28 Aug Gynecologic Infections- Pelvic Inflammatory Disease (PID), Bacterial Vaginosis (BV)

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• Gynecological infections
  • Sexually transmitted disease, or
  • Unrelated to a sexually transmitted disease.
  • Two major gynecological infections affect a woman, mostly during her childbearing years:
  • Pelvic inflammatory disease (PID):
    • General:
      • Sexually transmitted,
      • Infectious,
      • Affects the upper part of the female reproductive tract, including the ovaries, uterus, fallopian tubes, and other pelvic structures.
      • Multiple bacterial species linked as causative agents
      • Can be confined to the pelvis or can include the liver (then called Fitz-Hugh-Curtis syndrome).
    • Incidence:
      • US: 800,000 cases of PID are reported every year. Underreporting problem: CDC: Per year: about one million PID in the US per year, about 150,000 hospitalizations
    • Predisposing factors:
      • Multiple sexual partners,
      • History of sexually-transmitted diseases,
      • History of sexual abuse in the past,
      • Frequent vaginal douching may
      • Dilatation and curettage,
      • Hysteroscopy, or endometrial biopsy: ascending PID,
      • Female under the age of 25 years using oral contraceptive pills,
      • Intrauterine device: about nine-fold risk for having PID, and
      • Genetic predisposition: abnormalities in the immune system: increased risk of getting an infection with Chlamydia trachomatis.
    • Signs and Symptoms:
      • Lower abdominal or pelvic pain,
      • Cervical motion tenderness,
      • Uterine tenderness, and
      • Fever of greater than 101 degrees Fahrenheit.
      • Physical exam:
        • Rebound tenderness in the abdomen,
        • Foul-smelling vaginal discharge, and
        • Right upper quadrant abdominal pain and tenderness may increase the chance that the patient has Fitz-Hugh-Curtis syndrome. (Incidence rate:4%).
      • Etiology:
        • Organisms isolated in cultures of the cervical and vaginal discharge include Neisseria gonorrhea and Chlamydia trachomatis—both of which are exclusively sexually-transmitted.
        • The most common agent: Chlamydia with gonorrhea being the second most common organism.
        • 10-20 percent of untreated STDs from either of these organisms will lead to PID.
        • 30-40 percent of cases are considered polymicrobial, with more than one organism isolated.
        • Inflammation of the upper reproductive tract seems to facilitate the involvement of other types of bacteria, particularly anaerobic bacteria. Viruses, such as cytomegalovirus and herpes simplex type.
      • Pathology:
        • Starts with a vaginal infection in the vagina and cervix
        • Ascends into the upper reproductive tract.
        • Most common organism: Chlamydia and Gonorrhea infections,
        • Haemophilus influenzae, Gardnerella, Bacteroides and Peptococcus and other anaerobes can be part of the polymicrobial picture,
        • Best diagnostic tool: Laparoscope.
        • Elevated ESR and C-reactive protein in most cases,
        • Cultures and/or DNA probes for Chlamydia and gonorrhea should be done.
        • Unclear to be evaluated with ultrasound, MRI scan, or CT scan of the pelvis.
        • Two stages of PID:
          • First stage: Actual vaginal or cervical infection,
          • Second stage: Ascent of the organisms from the lower reproductive tract to the upper reproductive tract.
          • Hormonal changes in the cervical environment during the menstrual cycle predispose a woman to have ascending disease.
          • Infection may spill out of the fallopian tubes to affect the nearby bowel or may include peri-hepatic area (Fitz-Hugh-Curtis syndrome).
          • Lymphatic spread of infection is believed to be behind the extra-pelvic involvement.
          • Acute peritonitis can be seen in severe cases.
        • Treatment and Management:
          • Pain management,
          • Treatment of infection:
            • Aggressive antibiotic use is recommended: Eradicate the offending organisms: success rate: up to 75 percent of cases.
            • Surgery: Laparotomy: Irrigation of the pelvis, drainage of abscesses, release of adhesions or even the unilateral removal of an involved tube and ovary.
          • Reduction of complications.
            • Tube-related infertility:
              • Implantation failure occurs in up to 25 percent of patients who later have IVF.
              • Surgery: Lysis of adhesions,
            • Ectopic pregnancy, and
            • Chronic pelvic pain.
          • Complications:
            • Ectopic pregnancy
              • The risk of ectopic pregnancy is increased by up to 50 percent in women who have had PID
            • Tube-related infertility
              • Up to half of all women with known tube-related infertility will have scarring consistent with a previous PID infection and positive antibodies indicating a past Chlamydia infection.
              • The number of episodes of PID correlates positively with the risk of scarring and infertility.
            • Chronic pelvic pain:
              • About 25 percent of women with PID will have chronic pelvic pain later.
            • Tubo-ovarian abscess:
              • Low risk but life-threatening: rupture associated with peritonitis.

• Bacterial vaginosis (BV):
  • General:
    • Not usually sexually transmitted,
    • nonspecific vaginitis,
    • lack of real inflammatory response.
    • Causative agent: Gardnerella vaginalis: main bacterial species.
  • Incidence:
    • One-third of all women will have BV in their lifetime: US: ten million cases seen per year on an outpatient basis. 80 percent of men who have a sexual partner with BV grow out Gardnerella in urethral cultures.
  • Predisposing factors:
    • Recently used antibiotics,
    • Decreased levels of estrogen,
    • Vaginal douches,
    • Intrauterine device, and
    • New sexual partner (as some aspects of getting Gardnerella vaginalis is sexually-transmitted).
  • Signs and Symptoms:
    • Fishy vaginal odor,
    • Increased vaginal discharge,
    • Irritation of the vulva and
    • Pain with urination or with intercourse (which is the least common symptom).
  • Etiology:
    • Polymicrobial in nature, Gardnerella vaginalis: most common organism cultured.
      • Facultative anaerobe grows in patients who may or may not have a sexual partner.
    • Disruption in the normal vaginal flora triggers the chance that BV can occur.
    • Other anaerobic organisms also are cultured of the vaginal discharge in patients with BV.
  • Pathology:
    • The presence of clue cells on a saline smear of the vaginal discharge is the most specific criterion for the disorder.
    • pH of the discharge of greater than 4.5 is seen in up to 90 percent of patients.
    • Seventy percent will have a fishy odor to the discharge with a gray, thin, and homogeneous nature.
    • The culture will grow out Gardnerella, Lactobacillus species, or Mobiluncus species.
  • Treatment and Management:
    • Antibiotic coverage for Gardnerella vaginalis,
    • Pregnant women with known BV should be treated,
    • Treat BV before IUD insertion,
    • Douching and bubble baths should be avoided,
    • Any over-the-counter vaginal cleansing products should be avoided, and
    • Hypoallergenic soap should be used to wash the genitalia.
  • Complications:
    • Urinary tract infection caused by Gardnerella vaginalis,
    • Endometritis,
    • Chorioamnionitis (in pregnancy),
    • Cervicitis, and
    • Pelvic inflammatory disease.
    • Rare cases if untreated result in bacteremia with the causative agent.