1. GENITAL INFECTIONS
Dr.B.BOYLE

2. GENITAL INFECTIONS Vaginal Infections Prostatitis
Infections of the female pelvis
Post-Gynaelogical Surgery Infections
Pelvic Inflammatory Disease(Previous lecture)
FEMALE
Prostatitis
Epididymitis
Orchitis
Urethritis (Previous Lecture)
Balanitis
MALE

3. 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)

4. 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

5. 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

6. 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 non-erythematous
Discharge: grayish,thin,homogenous containing small bubbles

7. Bacterial Vaginosis Diagnosis(3/4) Guide Ph greater than 4.5(90%)
Homogenous white , smoothly adherent vaginal discharge
Positive whiff test (limited value)
Clue cells:direct microscopy of discharge reveals vaginal epithelial cells studded with tiny coccobacilli, edge of cells or obliterate the nucleus
Some clue cells seen in 90% of women
with BV
In normal women predominant type of
bacteria is large rods(Lactobacilli spp.)

8. 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

9. 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

10. Bacterial Vaginosis-Pathophysiology
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

11. Bacterial Vaginosis-Treatment
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.

12. Bacterial Vaginosis-Complications
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

13. 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

14. Bartholin`s Gland Abscess

15. Bartholin`s Gland Abscess

16. 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

17. 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

18. 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

19. Organisms isolated Gardnella vaginalis Mycoplasma hominis anaerobes
E.coli
Group B Streptococci
Enterococci
Aerobic Gram negative bacilli

20. 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 5-10% and another 10% subclinical
Causes arrest of progress of labour
Diagnosis : clinical mostly

21. 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

22. 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 %
Caesearan section rate: 10-50%
Secondary risk factors include BV

23. 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

24. 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

25. 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)

26. Pyosalpinx

27. Actinomyces Gram /Culture

28. Actinomyces Infection

29. 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

30. 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

31. Female Anatomy

32. 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

33. 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

34. 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

35. Pyometrum

36. 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

37. Tuboovarian Abscess

38. Genital Infections in Men
Prostatitis
Acute bacterial
Chronic bacterial
Chronic Pelvic Pain Syndrome
Granulomatous
Prostatic Abscess
Epididymitis
Non-specific
Sexually Transmitted
Orchitis
Viral
Bacterial

39. 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

40. Prostatitis
50% of men will experience symptoms at some stage of their lives

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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