIONS OF EXTERNAL AND INTERNAL STRUCTURES OF PRIMARILY VULVA, VAGINA AND CERVIX THESE INCLUDE: Vulvovaginitis Bacterial Vaginosis Trichomoniasis STD`s such as Chlymadia and Gonorrhoea

8. BACTERIAL VAGINOSIS DIAGNOSTIC POINTS: AMSELS CRITERIA ( 3 OUT OF 4 REQ.): Homogeneous Grey-White Discharge. Increased vaginal pH >4.5 Characteristic Fishy Smell Clue Cells Present on microscopy

9. CAUSATIVE FACTORS Investigations Management Depletion of lacto -bacilli in normal vaginal flora Gram Staining of Vaginal Discharge May resolve spontaneously Elevation of vaginal pH, i.e >4.5 Amsel Criteria Oral or topical Metronidazole Existence of Gardenella vaginalis Nugent Criteria Clindamycin 2% crèam vaginally Douching, PID Avoid Vaginal douching Preterm Birth Avoid vaginal over washing Misscarriage Oral Sex

10. VULVOVAGINAL CANDIDIASIS RISK FACTORS: Immunosuppression Antibiotics Pregnancy Diabetes OCP usage CLINICAL FEATURES: Vulval Itching Vulval soreness Thick Curd-like ,White Vaginal Discharge Dysuria with burning micturation Superficial dypareunia

11. INVESTIGATIONS: Erythema, Vulval fissuring and typical white adherent plaques on Vaginal Examination Microscopy: pseudo-hyphae on KOH wet mount and spores on gram stain Culture MANAGEMENT: (If symptomatic) Topical Intravaginal pessaries Oral imidazole i.e fluconazole For recurrence; Topical vulval antifungal+ use of aqueous cream+ cleansing agent Wear cotton underwear Avoid chemical irritants like soap

12. TRICHOMONIASIS Caused bt T.vaginalis Yellow-green Discharge with foul smell pH of discharge is > 4.5 Strawberry Cervix INVESTIGATIONS: Microscopy of discharge on saline wet mount: Mobile trichonomads with terminal spike and 4 flagella Culture of Discharge Colposcopy- Double loop punctuations of cervix and vagina Nucliec Acid Amplification test - DIAGNOSTIC MANAGEMENT: Oral Metronidazole Contact Tracing of Partners and Treatment

13. TYPES OF VAGINAL DISCHARGE CLEAR DISCHARGE: Healthy, pregnancy, ovulation GREY DISCHARGE: bacterial vaginosis PINK DISCHARGE: cervical bleeding WHITE DISCHARGE: healthy vulvo vaginal Candidiasis GREEN-YELLOW DISCHARGE: sexually transmitted disease RED DISCHARGE: mensturation cervical disorders

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