nullnullFemale Genital Tract Infections Prof. Zhao aimin, PhD. MD
Department of Obs & Gyn, Ren Ji Hospital
Email:zam0526@yahoo.com.cn
Tel:13917981090,18918358375The anatomy of the genital tract of womenThe anatomy of the genital tract of womenIntroductionIntroductionLower Genital Tract infections 下生殖道感染
vulvitis 外阴炎, vaginitis 阴道炎, cervicitis 宫颈炎
Upper Genital Tract Infections 上生殖道感染
Salpingitis 输卵管炎, Pelvic inflammatory disease 盆腔炎
Sexually Transmitted Diseases 性传播疾病
Lower Genital Tract infectionsLower Genital Tract infectionsVulvitisVulvitisEtiology 病因
Infections
bacteria, virus, candida 念珠菌, parasite 寄生虫
Allergic reactions 过敏反应
Dermatoses 皮肤病
contact dermatitis, psoriasis, neurodermatis
Atrophic changes 萎缩性改变
VulvitisVulvitisSymptoms
irritation 刺痛, itching 瘙痒,
abnormal discharge 分泌物
Signs
erythema 红斑, edema 水肿, excoriation 抓痕
skin ulcer, papillary lesionnullVulvitisVulvitisDiagnosis
Infections:
itching (moderate or severe) → candidia infection
ulcer, papillary lesion → STD
(herpes, syphilis, condyloma acumination)
itching, excreta, nits or eggs → parasitization
(the crab louse and the itch mite)
nullCandidiasisnullCondyloma acuminationnullParasitization: the crabnullThe crabVulvitisVulvitisSecondary allergic vulvitis
diffuse reddening of the skin, itching or burning, without obvious cause
Contact dermatitis
red and edematous skin, vesicle, or secondary infection
4. Neurodermatitis
chronic pruritus, excoriation
VulvitisVulvitisAtrophic lesions (postmenopausal women):
intense itching, symmetrically reddened,
thin, smooth vulvar skin.
Important!!
Perform a vulvar biopsy on the suspected lesion in order to rule out the vulvar cancer
VulvitisVulvitisTreatment
Infections
Non-specific vulvitis: sitz baths 坐浴
STD: screening test, special treatment
Infection with parasites: break the infection cycle
(remove the hair)
Allergic vulvitis
To find out the irritant and remove it, locally use hydrocortisone cream
VaginitisVaginitisVaginal secretion
Sources
Mucus from the cervix, endometrial fluid, exudates from the Bartholin’s and the Skene’s glands
Influences
Hormonal status, pregnancy, immunosuppression, inflammationnullVaginal dischargeVaginitisVaginitisBacterial vaginosis (BV)
Symptoms and signs
Fishy odor, vulvar irritation, increased yellow discharge
Laboratory examination
Saline wet mount: increased WBC, pH>4.5
clue cellnullclue cellsnullVaginitisVaginitisTreatment
Vaginal irrigation
Oral or intravaginal metronidazole
VaginitisVaginitisTrichomonal vaginitis 滴虫性阴道炎
Symptoms and signs
itching or burning, odorous
frothy vaginal discharge 泡沫样白带
dysuria, dyspareunia
edema or erythema of the vulva
Microscopic examination
wet mount: increased WBCs
trichomonas (flagella) 阴道毛滴虫
nullnullfrothy vaginal discharge trichomonasVaginitisVaginitisTreatment
Vaginal irrigation
Oral metronidazole: 0.2 tid p.o × 7d
Intravaginal metronidazole: 0.2 qN p.v × 7d
Treat the same disease of sexual partners: oral
Follow-up examination: maybe recur VaginitisVaginitisCandida Vaginitis 念珠菌性阴道炎
high risk factors
pregnancy, diabetes, obesity, immunosuppress therapy, antibiotic therapy(broad-spectrum), wearing tight clothing
symptoms and signs
itching, burning, dysuria, dyspareunia
bright red vulva and vagina
“cottage cheese” discharge 豆楂样或乳酪样白带null“cottage cheese” dischargeVaginitisVaginitis laboratory examination
wet mount: candida
candida culture
treatment
remove the induction factors
localize: irrigation imidazole 咪唑类
systemic
treatment saxul partnerCervicitisCervicitisCauses (Infectious cervicitis)
all possible infectious causes of cervicitis are sexually transmitted diseases (STDs)
Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas , herpes simplex virus (HSV), or human papillomavirus (HPV)
CervicitisCervicitisAcute cervicitis
Symptoms:
increased vaginal discharge
dysuria, urinary frequency
intermenstrual or postcoital bleeding
low abdominal or low back pain
CervicitisCervicitisHistory
focus on
the dyspareunia, vaginal discharge
genital skin lesions, abnormal vaginal bleeding,
dysuria, genital burning, genital itching
lower abdominal or pelvic pain
sexual history
CervicitisCervicitisPelvic Examination
Investigate the external genitalia
The speculum examination:
the cervix is reddened
edematous
easily friable and bleed.
yellow-green pus
The bimanual examination
cervical motion tendernessen, largement of the cervix
nullvaginal dischargenullthe cervix is reddenedCervicitisCervicitisLaboratory examination
pH of the secretions
microscopy with a saline wet mount
STDs screening test: gonorrhea, chlamydia, HPV, HSV
CervicitisCervicitisTreatment
Oral antibiotics
Oral antiviralsCervicitisCervicitisChronic cervicitis
Cervical erosion
Cervical hypertrophy
Cervical polyp
Naboth cyst
Endocervicitis
Upper Genital Tract InfectionsUpper Genital Tract InfectionsSalpingitisSalpingitisSigns
pain in the lower abdomen and pelvis
vaginal discharge
abnormal vaginal bleeding
Nausea and vomiting
Fever
Symptoms occur more frequently toward the end of menses or early in the menstrual cycle
SalpingitisSalpingitisPhysical examination:
lower abdominal tenderness
rebound tenderness
Pelvic examination:
adnexal tenderness
cervical motion tenderness
mucopurulent endocervical discharge
nullPelvic examination (The bimanual examination)SalpingitisSalpingitisLab studies
cervical cultures or other detection assays for Gonorrhea and Chlamydia
wet mount of cervicovaginal secretions
complete blood count, ESR and C-reactive protein
pregnancy test
urinalysis
SalpingitisSalpingitisImaging Study
Ultrasound
the diagnostic test of choice for evaluation of possible tuboovarian abscesses(TOAs) 输卵管卵巢脓肿
To rule out several other etiologies in the differential:
ovarian cyst, ovarian torsion 卵巢扭转, appendicitis阑尾炎, endometriosis子宫内膜异位症
Transabdominal or transvaginal ultrasound
SalpingitisSalpingitisDiagnosis
Clinical diagnosis is imprecise
No single historical, physical, or lab finding is both sensitive and specific for disease
The minimum criteria:
Lower abdominal tenderness with/without rebound
Adnexal tenderness
Cervical motion tenderness
SalpingitisSalpingitisThe additional criteria (one or more of the following):
Oral temperature greater than 38.3℃
Abnormal cervical or vaginal discharge
Elevated ESR, Elevated C-reactive protein
WBC>10,000
Laboratory documentation of cervical infection with gonorrhoeae or trichomatis
Pelvic abscess (bimanual exam or sonogram)SalpingitisSalpingitisThe definitive criteria
Laparoscopic abnormalities consistent with salpingitis
Histopathologic evidence of endometritis on endometrial biopsySalpingitisSalpingitisDifferentials
Ectopic pregnancy
Appendicitis
Ovarian cysts
Endometriosis
Gastroenteritis
Urinary tract infection
abortion SalpingitisSalpingitisTreatment
To cure acute infection efficiently, preserve fertility, prevent ectopic pregnancy, decrease the risk of long-term inflammatory SalpingitisSalpingitisMedical care (antibiotic treatment):
early diagnosis and treatment, broad-spectrum coverage of all major pathogens
Intravenous antibiotics
Oral antibiotics
SalpingitisSalpingitisSurgical care:
be required for cases of salpingitis complicated by TOAs that do not respond to medical management
Laparotomy 剖腹手术
be reserved for surgical emergencies, such as ruptured abscesses, or failed medical management of tuboovarian abscesses
Laparoscopy 腹腔镜手术
an important diagnostic and therapeutic tool
nullchlamydial pyosalpinx衣原体性输卵管积脓Pelvic inflammatory disease(PID)Pelvic inflammatory disease(PID)Definition
An inflammatory disorder of the uterus, fallopian tubes, and adjacent pelvic structures
Include endometritis, myometritis, salpingitis, oophoritis, parametritis
PIDPIDSymptoms
Lower abdominal pain
Abnormal vaginal discharge
vaginal bleeding
Temperature higher than 38 ℃
Nausea and Vomiting
PIDPIDPhysical
Lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness
Pelvic abscess or inflammatory complex detected by bimanual examination
Purulent material in the peritoneal cavity obtained by culdocentesis
Temperature higher than 38 ℃
PIDPIDCause
Chlamydia trachomatis 沙眼衣原体
the predominant STD organism causing PID
CMV
Gardnerella vaginalis, Escherichia coli 大肠杆菌
Anaerobic organisms 厌氧菌
Streptococcus agalactiae 粪链球菌
Neisseria gonorrhea 淋球菌
PIDPIDLab Studies
Vaginal wet mount: increased amount of white cells
Elevated ESR: nonspecific
Elevated CRP: nonspecific
Elevated WBC: nonspecific
Gonorrhea cultures: frequently negative in later stages
Chlamydial cultures: PID PID Imaging studies
Transvaginal sonography
be used to document an adnexal mass or demonstrate fluid-filled fallopian tubes
MRI
costly, seldom
Differentials
adnexal tumors, appendicitis, ectopic pregnancy, endometriosis
PIDPIDTreatment
Similar to that of the Salpingitisnullnormal genital tractnullPIDSexually Transmitted Diseases(STD)Sexually Transmitted Diseases(STD)Infection by Chlamydia Trachomatis
沙眼衣原体感染Infection by Chlamydia Trachomatis
沙眼衣原体感染Characteristic:
the most common cause of the genital tract infection, often coexist with gonorrhea
Manifestation:
Mucopurulent cervicitis, acute urethritis, salpingitis, PID
Medical history:
recurrent infections, chronic pelvic pain, infertility
asymptomatic, subtle or nonspecificInfection by Chlamydia TrachomatisInfection by Chlamydia TrachomatisDiagnosis
Screening tests: ELISA (cervical secretions)
Cultures: take long time
Antibiotic treatment
azithromycin, erythromycin 红霉素, amoxycillin 羟苄青霉素
Gonorrhea 淋病Gonorrhea 淋病A gram-negative bacteria: anaerobic organisms
The incidence is increasing
Manifestation:
Lower genital tract infection:
Purulent discharge from urethra, cervix, vagina or anus
PID (acute or chronic):
Pain, fever, tenderness, elevated WBC,
Salpingitis, TOAGonorrheaGonorrheaDiagnosis
Anaerobic culture, ELISA, Gram stain
Antibiotic treatment
cephalosporin, ampicillin Condyloma acuminationCondyloma acuminationCause
Human papillomavirus,HPV (DNA virus)
More than 70 subtypes
Types 16, 18, 45, 56 are highly associated with cervical cancer
Manifestation
Incubation period: 6 weeks to 3 months
Warts :vulva, vagina, cervix, perineum, and anusnullCondyloma acuminationCondyloma acuminationCondyloma acuminationDiagnosis
Physical examination
Biopsy of the warts
Treatment
laser surgery, cryotherapy, or surgical excision
Herpes genitalisHerpes genitalisCause:
Herpes simplex virus type 2, HSV2
DNA virus
Symptoms and signs:
burning, pain, dysuria, fever (low-grade)
lesions: Painful vesicles and ulcers with a red border
location: vulva, vagina, cervix, perineal, perianal skin
nullVulvar ulcer caused by Herpes simplex virusHerpes genitalisHerpes genitalisDiagnosis:
Sexual history: contact
Physical examination: vesicles 水泡 and ulcers 溃疡
Viral cultures (from the lesions): confirm
Differentials:
syphilis 梅毒
Herpes genitalisHerpes genitalisTreatment
Sitz baths 坐浴
Topical anesthetic 局部麻醉:
xylocaine 利多卡因
Oral or intravenous antiviral agents:
zovirax 病毒唑
Topical antibacterial cream:
to deal with secondary infections Syphilis Syphilis Cause
Treponema pallidum: anaerobic spirochete
Manifestation
Primary syphilis (3-4 wks after exposure,persists 2-6 wks):
The chancre (a painless ulcer): vulva, vagina, cervix, tongue, fingers
Secondary syphilis (6wks-6months after chancre, perststs 2-8 wks):
Rash(symmetric, asymptomatic): palm, soles
Condyloma lata
Fever, headache, generalized lymphadenopathy
nullCondyloma lataSyphilisSyphilisThe latent phase
The late stages of the syphilis(2 years after exposure):
Cause damage to the central nervous system, heart, and great vessels
Diagnosis
Serologic testing: RPR
Treatment
Benzathine penicillin G: 2,400,000 U IM (early stage)
nullThanks !Prof. Zhao aimin, PhD. MD
Department of Obs & Gyn, Ren Ji Hospital
Email:zam0526@yahoo.com.cn
Tel:13917981090,18918358375