GENITAL INFECTIONS

Dr.B.BOYLE
 GENITAL INFECTIONS
FEMALE MALE
 Vaginal Infections  Prostatitis
 Infections of the  Epididymitis
female pelvis
 Orchitis
 Post-Gynaelogical
Surgery Infections  Urethritis (Previous
 Pelvic Inflammatory Lecture)
Disease(Previous  Balanitis
lecture)
 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)
 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
 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
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
 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 Some clue cells seen in 90% of women
microscopy of discharge
with BV
reveals vaginal epithelial
cells studded with tiny In normal women predominant type of
coccobacilli, edge of cells
or obliterate the nucleus bacteria is large rods(Lactobacilli spp.)
 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
 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
 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
 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.
 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
 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
Bartholin`s Gland Abscess
Bartholin`s Gland Abscess
 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
 Infections of the female
Pelvis
 Intra-amniotic  Post-abortion
Infection Syndrome Infections
 Post Partum  Infections after
Endometritis Gynaecological
 Puerperal Ovarian Procedures
vein
Thrombophlebitis  Pelvis Inflammatory

 Episiotomy
Disease
Infections
 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
 Organisms isolated
 Gardnella vaginalis  E.coli
 Mycoplasma hominis  Group B Streptococci
 anaerobes  Enterococci
 Aerobic Gram
negative bacilli
 Presentation
 Maternal  Fetal
 Fetal Heart rate
 Fever abnormalities(TC ,DV)
 Tachycardia  PPROM –25%
subclinical infection
 Uterine tenderness
 Preterm labour and
 Uncommom: foul intact membranes 5-
smelling or grossly 10% and another 10%
purulent Amniotic subclinical
 Causes arrest of progress
fluid of labour
 Diagnosis : clinical
mostly
 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
 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 0.9-3.9%
 Caesearan section rate: 10-50%
 Secondary risk factors include BV
 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
 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
 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)
Pyosalpinx
Actinomyces Gram /Culture
Actinomyces Infection
 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
 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
Female Anatomy
 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
 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
 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
Pyometrum
 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
Tuboovarian Abscess
 Genital Infections in Men
 Prostatitis  Epididymitis
 Acute bacterial  Non-specific
 Chronic bacterial  Sexually Transmitted
 Chronic Pelvic Pain  Orchitis
Syndrome  Viral
 Granulomatous  Bacterial
 Prostatic Abscess
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
 Prostatitis
 50% of men will experience symptoms at
some stage of their lives
 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
 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
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
Chronic Bacterial Prostatitis
Urinary Tract Localization Using Sequential
Urine Cultures

Specimen Symbol Descripition

Voided Bladder VB1 Initial 5-10ml

cfu
1 VB3>>VB1
Voided Bladder VB2 Midstream 10 fold
2 specimen
Expressed EPS Secretions
Prostatic expressed from
secretion prostate by
digital massage
Voided Bladder VB3 First 5-10ml
3 after Prostatic
massage
 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
 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
 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
 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
 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
 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