Common Gynecological Infections

We are going to talking about the clinical presentation of common gynecological infections of the lower genital tract (vulva, vagina & cervix) and upper genital tracts (endometria, myometria, fallopian tubes, & ovaries).  An OB/GYN will also see patients with non-gynecological infections, like the breast and lower urinary tract (i.e. bladder & urethra), but we won’t be addressing these in this lecture!
 

Case #1

D.B. is a 45 y.o. G0P0 LMP about 2 weeks ago who presents to clinic for a routine gynecologic exam because she recently attended a lecture concerning women’s health issues @ her community group.  She has no complaints.  She has no significant past medical or surgical history.  She takes no medication and has no allergies.  She denies any history of STDs and recently ended a 5 yr. mutually monogamous relationship with another woman.  She smokes 5 cigarettes a day and has been smoking for 25 yrs.  She drinks alcohol occasionally on weekends and does not use drugs of any kind.  On review of systems she reports that over the last 5-10 yrs. she will occasionally have discharge which comes and goes.  It has no odor that she has noticed, nor does it produce any other symptoms.  On PE, she has normal appearing external genitalia, a small amount of yellowish, green vaginal discharge, cervix is normal, uterus & ovaries are normal on bimanual exam.  Wet mount reveals motile trichomonads.  à Diagnosis: Trichomonas
 

What is normal discharge?  There is normal and abnormal discharge to be aware of.

• Normally acidic (pH 4) maintained by normal vaginal flora, lactobacillus that producing hydrogen peroxide.
• White & floccular (meaning it has a bit of texture, and not really serous)
• Odorless
• Found in dependent portion of vagina, meaning when patient is supine, it’s collected in the posterior vagina…its not normal to be sticking to all the other walls!
   

What is the color of a normal vagina?  It’s normally pink, or whitish-pink. 
 

What is vaginitis?  Basically, it is just inflammation of the vagina.  It’s caused by many things, i.e. infections or atrophy.  Clinically speaking, we usually say vaginitis is caused by an infection (unless specifically noted as atrophic vaginitis), which is caused by 3 main offenders:

1. Bacterial vaginosis – covers about 40% of vaginitis cases
2. Trichomonas – 30%
3. Candidiasis – 30% (interestingly, many women automatically think they have a yeast infection, which is caused by Candida, but its not the most common cause of vagintis…and then they  just buy over-the-counter yeast infxn medication to treat.  In fact, most OTC meds advise the patient to make sure to have at least 1 prior diagnosis of Candida from a physician before they just start treating themselves with these antifungals!)

How are they diagnosed?  History & Physical & especially the Wet Mount**.

• In the lab we learned about taking a wet mount by taking a wet saline swab with drops on slide, then place swab in discharge and then put on swab.
• Dr. Pompeo says to take a slide, put small amount of discharge on dry swab (b/c you probably won’t have a saline swab available in the room), put on slide, then add 2 drops of saline and this disperses the discharge in a sun-ray fashion.  You would look for trichomonads in the center of the slide.

How do we distinguish between the different causes of infectious vaginitis?  You need to look at the specific symptoms to compare them.  Use this chart!

Why is bacterial vaginosis called a “nosis”, not really an “itis”?

Because this is not really a huge inflammatory response in the vagina as compared to the other causes.  Under a wet mount, you will NOT see a huuuuge increase in the amount of inflammatory cells as you would in the other cases!

Case #2

A.C. is a 32 y.o. G0P0 LMP 1 week ago who presents to clinic for a routine gynecologic exam because she recently attended a lecture concerning women’s health issues @ her community center.  She has no complaints.  She has no significant past medical or surgical history.  She takes no medications and has no allergies.  She denies any history of STDs and is currently in a mutually monogamous relationship with another woman.  She does not smoke, drink alcohol, or use drugs of any kind.  On PE, she has normal appearing external genitalia, cervix has a minimal amount of mucopurulent discharge.  Her uterus is normal sized & her ovaries are normal sized.  As part of her gynecologic exam, she has a Pap smear and swabs for gonorrhea and Chlamydia taken.  Two days later, the Chlamydia DNA PCR results come back positive.  à Dx: Mucopurulent cervicitis

What is mucopurulent cervicitis?

• Caused by bacterial organisms, most commonly Neisseria gonorrhea & Chlamydia trachomatis, and sometimes Mycoplasma species.
• Must show at least 10 or more WBC per high power field for diagnosis
• This is very very common
• Most of the time, gonorrhea & Chlamydia co infect!
• Many times these infections are asymptomatic!
• Risk factors usually have to do with sexual activity (i.e. age <24, low socioeconomic status, multiple sexual partners, age @ first coitus, urban residence, illicit drug use, unmarried status)

How is the diagnosis made?  Just like in case 1, history & PE, and lab testing.

Screening programs are critical!!! Gynecologists are infamous for screening!  For example, all the test for babies are just part of a massive screening program!  As a physician, you need to decide how you will screen your patients à you can either screen everyone (universal screening is done @ UH b/c such a high prevalence) or you can screen based upon risk factors (in which case you need to be able to administer an appropriate & thorough sexual history). 

Case #3

You are called to the OR by the general surgery team.  They have admitted L.M., a 20 y.o. G0P0 LMP 1/28/04 for presumed appendicitis.  The surgical team tells you that on the initial presentation she complained of lower abdominal pain for 4 days prior to admission; she began having nausea and vomiting yesterday the day of admission.  You quickly review her chart and find she has no significant past medical or surgical history.  She reported taking no medication or having any allergies.  She denied any history of STDs and reported hat she was a “lesbian”.    Her temp. on admission was 100.8 F, she had tenderness to palpation in the lower abdomen, right greater than left with guarding but no rebound.  No pelvic exam was done**.  Her WBC count was 13K with 5 bands.  She had a CT scan of the abdomen with contrast in the ER which was inconclusive for appendicitis.  She was admitted for observation late last night and was brought for diagnostic laparoscopy by the surgical team this morning when they felt she was worsening.  On laparoscopy, they see a small appendix which has some erythema at the tip; however, she also has bilateral pyosalphinges, with pus coming from the fimbriated end on manipulation on the fallopian tubes.  à Dx: PID (Pelvic Inflammatory Disease)

What really happened was the OB/GYN came in and got more info about the patients sexual history, and found out she had been taking drugs and having sex for money & drugs.  This increased her risk of having STDs….she ended up having gonorrhea and had developed PID. 

What is PID?

• Also known as acute salphingitis
• Most common serious infxn in young women
• Usually an ascending infection starting from a polymicrobial nature (i.e. gonorrhea), but 15% iatrogenic
•  Risk factors same as before…has to do with sexual activity. (here’s some specifics mentioned)
  • Coital frequency has interestingly not shown to increase the risk of PID!
  • Frequent douching increases risk
• This is a clinical diagnosis, based upon:

1. Lower abdominal tenderness
2. Cervical motion tenderness
3. Bilateral adnexal tenderness
4. You must also have one of these as well: temperature of 38C or higher, WBC >10K/mL, purulent material on culdocentesis, pelvic abscess on ultrasound or pelvic exam, or evidence of mucopurulent cervicitis

• But the laparoscopy is the gold standard for confirmation of diagnosis.

Why do we grossly overtreat PID?  Because of the serious sequelae of PID:

• Ectopic pregnancy
• Infertility (each subsequent episode of PID will increase your risk siginificantly!)
• Chronic pelvic pain
• Tubo-ovarian abscess
• Surgical intervention
• Subsequent PID

When do we hospitalize patients with PID? Mostly, we want to prevent infertility in patients of reproductive age.

• Nulliparity (no previous childbirths)
• Presence of  TOA (tubo-ovarian abscess à if this ruptures, you can die!)
• Pregnancy
• Adolescents
• HIV (but really depends on the immune status of the individual patient)
• Uncertain diagnosis (don’t send them home if you don’t know what’s wrong!)
• GI symptoms (i.e. unbearable abdominal pain)
• Peritoneal stage
• Presence of IUD (remember, 15% of PID cases are iatrogenic!)
• Recent operative diagnostic procedure
• Inadequate response to outpatient therapy (if you send a patient home with meds and they don’t get better very soon, then they need to come back for inpatient treatment!)

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