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

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PELVIC INFECTIONS & URINARY TRACT INFECTION

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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


Acute Salpingitis


  • 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


  • 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


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


EPIDEMIOLOGY

  • RISK FACTORS:

    • Young age

    • Multiple sex partners

    • Lack of condom use

    • Low Socio-economic class

    • Blacks/Caribbean origin

    • Genetics- HLA subtype A31 compared with HLA DQA 0501 and DQB 0402

    • ??? Bacterial Vaginosis

    • Indiscriminate/Improper use of antibiotics


Organisms associated with Pelvic inflammatory disease

Aerobic

  • Neisseriagonorrhoeae

  • Chlamydia trachomatis The big two

  • Ureaplasmaurealyticum

  • Mycoplasmagenitalium

  • Gardnerellavaginalis

  • Strep. pyogenes

  • Escherichia coli

  • Haemophilusinfluenzae

  • Mycoplasmahominis

  • Strep. pneumoniae

  • Mycobacterium tuberculosis


Anaerobic

  • Bacteroides sp.

  • Peptostreptococcus sp.

  • Clostridium bifermentans

  • Fusobacterium sp.

    Viruses

  • Herpes simplex

  • Echovirus

  • Coxsackie


NEISSERIA GONORRHOEAE

  • Neisseriagonorrhoeae is a gram negative diplococcus

  • Can be seen on microscopy as pairs of red kidney-shaped 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


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


  • 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


  • Polyathralgia

  • Tenosynovitis

  • Dermatitis

  • Conjunctivitis Opthalmia Neonatorum


Male Urethral Discharge

  • Discharge coming from the urethral meatus

  • May be frank pus, mucopurulent, or serous (clear)

  • Occasionally discharge will be white in colour

Gonococcal urethral discharge


DIAGNOSIS

  • Discharge – Urethral, Cervical, Anal, Pharynx

  • Thayer-Martins Media

  • Gram Negative Diplococci in leucocytes

  • ELISA

  • Nucleic Acid Amplification Test (NAATs)


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


CLINICAL PRESENTATION

  • ASYMPTOMATIC

  • FEVER

  • ABNORMAL VAGINAL DISCHARGE

  • LOWER ABDOMINAL PAIN

  • PAINFUL INTERCOURSE

  • IRREGULAR MENSTRUAL BLEEDING

  • PAINFUL MENSTRUATION

  • CERVICAL MOTION TENDERNESS

  • COMPLICATION ie Infertility


DIAGNOSIS

  • Based solely on lab test

  • Cell Culture isolation: sensitivity= 70-90%

  • Complement Fixation Methods

  • Immunofluorescence

  • DNA Probe


Genital Ulcer Disease

Syphilis

Chancroid

Herpes Simplex


Genital herpes vesicles


Typical vaginal discharge caused by trichomoniasis


“Strawberry cervix” due to T. vaginalis


PHYSICIANS’ ROLE

  • Understand the microbiology of STDs in order to appropriately diagnose and treat patients

  • To alleviate the symptoms and prevent future sequelae

  • To prevent the transmission to others including health care professionals

  • To do all of the above combined with patient education and counseling


Essential Steps In STI Care Management*

Syndrome

Assessment

Contact tracing

Compliance

Confidentiality

Condom use

Counseling

(diagnostic tools)

5Cs

Diagnosis

Treatment

(screening tests)

Risk

Assessment


ANTIBIOTIC Rx

  • CEPHALOSPORINS

    • Cefuroxime

    • Ceftriaxone

    • Cefpodoxime eg Orelox

  • MACROLIDES

    • Azithromycin

  • TETRACYCLINS

    • Doxycycline

  • FLUOROQUINOLONES

    • Ciprofloxacin, Levofloxacin, Ofloxacin


URINARY TRACT INFECTION

  • A urinary tract infection (UTI) is a bacterial inflammation in the urinary tract

  • Urethritis - Urethra

  • Cystitis – Bladder

  • Pyelonephritis - Kidneys


Risk factors

  • Women

    • Anatomy

    • Sexual intercourse

    • Pregnancy

  • Catheterization

  • Bladder/Kidney stones

  • Immunosuppression

  • Stroke/Bedridden

  • Family history

  • Diabetes Mellitus


CAUSES

  • E. Coli - 80 – 85%

  • Klebsiella

  • Pseudomonas

  • Proteus

  • Enterobacter

  • Rarely – Viruses and Fungi


SYMPTOMS & SIGNS

  • Lower Tract

    • Burning sensation on micturition

    • Frequency

    • Urgency

  • Upper Tract

    • Flank Pain

    • Fever

    • Haematuria/Pyuria

    • Nausea and Vomiting

    • Plus symptoms of the lower tract


SYMPTOM & SIGNS…..

  • In the Elder Post-menopausal

    • Incontinence

    • Altered sensorium

    • Fatigue

    • Sepsis

    • Plus earlier symptoms


DIAGNOSIS

  • HISTORY

  • LAB:

    • Urinalysis – Nitrites, Leucocytes, LeucocyteEsteraces

    • Urine m/c/c – WBCs, RBCs, Bacteria, Colony count ≥ 10,000/colony forming unit

      Asymptomatic bacteriuria : No symptom plus significant count


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


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