PELVIC INFECTIONS URINARY TRACT INFECTION DR AKINWUNMI L

PELVIC INFECTIONS & URINARY TRACT INFECTION DR. AKINWUNMI L. AKINWUNTAN MBBS (Ibadan), MHS Pop. & RH (Ibadan), FMCOG (Nig), FWACS OBSTETRICIAN & GYNAECOLOGIST

INTRODUCTION • Pelvic inflammatory disease (or disorder) (PID) is a term for inflammation of the uterus, fallopian tubes, and/or ovaries • It progresses to scar formation with adhesions to nearby tissues and organs • PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections 9/30/2020 2

Acute Salpingitis 9/30/2020 3

• STI or STD is often the cause, many other routes are possible, including lymphatic, postpartum (miscarriage or abortion) or intrauterine device (IUD) related, and hematogenous spread 9/30/2020 4

• The term "sexually transmitted diseases" is used to denote disorders spread principally by intimate contact • Although this usually means sexual intercourse, it also includes close body contact, kissing, cunnilingus, anilingus, fellatio, mouth–breast contact, and anal intercourse 9/30/2020 5

EPIDEMIOLOGY • In the United States , more than 750, 000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers • PID causes over 100, 000 women to become infertile in the US each year • About 2% of young women in the UK give a history of PID if asked, and about 1 in 50 consultations with general practitioners made by young women relate to PID 9/30/2020 6

EPIDEMIOLOGY • RISK FACTORS: – Young age – Multiple sex partners – Lack of condom use – Low Socio-economic class – Blacks/Caribbean origin – Genetics- HLA subtype A 31 compared with HLA DQA 0501 and DQB 0402 – ? ? ? Bacterial Vaginosis – Indiscriminate/Improper use of antibiotics 9/30/2020 7

Organisms associated with Pelvic inflammatory disease Aerobic • • • Neisseria gonorrhoeae Chlamydia trachomatis The big two Ureaplasma urealyticum Mycoplasma genitalium Gardnerella vaginalis Strep. pyogenes Escherichia coli Haemophilus influenzae Mycoplasma hominis Strep. pneumoniae Mycobacterium tuberculosis 9/30/2020 8

Anaerobic • Bacteroides sp. • Peptostreptococcus sp. • Clostridium bifermentans • Fusobacterium sp. Viruses • Herpes simplex • Echovirus • Coxsackie 9/30/2020 9

NEISSERIA GONORRHOEAE • Neisseria gonorrhoeae is a gram negative diplococcus • Can be seen on microscopy as pairs of red kidneyshaped organisms mostly sitting within polymorphs • Isolated in 40– 60% of women with acute salpingitis • It initially infects the cervix but ascends the upper genital tract in 10 -20% of untreated cases 9/30/2020 10

SYMPTOMS & SIGNS • Most women with gonorrhea are asymptomatic • When symptoms occur, they are localized to the lower genitourinary tract and include: – vaginal discharge, urinary frequency or dysuria, and rectal discomfort – Vulva/Vaginal itching • The incubation period is only 3– 5 days • Bartholinitis • Acute Pharyngitis/Tosillitis 9/30/2020 11

• Purulent vaginal discharge. • Urinary frequency and dysuria • Recovery of organism in selective media • May progress to pelvic infection or disseminated infection • The organism may be recovered from the urethra, cervix, anal canal, or pharynx 9/30/2020 12

• Polyathralgia • Tenosynovitis • Dermatitis • Conjunctivitis 9/30/2020 Opthalmia Neonatorum 13

Male Urethral Discharge • Discharge coming from the urethral meatus • May be frank pus, mucopurulent, or serous (clear) • Occasionally discharge will be white in colour 9/30/2020 Gonococcal urethral discharge 14

DIAGNOSIS • Discharge – Urethral, Cervical, Anal, Pharynx • Thayer-Martins Media • Gram Negative Diplococci in leucocytes • ELISA • Nucleic Acid Amplification Test (NAATs) 9/30/2020 15

CHLAMYDIA TRACHOMATIS • Is estimated to be the cause in about 60% of cases of salpingitis which may lead to PID • Chlamydiae are obligate intracellular microorganisms that have a cell wall similar to that of gram-negative bacteria • They are classified as bacteria and contain both DNA and RNA • Like viruses they grow intracellularly 9/30/2020 16

CLINICAL PRESENTATION • • • ASYMPTOMATIC FEVER ABNORMAL VAGINAL DISCHARGE LOWER ABDOMINAL PAINFUL INTERCOURSE IRREGULAR MENSTRUAL BLEEDING PAINFUL MENSTRUATION CERVICAL MOTION TENDERNESS COMPLICATION ie Infertility 9/30/2020 17

DIAGNOSIS • Based solely on lab test • Cell Culture isolation: sensitivity= 70 -90% • Complement Fixation Methods • Immunofluorescence • DNA Probe 9/30/2020 18

Genital Ulcer Disease Syphilis 9/30/2020 Chancroid Herpes Simplex 19

Genital herpes vesicles 9/30/2020 20

Typical vaginal discharge caused by trichomoniasis 9/30/2020 21

“Strawberry cervix” due to T. vaginalis 9/30/2020 22

PHYSICIANS’ ROLE 1. Understand the microbiology of STDs in order to appropriately diagnose and treat patients 2. To alleviate the symptoms and prevent future sequelae 3. To prevent the transmission to others including health care professionals 4. To do all of the above combined with patient education and counseling 9/30/2020 23

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Essential Steps In STI Care Management* Syndrome Assessment Contact tracing (diagnostic tools) Diagnosis Treatment (screening tests) Risk Assessment 9/30/2020 Compliance 5 Cs Confidentiality Condom use Counseling 27

ANTIBIOTIC Rx • CEPHALOSPORINS – Cefuroxime – Ceftriaxone – Cefpodoxime eg Orelox • MACROLIDES – Azithromycin • TETRACYCLINS – Doxycycline • FLUOROQUINOLONES – Ciprofloxacin, Levofloxacin, Ofloxacin 9/30/2020 28

URINARY TRACT INFECTION • A urinary tract infection (UTI) is a bacterial inflammation in the urinary tract • Urethritis - Urethra • Cystitis – Bladder • Pyelonephritis - Kidneys 9/30/2020 29

Risk factors • Women – Anatomy – Sexual intercourse – Pregnancy • • • Catheterization Bladder/Kidney stones Immunosuppression Stroke/Bedridden Family history Diabetes Mellitus 9/30/2020 30

CAUSES • • • E. Coli - 80 – 85% Klebsiella Pseudomonas Proteus Enterobacter Rarely – Viruses and Fungi 9/30/2020 31

SYMPTOMS & SIGNS • Lower Tract – Burning sensation on micturition – Frequency – Urgency • Upper Tract – Flank Pain – Fever – Haematuria/Pyuria – Nausea and Vomiting 9/30/2020 – Plus symptoms of the lower tract 32

SYMPTOM & SIGNS…. . • In the Elder Post-menopausal – Incontinence – Altered sensorium – Fatigue – Sepsis – Plus earlier symptoms 9/30/2020 33

DIAGNOSIS • HISTORY • LAB: – Urinalysis – Nitrites, Leucocyte Esteraces – Urine m/c/c – WBCs, RBCs, Bacteria, Colony count ≥ 10, 000/colony forming unit Asymptomatic bacteriuria : No symptom plus significant count 9/30/2020 34

TREATMENT • UNCOMPLICATED – Oral Antibiotics – Cephalosporins eg Cefuroxime (Axacef) – Quinolones eg Ciprofloxacin (Cyplox) – Usually a 3 -5 day course is sufficient • PYELONEPHRITIS – Requires prolonged medication – Parenteral – Ceftriaxone – Amoxicillin/Clavulanate 9/30/2020 35

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