GENITAL INFECTIONS

1. GENITAL INFECTIONS Dr.B.BOYLE

2. Vaginal Infections Infections of the female pelvis Post-Gynaelogical Surgery Infections Pelvic Inflammatory Disease(Previous lecture) Prostatitis Epididymitis Orchitis Urethritis (Previous Lecture) Balanitis GENITAL INFECTIONS FEMALE MALE

3. 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)

4. 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~105-6of 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

5. 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

6. 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 non-erythematous • Discharge: grayish,thin,homogenous containing small bubbles

7. Bacterial Vaginosis • Diagnosis(3/4) Guide • Ph greater than 4.5(90%) • Homogenous white , smoothly adherent vaginal discharge • Positive whiff test (limited value) • Clue cells:direct microscopy of discharge reveals vaginal epithelial cells studded with tiny coccobacilli, edge of cells or obliterate the nucleus • Some clue cells seen in 90% of women with BV • In normal women predominant type of bacteria is large rods(Lactobacilli spp.)

8. 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

9. 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

10. Bacterial Vaginosis-Pathophysiology • 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

11. Bacterial Vaginosis-Treatment • 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.

12. Bacterial Vaginosis-Complications • 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

13. 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

14. Bartholin`s Gland Abscess

15. Bartholin`s Gland Abscess

16. 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

17. Intra-amniotic Infection Syndrome Post Partum Endometritis Puerperal Ovarian vein Thrombophlebitis Episiotomy Infections Post-abortion Infections Infections after Gynaecological Procedures Pelvis Inflammatory Disease Infections of the female Pelvis

18. 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

19. Gardnella vaginalis Mycoplasma hominis anaerobes E.coli Group B Streptococci Enterococci Aerobic Gram negative bacilli Organisms isolated

20. 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 5-10% and another 10% subclinical Causes arrest of progress of labour Diagnosis : clinical mostly Presentation

21. 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

22. 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

23. 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

24. 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

25. 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)

26. Pyosalpinx

27. Actinomyces Gram /Culture

28. Actinomyces Infection

29. 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

30. 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

31. Female Anatomy

32. 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

33. 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

34. 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

35. Pyometrum

36. 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

37. Tuboovarian Abscess

38. Prostatitis Acute bacterial Chronic bacterial Chronic Pelvic Pain Syndrome Granulomatous Prostatic Abscess Epididymitis Non-specific Sexually Transmitted Orchitis Viral Bacterial Genital Infections in Men

39. 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

40. Prostatitis • 50% of men will experience symptoms at some stage of their lives

41. 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

42. 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

43. 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

44. Chronic Bacterial Prostatitis cfu VB3>>VB1 10 fold

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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