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女性生殖系统炎症

2009-08-04 50页 ppt 6MB 111阅读

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女性生殖系统炎症nullnullInflammation of the Female Reproductive TractnullSelf-cleaning (lactobacillus) Mucusnull1. Vulvitis (外阴炎) Bartholinitis/Bartholin’s cyst (前庭大腺炎/前庭大腺囊肿) 2. Vaginitis (阴道炎) 3. Cervicitis (宫颈管炎) 4. Pelvic inflammatory disease (PID) (盆腔炎) Genital...
女性生殖系统炎症
nullnullInflammation of the Female Reproductive TractnullSelf-cleaning (lactobacillus) Mucusnull1. Vulvitis (外阴炎) Bartholinitis/Bartholin’s cyst (前庭大腺炎/前庭大腺囊肿) 2. Vaginitis (阴道炎) 3. Cervicitis (宫颈管炎) 4. Pelvic inflammatory disease (PID) (盆腔炎) Genital tuberculosis (生殖器结核) Sexually transmitted diseases (STD) (性传 播疾病)nullnull Vulvitis (外阴炎)nullClinical Manifestation Vulvar pruritus (瘙痒) Pain Burning sensation Congestion (充血) Swelling Eczema (湿疹) nullnullEtiology Specific organisms or non-infective dermatitis (皮炎) Irritation from vaginal discharge (分泌物) or menses Lack of vulvar hygiene Glycourianull Treatment Keep the vulva clean and dry Remove the cause 1/5000 kMnO4 (potassium permanganate, PP) solution bath Antibiotics ointment nullBartholinitis (前庭大腺炎) Infection of the major vestibular glands (前庭大腺) (Bartholin’s glands) (巴氏腺) Bartholin’s Cyst (前庭大腺囊肿)nullMajor vestibular glands (Bartholin’s glands)nullBartholinitis Etiology Staphylococcus, E.coli, streptococcus, enterococcus, gonococcus, and polymicrobial infection is common. Clinical manifestation Symptoms of a local infection Abscess of Bartholin gland: a painful red swelling Treatment Antibiotics (Ampicillin) in the early stage Drain the abscess (excision of an elliptical piece of skin) null Marsupialization (造口术) for preservation of the gland function Excision for recurrent casesBartholin’s Cystnull Trichomonal vaginitis (滴虫性阴道炎) Candidal Vulvovaginitis (假丝酵母菌性外阴阴道炎) Bacterial Vaginosis (BV) (细菌性阴道病) Senile vaginitis (老年性阴道炎) Infantile vulvovaginitis (婴幼儿外阴阴道炎)VaginitisnullnullnullTrichomonal Vaginitis 滴虫性阴道炎 (Trichomoniasis) null Etiology Trichomonad (毛滴虫): A flagellate protozoan (有鞭毛原虫) Best living environment : Moist, anaerobic, pH: 5.2-6.6null Transmission 1. Sexual contact (70% male infection, asymptomatic carrier) 2. Nonsexual transmission (iatrogenic) Pathogenesis The trichomonad lives on glycogen and iron of the host cell Direct contact and damage of the target cell Induction of immune reaction resulting in inflammationnull Clinical Picture Latent period: 4-28 days Asymptomatic: 25-50% Symptoms: Main: Profuse vaginal discharge and pruritus Occasional: odor, pain, dyspareunia , dysuria, infertility nullnull Characteristics of the vaginal discharge Copious (大量的) , Purulent (脓性的), Gray to yellow color, Malodorous (恶臭的), Frothy (起泡沫的)Strawberry cervix: Tiny, punctate hemorrhages (点状出血) grossly visible on the mucosanull Diagnosis 1. Microscopic (wet mount) identification of the trichomonad (60%-70%) 2. Precautions for the examination Avoid : intercourse 1-2 days before examination washing and medication lubricant heat preservation 3. Culture for suspected cases 4. PCR (Polymerase chain reaction)nullnull Treatment (1) 1. Systemic therapy (First choice) Oral metronidazole (甲硝唑,灭滴灵) a) 2g single dose b) 400mg, twice or 3 times a day, for 7 days. 2. Topical application (≤50%) a) Effervescent tablets (泡腾片)of metronidazole 200mg/day, 7-10 days b) Metronidazole gel c) Acidification of vagina with 1% lactic acid or 0.5% acetic acidnull Treatment (2) Criterion for cure: Negative finding in postmenstrual examination of the vaginal discharge for three times Failure rate: 5%-10% Poor compliance Repeated infection To avoid repeated infection: Sterilization of underwear, towels, etc Treatment of the sexual partner Metronidazole is still effective in recurrent cases. nullnull Candidal Vulvovaginitis 假丝酵母菌性外阴阴道炎 (Vulvovaginal Candidiasis)null Etiology 1. Very common a) About 1/3 of vaginitis cases are caused by fungal infection. b) About 75% of women develop candidiasis at least once in life. 2. The etiologic agent is Candida (假丝酵母菌/念珠菌). Candida albicans (白假丝酵母菌) is responsible for 80-90% of vulvovaginal candidiasis. null3. Candida albicans is an opportunistic pathogen. 1) Suitable environment: acidic (<4.5), warm, and moist 2) Candida albicans can be isolated from 10-20% nonpregnant and 30% pregnant asymptomatic women.Treatment is not indicated unless symptoms are present. null Predisposing factors 1. Pregnancy 2. Diabetes mellitus 3. Immunosuppressants 4. Broad-spectrum antibiotics suppressing the vaginal normal flora (esp. lactobacillus) 5. Others: restrictive synthetic underwear, obesity, contraceptive medication null Transmission 1) Endogenous infection (most often) Vagina, oral cavity, intestinal tract 2) Sexual contact 3) Contacting fomites (污染物) null Pathogenesis Two phases of candida albicans 1) Yeast spores (芽孢相): Asymptomatic parasitism 2) Pseudohyphae (菌丝相): Pathogenic 3) Mechanism: a) Candida at the pseudohypha phse penetrate vaginal epithelium for nutrients b) Growing candida albicans release proteolytic enzymes and toxins etc. resulting in inflammation reaction null Clinical Picture 1. Vulvovaginal pruritus (main) usually intense, coincident with menses or intercourse 2. Increased vaginal discharge The classic finding is white, thick,curd-like discharge forming patches adherent to the vaginal walls. null Diagnosis 1. Wet mount microscopic identification of candida albicans in the discharge Saline: 30-50% 10% KOH: 70-80% 2. Gram’s stain: 80% 3. Culture: higher sensitivity and drug test 4. Measurement of pH value may be useful for discovering cases of complicated infection (4.0-4.7). a pH<4.5 simple infection a pH>4.5 combined infectionnullnull Treatment 1. Elimination of predisposing factors 2. Topical application of antifungal agents Vaginal suppositories(栓剂): 1) Miconazole (咪康唑/达克宁) a) 200mg/day for 7days b) 400mg/day for 3 days 2) Clotrimazole (克霉唑) a) 150mg/day for 7 days b) 150mg, twice a day for 3 days c) 500mg single dosenull3) Nystatin (制霉菌素/米可定) 100,000units/day for 10-14 days 4) Methyl violet (龙胆紫) 0.5-1% , 3-4 times/week for 2 weeks. 3. Systemic medication Oral agents are used only for cases that can not be treated with topical application of antifungal drugs. Fluconazole (氟康唑/大扶康) 150mg, single use. 2) Itraconazole(伊曲康唑/斯皮仁诺) a) 200mg/day for 3-5 days b) 400mg for 1 day divided in two dosesnull3) Ketoconazole (酮康唑) 200mg, once or twice/day until culture result is negative Hepatotoxicity may occur. Points of note for treating VVC Treatment should be followed-up with a premenstrual examination of the vaginal discharge. Approximately 10% of cases will not respond to initial therapy. Prolongation of treatment up to 14 days may cure some patients. Identification and elimination of predisposing factors is important. Recurrent VVC should be treated with oral therapy followed by prophylactic doses.nullTreatment of sexual partner?No treatment for asymptomatics. 15% should be treatednullnullnullBacterial Vaginosis 细菌性阴道病null Etiology 1. Imbalance of normal vaginal flora Diminution of Doderlein lactobacillus and increase in other bacteria, in particular, anaerobic bacteria. 2. Causative factors of the imbalance are unknown Gardnerella vaginalis (加德纳菌)null Clinical Picture Symptoms: 1. 10-40% asymptomatic 2. Mild pruritus or burning sensation 3. Increased vaginal discharge and fishy odor Signs: Discharge: thin, greyish-white, homogenous, but not sticky No inflammation reaction (No epithelial edema or erythema) null Diagnosis Identification of clue cells *(wet mount in saline) together with 2 of the following 3 items 1. Vaginal discharge: homogenous, thin and white 2. pH>4.5: in virtually all cases, usu. 5.0-5.5 3. Positive Whiff test (with 10% KOH) * Clue cells are desquamated epithelial cells covered with clumps of coccobacili esp. Gardnerella vaginalis (加德纳菌), which gives the cells a speckled (有小斑点) appearance.nullWhiff testnullnull Treatment (1) 1. Systemic therapy (oral) (80%) 1) Metronidazole 400mg, 2-3 times a day for 7 days 2) Clindamycin (克林霉素/氯林霉素/氯洁霉素) 300mg, twice a day for 7 days 2. Topical therapy (80%) 1) Effervescent tablets of metronidazole 200mg/day, for 7-10 days 2) 2% Clindamycin cream, once a day for 7 days 3. Vaginal washing 1-3% H2O2 , 1% lactic acid, 0.5% acetic acid null Treatment (2) 1. Systemic or topical treatment has the same cure rate (80%). 2. Patients who are asymptomatic, but scheduled to have a gynecologic surgical procedure should be treated. 3. Patients who are pregnant can be treated with oral metronidazole. 4. Follow-up examination should be given 1-2 and 3-4 weeks (postmenstrual) after the treatment. Criteria for cure: Absence of clue cells with at least 1 of the following items: a) Normal vaginal discharge b) pH≤4.5 c) Whiff test negativenullOther forms of vulvovaginitis 1. Senile vaginitis (老年性阴道炎) Atrophic vaginitis(萎缩性阴道炎) Infantile vulvovaginitis (婴幼儿外阴阴道炎) nullnullDifferential Diagnosis of vaginitisBacterial Vaginosis Candidiasis TrichomoniasisComplaints Vaginal discharge Vaginal epithelium Vaginal pH Whiff test Microscopic examinationdischarge↑mild pruritussevere pruritus burningdischarge↑ mild prurituswhite homogenous fishy white curd-like thin purulent frothynormaledema erythemapunctate hemorrhage>4.5 (4.7-5.7) <4.5 >5 (5.6-6.5) + - -Clue cells WBC rare Candida WBC some Trichomonad WBC manynullnull Inflammation of the Cervix 1. Common: 50% women of reproductive age 2. May lead to pelvic infection 3. Need to identify a venereal disease and differentiate from malignancies Cervicitis: Vaginal portion of the cervix (Ectocervix) Mucosa of the cervical canal (Endocervix)nullAcute Cervicitisnull Etiology Neisseria gonorrhoeae (淋病奈瑟菌) Chlamydia trachomatis (沙眼衣原体) causing superficial infection of the cervical columnar mucosa 2. Staphylococcus (葡萄球菌), streptococcus (链球菌), enterococcus (肠球菌) causing infection after an abortion, puerperium, cervical injury, foreign bodies null Clinical Picture Symptoms 1. Asymptomatic 2. Mucopurulent vaginal discharge Vaginal irritation symptoms:pruritus, burning sensation Lumbosacral pain, Intermenstrual bleeding, postcoital bleeding Symptoms of the lower urinary tract Signs Inflammation of the cervix with mucopurulent discharge (MPC for mucopurulent cervicitis)nullnull Diagnosis 1. Gram’s stain of the cervical discharge for leukocyte ≥30/HP or ≥10/×1,000 2. Tests for gonococcus and chlamydia 3. Wet mount microscopy for trichomonads nullnull Management Systemic medication Choice of drugs depends on the pathogens. Examples: Gonorrhea infection:Third generation Cephalosporins Ceftriaxone Sodium (头孢曲松钠/头孢三嗪/菌必治/罗氏芬) (头孢克) Spectinomycin (大观霉素/壮观霉素/淋必治) Chlamydia trachomatis Doxycycline (多西环素) Azithromycin (阿奇霉素) Erythromycin (红霉素) Ofloxacin (氧氟沙星) nullChronic Inflammation of the Cervix nullnull Cervical Erosion Etiology When the stratified epithelium (复层上皮) which normally covers the vaginal portion of the cervix is replaced by columnar epithelium which is continuous with that of the cervical canal. 2. Most erosion are not infected, nor they are the result of inflammation. 3. Occurs in the newborns, pregnancy, oral contracepivesnull Clinical Features Symptoms The only symptom is a mucoid discharge. A slight postcoital bleeding (but malignancy should be excluded) Signs A red area is seen around the external os. Classification Depends on the depth and area of the lesion Types: simple, granular, papillary Grades: I (<1/3), II (1/3-2/3), III (>2/3)null Treatment Erosion found on routine examination should not be treated unless it is causing troublesome discharge. A cervical smear is needed before the treatment, and if necessary, colposcopy (阴道镜) and biopsy. Cervical ectropion (宫颈外翻) Physical therapy Thermal cauterization, Cryotherapy, Laser therapynullnull Cervical Polyps Small pedunculated neoplasms of the cervix Endocervical polyp: Originating from the endocervix Ectocervical polyp: Originating from the vaginal portion null Pathology Gross appearance: Endocervical polyp: Red or pink, rounded or tongue-like Ectoervical polyp: Pale, flesh-colored, smooth, rounded with a broad pedicle Microscopic: Vascular connective tissue stroma covered with columnar or squamous epithelium or both. Congestion, edema or leukocytein filtration may be present.null Clinical Features Some are asymptomatic. Slight postcoital bleeding Treatment Cervical polyp should be treated. Malignant change (<1%) Polypoid cervical cancer Twisting off a polyp without an anesthetic and cauterizing the base. Recurrent cases are treated with canal dilation and cauterization of the stalk. null Chronic Endocervicitis (宫颈粘膜炎) (Infection) Etiology Pathogens: Normal cervical and vaginal flora Pathology Thickened endocervix that produces a whitish pus A cervical os surrounded by a reddish area Hypertrophy of the lacerated cervix null Clinical Features 1. Persistent leukohrrea usu. mucopurulent 2. Slight postcoital staining 3. Pains lower abdominal discomfort, lumbosacral backache, dysmenorrhea, dyspareunia 4. Infertility 5. Urinary symptoms frequency, urgency, dysuria due to subvesical lymphangitis not to cystitis null Diagnosis The characteristic discharge from external os of the cervix. Cytologic and colposcopic studies are helpful, but only biopsy is definitive. Cultures are not so helpful. null Treatment Even if chronic endocervicitis is asymptomatic, it should be treated. 1. Medical treatment Systemic rather than topical Based on culture and sensitivity test 2. Surgical treatment A note of caution: postoperative bleeding, infection, stricture formation, infertility. Methods: thermal therapy, cryotherapy, laser therapy conization, hysterectomy.nullnull Nabothian Cysts Retention cysts of the cervical glands caused by obstruction of the gland orifices by the growth of squamous epithelium. The cysts may be infected and contain pus. Cervical Hypertrophynullnull Cervical HypertrophynullnullPelvic Inflammatory Disease (PID) Infection of the upper genital tract Terms: Endometritis (子宫内膜炎) Salpingitis (输卵管炎) Oophoritis (卵巢炎) Myometritis (子宫肌炎) Pyosalpinx (输卵管积脓) Hydrosalpinx (输卵管积水) Peritonitis (腹膜炎) Tubal ovarian abscess (TOA) (输卵管卵巢脓肿)null Epidemiology Sexual activity A disease of sexually active, menstruating women. Acute PID occurs in 1-2% of young sexually active women annually. Age The peak incidence occurs in their late teens and early twenties. The most common serious infection in women of 16-25 years of agenullContraceptive practices Contraceptive methods No.of PID/woman-years Sexually active, using no contraception: 3.42 Oral contraceptives: 0.91 Barrier methods 1.39 Intrauterine devices (IUD) 5.21nullFinancial cost In USA, $3.5 billion annually in 1990s Medical sequelae Ectopic pregnancy: 6-10 fold increase PID accounts for 50% Chronic pain: 4 fold increase Infertility: acute PID account for 5-60% of cases Tubal obstruction: 11.4%, 23.1%,54.3% from 1, 2, 3 episodes of infection Mortality: septic shock and deathnull Etiology Pathogens that are sexually transmitted 1) Neisseria gonorrhoeae: in USA, 40-50% cases of PID 2) Chlamydia trachomatis: in USA, 10-40% cases of PID The two pathogens may account for 2/3 of the PID 3) Mycoplasma (支原体) Recovered from the pus in 2-20% cases of salpingitis Endogenous bacteria 1) Aerobic: streptococci, staphylococci, Escherichia coli 2) Anaerobic: Bacteroides fragilis (脆弱类杆菌), peptococcus (消化球菌) , peptostreptococcus (消化链球菌) null Spreading Route of Infection 1. Ascending along the reproductive tract For non-pregnant and non-puerperal women Gonococcus, C. trachomatis, staphylococcus 2. Lymphatic vessels In puerperal infection, post-abortion infection and IUD associated infection Streptococcus, E.coli, anaerobic bacteria 3. Blood vessels Tuberculosis 4. Direct spreading Infection from other visceral organs.nullAcute PIDnull Predisposing Factors 1. Intrauterine manipulation e.g. artificial abortion , IUD, etc. 2. Infection in the lower reproductive tract, esp. STD 3. Sexual activity 4. Bad hygiene 4. Direct spreading from adjacent viscera 6. Acute onset of a chronic PIDnull Pathology 1. Acute endometritis and myometritis 2. Acute salpingitis, pyosalpinx and tubo-ovarian abscess (TOA) 3. Acute pelvic peritonitis 4. Acute inflammation of the peritoneal connective tissue (parametritis)(宫旁结缔组织炎) 5. Septicemia (败血症) and pyemia (脓毒血症) 6. Fitz-Hugh-Curtis syndromenullnullnull Fitz-Hugh-Curtis syndrome Perihepatitis: inflammation of Glisson’s capsule without involvement of the liver parenchyma. Suppurative (脓性) and fibrous exudation of the capsule occurs causing adhesion between the capsule and the anterior peritoneum. It happens in 5-10% cases of salpingitis. It is caused by gonococcus or Chlamydia trachomatis. Edema and adhesion of the capsule may lead to pain in the upper abdominal region.nullnull Clinical Features Symptoms Vary depending on severity and extent of the infection and types of pathogens Most common: lower abdominal pain, fever, increase in vaginal discharge. Gonorrhea/Chlamydia Trichomatis Signs Variable Typical: Bimanual examination:null Diagnosis Criteria for the diagnosis of PID Minimum: Pain on compression of uterine body or the adnexal region 2) Tenderness of the cervix Specific: 1) Biopsy of the endometrium showing endometritis 2) Ultrasound/MRI identification of liquid-filled enlarged oviducts or TOA 3) Laparoscopic examination Additional: null Differential DiagnosisAppendicitisRupture or abortion of tubal pregnancyTorsion or rupture of an ovarian tumornull Treatment (1) 1. Systemic medication (Ideal) Based on drug sensitivity test (Empirical) Combination use of dru
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