Reproductive Tract Infections

1. Reproductive Tract Infections

2. The relationships of reproductive tract infections (RTI’s), STDs and sexually transmitted infections (STI’s) • “Infection” means the presence of a microorganism in the body • “Disease” means the presence of an adverse bodily state

3. All infections that occur in the genital tract are RTI’s, but not all of them are sexually transmitted • Although not all infections result in disease: • STI’s need to be identified and treated because they are capable of ultimately causing disease, either in the person infected or in someone who might be infected by that person.

4. The natural protection of the lower genital tract is provided by several factors • The integrity of the cell layers of the lower genital tract: • The vagina is covered with stratified squamous epithelium uninterrupted by any opening : the vaginal skin. • The thickness of that epithelium is determined by the balance of the sex hormones. • In young girls and older women the lining of the vagina is only few cell layers thick

5. The balance between the natural micro-organisms. • The Normal Vaginal Flora: many micro-organisms living in balance with each-other. 1) The Lactobacillus acidophilus (L. vaginalis, Doderlein's bacilli) 2) Other types of bacterial flora: The cocci belong to the bowel flora and accepted in a "healthy vaginal environment" (the mixed flora). 3)Other bacteria in the normal flora include Gardnerella vaginalis, E coli and several anaerobic bacteria, and mycoplasma. • The acidity of the vagina (pH). • The vagina usually has an acidic environment (a low pH). • This is due to the action of the Lactobacillus vaginalis which acts on the glycogen content of the vaginal cells to produce lactic acid. • The normal vaginal pH is 3.8-4.2, preventing the overgrowth of bacteria and yeast. • Conditions that makes the pH of the vagina alkaline: Menstrual flow, certain infections, and semen. • "Lactobacillosis": Abnormal condition of too many lactobacilli. Frequently there are associated symptoms similar to candidiasis (too many is too much). There is no symptomatic improvement if given treatment of candidiasis.

6. Normal Vaginal Flora • 108-109 anaerobes / ml. • 107-108 aerobes / ml. • Corynebacterium 84% • Lactobacilli ( Doderlein) 82% • Staph 66% • Micrococci 37% • Strept Faecalis 34% • Anaerobic Strept. 22% • Candida albicans 17%

7. The Normal Vaginal Discharge • Composition: • Cervical secretions. • Vaginal secretions as epithelial transudation. • Epithelial cells. • Bacterial flora. • Characters: • Milky white or mucoid, with specific smell. • It is not associated with itching or burning.

8. The amount of the normal discharge varies according to time of cycle: • It increases premenstrual and at mid-cycle when it is watery and may constitute the ovulatory cascade which is sometimes blood tinged. • It is scantier immediately postmenstrual and is generally viscid in the second half of the cycle. • Personal behavior • Vulval hypersensitivity: menstrual pads, soaps, synthetic fibers, toilet tissue, and medications. • Local contraceptives: Sensitivity may develop to spermicides, or condoms or diaphragms. • Fostering of fungal and bacterial growth: Tight, non-porous underclothing or poor hygiene. • Leucorrhea is a term used in two ways. • Usually it is used to indicate the flow of excessive normal vaginal discharge. • Sometimes, the term is used to indicate all abnormal vaginal discharge except when stained with blood.

9. Candidiasis Dimorphic organisms exist in yeast and mycelial phases.

10. Candidiasis • 75% of women will experience an episode at some time during their life. • 1/10 will suffer recurrent attacks • Genus: Candida • albicans 90% • tropicalis • pseudotropicalis • stellatoidea • krusei 10% • parapsilosis • guilliermondi

11. Predisposing Factors: • Decrease in host local or systemic immunity: • Pregnancy • Diabetes Mellitus • Debilitating diseases: uremia, malignancy • Broad spectrum antibiotics: disturb normal flora • Other genital infections , genital trauma • Oral Contraceptive Pills

12. Precipitating Factors: • Improper genital hygiene: • Direction of wiping • Vaginal douching • Self medications • Clothing: • Tight • Non-absorbent • Humidity All dresssed up for candidiasis

13. Source of Infection • Endogenous: 75% • GIT • Deep layers of vagina where yeast penetrates and is impervious to topical treatment. • Exogenous: 25% • Male partner • Instrumental contamination

14. Clinical picture • Itching • more with warmth • more at night • causes Dysuria and Dyspareunia • Discharge • not a constant feature • cottage cheese curds • may be thin, mucopurulent

15. Clinical Picture

16. Diagnosis • Clinical Features: Unreliable • Confirm by microscopy: • Wet mount + 10-20% K(OH) • Germinated Filamentous Candida • Gram stain

17. Diagnosis • High Vaginal Swab Culture: • Sabouraud’s Agar • Nickerson’s media • Trichosel broth

18. Diagnosis • Slide latex agglutination test • particles coated with immunoglobulin against cell wall fragments of candida albicans • If the patient is symptomatic and wet mounts and KOH preparations fail to reveal trichomonads, bacterial vaginosis or candidiasis, Fungal culture should be done

19. Treatment • Success depends upon: • Identifying Symptomatic women with definite Candida organisms. • Correcting the predisposing & precipitating factors. • Avoiding short term erratic treatment.

20. Treatment • Gentian Violet: Hexamethyl-Pararosaniline (1%) • Paint the vulvovaginal area, repeat every 72 h. for 2-3 weeks. ( Friedrich’s technique) • Allergy (1%), Messy, Office procedure. • Resistant and recurrent cases respond well

21. Treatment • Boric Acid: • Not commercially available • Easy produced using size 0 gelatin capsules and 600 mg of boric acid powder. • One capsule daily for 14 days • 100% cure rate immediately, 5% recurrence in 30 days. • 90% cure rate in case of Nystatin failure

22. Treatment • Azole Compounds: • Clotrimazole • Miconazole • Butoconazole • Terconazole • Non of these compounds are more effective than the other, nor does any treatment schedule seem superior. • All exhibit their antifungal action through inhibiting cytochrome enzymes [C450].

23. Clotrimazole 100 mg x 7 200 mg x 3 500 mg x 1 Miconazole 100 mg x 7 200 mg x 3 Butoconazole 5 gm of 2% cream x 3 Terconazole 80 mg x 3 5 gm of 0.4% cream x 7 Treatment Azole Compounds:

24. Treatment • Nystatin: • Polyene antibiotic produced by Streptomyces noursei • Vaginal supp. 100 000 units / night / 14 nights • Least active antifungal, poor for recurrent infection, oral form ineffective to eliminate rectal reservoir.

25. Treatment • Fluconazole: • Orally absorbed antifungal with a BISTRIAZOLE structure. • Less side effects • Single oral dose = better compliance • Rapid relieve of symptoms • Effective elimination of the rectal reservoir

26. Treatment • Ketoconazole: • Orally absorbable IMIDAZOLE • 400 mg / day x 5 days • Hepatic toxicity: • Hepatocellular liver injury 1 in 10 000 • nonprogressive serum transaminase elevation 5% • REVERSIBLE • Itraconazole

27. Trichomoniasis Etiology/Epidemiology: Caused by Trichomonos Vaginalis Women affected more than men Transmitted sexually and by communal bathes Clinical Presentation: • Women: 25% ae asymptomatic • Discharge, Pruritus, Dysuria, Dyspareunia, Excoriated vulva, post coital spotting • Men are in most of the cases asymptomatic

28. Trichomoniasis Diagnosis: Vaginal Discharge is malodorous, yellow-green, foamy Excoriated vulva and vagina Organism apparent on wet mount Treatment: Metronidazole 2 gram PO once ( both partners) Recurrent cases: repeat treatment for 3-5 days

32. Bacterial Vaginosis Etiology/Epidemiology: Overgrowth of vaginal flora with 100 times increase in Gardenerella vaginalis. Some women are asymptomatic, others present with PID Commenest cause of vaginal discharge Clinical Picture: Discharge plus little or no itching or burning.

33. Bacterial Vaginosis Diagnosis: • Whiff test (amine test) with 10% KOH • Clue cells • Culture and pH are not helpfull Treatment: • Metronidazole 2 gram orally once • Metronidazole vaginal suppositories over 5 days • Clindamycine orally over 7 days • Clindamycin vaginal cream over 3 days

38. Genital Herpes 5 H.S.V. particles attacking surface of cell

39. Genital Herpes Early HSV Advanced HSV

40. Genital Herpes • Genital herpes affects an estimated 60 million Americans. • Approximately 500,000 new cases of this incurable viral infection develop annually. • Herpes infections are caused by herpes simplex virus (HSV). E-M image of Herpes Simplex viral particle

41. Genital Herpes • The major symptoms of herpes infection arepainful blisters or open sores in the genital area. • These may be preceded by a tingling or burning sensation in the legs, buttocks, or genital region. • The herpes sores usually disappear within two to three weeks, but the virus remains in the body for life and the lesions may recur from time to time.

42. Genital Herpes • Severe or frequently recurrent genital herpes is treated with one of several antiviral drugs that are available by prescription. • These drugs help control the symptoms but do not eliminate the herpes virus from the body. • Suppressive antiviral therapy can be used to prevent occurrences and perhaps transmission.

43. Genital Herpes • Local therapy and Supportive care: • Sitz bath, warm compressants, analgesics for local relief • Episodic treatment • Acyclovir: 400 mg x 3 / day for 7 days • Famciclovir: 250 mg x 3 / day for 7 days • Valacyclovir: 1 gram orally twice • Parentral Therapy: • Acyclovir 5 to 10 mg/Kg three times daily 5-7 days

44. Genital Herpes • Women who acquire genital herpes during pregnancy can transmit the virus to their babies. • Untreated HSV infection in newborns can result in mental retardation and death.

45. Genital Warts • Genital warts (condylomata acuminata) are caused by human papillomavirus, a virus related to the virus that causes common skin warts.

46. Genital Warts • Genital warts usually first appear as small, hard painless bumps in the vaginal area, on the cervix, the penis, or around the anus.

47. Genital Warts • If untreated, they may grow and develop a fleshy, cauliflower-like appearance.

48. Genital Warts • Genital warts infect an estimated 1 million Americans each year. • In addition to genital warts, certain high-risk types ( 16 & 18) of HPV cause cervical cancer and other genital cancers.

49. Genital Warts • Genital warts are treated by: • Topical drug (applied to the skin) • 25% podophyllin in benzoin • Trichloroacetic acid and Bichloroacetic acid • Imiquinod 5% topical cream (Interferon-alpha inducer) • Freezing , Laser therapy, Electrocautery. • Injections of a type of interferon. • If the warts are very large, they can be removed by surgery

50. Understanding the basic facts about STDs • The ways they are spread • Their common symptoms • How they can be treated Is the first step toward prevention.