Inflammatory diseases of genital organs

1. Inflammatory diseases of genital organs Peng-Hui Wang, M.D., Ph.D. Associate Professor Department of Obstetrics and Gynecology Taipei Veterans General Hospital National Yang-Ming University School of Medicine 王 鵬 惠 台北榮民總醫院婦產部暨國立陽明大學醫學院婦產科學系 16 November 2009 陽明大學醫學系五年級

2. Topics • Bacterial infections: Syphilis, Gonorrhoea, Chlamydia trachomatis, Mycoplasma genitalium, • Lymphogranuloma venereum, Chancroid and Donovanosis. • Viral infections: Human Immunodeficiency Virus (HIV), Hepatitis B and C, Human T-cell • Lymphotrophic Virus (HTLV-1), Human papilloma virus (HPV) and Herpes simplex virus (HSV). • Protozoal infections: Trichomonas vaginalis. • Infestations: Scabies, and Pediculosis (crabs). • Syndromes in men: Non-gonococcal urethritis (NGU), and Prostatitis. • Syndromes in women: Pelvic inflammatory disease (PID), Vaginal discharge, bacterial vaginosis (BV), and Cervicitis. Best Pract Res Clin Obs Gyn 2009;23:647-60 . 王 鵬 惠

3. The Normal Vagina • Vaginal discharge: • Vulvar secretion from sebaceous, sweet, Bartholin, Skene gland • Transudate from vaginal wall • Exfoliated vaginal and cervical cells • Cervical mucus • Endometrial and oviduct fluid • Microorganisms and their metabolic products • Predominantly aerobic • Lactobacilli • Vaginal PH < 4.5 (by lactic acid) • Gram stain (+) • Superficial epithelial cell, few WBCs, few clue cell 王 鵬 惠

4. Pyogenic Conditions Of Vulva – Follicular/ Glandular Infection • Infection arising within hair follicles • Folliculitis, furuncles, carbuncles • Obesity, sweating, DM, poor hygiene • Pain and tenderness, erythematous papule or pustule • Antibiotics, I&D • Bartholin duct abscess • Infection of Bartholin gland result in occlusion of duct • Pain, tenderness, redness, swelling • Hot sitz bath, antibiotics, I&D 王 鵬 惠

5. Bacterial Vaginosis (BV) • Most common, 45 % • Non-specific vaginitis, Gardnerella vaginitis • Loss of lactobacilli, overgrowth of anaerobic bacteria • Gardnerella vaginalis • Frequent sexual intercourse, use of douches • Symptom: • Fishy vaginal odor • Profuse gray-color discharge homogenous • Thin discharge, heavy cream • No significant itching symptom 王 鵬 惠

6. Diagnosis (CDC-recommended Amsel criteria) • Sensitivity > 90%, specificity 77% • At least 3 of the 4 criteria to diagnose BV clinically: • 1) thin, white-to-gray, noninflammatory,homogenousdischarge that smoothly coats the vaginal walls • 2) positive whiff-amine test (a “fishy” odor produced when a drop of 10% KOH is added to vaginal discharge) • 3) vaginal pH greater than 4.5 • 4) greater than 20% clue cells (bacterial-studded epithelial cells) in saline wet mount per high-power microscopic field (most reliable of the four criteria) Pediatrics in Review 2008;29:209-11 王 鵬 惠

7. Complications of BV • Consistently associated with an increased risk of HIV infection • Consistently associated with an increased risk of PID • Consistently associated with an increased risk of postoperative infection (hysterectomy, therapeutic abortion) APMIS 2005;113: 233-45. AIDS 2008;22:1493-501. Curr Opin Pediatr 2005;17:473-479. 王 鵬 惠

8. Treatment is indicated for women • Symptomatic (A) • Undergoing some surgical procedures (A) • No benefit in low- or average-risk pregnancies and asymptomatic • Report a beneficial change in their discharge following treatment in volunteer. British Association for Sexual Health and HIV Ann Intern Med 2008;148:220-233. 王 鵬 惠

9. Treatment of BV (Pseudomembranous colitis) Curr Opin Pediatr 2005;17:473-479. 王 鵬 惠

10. Summary of BV • Most common cause of vaginal infections in women of childbearing age • 40~50% of symptomatic vaginal discharge • Prevalence: 10% ~ 50% • Diagnosis: thin, white-to-gray, noninflammatory,homogenousdischarge; positive whiff-amine test ; pH greater than 4.5; presence of clue cells • A sexually transmitted disease (STD): partners –not for treatment • Treatment is effective (metronidazole and clindamycin), but recurrence is common • Asymptomatic or non-pregnant women should be screened and treated for BV before certain surgeries • Symptomatic pregnant women should be screened and treated for BV J Fam Pract 2007;56:S1-6 . Pediatrics in Review 2008;29:209-11. 王 鵬 惠

11. Vaginitis – Candida [2004] • 2nd common, 35 % • Yeast vaginitis, monila, 85-90% Candida albicans • 75% women during lifetime; 45% women has 2 or more per year • Factor • Pregnancy: 1/3 pregnant women, high hormone level, acidity of vaginal fluid • Oral contraceptives: higher dose E2 • Antibiotics: disturbs the normal flora • Metabolic factors: DM, decreased cellular immunity • Sexual transmission: not a STD • Symptom • Vulvar pruritus/ burning/ erythema • Vaginal discharge: cottage cheese • Erythema and edema of the vulva • Dysuria 王 鵬 惠

12. Diagnosis/Treatment of Candida • Diagnosis • Clinical features • Vaginal PH is usually normal (< 4.5) • Fungal elements: • Wet-mount • Stained smear: methylene blue, gram stain • Culture • Treatment • Polyene family: amphotericin B, nystatin • Imidazole compounds: fluconazole, ketoconazole, clotrimazole • Topical steroid to release irritation 王 鵬 惠

13. Vaginitis - Trichomoniasis • 3rd common, 20% • Sexually transmitted • Actively motile, unicellular, flagellated parasite • Anaerobic • Symptom • Often asymptomatic • Profuse, frothy discharge, yellow-greenish in color foul odor, vulvar pruritus • Patchy vaginal erythema and colpitis macularis (strawberry cervix) 王 鵬 惠

14. Trichomonas vaginalis • A flagellated protozoan • A common cause of vaginal irritation in women • The most common nonviral sexually transmitted disease in the world (male:1.7%~13%; female: 2.0%~23%) • The most common curable sexually transmitted infection British Association for Sexual Health and HIV Curr Opin Infect Dis 2008;21:56-64. Clin Infect Dis 2007;44:S123-9 王 鵬 惠

15. Symptoms and Signs(female: evidence level III) British Association for Sexual Health and HIV • 10 - 50%: asymptomatic • The commonest symptoms: vaginal discharge, vulval itching, dysuria, or offensive odor , rare abdominal discomfort • Vaginal discharge: up to 70% - varying in consistency from thin and scanty to profuse and thick; the classical discharge of frothy yellow occurs in 10-30% of women • Associated with vulvitis and vaginitis • 2%: strawberry cervix appearance to the naked eye. • Higher rates are seen on colposcopic examination. • 5-15%: no abnormalities on examination. 王 鵬 惠

16. Management- general advise • Sexual partner(s) should be treated simultaneously. • Avoid sexual intercourse (including oral sex) until they and their partner(s) have completed treatment and follow-up. Curr Opin Infect Dis 2008;21:56-64.; Clin Infect Dis 2007;44:S123-9 王 鵬 惠

17. Management- general advise • A detailed explanation of their condition with particular emphasis on the long-term implications for the health of themselves and their partner(s). • Giving them clear and accurate written information. • Screening for coexistent STD should be undertaken in both men and women. Curr Opin Infect Dis 2008;21:56-64.; Clin Infect Dis 2007;44:S123-9 王 鵬 惠

18. Summary of Trichomoniasis • Diagnosis • Clinical features • Vaginal PH > 6 • Saline wet-mount slide: motile trichomonas • Whiff test (+) • Culture • Treatment • Metronidazole • oral, IV, vaginal • the drug of choice • sexual partner should also be treated 王 鵬 惠

19. Spectrum Subclinical, asymptomatic infection Severe, life threatening illness Sequelae Chronic pelvic pain Ectopic pregnancy Infertility PIDInfection of the upper genital tract in women • Classification • Endometritis • Parametritis • Salpingitis • Oophoritis • Tubo-ovarian abscess • Peritonitis Am Fam Physician 2006;73:859-64. 王 鵬 惠

20. Pelvic inflammatory disease • Inflammation and infection in the upper genital tract (ascending to endometrium, fallopian tubes) • endometritis, salpingitis, peritonitis • Most common infection of women aged 16-25 yrs • Pathophysiology • sexually transmitted microorganism (N. Gonorrhea , C. trachomatis) • after procedure (IUD, D&C, EM biopsy..) : 15 % of PID • Symptom: • Abdominal pain, pelvic pain, purulent vaginal discharge, abnormal vaginal bleeding , fever, uterine tenderness, adnexal tenderness, uterine motion pain, abdominal tenderness, rebound tenderness, leukocytosis 王 鵬 惠

21. Diagnostic criteria of PID (2005 test) PID TB Am Fam Physician 2006;73:859-64. 王 鵬 惠

22. Therapy recommendations Tarivid Cravit Am Fam Physician 2006;73:859-64. 王 鵬 惠

23. Tuboovarian abscess • An end-stage process of acute PID • Palpable a pelvic mass during bimanual examination • Treatment • Antibiotics (Clincin+GM) • 75% : antimicrobial therapy alone • Failure of medical therapy -> drainge of the abscess 王 鵬 惠

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25. Syphilis, Gonorrhea, TB Fitz-Hugh and Curtis syndrome Inflammation of liver capsule associated with a genital tract infection Recognized clinically or laparoscopically in 3-37% of patients with PID Toxic shock Syndrome Toxic shock syndrome (TSS) is an acute illness caused by toxin-producing Staphylococcus aureus. Others Korean J Radiol 2007;8:40-47 王 鵬 惠

26. Syphilis BPRCOG 2009;23:647-660 王 鵬 惠

27. Syphilis BPRCOG 2009;23:647-660 王 鵬 惠

28. Summary of PIDAt a glance • The CDC diagnostic criteria (2005) • Uterine, adnexal, or cervical motion tenderness • With no other obvious cause in women • At risk of PID • Empiric treatment • Screening of STD can reduce the risk of PID • Initiated promptly in all women with risk of PID • Must cover C. trachomatis and N. gonorrhoeae • Consider the possibility of fluoroquinolone-resistant N. gonorrhoeae Am Fam Physician 2006;73:859-64. 王 鵬 惠

29. Typical features of vaginitis NEJM 2006;355:1244-52 王 鵬 惠

30. NEJM 2006;355:1244-52 王 鵬 惠

31. Diagnostic test for T. vaginalis Sensitivity Specificity Comment Test NEJM 2006;355:1244-52 王 鵬 惠

32. Treatment Recommendations for BV or Trichomoniasis NEJM 2006;355:1244-52 王 鵬 惠

33. MMWR Morb Mortal Wkly Rep. 2007 Apr 13;56(14):332-6. • CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease (PID). • Only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea. 王 鵬 惠

34. THE END AND BEGINNING Thanks for your attendance and your attention Take home message 王 鵬 惠

35. 考題 (陰道) • 1.以下何者不正確? • A.正常陰道pH<4.5 • B. 正常陰道菌稱為厭氣性(anaerobic) • C.陰道pH值主要靠lactic acid維持 • D.最多的陰道菌株為 Lactobacilli • 2. 下列有關正常陰道的敘述何者是錯誤的? • A. pH<4.5 • B.陰道菌叢通常是嗜氧性的 • C. 很多clue cells • D.停經後未使用荷爾蒙的婦女,陰道的脫落細胞常為parabasal cells 王 鵬 惠

36. 考題 (陰道) • 健康婦女的陰道最常見的細菌 • A. Bacteroides • B. Staphylococcus aureus • C. Lactobacilli • D. Gardnella vaginalis • 陰道中正常微生物最常見的為下列何者？ • A. 加德諾菌 • B. 黴漿菌 • C. 乳酸桿菌 • D. 大腸菌 王 鵬 惠

37. 考題 (陰道) • 下列何者是治療單純陰道滴蟲感染的要點？ • (A)Penicillin 類藥物 • (B)磺胺劑治療 • (C) 性伴侶一起治療 • (D)Metronidazole 單一劑口服 • 下列何者是診斷細菌性陰道炎的依據之一？ • (A) 出現少量clue cell • (B) pH 值4.0 • (C)出現lactobacilli • (D) Whiff test 陽性 王 鵬 惠

38. 考題 (骨盆腔炎) • 治療急性骨盆腔炎下列的廣效抗生素配方最適宜者為? • A. tetracycline+ampicillin • B. balidixic acid+ofloxacin • C. clindamycin+metronidazole • D. ofloxacin+metronidazole • 急性骨盆腔炎的”確定診斷”方法是: • A.骨盆腔檢查 • B.病史問診 • C.血液中白血球數 • D.診斷性腹腔鏡 王 鵬 惠

39. 考題 (骨盆腔炎) • 毒性休克症候群有關之病原為 • A.葡萄球菌 • B.大腸菌 • C.人類乳突病毒 • D.病原仍不明 • 下列微生物較少引起骨盆腔發炎? • A. N. gonorrhea • B. Chlamydia • C. Streptococci • D. Candida albicans 王 鵬 惠

40. 考題 (骨盆腔炎) • 下列何者為現今引起急性輸卵管炎最常見之病原？ • A.淋病雙球箘 • B.徵漿菌 • C.披衣菌 • D.肺結核桿菌 • 對剖腹生產後骨盆腔發炎的治療,下列何種抗生素導致有抗藥性的細菌因過度增生而引發偽膜性結腸炎？ • A. GM • B. Clindamycin • C. Metronidazole • D. Chloramphenicol 王 鵬 惠

41. 考題 (感染) • 一位30歲女性主訴陰道白色分泌物增加，與先生同房後含有類似“魚腥味”的臭味，但會陰並沒有明顯的搔癢。最可能的診斷是 • A. 細菌性陰道炎 • B.念珠菌陰道炎 • C.陰道滴蟲感染 • D.乳酸菌增生 • 陰道滴蟲感染是 • A.性傳染疾病 • B.大部份是由公共浴室傳染 • C.由母親垂直傳染 • D.由腸道傳染 王 鵬 惠

42. 考題 (感染) • 有一個35歲婦女至婦科門診求診，主訴陰道有膿狀、臭味分泌物乃外陰搔癢，內診時發現子宮頸有草莓紅斑，最可能的診斷為 • A.子宮頸癌 • B.念珠菌感染 • C.非特異性陰道炎 • D.陰道滴蟲感染 • 下列何者是陰道淋菌的培養方法? • A. KOH • B. Thayer-Martin medium • C. cell culture • D. agar culture 王 鵬 惠