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Genital tract infections
Wednesday, October 03, 2012 9:03 AM
Bacterial genital tract infections
Majority are infectious diseases which are transmitted by sexual contact
(^) Most of the causative organisms easily become non viable outside the patient o (^) Their survival depends on transmission by contact between mucosal surfaces (^) Clinical manifestations depend on o (^) Sexual behaviour or practices or orientation o (^) The causative agent
Incidence
(^) Determinate by social and individual's attitude and behaviour o (^) Un safe sex practices including multiple partners cause the incidence to rise o (^) Safer sex practice reduce the infection rate include : (^) Abstinence (^) One faithful partner (^) Proper use of effective protective barrier methods when in doubt of partner's sexual behaviour (^) Examples of sexually transmitted bacterial infections
Disease Causative agent
Gonorrhoea o^ Gonorrhoeae
Chancroid 8. ducreyi
Syphilis 20. Pallidum pallidum
Non specific or non gonococcal Urethritis and
cervicitis
Chlamydia trachomatis (D or K)
Creaplasma urealyticum
Mycoplasma species
Lymphogranuloma venereum (LGV) Chlamydia trichomatis (L)
Granuloma inguinale (donovanosis) Calymmatobacterium granulomatous
Infections which may or may not be STI
Bacterial vaginosis Gardnerella vaginalis
Fungal infection - candidiasis Candida albicans
Gonorrhoea
(^) Clinical manifestations (^) Adult males o (^) Mainly Urethritis initially
(^) Burning sensation when passing urine a few days after exposure (^) Discharge of pus o (^) swelling and pain due to inflammation of periurethral tissues associated with local spreads (^) Adult females o (^) Mainly endocervicitis - symptomatic or asymptomatic o (^) Manifestations - include cervical & vaginal discharge initially (^) Other manifestations of N. gonorrhoea infection (^) Inflammatory processes in other sites than the genitourinary system to sexual practices (^) Ophthalmia neonatorum (^) Conjunctivitis resulting from introduction of bacteria into the eye (^) Vulvovaginitis in young females associated with o (^) Sexual offences by infected adult males o (^) Rarely from contaminated items such as towels (^) Complications (^) Local spread o (^) Males (^) To periurethral tissues including the prostrate resulting in prostatis to epididymius resulting in epidiymitis o (^) Females (^) Vaginal canal causing vaginitis (^) Bartholin's gland resulting in endometritis (^) Fallopian tubes resulting in salpingitis (^) Dissemination o (^) Causing disseminated disease characterized by (^) Septica (^) Long term complication o (^) Associated with untreated infections or inadequate treatment of acute infections (^) Urethral stricture in males (^) Complications in females which may interfere with reproduction (^) Blindness from ophthalmia neonatorum (^) Lab investigations of gonococcal infection (^) Specimens o (^) Swabs or smears of discharge from (^) Urethra (^) Cervical canal (^) Eye (^) Others including pus from Bartholin's gland o (^) Blood for culture for disseminated infection o (^) Urine (esp. in males discharge is hard to get) (^) Procedures o (^) Discharge specimens are (^) Either stained for microscopic examination and inoculated onto the medium immediately after collection or (^) Placed in a transport medium before delivery to the lab
(^) Lab (^) Specimens similar to N.gonorrhoeae o (^) Urethral or cervical discharge - (^) Procedure o (^) gram stain shows pus cells & negative for gram negative diplococci or other gram stainable bacteria o (^) Culture for N. gonorrhoea negative o (^) Confirmed by examination of smears & swabs for Chlamydia or Antigens of Chlamydia or mycoplasma (^) Staining by special stains for: o (^) Chlamydia or o (^) Antigens of Chlamydia by different methods including immunofluorescence staining (^) DNA probe amplification - PCR, LCR (^) Culture of Chlamydia - on living cells (^) Culture of mycoplasma on specific artificial medium
Antimicrobial specificity of Chlamydia and mycoplamas
(^) Susceptible to several antimicrobials o (^) Tetracyclines o (^) Erythromycin o (^) Doxycycline o (^) Azithromycin
Chancroid (soft sore)
(^) Manifestations o (^) Incubation period followed by o (^) Papule on external genitalia o (^) Erodes and forms a painful non-indurated ulcer with rugged edges & pus in the base - chancroid (^) Can be Single or multiple o (^) Associated with painful enlarged inguinal LNs (buboes) which develop into abscesses and are associated with pus formation (^) Lab examination o (^) Specimen (^) Swab from the ulcer o (^) Procedure (^) Smear from ulcer - gram stain for gram -ve short bacilli o (^) Culture on nutritionally rich medium with growth factor x, incubation in moisture, additional 5-10% CO 2 o (^) Incubate at 37°C for 48 hours or longer o (^) Colonial morphology & gram stain o (^) Others - PCR for detection and identification (^) Antibiotic susceptibility o (^) Susceptible to
(^) Erythromycin (^) Azithromycin (^) Ciprofloxacin (^) Ceftriaxone
Lymphogranuloma venereum (LGV)
(^) Manifestations o (^) Initially a painless ulcer on the external genitalia o (^) Infection spreads to the LN thru lymphatic drainage o (^) Associated with painful lymphadenitis and lymphangitis and enlarged inguinal and femoral LN or buboes o (^) Males: primary lesion initially - painless ulcer on external genitalia associated with painful enlarged inguinal & femoral LNs (buboes) o (^) Females: lesions on genital and anal regions, pelvic LN involvement, possible extension to rectum o (^) long term complications are due to chronic inflammatory processes associated with (^) Healing and fibrous tissue formation (^) Lymphatic drainage (^) Strictures (^) Lab Dx o (^) Serology - detection of specific antibodies in serum using special immunological techniques - immunofluorescence o (^) cell culture for isolation and identification o (^) Fluorescent antibody test for antigen detection o (^) Molecular methods of detection such as PCR (^) Antibiotic susceptibility o (^) Tetracyclines including doxycycline o (^) Erythromycin
Syphilis
(^) Not as common as was observed years ago (^) Has severe long term complications if no treatment (^) Transmission of T. pallidum pallidum o (^) Sexual transmission resulting in venereal syphilis (^) Main methods of transmission o (^) Vertical transmission (^) From infected mother to baby resulting in congenital o (^) Via transfusion (^) Manifestations o (^) Incubate ≈ 3-90 days o (^) Manifestations grouped into clinical stages - primary, secondary, tertiary and late (or quaternary) o (^) Congenital syphilis - a result of transmission from mother to a baby o (^) The infections lesions is on skin or mucous membranes of the external genitalia organs for the majority
o (^) Associated with the majority of vaginosis in adult females (^) Manifestations o (^) Watery vaginal discharge (^) Complications in pregnancy o (^) Chorioamnionitis o (^) Premature rupture of membranes o (^) Preterm delivery (^) Disease based on among other findings (lab diagnosis) o (^) Watery vaginal discharge o (^) pH of vaginal fluid ≥4. o (^) Fishy or amine odour o (^) Presences of clue cells o (^) Culture of little use in diagnosis (^) Control and prevention of bacterial STIs o (^) Active participation and co-operation of the (^) Community (^) Individual adults (^) Patients (^) Health workers o (^) Methods (^) Education on (^) Safer sex practices and unsafe sexual practices (^) Prompt diagnosis & treatment (^) Contact tracing and treatment (^) Proper clinical examination and lab tests for other sexually transmitted infections (^) Antimicrobial Susceptibility o (^) Metronidazole and o (^) Clindamycin Candidiasis (^) Manifest with whitish patches - itchiness on mucus membrane - whitish relatively thick vaginal discharge (^) Lab confirmation o (^) Microscopy of vaginal discharge - KOH mount o (^) Gram stained k- gram positive yeast cells, budding with or without pseudohyphae (^) Antifungal management o (^) Local application of creams or tablets - azole derivatives - clotrimazole o (^) Orally admin treatment - fluconazole The syndromic approach in management of STD & STI (^) An approach to treatment which manages an STD as a syndrome - uses signs and symptoms of to determine the antimicrobial treatment (^) Consideration of more common causative agents may be required in some cases
(^) Antimicrobials are chosen to cover major pathogens responsible for syndrome including bacterial and other organisms which may be responsible for the manifestation
Syndrome Symptoms Etiological agent
Urethritis in males Urethral discharge o^ Gonorrhoeae
o (^) urealyticum o (^) trachomatis
(T. vaginalis HSV)
Parasite and viral
Mucopurulent cervicitis Vaginal discharge 14.^ Gonorrhoeae
3. trachomatis
Vulvovaginitis Vaginal discharge 3.^ albicans
20. vaginalis
Bacterial vaginosis (BV) Vaginal discharge BV - associated bacteria
Acute PID Lower abdominal pain 14.^ Gonorrhoeae
- trachomatis
BV associated bacteria
Ulcerate genital lesions genital ulceration 20.^ pallidum
- ducreyi
- Trachomatis
- Granulomatis
- vaginalis (HSV)
Viral causes
Approach to prevention
(^) Applies 4C’s o (^) C ounseling (^) Talking to patient (^) Discussion of other 3 C’s o (^) C ompliance (^) Emphasis on adherence to (^) Taking medication (^) Following instructions (^) Finishing the course (^) Avoiding other medications o (^) C ondom use and other barrier methods (^) Proper and consistent use of barrier methods o (^) C ontact tracing & treatment of all contacts
Advantages of syndromic management
(^) Treatment given at 1st^ visit o (^) Patient not lost to follow up
