GENITAL INFECTIONS Dr.B.BOYLE Copyright@
GENITAL INFECTIONS Dr.B.BOYLE Copyright@ GENITAL INFECTIONS FEMALE Vaginal Infections Infections of the female pelvis Post-Gynaelogical Surgery Infections Pelvic Inflammatory Disease(Previous lecture) MALE Prostatitis Epididymitis Orchitis Urethritis (Previous Lecture) Balanitis Vaginal Infections Normal Flora Candidiasis (Previous lecture) Trichomoniasis (Previous lecture) Bacterial Vaginosis Staphylococcal Infection Foreign Body Vaginitis Herpes Simplex Virus (Previous lecture) Human Papillomavirus (Previous lecture) Normal Vaginal Flora(p-p) Variety of bacteria, primarily obligate and facultative anaerobes More that 105 lactobacilli per ml of vaginal material recovered from 75% of women Primarily Lactobacillus crispatus, Lactobacillus jensonii Viridans Streptococci and S.epidermidis found in 50% of women One sixth of women have large numbers~105-6 of Bacteroides and Prevotella spp. Gardnerella vaginalis in 30-90% of women Staphylococcus aureus in 5% of women Yeasts carried in 15-20% of healthy women Vaginal Secretion Endocervical secretions combine sloughed epithelial cells and normal bacteria to form physiologic discharge, occasionally give rise to leukorrhoea Often increased during pregnancy or with the use of oral contraceptives Floccular and no bubbles present Lactobacillus spp. Prevents growth of other organisms particulary anaerobes by the Hydrogen peroxidase system Bacterial Vaginosis Described by Gardner and Dukes 1955 Predominant symptom -Vaginal odour Perivaginal irriation is much milder than candidiasis or trichomoniasis 90% mild to moderate discharge, often visible Labia and vulva nonerythematous Discharge: grayish,thin,homogenous containing small bubbles Bacterial Vaginosis Diagnosis(3/4) Guide Ph greater than 4.5(90%) Homogenous white , adherent vaginal discharge Positive whiff test (limited value) Clue cells:direct microscopy of discharge Some clue cells seen in 90% of women reveals vaginal epithelial with BV cells studded with tiny coccobacilli, edge of cellsIn normal women predominant type of or obliterate the nucleus bacteria is large rods(Lactobacilli spp.) Bacterial Vaginosis Gardnerella Vaginalis is isolated from 92-98% of women with BV, however also isolated from asymtomatic females Risk factors: higher in those with more sexual partners(male and female) , Higher in those with STI, symptoms often appear in women shortly after becoming sexually active, 80% partners have organism isolated, higher in those who douche or use intrauterine devices however is seen in virgins Because of the association with STI`s , those screened in STI`s clinics are also screened for G.vaginalis Gardnerella Vaginalis Faculative anaerobic, gram variable organism Has been shown to consume ammonia produced by anaerobes Has phospholipase A2 activity Produces B-haemolysis on human blood agar or blood agar with gelatin added, small pinpoint colonies Bacterial VaginosisPathophysiology BV is actually a synergistic infection involving not only G.vaginalis but certain anaerobic bacteria as well Evidence Numbers of anaerobes are dramatically increased in women with BV (Bacteroides and Prevotella spp. Etc) Asymtomaic carriers Odour due to aromatic amines produced by anaerobes (Volatilised at basic Ph hence positive whiff test) Reduction in Lactobacilli spp., allow G.vaginalis AND anaerobes to thrive Bacterial VaginosisTreatment BV not considered a benign condition Treatment oral or intravaginal gel of metronidazole 5-7 days or clindamycin intravaginal cream Metronidazole first choice as part of recovery is recolonization with Lactobacillus spp. Bacterial VaginosisComplications Amnionitis and Premature labour and delivery Late term miscarriage Postpartum fever, endometritis and salpingitis (particulary following abortion) Wound infection and vaginal cuff infection post hysterectomy Occassionally septicaemia associated with these conditions Other vaginal Infections Staphylococcus Spp.and Toxic shock Syndrome Secondary anaerobic infections associated with foreign bodies such as tampon, contraceptive devise(diaphragm, condom etc) In childrem a variety of objects produces foul odour , scanty discharge with blood Age related Neonates may acquire trichomonal or candidal vulvovaginitis after passage through the birth canal, can be treated Vaginal discharge after neonatal period is abnormal and should be promptly investigated N.gonorrhoeae and C.trachomatis produce vulvovaginitis as prepubscent vagina not cornified, require through investigation , including possibility of sexual abuse Infections of the female Pelvis Intra-amniotic Infection Syndrome Post Partum Endometritis Puerperal Ovarian vein Thrombophlebitis Episiotomy Infections Post-abortion Infections Infections after Gynaecological Procedures Pelvis Inflammatory Disease Intra-amniotic Infection Syndrome Chorioamnionitis Is clinically detectable infection of the uterus and it`s contents during pregnancy 1-2% of women with full term pregnancy and 25% of women with preterm labour Most cases are ascending in origin, occurring after prolonged rupture of membranes Few cases from transplacental spread of bacteremia e.g Listeria monocytogenous Rare cases after diagnostic amniocentesis etc Risk factors: PROM, MVE, young age, Low SE group, nullparity and Bacterial vaginosis Organisms isolated Gardnella vaginalis Mycoplasma hominis anaerobes E.coli Group B Streptococci Enterococci Aerobic Gram negative bacilli Presentation Maternal Fever Tachycardia Uterine tenderness Uncommom: foul smelling or grossly purulent Amniotic fluid Fetal Fetal Heart rate abnormalities(TC ,DV) PPROM –25% subclinical infection Preterm labour and intact membranes 510% and another 10% subclinical Causes arrest of progress of labour Diagnosis : clinical mostly Management Antibiotics started as soon as suspected not postpartum Delivery essential to cure Antibiotic administration reduces frequency of neonatal pneumonia, bacteremia and cures maternal infection As Group B Streptococci and E .coli most common isolates from newborn, combination of Ampicillin or Penicillin and Gentamicin used if delivered vaginally Post-partum Endometritis Postpartum infection of the uterus Most common cause of puerperal fever Predominant predictor: Caesearan section particularly after labour or premature rupture of membranes Rates vaginal delivery 0.9-3.9% Caesearan section rate: 10-50% Secondary risk factors include BV Cause of PP Endometritis It is a polymicrobial Infection Endometrial isolates: Group B Streptococci, enterococci, G.vaginalis, E.coli, Prevotella bivia, Bacteroides spp and Peptostretococcus Blood isolates: Group B Streptococcus and G.vaginalis most common Presentation Fever on 1st or 2nd day postpartum Lower abdominal pain Uterine tenderness Leucocytosis Blood cultures should be taken positive in up to 20% If late onset and at risk test for Chlamydia infection Treatment: INTRAVENOUS ANTIBIOTICS Treatment failures If fever persists despite appropriate antimicrobial therapy consider wound or pelvic abcess, puerperal ovarian vein thrombophlebitis and non-infectious fever( drug-fever, breast engorgement) Puerperal Ovarian Vein Thrombophlebitis Syndrome resulting from acute thrombosis of one or both ovarian veins in the postpartum period 1/2000 deliveries or 1-2 cases per 100 patients with PP infection Onset variable but usually 2-4 days after delivery Puerperal Ovarian Vein Thrombophlebitis Temperature , Tachycardia Lower abdominal pain often on right side Previous diagnosis of PPE not responding to antimicrobial therapy ½ to 2/3 have a rope-like mass Ileus and respiaratory distress may be present Therapy: antimicrobial therapy and Heparin Episiotomy Infections Uncommon Infection 0.1% become infected, higher rate if 3rd or 4th degree extensions 4 types Simple Episiotomy Infection (skin and superficial fascia) Superficial fascia infection without necrosis Infection of the superficial fascia with necrosis(necrotizing fascitis) Myonecrosis (deep fascia)-C.perfringens Post abortal Infection Ascending Process More common if retained products of conception or operative trauma Risk factors: greater duration of pregnancy, technical difficulties and unsuspected presence of STI Symptoms: Fever, chills, abdominal pain, vaginal bleeding and passage of tissue Onset: usually 4 days after procedure Temp, TC, abdominal tenderness Post abortal Infection C.perfringens has a characteristic presentation in PAI, massive intravascular hemolysis producing jaundice, severe anaemia Treatment is removal of infected material and antibiotics Use of Prostaglandin E 2 is contraindicated in the presence of pelvic infection Prevention and Prophylaxis Infection after Gynaecological Procedures E.coli, Klebsiella, Proteus, Enterobacter spp, B.fragilis and enterococci are the most common causes of postop infection in 5 days post –op Risk Factors: Duration of Surgery, Abdominal approach, age-premenopausal, bacterial vaginosis for abdominal surgery 4 forms: Pelvic celluitis, cuff celluitis, cuff abscess, pelvic abscess Role of Prophylaxis Genital Infections in Men Prostatitis Acute bacterial Chronic bacterial Chronic Pelvic Pain Syndrome Granulomatous Prostatic Abscess Epididymitis Non-specific Sexually Transmitted Orchitis Viral Bacterial Host Defences in the Male Organisms that ascends through the urethra cause most infections of the urogenital ducts and accessory sex organs Flushing gives some protection Prostatic antibacterial factor (zinc containing polypeptide) secreted by prostate Presence of leucocytes Immunoglobulins Those with secretory dysfunction may have increased Ph of prostatic fluid, reduced calcuim, citric acid changes in prostatic fluid enzymes Prostatitis 50% of men will experience symptoms at some stage of their lives Acute Bacterial Prostatitis Causes: Enterobacteriaceae, Pseudomonads and Enterococci Urinary frequency , dysuria Lower UT obstruction due to odema of prostate Signs of systemic toxicity are common Lower abdominal pain, suprapubic discomfort Exquisite tenderness on PR exam Acute Bacterial Prostatitis Urinalysis : pyuria, C/S POSITIVE Bacteremia may also be present Antimicrobial therapy penetrate prostate Complications: Prostatic abscess, Prostatic infarction, chronic bacterial prostatitis and granulomatous prostatitis Chronic Bacterial Prostatitis Present with recurrent bacterial urinary tract infections caused by the same organism, asymptomatic inbetween Prostate normal on rectal exam Urinary localization studies establish diagnosis Causes: most important gram negative rods(Enterobacteriaceae and Pseudomonads) Treatment: Ciprofloxacin or trimethoprim( achieve good concs in prostatic tissue) Patients may require suppressive therapy Chronic Bacterial Prostatitis Urinary Tract Urine Cultures Localization Using Sequential Specimen Symbol Descripition Voided Bladder 1 VB1 Initial 5-10ml Voided Bladder 2 VB2 Midstream specimen Expressed Prostatic secretion EPS Secretions expressed from prostate by digital massage Voided Bladder 3 VB3 First 5-10ml after Prostatic massage cfu VB3>>VB1 10 fold Granulomatous Prostatitis Most cases follow an episode of acute bacterial prosatitis Tuberculosis prosatitis secondary to tuberculosis elsewhere in the genital tract Iatrogenic following those who receive intravesical Calmette-Guerin bacillus treatment for transitional cell carcinoma of bladder Crytococcosis Prostatic Abscess Rare Most patients are diabetics, immunocompromised, inappropriate treated acute prostatitis, urinary tract obstruction, foreign body Ascending route: common uropathogens, S.aureus Febrile, irritative voiding But fluctant area on prostate or seEn on US, MRI Treatment : Drainage and antimicrobial therapy Non-Specific Bacterial Epididymitis Most common cause in men over 35 years is gram negative rods in 2/3 and gram positive in 20% Often recent history of urinary tract manipulation (weeks or months after) or urology pathology Occurs if patient was bacteriuric TB: most common male manifestation , heaviness, swelling, beadlike vas deferens, sinuses Treatment: antimicrobials to cover gram negative rods and Gram positive cocci, local measures , if TB , antituberculosis therapy Sexually Transmitted Epididymitis Most common type in young men C.trachomatis and N.gonorrhoeae major pathogens C.trachomatis 1-45 days post exposure, 10 days average Patient most be evaluated for other STI`s Viral Orchitis Most cases of orchitis are viral Mainly mumps Mumps rarely cases orchitis in prepubertal males but 20% of postpubertal males with mumps Testicular pain and swelling 4-6 days after parotiditis, 70% unilateral (contra 1-9 days) May be systemically unwell Resolve 4-5 days in mild cases 50% testes undergo some atrophy, but rarely results in infertility Coxsackie B virus also Bacterial Orchitis Usually contiguous spread to give Epididymoorchitis E.coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococci or Streptococci Acutely ill: high fever, marked swelling and pain of affected testes, nausea , vomiting Tender, hydrocoele, skin oedematous and erytematous Complications: infarction of testis, Abscess formation and scrotal pyocele
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