复旦妇产科大课课件：PID（朱芝玲）

Genitalinflammatorydiseases朱芝玲复旦大学附属妇产科医院FemaleReproductiveOrgans

NORMALVAGINALFLORA&DISCHARGEHEALTHYVAGINAISANECOSYSTEMDYNAMICEQUILIBRUMEXIXTSBETWEEN: - Epithelium - NormalColonizingOrganisms (mostlyLactobacilliSPP) - LocalSecretoryandCelluarImmuneFactors - VaginalpHmaintainedAcidic(3.8–4.4)CreatesunfavourableenvironmentforPathogens

NORMALpHMECHANISMEstrogenincreasesEpithelialGlycogenLactobacilliMetaboliseGlycogenintoLacticAcidLacticAcidmaintainsacidpHSIMPLEOFFICEANALYSISpH–litmus/nitrazinepaper(nitrazineturnsblue)“Whff”test–10%KOH–2dropsMicroscopy–Wetmount,WBCS,Trichomonas,MoniliaIfnomicroscopeavailableAddhydrogenperoxideFoamingbubblesifthereareWBCsNobubblesifnoWBCs(BV,Yeast)PATHOLOGICVAGINALDISCHARGECommoncausesinlowergenitaltractBacterialvaginosisCandidal

vulvo

vaginitisTrichomonas

vaginalisBacterialVaginosis

Affects25%ofwomen50%ofwomenasymptomaticCommonestcauseofvaginalcomplaint.Specifictriggernotknown,butBVrelatedto:Intercourse–especiallynewpartner,sexualaidsSpermicides,douchesOtherinfectionsBACTERIALVAGINOSISBV

DIAGNOSISGrayhomogenousdischargeadherenttovaginalwalls–noerythema/edema.pHakaline(over4.5)Presenceof“Cluecells”CellsstuddedwithbacteriaCellwallindistinctFishyamineodorwhen10%KOHadded(TV,semenalsocausesodorreleases.PaucityoflactobacilliRelativeabsenceofWBCs.BacterialVaginosis

MEDICATIONALTERNATIVESOralmetronidazole400mgBDfor7daysOralclindamycin300mgBDfor7daysMetronidazoleGel(0.75%)BDfor5daysClindamycinCream(2%)qidfor7daysSingle3%HydrogenPeroxidevaginalwashoutNotreatmentforpartner?(Rxunrelatedtorecurrence)Recurrencenotuncommon–1)Repeattreatment -2)Longercourse7) Inpregnancy,useAmpicillinCANDIDIASIS

CANDIDAVAGINITISSecondmostcommoncauseofdischarge.Epidemiology:CandidaalbicansmostcommonorganismNonalbicans

SSP.e.g.C.tropicalis,C.glabratamoreresistanttotreatment.RISKFACTORSAlteredimmuneresponse,immunesuppressivedrugs,HIVwithlowCD4countIncreasedbloodglucoselevelsEradicationoflactobacilluswithbroadspectrumantibiotics.Occursinacidicestrogen-richenvironmentDIAGNOSISChiefcomplaint–itching/burningmoresevereatnights.ClinicalfindingsVulvar

erthema/edema/fissureExcoriationfromscratchingWhitevaginaldischarge(variesfromthinwhitetocurdy)NormalvaginalpH(acidic)WetmountwithKOH100%specific(psuedohyphae)PSEUDOHYPHAEMANAGEMENT–IMIDAZOLE/TRIAZOLEPREPARATIONS

1)Antifungalcreams,suppositoriesegButoconazoleClomitrazoleMiconazoleTioconazoleTerconazole

Forseventotendays(maygetburning/irritation)2)Singleisoconazole

pessary3)Pregnancy–localtherapyonlyTREATMENT(CANDIDA)

OralantifungalagencyNauseaAbdominalpainHeadachePotentiallyhepatotoxicThreedayoraltherapy(itraconazole)Singledoseoralfluoconazole(150mgoritraconzole300mg).Notreatmentnecessaryforasymptomaticpartner. (Doesnotreducerecurrence).TREATMENT(CANDIDA)Recurrence:RepeatwithLongercourse(localRXweeklyx4Monthlysingledoseimidazolex6HypersensitivitytolocalRX–1%G.V.(Culture)Naturalyoghurtonatamponnightlyx3TrichomoniasisTrichomonas

vaginalisFoundinsemenorurineofmalescarriersVaginalinfectioncausesirritationandprofusedischargeDiagnosisbymicroscopicidentificationofprotozoanTreatment:metronidazoleTRICHOMONASVAGINALISEpidemiologyHumansaretheonlyhost(75%ofprostitutes)SexuallytransmittedprotozoalparasitewithfourflagellaResidesasymptomaticallyinmalesemen(90%)and50%ofwomenBothpartnersrequiretreatmentDIAGNOSISVulvar

erythemaandedemaProfuse,offensive,frothy,green-yellowdischargeTrichomonas

cervicitis–red,punctuatelesions–“strawberrycervix”(10%).VaginalpHalkaline(over4.5)Wetprep–detects70%-moreorganisms.Culture–100%Specific.‘Strawberry’Cervix

MANAGEMENT(TRICHOMONAS)Metronidazole400–500mgBDforsevendays(bothpartners)Fasigyn–singledose(2g)Avoidinpregnancyandlactation(uselocalCanestan)recurrence–reinfection,repeatRx(85%).Repeattreatment–longercourse(14days)Higherdose(Metronidazole800mg12hourlyforfivedays)ESP.ifonDilantin,phenobarb).SinglevinegarvaginalwashoutNote:Disulfurameffectwithalcohol.PID:anacuteclinicalsyndromeassociatedwiththespreadofmicroorganismsthroughthevaginaintotheuterus,fallopiantubes,andovary(uppergenitaltract)PathogenesisofPIDPrimaryendocervicitis•N.gonorrhoeae•

C.trachomatis•

other?Factorsinfluencingspreadof

bacteria•cervicalandendometrialinfection•stateofcervicalmucus•retrogrademenstruation•uterineinstrumentationConsequencesofascending

infection•hydrosalpinx•tuboovarianabscess•peritonitis,perihepatitisLong-termsequellae•chronicpain•infertility•tubalpregnancyPID-ClinicalFeaturesLowerabdominalpain allVaginaldischarge ~1/2Vaginalbleeding ~1/2Dysuria ~1/4Nausea,vomiting,anorexia ~1/4SYMPTOMSPID-ClinicalFeaturesAbdominaloradnexaltenderness allCervicaltenderness allAdnexalenlargement ~1/3Fever ~1/3RUQtenderness upto1/3SIGNSMicrobiologyofPIDChlamydiatrachomatisNeisseriagonorrhoeaeMycoplasmagenitalium,

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