妇科生殖系统炎症

1、Inflammation of the Female Reproductive TractSelf-cleaning(lactobacillus)Mucus1. Vulvitis (外阴炎) Bartholinitis/Bartholins cyst (前庭大腺炎前庭大腺囊肿)2. Vaginitis (阴道炎)3. Cervicitis (宫颈管炎)4. Pelvic inflammatory disease (PID) (盆腔炎) Genital tuberculosis (生殖器结核) Sexually transmitted diseases (STD) (性传 播疾病) Vulvit

2、is (外阴炎)Clinical Manifestation Vulvar pruritus (瘙痒) Pain Burning sensation Congestion (充血) Swelling Eczema (湿疹)Etiology Specific organisms or non-infective dermatitis (皮炎) Irritation from vaginal discharge (分泌物) or menses Lack of vulvar hygiene Glycouria Treatment Keep the vulva clean and dry Remove

3、 the cause 1/5000 kMnO4 (potassium permanganate, PP) solution bath Antibiotics ointment Bartholinitis (前庭大腺炎) Infection of the major vestibular glands (前庭大腺)(Bartholins glands) (巴氏腺)Bartholins Cyst (前庭大腺囊肿)Major vestibular glands (Bartholins glands)BartholinitisEtiologyStaphylococcus, E.coli, strept

4、ococcus, enterococcus, gonococcus, and polymicrobial infection is common.Clinical manifestationSymptoms of a local infectionAbscess of Bartholin gland: a painful red swellingTreatmentAntibiotics (Ampicillin) in the early stageDrain the abscess (excision of an elliptical piece of skin) Marsupializati

5、on (造口术) for preservation of the gland function Excision for recurrent casesBartholins Cyst Trichomonal vaginitis (滴虫性阴道炎) Candidal Vulvovaginitis (假丝酵母菌性外阴阴道炎) Bacterial Vaginosis (BV) (细菌性阴道病) Senile vaginitis (老年性阴道炎) Infantile vulvovaginitis (婴幼儿外阴阴道炎)VaginitisTrichomonal Vaginitis 滴虫性阴道炎 (Trich

6、omoniasis) EtiologyTrichomonad (毛滴虫)：A flagellate protozoan (有鞭毛原虫)Best living environment : Moist, anaerobic, Transmission1. Sexual contact (70% male infection, asymptomatic carrier)2. Nonsexual transmission (iatrogenic) PathogenesisThe trichomonad lives on glycogen and iron of the host cellDirect

7、contact and damage of the target cellInduction of immune reaction resulting in inflammation Clinical PictureLatent period: 4-28 daysAsymptomatic: 25-50%Symptoms： Main: Profuse vaginal discharge and pruritus Occasional: odor, pain, dyspareunia , dysuria, infertility Characteristics of the vaginal dis

8、chargeCopious (大量的) ,Purulent (脓性的),Gray to yellow color, Malodorous (恶臭的), Frothy (起泡沫的)Strawberry cervix:Tiny, punctate hemorrhages (点状出血)grossly visible on the mucosa Diagnosis1. Microscopic (wet mount) identification of the trichomonad (60%-70%)2. Precautions for the examination Avoid : intercou

9、rse 1-2 days before examination washing and medication lubricant heat preservation3. Culture for suspected cases4. PCR (Polymerase chain reaction) Treatment (1)1. Systemic therapy (First choice) Oral metronidazole (甲硝唑，灭滴灵） a) 2g single dose b) 400mg, twice or 3 times a day, for 7 days.2. Topical ap

10、plication (50%) a) Effervescent tablets (泡腾片)of metronidazole 200mg/day, 7-10 days b) Metronidazole gel c) Acidification of vagina with 1% lactic acid or 0.5% acetic acid Treatment (2)Criterion for cure: Negative finding in postmenstrual examination of the vaginal discharge for three timesFailure ra

11、te: 5%-10% Poor compliance Repeated infectionTo avoid repeated infection: Sterilization of underwear, towels, etc Treatment of the sexual partnerMetronidazole is still effective in recurrent cases. Candidal Vulvovaginitis假丝酵母菌性外阴阴道炎 (Vulvovaginal Candidiasis) Etiology1. Very common a) About 1/3 of v

12、aginitis cases are caused by fungal infection. b) About 75% of women develop candidiasis at least once in life.2. The etiologic agent is Candida (假丝酵母菌/念珠菌). Candida albicans (白假丝酵母菌) is responsible for 80-90% of vulvovaginal candidiasis.3. Candida albicans is an opportunistic pathogen. 1) Suitable

13、environment: acidic (4.5), warm, and moist 2) Candida albicans can be isolated from 10-20% nonpregnant and 30% pregnant asymptomatic women.Treatment is not indicated unless symptoms are present. Predisposing factors1. Pregnancy2. Diabetes mellitus3. Immunosuppressants4. Broad-spectrum antibiotics su

14、ppressing the vaginal normal flora (esp. lactobacillus)5. Others: restrictive synthetic underwear, obesity, contraceptive medication Transmission1) Endogenous infection (most often) Vagina, oral cavity, intestinal tract2) Sexual contact3) Contacting fomites (污染物) PathogenesisTwo phases of candida al

15、bicans1) Yeast spores (芽孢相): Asymptomatic parasitism2) Pseudohyphae (菌丝相): Pathogenic3) Mechanism: a) Candida at the pseudohypha phse penetrate vaginal epithelium for nutrients b) Growing candida albicans release proteolytic enzymes and toxins etc. resulting in inflammation reaction Clinical Picture

16、1. Vulvovaginal pruritus (main) usually intense, coincident with menses or intercourse 2. Increased vaginal discharge The classic finding is white, thick,curd-like discharge forming patches adherent to the vaginal walls. Diagnosis 1. Wet mount microscopic identification of candida albicans in the di

17、scharge Saline: 30-50% 10% KOH: 70-80%2. Grams stain: 80%3. Culture: higher sensitivity and drug test4. Measurement of pH value may be useful for discovering cases of complicated infection (4.0-4.7). a pH4.5 combined infection Treatment1. Elimination of predisposing factors2. Topical application of

18、antifungal agents Vaginal suppositories(栓剂)： 1) Miconazole (咪康唑/达克宁) a) 200mg/day for 7days b) 400mg/day for 3 days 2) Clotrimazole (克霉唑) a) 150mg/day for 7 days b) 150mg, twice a day for 3 days c) 500mg single dose3) Nystatin (制霉菌素/米可定) 100,000units/day for 10-14 days4) Methyl violet (龙胆紫) 0.5-1% ,

19、 3-4 times/week for 2 weeks. 3. Systemic medicationOral agents are used only for cases that can not betreated with topical application of antifungal drugs.Fluconazole (氟康唑/大扶康) 150mg, single use.2) Itraconazole(伊曲康唑/斯皮仁诺) a) 200mg/day for 3-5 days b) 400mg for 1 day divided in two doses3) Ketoconazo

20、le (酮康唑) 200mg, once or twice/day until culture result is negative Hepatotoxicity may occur. Points of note for treating VVC Treatment should be followed-up with a premenstrual examination of the vaginal discharge. Approximately 10% of cases will not respond to initial therapy. Prolongation of treat

21、ment up to 14 days may cure some patients. Identification and elimination of predisposing factors is important. Recurrent VVC should be treated with oral therapy followed by prophylactic doses.Treatment of sexual partner?No treatment for asymptomatics.15% should be treatedBacterial Vaginosis 细菌性阴道病

22、Etiology1. Imbalance of normal vaginal flora Diminution of Doderlein lactobacillus and increase in other bacteria, in particular, anaerobic bacteria.2. Causative factors of the imbalance are unknown Gardnerella vaginalis (加德纳菌) Clinical PictureSymptoms:1. 10-40% asymptomatic2. Mild pruritus or burni

23、ng sensation3. Increased vaginal discharge and fishy odorSigns: Discharge: thin, greyish-white, homogenous, but not sticky No inflammation reaction (No epithelial edema or erythema) DiagnosisIdentification of clue cells *(wet mount in saline) together with 2 of the following 3 items 1. Vaginal disch

24、arge: homogenous, thin and white3. Positive Whiff test (with 10% KOH)* Clue cells are desquamated epithelial cells covered with clumps of coccobacili esp. Gardnerella vaginalis (加德纳菌), which gives the cells a speckled (有小斑点) appearance.Whiff test Treatment (1)1. Systemic therapy (oral) (80%) 1) Metr

25、onidazole 400mg, 2-3 times a day for 7 days 2) Clindamycin (克林霉素/氯林霉素/氯洁霉素) 300mg, twice a day for 7 days2. Topical therapy (80%) 1) Effervescent tablets of metronidazole 200mg/day, for 7-10 days 2) 2% Clindamycin cream, once a day for 7 days3. Vaginal washing 1-3% H2O2 , 1% lactic acid, 0.5% acetic

26、 acid Treatment (2)1. Systemic or topical treatment has the same cure rate (80%).2. Patients who are asymptomatic, but scheduled to have a gynecologic surgical procedure should be treated.3. Patients who are pregnant can be treated with oral metronidazole.4. Follow-up examination should be given 1-2

27、 and 3-4 weeks (postmenstrual) after the treatment.Criteria for cure:Absence of clue cells with at least 1 of the following items: a) Normal vaginal discharge c) Whiff test negativeOther forms of vulvovaginitis1. Senile vaginitis (老年性阴道炎) Atrophic vaginitis(萎缩性阴道炎)Infantile vulvovaginitis (婴幼儿外阴阴道炎)

28、Differential Diagnosis of vaginitisBacterial Vaginosis Candidiasis TrichomoniasisComplaintsVaginaldischarge Vaginalepithelium Vaginal pHWhiff testMicroscopicexaminationdischargemild pruritussevere pruritus burningdischarge mild prurituswhite homogenous fishy white curd-like thin purulent frothynorma

29、ledema erythemapunctate hemorrhage4.5 (4.7-5.7) 4.5 5 (5.6-6.5) Clue cells WBC rare Candida WBC some Trichomonad WBC many Inflammation of the Cervix1. Common: 50% women of reproductive age2. May lead to pelvic infection3. Need to identify a venereal disease and differentiate from malignanciesCervici

30、tis: Vaginal portion of the cervix (Ectocervix) Mucosa of the cervical canal (Endocervix)Acute Cervicitis EtiologyNeisseria gonorrhoeae (淋病奈瑟菌) Chlamydia trachomatis (沙眼衣原体) causing superficial infection of the cervical columnar mucosa2. Staphylococcus (葡萄球菌), streptococcus (链球菌), enterococcus (肠球菌)

31、 causing infection after an abortion, puerperium, cervical injury, foreign bodies Clinical PictureSymptoms1. Asymptomatic2. Mucopurulent vaginal discharge Vaginal irritation symptoms:pruritus, burning sensation Lumbosacral pain, Intermenstrual bleeding, postcoital bleeding Symptoms of the lower urin

32、ary tractSigns Inflammation of the cervix with mucopurulent discharge (MPC for mucopurulent cervicitis) Diagnosis1. Grams stain of the cervical discharge for leukocyte 30/HP or 10/1,0002. Tests for gonococcus and chlamydia3. Wet mount microscopy for trichomonads ManagementSystemic medicationChoice o

33、f drugs depends on the pathogens.Examples: Gonorrhea infection：Third generation Cephalosporins Ceftriaxone Sodium (头孢曲松钠/头孢三嗪/菌必治/罗氏芬) (头孢克) Spectinomycin (大观霉素/壮观霉素/淋必治)Chlamydia trachomatis Doxycycline (多西环素) Azithromycin (阿奇霉素) Erythromycin (红霉素) Ofloxacin (氧氟沙星) Chronic Inflammation of the Cervi

34、x Cervical Erosion EtiologyWhen the stratified epithelium (复层上皮) which normally covers the vaginal portion of the cervix is replaced by columnar epithelium which is continuous with that of the cervical canal.2. Most erosion are not infected, nor they are the result of inflammation.3. Occurs in the n

35、ewborns, pregnancy, oral contracepives Clinical FeaturesSymptomsThe only symptom is a mucoid discharge.A slight postcoital bleeding (but malignancy should be excluded)SignsA red area is seen around the external os.Classification Depends on the depth and area of the lesionTypes: simple, granular, pap

36、illaryGrades: I (1/3), II (1/3-2/3), III (2/3) Treatment Erosion found on routine examination should not be treated unless it is causing troublesome discharge. A cervical smear is needed before the treatment, and if necessary, colposcopy (阴道镜) and biopsy. Cervical ectropion (宫颈外翻)Physical therapy Th

37、ermal cauterization, Cryotherapy, Laser therapy Cervical Polyps Small pedunculated neoplasms of the cervix Endocervical polyp: Originating from the endocervix Ectocervical polyp: Originating from the vaginal portion PathologyGross appearance:Endocervical polyp: Red or pink, rounded or tongue-likeEct

38、oervical polyp: Pale, flesh-colored, smooth, rounded with a broad pedicleMicroscopic:Vascular connective tissue stroma covered with columnar or squamous epithelium or both. Congestion, edema or leukocytein filtration may be present. Clinical FeaturesSome are asymptomatic.Slight postcoital bleeding T

39、reatmentCervical polyp should be treated. Malignant change (1%) Polypoid cervical cancer Twisting off a polyp without an anesthetic and cauterizing the base. Recurrent casesare treated with canal dilation and cauterizationof the stalk. Chronic Endocervicitis (宫颈粘膜炎) (Infection) EtiologyPathogens: No

40、rmal cervical and vaginal flora Pathology Thickened endocervix that produces a whitish pus A cervical os surrounded by a reddish area Hypertrophy of the lacerated cervix Clinical Features1. Persistent leukohrrea usu. mucopurulent2. Slight postcoital staining3. Pains lower abdominal discomfort, lumbo

41、sacral backache, dysmenorrhea, dyspareunia4. Infertility5. Urinary symptoms frequency, urgency, dysuria due to subvesical lymphangitis not to cystitis Diagnosis The characteristic discharge from external os of the cervix. Cytologic and colposcopic studies are helpful, but only biopsy is definitive.

42、Cultures are not so helpful. TreatmentEven if chronic endocervicitis is asymptomatic, it should be treated. 1. Medical treatment Systemic rather than topical Based on culture and sensitivity test2. Surgical treatment A note of caution: postoperative bleeding, infection, stricture formation, infertil

43、ity. Methods: thermal therapy, cryotherapy, laser therapy conization, hysterectomy. Nabothian CystsRetention cysts of the cervical glands caused byobstruction of the gland orifices by the growthof squamous epithelium. The cysts may be infectedand contain pus. Cervical Hypertrophy Cervical Hypertroph

44、yPelvic Inflammatory Disease (PID)Infection of the upper genital tractTerms: Endometritis (子宫内膜炎) Salpingitis (输卵管炎) Oophoritis (卵巢炎) Myometritis (子宫肌炎) Pyosalpinx (输卵管积脓) Hydrosalpinx (输卵管积水) Peritonitis (腹膜炎) Tubal ovarian abscess (TOA) (输卵管卵巢脓肿) EpidemiologySexual activity A disease of sexually a

45、ctive, menstruating women. Acute PID occurs in 1-2% of young sexually active women annually.Age The peak incidence occurs in their late teens and early twenties. The most common serious infection in women of 16-25 years of ageContraceptive practices Contraceptive methods No.of PID/woman-yearsSexuall

46、y active, using no contraception: Intrauterine devices (IUD) Financial cost In USA, $3.5 billion annually in 1990sMedical sequelae Ectopic pregnancy: 6-10 fold increase PID accounts for 50% Chronic pain: 4 fold increase Infertility: acute PID account for 5-60% of cases Tubal obstruction: 11.4%, 23.1

47、%,54.3% from 1, 2, 3 episodes of infection Mortality: septic shock and death EtiologyPathogens that are sexually transmitted 1) Neisseria gonorrhoeae: in USA, 40-50% cases of PID 2) Chlamydia trachomatis: in USA, 10-40% cases of PID The two pathogens may account for 2/3 of the PID 3) Mycoplasma (支原体

48、) Recovered from the pus in 2-20% cases of salpingitis Endogenous bacteria 1) Aerobic: streptococci, staphylococci, Escherichia coli 2) Anaerobic: Bacteroides fragilis (脆弱类杆菌), peptococcus (消化球菌) ， peptostreptococcus (消化链球菌) Spreading Route of Infection1. Ascending along the reproductive tract For n

49、on-pregnant and non-puerperal women Gonococcus, C. trachomatis, staphylococcus 2. Lymphatic vessels In puerperal infection, post-abortion infection and IUD associated infection Streptococcus, E.coli, anaerobic bacteria3. Blood vessels Tuberculosis4. Direct spreading Infection from other visceral org

50、ans.Acute PID Predisposing Factors1. Intrauterine manipulation e.g. artificial abortion , IUD, etc.2. Infection in the lower reproductive tract, esp. STD3. Sexual activity 4. Bad hygiene4. Direct spreading from adjacent viscera6. Acute onset of a chronic PID Pathology1. Acute endometritis and myomet

51、ritis2. Acute salpingitis, pyosalpinx and tubo-ovarian abscess (TOA)3. Acute pelvic peritonitis4. Acute inflammation of the peritoneal connective tissue (parametritis)(宫旁结缔组织炎)5. Septicemia (败血症) and pyemia (脓毒血症)6. Fitz-Hugh-Curtis syndrome Fitz-Hugh-Curtis syndrome Perihepatitis: inflammation of G

52、lissons capsule without involvement of the liver parenchyma. Suppurative (脓性) and fibrous exudation of the capsule occurs causing adhesion between the capsule and the anterior peritoneum. It happens in 5-10% cases of salpingitis. It is caused by gonococcus or Chlamydia trachomatis. Edema and adhesio

53、n of the capsule may lead to pain in the upper abdominal region. Clinical FeaturesSymptoms Vary depending on severity and extent of the infection and types of pathogensMost common: lower abdominal pain, fever, increase in vaginal discharge.Gonorrhea/Chlamydia TrichomatisSigns VariableTypical: Bimanu

54、al examination: DiagnosisCriteria for the diagnosis of PIDMinimum:Pain on compression of uterine body or the adnexal region2) Tenderness of the cervixSpecific:1) Biopsy of the endometrium showing endometritis2) Ultrasound/MRI identification of liquid-filled enlarged oviducts or TOA3) Laparoscopic examinationAdditional: Differential DiagnosisAppendicitisRupture or abortion of tubal pregnancyTorsion or rupture of