GENITAL INFECTIONS Dr.B.BOYLE [email protected]

GENITAL INFECTIONS
Dr.B.BOYLE
[email protected]
GENITAL INFECTIONS
FEMALE

Vaginal Infections
 Infections of the
female pelvis
 Post-Gynaelogical
Surgery Infections
 Pelvic Inflammatory
Disease(Previous
lecture)
MALE





Prostatitis
Epididymitis
Orchitis
Urethritis (Previous
Lecture)
Balanitis
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)
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~105-6 of
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
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
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 nonerythematous
 Discharge:
grayish,thin,homogenous
containing small bubbles
Bacterial Vaginosis

Diagnosis(3/4) Guide
 Ph greater than 4.5(90%)
 Homogenous white ,
adherent vaginal discharge
 Positive whiff test (limited
value)
 Clue cells:direct
microscopy of discharge Some clue cells seen in 90% of women
reveals vaginal epithelial
with BV
cells studded with tiny
coccobacilli, edge of cellsIn normal women predominant type of
or obliterate the nucleus
bacteria is large rods(Lactobacilli spp.)
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
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
Bacterial VaginosisPathophysiology






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
Bacterial VaginosisTreatment

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.
Bacterial VaginosisComplications





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
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
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
Infections of the female
Pelvis

Intra-amniotic
Infection Syndrome
 Post Partum
Endometritis
 Puerperal Ovarian
vein
Thrombophlebitis
 Episiotomy
Infections

Post-abortion
Infections
 Infections after
Gynaecological
Procedures
 Pelvis Inflammatory
Disease
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
Organisms isolated

Gardnella vaginalis
 Mycoplasma hominis
 anaerobes

E.coli
 Group B Streptococci
 Enterococci
 Aerobic Gram
negative bacilli
Presentation





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 510% and another 10%
subclinical
Causes arrest of progress
of labour
Diagnosis : clinical
mostly
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
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
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
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
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)
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
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
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
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
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
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
Genital Infections in Men






Prostatitis
Acute bacterial
Chronic bacterial
Chronic Pelvic Pain
Syndrome
Granulomatous
Prostatic Abscess






Epididymitis
Non-specific
Sexually Transmitted
Orchitis
Viral
Bacterial
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
Prostatitis

50% of men will experience symptoms at
some stage of their lives
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
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
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
Chronic Bacterial Prostatitis
Urinary Tract
Urine Cultures
Localization
Using Sequential
Specimen
Symbol
Descripition
Voided Bladder
1
VB1
Initial 5-10ml
Voided Bladder
2
VB2
Midstream
specimen
Expressed
Prostatic
secretion
EPS
Secretions
expressed from
prostate by
digital massage
Voided Bladder
3
VB3
First 5-10ml
after Prostatic
massage
cfu
VB3>>VB1
10 fold
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
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
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
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
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
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