Genital Tract Infections

Genital Tract Infections Definition - Genital / reproductive tract infections are a communicable disease that are transmitted predominantly by sexual contact and caused by wide range of bacterial, viral, protozoal and fungal agents . Classification 1 Exogenous - acquired by sexual activity - Referred to as sexually transmitted diseases (STDs) 2 Endogenous :- Results from organisms that are members of the patient’s normal genital flora In female genital tract infection divided into 1. Lower genital tract infection : acquired by -Sexual contact -direct contact 2. Upper genital tract infection : -due to extension of a lower genital tract infection Discharge diseases [A] Vaginal discharge 1.Bacterial vaginosis - Gardnerella vaginalis - mobiluncus spp 2. Candidal vulvovaginitis -candida albicans - non albicans candida spp 3. Trichomoniasis -Trichomonas vaginalis [B] Urethral discharge 1.Gonococcal - Neiserria gonorrhoeae 2. Nongonococcal (NGU) - Clamydia trachomatis - Mycoplasma hominis - Mycoplasma genitalium - Ureaplasma urealyticum - Trichomonas vaginalis - candida albicans - herpes simples virus Lower genital tract infection Vaginal discharge diseases Vaginitis /Vaginosis – inflammation of vaginal mucosa Patient present with – abnormal vaginal discharge - offensive odour - itching Causative agents - T. vaginalis Symptoms - profuse ,slightly offensive ,yellow green ,frothy vaginal discharge - itching Candida albicans ( responsible for 80-90 % cases of vaginal candidiasis) symptoms - thich and “cheesy” in appearance white vaginal discharge - perivaginal itching (courd like appearance) Bacterial vaginosis (BV) Causative agent : Polymicrobial in etiology - Gardnerella vaginalis – most common - Prevotella spp. - Porphyromonas spp. - Peptostreptococci - Mobiluncus spp. (curved, motile rods) - mycoplasma Symptoms : Foul- smelling profuse watery vaginal discharge. Fishy odour (d/t polyamines- products of bacterial metabolism) CERVICITIS - Inflammation of cervix - Purulent Discharge from endocervix Causative agents - N. gonorrhoeae - C. trachomatis - HSV - HPV Anorectal lesions Proctitis – inflammation of rectum Causative agent - N. gonorrhoeae - C. trachomatis -HSV Symptoms – Mucopurulent anal discharge Anal pain Bleeding Itching Tenesmus (painful straining during a bowel movement) NOTE – Anorectal lesions are common in HIV infected patients and include - Anal condylomata - Anal abscess - Ulcers Causative agent :-- CMV, Campylobacter spp., Shigella, HSV, Mycobacterium avium complex Bartholinitis ( Bartholin’s gland abscess) Causavive agents - N. gonorrhoeae - C. trachomatis - Anaerobic infection Upper genital tract infection - Ascending infection from lower genital tract Caused by - Surgery - Instrumentation - During childbirth (parturition) and abortion - dilation of cervix PID ( pelvic inflammatory Disease) : include - Endometritis - Salpingitis - Peritonitis ( Localised / generalised) - Abscesses involving the fallopian tubes or ovaries Symptoms : - Intermittent abdominal pain - dysuria - Systemetic symptoms –fever, headache, - Permanent scarring of fallopian tubes - Infertility Causative agents - N. gonorrhoeae - C. trachomatis - anaerobes - Streptococci - Gram negative rods - Mycoplasma weight loss Infections associated with Pregnancy  Prenatal ( infections that occour anytime before birth or during pregnancy) Acquired by - Blood borne - Ascending route from mother to infant Transplacental Bacteria – Listeria monocytogenes - Treponema pallidum Viruses – CMV -HIV - Rubella - parvovirus B19 - Enteroviruses Parasites - Toxoplasma gondii Ascending Bacteria – Group B streptococci - E.coli - L. monocytogenes - C.trachomatis – Genital mycoplasma viruses – CMV - HSV  Natal (d/t infected birth canal ) Bacteria - Group B streptococci - E.coli - L. monocytogenes - C.trachomatis - N.gonorrhoeae Viruses – CMV - HSV - HIV - HBV - enteroviruses  Post-natal (after birth ) all organism listed above Other - RSV GTI in Males  Epididymitis - Inflammation of epididymis Symptoms – Fever - pain and swelling of testicles Causative agents – - C. trachomatis - N. gonorrhoeae  Prostatitis - Inflammation of prostate Symptoms – Perinial,lower back or lower abd. Pain - Urinary discomfort - Ejaculatory complaints - Dysuria - Urinary frequency - Symptoms assiociated with lower UTI - Systemic sign of illness - fever  Orchitis - Inflammation of testis - Uncommon - Acquired by dissemination of viruses - Most common cause - Mumps Genital ulcers Definition :- Ulcerative, erosive, pustular or vesicular genital lesion(s) with or without regional lymphadenopathy caused by a number of sexually transmitted infections (STIs) and non– STI-related conditions. Etiology • STIs:  Herpes simplex virus type 1 or 2 (HSV-1 or HSV-2)  Treponema pallidum spp. causing primary syphilis.  Haemophilus ducreyi causing chancroid.  Chlamydia trachomatis serotype L1,L2 or L3 causing lymphogranuloma venereum (LGV).  Klebsiella granulomatis causing granuloma inguinale (donovanosis) • Non–STI-related infections or conditions Infectious non–STI-related causes of genital ulcers Non - Infectious non–STI-related causes of genital ulcers Infectious non–STI-related causes of genital ulcers Fungal Candida Deep fungai Viral CMV VZV EBV bacterial Sreptococcal spp. Staphylococcal spp Pseudomonas spp Salmonella spp Mycobacteria Parasite (scabies) Non - Infectious non–STI-related causes of genital ulcers Herpes genitalis Causative agent : HSV-1 or HSV-2  Incubation period 2-7 days  ulcer – multiple vesicular lesion that rupture and become painful, shallow ulcer Constitutional symptoms – present Lymphadenopathy – Bilateral, Tender, Firm, Non-suppurative (pelvic region) Syphilis (primary) Causative agent : Treponema pallidum Incubation period 9-90 days  ulcer – single,painless,non tender,welldemarcated ulcer (chancre) with a clean base and indurated border Lymphadenopathy – Bilateral, non-tende, Firm, Non-suppurative Chancroid  Causative agent : haemophilus ducreyi  Incubation period 1-14 days  ulcer – single or multiple painful,tender,non-idurated with serpiginous border and friable base covered with necrotic often purulent exudate  Lymphadenopathy – Unilateral, Tender, Suppurative, Uni-Locular ( k/as bubo) LGV Causative agent : Chlamydia trachomatis Incubation period 3 days to 6 weeks  ulcer – small,shallow,painless genital or rectal papule or ulcer, no induration. Lymphadenopathy – Unilateral, Tender, Suppurative, Multi-Locular GI (donovanosis)  Causative agent : Klebsiella granulomatis Incubation period 1-4weeks ( upto 6 months)  ulcer –persistant painless beefy red (highly vascular) papule or ulcer which may be hypertrophic,necrotic or sclerotic Lymphadenopathy – no May have sub-cutaneous granuloma (pseudo bubo) Lab.Diagnosis of GTI Specimen A) In men: a) Acute infection- Urethral discharge b) Chronic infectioni) Morning drop ii) Discharge collected after prostatic massage iii) Centrifuged deposit of urine B) In women: i) Urethral discharge ii) Cervical swabs C) In both the sexes: Blood, CSF, synovial fluid, throat swab, rectal swab & material from skin rashes.  Discharge from infected area Vaginal ,cervical,urethral discharge – collected in sterile container  Swab -When discharge is scanty or very thick -collected with a sterile swab or endocervical curette from base or edge of ulcer Note: 1.Cotton or rayon swab pretreated with charcoal ( to adsorb material toxic to gonococci ) are used 2. Cotton or rayon swab also used to collect specimens for isolation of mycoplasma and chlamydiae 3.Calcium alginate swabs more toxic for HSV, gonococci, mycoplasma and chlamydiae than treated cotton swab 4. Dacron swabs are least toxic  recommended for viral specimens also acceptable for genital mycoplasma and chlamydiae . 5. chlamydiae are intracellular pathogen ,it is important to remove epithelial cells (with swab) from urethral mucosa 6. Separate swabs for cultivation of gonococci, chlamydiae and ureaplasma are required 7. A few drops of first voided urine for detection of gonococci in male can be used  Fluid from genital vesicle material from incised genital vesicles collected in sterile capillary tubes  Blood For serological tests and for culture ( in suspected gonococcal bacteremia) For gonococci : Transport -modified stuart’s transport media - amie’s charcoal transport media - held at room temp. until inoculated to culture media (good recovery if cultured within 12 hours of collection) chlamydiaespecimens for chlamydiae culture should be transported on ice ( if transported at room temp. should be inoculated within 15 min of collection)  Specimen stored at 4°C for 24 hours  for more than 24 hrs – specimen should be quick frozen in a dry ice and 95 % ethanol bath and stored at -70°C until cultured Mycoplasma  in Genital mycoplasma transport media On ice or at room temp. If not in Genital mycoplasma transport media, specimen should be transported on ice to suppress the growth of contaminating flora Direct microscopic examination Wet mount Trichomoniasis – pus cells and motile trophozoite of tricomonas vaginalis (corkscrew motility) Candidosis  budding yeast cell and pseudohyphae of candida albicans Gram staining Bacterial vaginosis – gram variable pleomorphic coccobacilli - clue cells (vaginal epithelial cells with adherent bacteria) - absence of pus cells Mobiluncus -- curved gram negative bacilli Gonorrhoea (N. gonorrhoeae) – numerous polymorphs gram-negative intracellular diplococci with adjacent sides concave, being typically kidney shaped. usually found with in the polymorphs . They possess pili on their surface. Note : viellonella and gram negative coccobacilli may resemble gonococci H. ducreyi – gram negative coccobacilli in pairs (school of fish or railroad tracks) Candida albicans – gram positive budding yeast cells pseudohyphae and Giemsa staining or Wright stain Klebsiella granulomatis -- coccoid rod shaped organism found within histiocyte and giant cells Donovan bodies – (bipolar staining rods intracellularly within the cytoplasmic vacuoles(phagosomes)of large macrophages). -Wright –Giemsa method – stains body of bacteria blue and cytoplasm pink -papanicolau`s method -silver stains • To increase specificity of diagnosis Dieterle,Wharthin- starry and rapid Giemsa stains used Dark ground microscopy or fluorescent microscopy In suspected cases of primary and secondary syphilis Culture CHLAMYDIA TRACHOMATIS Sample collection: Male-Urethral swab, prostatic secretion, semen Female-urine, cervical swab, vaginal swab -- Identification of elementary chlamydial bodies and larger inclusions -- Culture- McCoy cells or HeLa cell line -- Immunofluorescence with monoclonal antiserum • N.gonorrhoeae –Modified Thayer-Martin medium with antibiotics (Vancomycin, Colistin & Nystatin.) - New York City medium ( also for mycoplasma ) - JEMBEC plates (martin lewis agar is used )  Blood culture in suspected gonococcal bacteremia Colony morphology: Colonies are small, round, translucent, convex or slightly umbonate with finely granular surface & lobate margins. Biochemical reactions: (N. gonorrhoeae) 1) Oxidase test: Positive 2) Ferments only glucose but not maltose. • H.ducreyi – Chocolate agar supplemented with 1% IsoVitalex and 3µg/ml vancomycin • HSV 1 and 2 – cell culture • • • • • • • • • Human foreskin fibroblasts* MRC-5* A549, Rhabdomyosarcoma Mink lung Primary rabbit kidney CV-1 Vero and HEp-2 cells. *More Sensitive Tzanck Smears: – Wright - Giemsa stained smears examined under light microscopy. H&E or Pap Stains can also be used. • Typical cytopathic changes in genital epithelial cells seen. The cells become enlarged, with intranuclear inclusions, often with the formation of multinucleated cells • Candida albicans-- SDA Columbia agar base with 5 % sheep blood and colistin and nalidixic acid (CNA) • K.granulomatis – difficult to cultivate • Examination of stained smears :K.granulomatis is detected in infected tissues by presence of Donovan bodies ,which consists of organism contained within the cytoplasmic vacuoles(phagosomes)of large macrophages. • Specimen is taken from the base or edge of ulcerated lesions or regional lymph nodes if enlarged or ulcerated esp if ulcer gives negative results. -Wright –Giemsa method –which stains body of bacteria blue and cytoplasm pink -papanicolau`s method -silver stains • To increase specificity of diagnosis Dieterle,Wharthinstarry and rapid Giemsa stains used T. vaginalis – - Diamond’s medium (enriched with yeast extract and supplemented with inactivated horse serum, amphotericin B, penicillin G, and gentamicin) - Incubate at 30-35ºC for 1-3 days - Examine the culture microscopically for the presence of trophozoites Newer techniques In Pouch TV diagnostic system -for wet mount examination and culture of Trichomonas vaginalis Non-culture tests – Amplified tests (NAATs) • Polymerase chain reaction (PCR) (Roche Amplicor) • Transcription-mediated amplification (TMA) (Gen-Probe Aptima) • Strand displacement amplification (SDA) (BectonDickinson BD ProbeTec ET) – Non-amplified tests • DNA probe (Gen-Probe PACE 2, Digene Hybrid Capture II) Serology Serum sample for serological tests • in syphilis – VDRL, TPHA, TPI • Chlamydial infection – CFT • Genital herpes infection – ELISA Skin test Frei test for LGV Lab diagnosis of Candidal Vulvovaginitis Genital Wart Diseases 1. Condyloma acuminatum 2. Molluscum Contagiosum Condyloma acuminatum • Causative agent -Double stranded DNA virus that belongs to Papovaviridae family. • Genital types of HPV virus have specific affinity to genital skin and mucosa. • Infection generally indicated by the detection of HPV dna or capsid protein. Low risk type : -- HPV type 6 and 11 mostly causes visible warts on anogenital parts. high risk type : -- HPV type 16 and 18 found in more than 50% of anogenital cancers. Clinical menifestations of condyloma acuminata • These warts have cauliflower like appearance . • May be skin colour pink or hyperpigmented. • May be keratotic on skin and non keratinised on mucous surface. • Highly contagious disease spread via direct contact. • • 1. 2. 3. • • DIAGNOSIS Diagnosis by direct visual inspection in bright light. Diagnonsis can be confirmed by biopsy when Patient is immunocompromised Warts are continuously bleeding Warts not responding to treatment HPV specific DNA test Pap test screening Molluscum Contagiosum • Causative agent- poxvirus (molluscum contagiosum virus) • lesions, known as Mollusca, are small, raised, and usually white, pink, or flesh-coloured ( pearly appearance) with a dimple or pit in the center Lab diagnosis • Diagnosis is made on the clinical appearance • the virus cannot routinely be cultured • The diagnosis can be confirmed by excisional biopsy • Histologically, molluscum contagiosum is characterized by molluscum bodies in the epidermis, above the stratum basale, which consist of large cells with abundant granular eosinophilic cytoplasm (accumulated virions) and a small peripheral nucleus. High-magnification micrograph of molluscum contagiosum, showing the characteristic molluscum bodies, H&E stain Genital Ulcers – TREATMENT(NACO GUIDELINES)  If vesicles or multiple painful ulcers are present treat for herpes Tab. Acyclovir 400mg orally, three times a day for 7 days  If vesicles are not seen and only ulcer is seen, treat for syphilis and chancroid and counsel on herpes genitalis To cover syphilis give Inj Benzathine penicillin 2.4 million IU IM after test dose in two divided doses (with emergency tray ready) (In individuals allergic or intolerant to penicillin, Doxycycline 100mg orally, twice daily for 14 days) + • Tab Azithromycin 1g orally single dose or • Tab. Ciprofloxacin 500mg orally, twice a day for three days to cover chancroid • Treatment should be extended beyond 7 days if ulcers have not epithelialized . Refer to higher centre • If not responding to treatment • Genital ulcers coexistent with HIV • Recurrent lesion GRANULOMA INGUINALE • Doxycycline 100 mg BD for 21 days ALTERNATIVE REGIMENS • Trimethoprim-sulfamethoxazole double strength BD for 21 days • Erythromycin 500 mg qid for 21 days • Ciprofloxacin,tetracycline,azithromycin LYMPHOGRANULOMA VENEREUM • Doxycycline 100 mg BD for 21 days • Erythromycin 500 mg qid for 21 days