女性生殖道炎症（英2011.05.17）

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