Gynaecological Infections

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Chapter 7 Gynaecological Infections

Inflammation in the Lower Gynaecological Tract 132

Defence Mechanisms 132

Vulval Inflammation 133

Treatment 133

Vaginal Discharge and Infection 134

Composition 134

Source of Vaginal Discharge 134

Clinical Features 134

Complaints of Vaginal Discharge 135

Examination 135

Leucorrhoea 135

Vaginal Discharge 136

Candida Albicans 136

Bacterial Vaginosis 137

Trichomonas Vaginalis 137

Atrophic Vaginitis 139

Vulvovaginitis in Children 139

Foreign Bodies 139

Other Causes of Vaginitis 139

Genital Herpes 140

Clinical Findings 140

Diagnosis 140

Treatment 140

Genital Warts 141

Clinical Findings 141

Differential Diagnosis 141

Histology 141

Treatment 141

Bacterial Infections 142

Chlamydia Trachomatis 142

Tropical Sexually Transmitted Infections 143

Lymphogranuloma Venereum (LGV) 143

Granuloma Inguinale 143

Chancroid 143

Clinical Features 144

Examination 144

Treatment 144

Sexual Partners 144

Primary Syphilis 145

Diagnosis of Syphilis 146

Signs and Symptoms of Syphilis 147

Toxic Shock Syndrome 147

Physiological Variation of the Cervix 148

Cervical Ectopy 148

Pelvic Inflammatory Disease 149

Acute PID 149

Bacteriology 149

Differential Diagnosis 149

Management 149

Chronic PID 150

Genital Tuberculosis 151

Clinical Features 151

Diagnosis 151

Pathology 151

Treatment 152

Inflammation in the lower gynaecological tract

Under normal conditions, the vulva, vagina and ectocervix are the habitat of various types of infective agents, but they are a threat only if normal defence mechanisms are altered.

Defence mechanisms

1. Vaginal acidity

Glycogen is produced by vaginal epithelium influenced by oestrogens and is converted to lactic acid by Doderlein’s bacillus (a type of B. acidophilus). This maintains the vaginal pH between 3 and 4 which inhibits most other organisms.

2. Thick layer of vaginal squamous epithelium

This is a considerable physical barrier to infection. Continual desquamation of the superficial kerato-hyalin layer and glycogen production, both dependent upon ovarian oestrogen action, combat bacteria. In children and postmenopausal patients, the epithelium lacks oestrogen stimulation and is thin and easily traumatised or infected.

3. Closure of the introitus

The vaginal canal is only a potential space kept closed by the surrounding muscles and provides another physical barrier. This, however, alters following sexual activity and pregnancy.

4. Glandular secretions from the cervix and Bartholin’s glands maintain an outward fluid current helping to clear the canal of debris. In addition, cervical secretion contains immunoglobulins, especially IgA, and there are varying numbers of polymorphs, lymphocytes and macrophages.

Vulval inflammation

Vulval inflammation is not uncommon but is usually an extension of infection from the vagina. A mild reaction may arise because of physical and anatomical conditions in the area, such as (a) moistness and (b) proximity of urethra and anus.

The area is not only naturally moist but also warm, particularly in obese patients. The folds of fat harbour moisture, and chafing occurs between them. The proliferation of bacteria is encouraged. Urinary incontinence and unsuspected glycosuria may add to this. It is important to test the urine for sugar in all patients.

Incidental factors may intensify any reaction resulting from these conditions, for example, the wearing of nylon underwear which is heat-retaining and non-absorptive. Chemical factors such as washing underclothes with detergents, and using toilet powders, perfumes and deodorants, which intensify the reaction, may be associated with this. The clinical result is irritation and itching leading to scratching. Continual itch-scratch-itch leads to maceration of the skin and may invite infection. Careful attention to personal hygiene is essential. Obese patients should be encouraged to lose weight and all the incidental factors mentioned above should be avoided.

Search for lice or scabies should be made where appropriate.

One of the complications of vulvar inflammation is obstruction of the duct of Bartholin’s gland. Cystic dilatation and abscess formation are apt to follow. The condition occurs during a woman’s sexual life. Any organism, staphylococcal, coliform or gonococcal, may be found.

The gland lies partly behind the bulb of the vestibule and is covered by skin and the bulbospongiosus muscle. The duct is 2 cm long and opens into the vaginal orifice lateral to the hymen.

Treatment

Marsupialisation (Gk. marsipos, a bag). The cyst or abscess is widely opened within the labium minus and drained, and its walls sutured to the skin leaving a large orifice, which it is hoped will form a new duct orifice and allow conservation of the gland. A ribbon-gauze pack is inserted for 48 h by some surgeons.

Vaginal discharge and infection

A small amount of vaginal discharge is normal in adult life and may be excessive in the presence of cervical ectopy. Cervical ectopy is where the glandular epithelium from the endocervix is visible on the ectocervix.

Composition

The vaginal discharge is composed of tissue fluid, cell debris, carbohydrate, lactobacilli and lactic acid. The pH is about 4.5, a degree of acidity that inhibits the growth of organisms other than the lactobacilli.

Source of vaginal discharge

Vulva: Greater vestibular glands, glands of vulval skin.

Vagina: Mainly desquamated epithelial cells which liberate glycogen. The lactobacilli metabolise the glycogen to lactic acid. Vaginal transudate (secretion from tissues and capillaries of the mature vagina) is often described; vaginal epithelium is certainly not water resistant (like transitional epithelium). There are no mucosal glands.

Cervix: Alkaline mucous secretion which becomes copious and watery during ovulation.

Uterine glands also discharge into the vagina.

Clinical features

Volume: The need to wear a pad or tampon continuously suggests excessive discharge.

Onset: Onset can be associated with the end of a pregnancy, the contraceptive pill, a course of antibiotic.

Colour: Normal discharge is white but stains yellow or pale brown on clothing or pads. A greenish-yellow colour suggests pyogenic infection, commonly accompanied by an unpleasant odour. Red or dark brown suggests blood.

Irritation: Any discharge can in time excoriate the vulva, but often Candida and Trichomonas cause itching.

Complaints of vaginal discharge

Women will complain under the following conditions.

(a) There appears to be an excessive amount of staining on the clothing.

(b) They detect an offensive smell.

(c) They suffer local irritation.

There is often little correlation between symptoms and signs. Some women will complain of what is really normal; and gynaecologists regularly observe heavy and purulent discharge in women who deny any symptoms at all.

Examination

1. Vulva, perineum and thighs are inspected for signs of excoriation. The vestibular glands and urethral meatus are observed and palpated.

2. Vaginal walls and cervix are examined through a speculum. Normal vaginal epithelium is pink, the rugae are well marked and the epithelial surface of the cervix smooth and moist. Normal discharge is white and odourless.

3. A bimanual examination should always be made.

4. Specimens of discharge are taken for microscopy and culture. Chlamydia must be excluded. Cervical rather than vaginal swabs should be taken and a separate swab and appropriate medium are essential for Chlamydia. A urine sample can also be taken for Chlamydia DNA analysis.

Leucorrhoea

This means an excessive amount of normal discharge – a very subjective assessment. The patient will complain of constantly having to change her clothes but there will be no irritation and appearance will be normal. The smell will be the normal vulval odour (from the action of commensal bacteria on the secretions of the apocrine sex glands); microscopy will reveal normal appearances and culture will grow only lactobacilli.

The patient should be reassured and given an explanation of normal physiology. No local treatment is necessary.

Vaginal discharge

Candida albicans

This is yeast and exists in two forms – slender branching hyphae or as a small globular spore which multiplies by budding.

Source of Infection

This organism may exist as a normal commensal in the rectum and small numbers may be found in the vagina. Sexual transmission is also possible. Symptomatic infection is most likely to arise when there are predisposing conditions, examples of which are given below:

1. Pregnancy. The vagina provides a tropical microclimate and the high concentration of sex steroids in the blood maintains an increased glycogen formation in the vaginal epithelium and may alter the local pH.

2. Immunosuppressive therapy. This includes cytotoxic drugs and corticosteroids. There is also thought to be a natural degree of immunosuppression during pregnancy.

3. Glycosuria. This may be due to undiscovered diabetes, but again a mild degree of glycosuria may exist in a normal pregnancy because of the lowering of the renal threshold for sugar.

4. Antibiotic therapy. Systemic antibiotics destroy the normal bacteria, thus reducing the competition for nutrients, leaving the field clear for C. albicans.

Clinical Features

The patient is usually between 20 and 40, when oestrogen support of the epithelial glycogen content is at its highest. The complaint is of irritant discharge and dyspareunia. Examination reveals an inflamed and tender vagina and vulva with white plaques resembling curdled milk adhering to the vaginal wall and vulva. Removal of the plaque reveals a red inflamed area. Pre-pubertal or postmenopausal infection is less common.

Treatment

A single 500 mg clotrimazole pessary, with external application of 1% clotrimazole cream, offers convenient therapy. Routine treatment of partners is unlikely to reduce recurrence rates. In persistent or recurrent infection, confirmation of the diagnosis by culture and determination of sensitivity to treatment are important.

Oral antifungal medication can also be used.

Bacterial vaginosis

For a long time, a large number of cases of vaginitis were labelled non-specific because of disagreement regarding the infective agent. These cases were characterised by a non-irritating, foul-smelling discharge. The discharge contains a mixture of bacteria.

Clinical Features

The patient complains of a foul-smelling discharge, and examination confirms both the discharge and the odour. In appearance, the discharge is thin, greyish and sometimes shows bubbles. A vaginal smear reveals the presence of ‘clue’ cells. Gram staining is usually negative but can be variable.

Pus cells tend to be few in number. Lactobacilli are also scanty but frequently many other bacteria are present. The pH of the fluid is raised. Although the main complaint is of malodorous discharge, some patients will have pruritus, frequency, dysuria and dyspareunia.

Treatment

Oral metronidazole appears to be effective. Clindamycin vaginal cream may also be employed. Male partners should also be treated.

Trichomonas vaginalis

T. vaginalis is a protozoan organism, which infests the vagina in women and the urethra, prepuce and prostate in men. It is a common cause of irritant vaginal discharge.

T. vaginalis is a single-cell organism about 20μ × 10μ, with four flagellae and an undulating membrane which gives it a characteristic jerky movement. It is transmitted mainly during sexual intercourse.

Clinical Features

In the acute phase, the patient complains of severe vaginal tenderness and pain, and an irritant discharge. The vagina is seen to be inflamed, sometimes with a patchy strawberry vaginitis, and there is a copious, offensive, frothy discharge. Frequently there is a burning sensation, pruritus, dysuria and dyspareunia. In the latent or dormant phases, there are no symptoms although the presence of the organism can be demonstrated, often in a cervical smear.

Incidence

T. vaginalis affects perhaps 18% of the female population. It is commonly found in patients with gonorrhoea and is associated with cervical dysplasia. No cause-and-effect relationship has been proved.

Diagnosis

Diagnosis is by observation of the motile organisms in a fresh smear diluted with saline and by laboratory culture.

Treatment

Always systemic and, if possible, including the patient’s sexual partner. Metronidazole (Flagyl) 400 mg thrice daily for a week, or 2 g orally once daily.

Pathology

Passing from host to host during coitus, T. vaginalis attaches itself to the vaginal epithelium and multiplies rapidly, taking glycogen away from lactobacilli, which disappear. The vaginal pH rises to about 5.5, allowing the increase of bacterial pathogens that aggravate the infection and resulting discharge.

Vaginitis

Atrophic vaginitis

This occurs at times when ovarian activity ceases with the onset of menopause, after surgical removal of the ovaries or following ablation by radiotherapy or chemotherapy.

Clinical Features

Symptoms consist of irritation and vaginal dryness. Discharge may occur if superimposed infection has occurred. Examination of the vaginal mucosa reveals a rash of petechial haemorrhages and there may be ulceration. Smears show rounded epithelial cells, with no glycogen, many polymorphs and bacteria. In neglected cases intravaginal adhesions may develop. Topical vaginal oestrogen quickly reverses the changes. This is available as creams or pessaries. There is also a silicon vaginal ring containing oestrogen for management of atrophic changes.

Vaginal smear of atrophic type, with numerous polymorphs, a mixed bacterial content and para-basal epithelial cells.

Vulvovaginitis in children

This is a less common condition and arises only in certain circumstances, for example, those given below.

(a) Sexual interference.

(b) Insertion of foreign bodies by a child herself.

(c) Threadworm infestation.

With reference to the above points.

(a) the changes will be those of physical damage to the tissues. Infection will depend to some extent on whether the person guilty of the offence is a carrier of a specific agent.

(b) infection may arise from bowel commensals.

(c) the diagnosis may be made by applying Sellotape (Scotch tape) to the vulva then pressing the tape onto a microscope slide for microscopic examination.

Many of the cases of vulvovaginitis may arise from the irritation caused by threadworms. Scratching will lead to maceration of the skin, which in turn will encourage bacterial contamination.

Foreign bodies

Vaginitis due to foreign bodies is sometimes seen in adults. Tampons, contraceptive devices and supportive pessaries used for prolapse may be left, forgotten, in situ. These give rise to an offensive purulent discharge. Bacteriological investigation will give an indication of the type of infection and appropriate treatment following removal of the offending body.

Other causes of vaginitis

Secondary vaginitis may arise because of contamination of the vagina through fistulous openings (vesicovaginal or rectovaginal) following injury, surgical operations or tumour growth. Repeated attacks of infection may occur. Treatment is obviously repair of the fistula where this is possible.

In all cases of vaginal discharge, the possibility of malignant disease in the tract must be considered.

Genital herpes

Herpes simplex virus (HSV) types 1 and 2 may affect the lower genital tract or the mouth. It is highly infectious – 80% of women in contact with male carriers become infected. The initial attack may be severe. There may be, in 50% of victims, less severe recurring attacks every 3 or 4 weeks and they represent a potential for wide dissemination to others in the immediate environment. The incubation period is short – 3–7 days.

Clinical findings

The disease affects the vulvovaginal and peri-anal regions but may be transmitted to the mouth. The patient complains of burning, itching and hyperaesthesia of the area and the skin shows evidence of acute inflammation – oedema and erythema. There is usually a vaginal discharge. If the peri-urethral area is involved, there may be dysuria and retention of urine.

The specific lesions start as small indurated tender papules which become vesicles and quickly break down to form shallow ulcers, 5 mm or more in diameter, with a yellowish grey slough in the base. These can be seen on the vulva and labia, but in some cases they are confined to the vagina and cervix and there may be no external evidence of the disease. In these circumstances the ulcers may be large and could be mistaken for carcinoma of the cervix. The inguinal nodes are enlarged. The infection is accompanied by general symptoms of malaise, headache and even encephalitis. Sacral ganglion involvement causes neuralgia.

The acute phase lasts for 4–5 days. The lesions heal over 8–10 days and then a latent period ensues during which the virus remains in the sacral ganglia. Further attacks may follow.

Infection of the neonate can lead to herpes encephalitis with a primary infection.

Diagnosis

Clinical suspicion is confirmed by tissue culture isolation of virus or detection of virus antigen by immunofluorescence or ELISA techniques. Some degree of immunity may be conferred during recurrent attacks and a search for antibodies will help to differentiate primary from second attacks.

Treatment

Ice packs, local analgesia (2% lidocaine), non-steroidal analgesic creams, saline bathing and systemic analgesics help relieve acute local symptoms. Aciclovir 3% ointment, applied repeatedly, is effective only if commenced at the onset of signs and symptoms.

Oral antiviral agents such as aciclovir for 5 days may be commenced within 5 days of onset of a first episode. Antibiotics may be required if there is secondary infection. Antiviral agents do not eradicate the virus and recurrent episodes may occur.

Genital warts

Genital warts are a common viral infection. They are caused by human papilloma viruses (HPVs) which are transmitted sexually, with more that 50% of contacts developing lesions. Numbers 6 and 11 are particularly associated with warts or condylomata. Infectivity is greatest just after appearance of a wart. Incubation varies from a few weeks to 9 months or more.

Clinical findings

A single warty growth quickly spreads to form multiple growths showing a tendency to fuse. They are pinkish with dry surfaces unless macerated and are of softer consistency than the ordinary skin wart. The growths develop in moist areas and especially during pregnancy. They affect the labia, peri-anal area, perineum and the lower part of the vagina, and may even spread to the thighs. Secondary infection may give rise to purulent discharge.

Differential diagnosis

1. Syphilitic condylomata. These are more widespread and not confined to the genital area. They are also flatter and more rounded. Treponemes can be found in the tissue fluid. Serological tests will of course confirm the diagnosis.

2. Benign papilloma. This is commonly single and similar to ordinary skin warts.

3. Verrucous carcinoma. This is a locally malignant lesion, but vulval carcinoma is rare in premenopausal patients. Biopsy will differentiate the two conditions.

4. Sometimes, genital warts affect the cervix and can resemble carcinoma.

Histology

The warts have a central core of connective tissue covered by a thick layer of prickle cells. Chronic inflammatory changes are present in the dermis.

Treatment

Podophyllotoxin, a cytotoxic agent, can be used. It is topically painted on the lesions. It is toxic if used systemically and may not be used in pregnancy.

Imiquimod cream is an alternative. It works by stimulating the immune response but is also unsuitable during pregnancy.

Cryo-cautery, electro-cautery and laser ablation can be employed. Lesions may recur and may also regress spontaneously.

Bacterial infections

Chlamydia trachomatis

This is a widespread gynaecological infection.

Clinical Features

The initial symptoms in women are often mild and may in fact be asymptomatic. Discharge may be present, varying from watery to frankly purulent according to the severity of the reaction to the disease. In severe cases, there is obvious cervicitis which looks like an infected erosion. Sometimes, there is a punctate haemorrhagic inflammation with microabscesses. Occasionally, there are few changes in the vagina and the first evidence of infection is the appearance of a salpingitis. It is an important cause of chronic pelvic inflammation. A gelatinous exudate is formed in the Pouch of Douglas which proceeds to multiple adhesions and tubal occlusion.

It is an important cause of infertility. Ophthalmia neonatorum occurs if there is transmission to the neonate during delivery.

Reiter’s syndrome with urethritis, arthritis and conjunctivitis is more common in the infected male.

It may spread to cause perihepatitis with so-called violin string adhesions to the parietal peritoneum. This is accompanied by acute pain in the upper right quadrant and is known as Fitz–Hugh–Curtis syndrome. It can be mistaken for cholecystitis or pancreatitis.

Diagnosis

Culture of Chlamydia requires sampling of endocervical cells, urethral cells or endosalpinx cells (salpingitis detected at surgery). They should be sent in special transport medium to an appropriate laboratory.

Nucleic acid amplification techniques are now commonly used to diagnose chlamydia from a vulval swab or a first-void urine sample, with 30% greater sensitivity than viral culture.

The organism can be seen under the microscope. It is intracellular. Staining by an immunofluorescence technique confirms the diagnosis. It multiplies like bacteria, but like viruses can only do so within cells. It contains both DNA and RNA.

Treatment

Azithromycin 1 g as a single dose or doxycycline 100 mg orally, twice a day for 7 days. Azithromycin and doxycycline are equally effective. The primary advantage of azithromycin is that it is administered in a single dose. Erythromycin should be given in pregnancy.

Tropical sexually transmitted infections

Lymphogranuloma venereum (LGV)

LGV is attributed to a strain of Chlamydia. This is rare in the developed countries.

Clinical Findings

The primary lesion is a small painless ulcer with raised irregular borders which may involve the labia, clitoris or urethra. It appears 1–3 weeks after infection. Several weeks later the inguinal and iliac lymph nodes enlarge, become soft and fluctuant and this is followed by rupture creating discharging sinuses. The lesions eventually heal with the creation of large fibrous scars. In the process, the urethra may be virtually destroyed and the rectum stenosed. The pelvic organs may be involved in the same way giving rise to intestinal obstruction and various fistulous communications.

Histologically, the reaction is of granulomatous type. Lymph channels are often obstructed giving rise to elephantiasis of the vulva. The picture shows an advanced case of LGV.

Treatment: Tetracyclines, doxycyline or erythromycin is effective.

Granuloma inguinale

Granuloma inguinale is another tropical ulcerative condition, caused by Klebsiella granulomatis; this begins as a painless genital, inguinal or peri-anal nodule, which ulcerates. Local lymphatic glands enlarge, but do not ulcerate.

Prolonged antibiotic treatment is required.

Chancroid

This lesion is due to infection by Haemophilus ducreyii. After a short incubation period, a red macule appears, which quickly changes to a pustule and then an ulcer. The ulcers are numerous and vary in size from millimetres to several centimetres. They are well defined with projecting margins but shallow with a greenish slough in the base. These ulcers are soft and painful. This, together with the short incubation period, helps to differentiate them from syphilitic lesions. The labia major, clitoris and peri-anal regions are affected. Two weeks later the local lymph nodes tend to enlarge and suppurate. There is usually secondary infection and the discharge is foul smelling.

Treatment

Azithromycin, ceftriaxone or erythromycin may be used.

Gonorrhoea

Gonorrhoea in women carries a high risk of salpingitis and sterility, but early diagnosis is difficult to achieve. Symptoms are often mild or absent.

Clinical features

The classical history is of urethritis, vaginal discharge and menstrual upset of sudden onset, but any infection in the genital area, however it presents, may be gonococcal. After the acute phase, vaginal discharge will persist, followed in approximately 15% of cases by signs of pelvic inflammatory disease (PID).

Systemic signs – conjunctivitis, dermatitis, arthritis – are rare in women.

Examination

The labia are held apart, and the urethra, Skene’s ducts and Bartholin’s ducts examined for signs of infection. Swabs are taken from the cervix which is the main reservoir of infection.

Diagnosis is a laboratory procedure. Intracellular diplococci may be seen with Gram staining, or the more time consuming immunofluorescent method. Alternative tests include nucleic amplification tests (NAATs) and nucleic acid hybridisation tests. NAATs are more sensitive than culture and can also be used as diagnostic/screening tests on non-invasively collected specimens (urine and self-taken vaginal swabs). Caution is required in interpretation of positive results as the specificity of NAATs is not 100%. Confirmation of a NAAT positive result by culture is advisable. This is also useful to assess for antibiotic sensitivities.

Treatment

Uncomplicated anogenital infection in adults: ceftriaxone 250 mg IM as a single dose or cefixime 400 mg oral as a single dose. Antimicrobial therapy should take account of local patterns of antimicrobial sensitivity to Neisseria gonorrhoeae. The chosen regimen should eliminate infection in at least 95% of those presenting in the local community. Alternative regimens may be required when an infection is known to be unresponsive to these antimicrobials.

Sexual partners

Partner notification should be pursued in all patients identified with gonococcal infection, preferably by a trained health adviser in genito-urinary medicine.

Syphilis

Syphilis is an uncommon disease in gynaecological practice, but any genital sore should come under suspicion. It is less uncommon in association with human immunodeficiency virus. Pregnant women continue to be screened for syphilis in the UK despite its very low levels, as transmission can occur to the fetus.

Primary syphilis

The chancre (a corruption of ‘cancer’) has an incubation period of about a month and its appearance is often accompanied by pyrexia and malaise. The most common site is the vulva and then the cervix, but infection can occur anywhere. The chancre is the point at which the treponema enters the body.

The typical chancre is about 1 cm in diameter and begins as a reddish papule which becomes ulcerated. It is painless and highly infective. The inguinal glands are markedly enlarged.

Diagnosis requires the identification of Treponema pallidum in the exudate of the chancre or in material aspirated from an enlarged gland. Treponemata are not easily recognisable in stained preparations and the dark-ground illumination of fresh specimens is used. Light is reflected off the edges of the organisms, making them easy to perceive and they are recognised by their shape and movement. T. pallidum must be distinguished from other treponemata.

Diagnosis of syphilis

Positive identification of T. pallidum is difficult for various reasons including the failure, so far, to grow the organism in vitro. The usual method of diagnosis is by serological tests, which become positive 4–6 weeks after infection.

Enzyme immunoassay (EIA) tests which detect antitreponemal IgM and IgG antibodies are useful as screening tests. Confirmation is required in the context of a positive EIA.

These include TPHA (Treponema pallidum haemagglutination) and fluorescent treponemal antibody absorption. False positives can occur.

Fluorescent Treponemal Antibody

Principle of Fluorescent Treponemal Antibody tests (FTA)

1. Antihuman globulin (AHG) is combined with fluorescein.

2. Dead treponeme is combined with test serum. If subject is infected, the treponeme acquires a coating of globulin antibody.

3. 1 and 2 are combined and the treponeme becomes fluorescent.

Signs and symptoms of syphilis

Signs and symptoms of the spread of T. pallidum throughout the whole body appear usually about 2 months after the primary stage, and the disease may present in this phase to the gynaecologist.

There is likely to be a mild pyrexia and malaise, but the dominating signs are a generalised lymphadenopathy and mucocutaneous lesions. ‘Snail track’ ulcers appear on mucosal surfaces, and the skin develops a very wide variety of macular and papular rashes. In warm moist areas such as the breast flexures and the vulva, the papules become hypertrophic and flattened and present as ‘condylomata lata’, which are highly infective.

Diagnosis is by the demonstration of T. pallidum in the lesions and by serological tests.

Treatment of Early Contagious Syphilis

T. pallidum is sensitive to many antibiotics, but reactions are common and care is required in treatment. Prolonged antibiotic treatment, mainly penicillin based, is required and long-term follow-up should be performed by an infectious disease specialist.

If not treated in the early stages, syphilis leads to a complex immune reaction and the patient can develop cardiovascular and neurological complications many months or years later.

Toxic shock syndrome

This is a very rare syndrome which can arise in women using tampons. It is caused by exotoxins produced by staphylococci which may be carried by the woman herself in various sites such as the vagina, cervix, perineum or nasopharynx.

Clinical Signs

There is a rapid onset of fever often with vomiting, diarrhoea, muscular aches and skin erythema. It can be a life-threatening condition.

Treatment should provide general supportive measures and antibiotic treatment, usually clindamycin.

Physiological variation of the cervix

Cervical ectopy

Columnar epithelium appears on the cervical surface. This is usually because of physiological changes, for example, eversion which occurs as the cervix develops during puberty and the squamocolumnar junction becomes visible. This is physiological and no treatment is required. It is also common in pregnancy and while on the contraceptive pill.

Women who have symptoms relating to an ectopy may opt for local treatment with the aim of ablating the columnar cells so that squamous cells develop. A number of techniques have been employed. The patient will experience a prolonged heavy discharge and the ectopy may recur.

Pelvic inflammatory disease

Infection of the fallopian tubes usually involves the ovaries and peritoneum, and the combined infection is called pelvic inflammatory disease (PID). It results from ascending infection by micro-organisms from the vagina or cervix. Its incidence is closely related to that of sexually transmitted diseases and it is predominantly a disease of young, sexually active, women.

Acute pid

The following clinical features are suggestive of a diagnosis of PID: bilateral lower abdominal tenderness (sometimes radiating to the legs); abnormal vaginal or cervical discharge; fever (greater than 38°C); abnormal vaginal bleeding (intermenstrual, postcoital or ‘breakthrough’); deep dyspareunia; cervical motion tenderness on bimanual vaginal examination and adnexal tenderness on bimanual vaginal examination (with or without a palpable mass).

Bacteriology

N. gonorrhoea and C. trachomatis are said to be the commonest pathogens, but anaerobic organisms are often found in pelvic abscesses.

Differential diagnosis

Appendicitis

Signs are mainly right sided, and the menstrual cycle is undisturbed.

Diverticulitis

This is a disease mainly of older women and signs are left sided.

Torsion of Pedicle of a Cyst

There may be a history of intermittent pain over several months. A cyst should be palpable.

Tubal Pregnancy

A positive HCG pregnancy test should suggest ectopic pregnancy.

Management

In the Outpatient Setting

An intrauterine device, if in the uterus, should be removed. After swabs have been taken from the vagina and cervix, a broad spectrum antibiotic such as doxycycline, azithromycin or ampicillin should be given. This should be on the basis of one of the following regimens recommended by the Royal College of Obstetricians and Gynaecologists, UK (Greentop Guideline 32, Management of Acute Pelvic Inflammatory Disease):

• Oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days

• Intramuscular ceftriaxone 250 mg single dose followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days.

If acute signs and symptoms persist, an ultrasound should be carried out to search for abscess formation. Surgical intervention to drain abscesses may be required.

Referral to a genito-urinary medicine clinic is advisable. Without tracing and treatment of contacts, reinfection is likely. Acute PID may be relatively asymptomatic, but this does not preclude tubal damage, infertility and ectopic pregnancy. Ectopic pregnancy follows in almost 10% of subjects compared with a background rate of 1.5%.

Pelvic inflammatory disease

Chronic PID

The patient complains of pelvic pain made worse during the periods, which are irregular and heavy. Dyspareunia is common. There is a 10-fold increase in hysterectomy after PID.

Examination

Some swelling may be felt, but often there is little to find except tenderness in the fornices.

Pathology

All degrees of inflammation are met with, from salpingitis alone to a widespread inflammatory reaction involving all the pelvic tissues. It is rare to recover any organism in chronic PID, other than in the case of tuberculosis. The ascending infection first attacks the tubes which are sealed off by oedema and adhesions. The tubes either swell up with watery exudate forming a hydrosalpinx or pyosalpinx; or they become highly thickened and adherent to the ovary. The ovary may also be the seat of abscess formation, and the uterus and adnexa, normally mobile, become fixed by adhesions.

Treatment

The course of chronic PID is not predictable, and mild degrees may resolve spontaneously. Where possible, any infective agents should be identified and treated. Hydrosalpinx and any abscess formation must be relieved by laparotomy and drainage. In advanced cases however, the only effective treatment is operation to remove the uterus and tubes and perhaps the ovaries as well.

Genital tuberculosis

Tuberculosis is a rare disease in gynaecology. It attacks the fallopian tubes and the endometrium. Lesions elsewhere in the genital tract are uncommon.

Clinical features

The patient is usually a young woman seeking treatment for primary infertility or complaining of irregular menstruation or perhaps abdominal pain.

Diagnosis

1. Histological evidence from curettings. This is the commonest method and it is assumed that the tubes are also infected.

2. Laboratory culture.

3. Biopsy from any suspicious ulcerated area in the vagina or vulva.

4. By laparoscopic inspection and biopsy.

Once evidence of genital infection is obtained, the respiratory and urinary tracts must also be investigated.

Pathology

This infection is blood borne, usually from a primary focus in the lung or kidney, and it infects the tubes, spreading thence to the endometrium.

The tubes may appear normal (endosalpingitis) but usually display the distortion and swelling of chronic infection, and small pinhead tubercles appear on the serosa.

The endometrium also shows tuberculous follicles, best developed in the premenstrual phase. There may be debris in endometrial glands.

Treatment

Antituberculous Chemotherapy

A combination of rifampicin, isoniazid and ethambutol has been used effectively in recent years. This should be managed by an infectious disease specialist.

Surgery

Surgery may be required when chemotherapy has failed (about 5% of cases) or in combination with chemotherapy in older women. All infected tissue must be removed to avoid subsequent fistulous openings in the bowel or bladder.

Tuberculosis and Infertility

Failure to conceive is probably the most important consequence of genital tuberculosis, and 90% of women presenting with the disease will never have a pregnancy. There is also an increased chance of ectopic gestation.

Human immunodeficiency virus

Transmission

The following are the main modes of transmission of human immunodeficiency virus (HIV):

• Unprotected penetrative sex with someone who is infected.

• Injection or transfusion of contaminated blood or blood products, donations of semen (artificial insemination), skin grafts or organ transplants taken from someone who is infected.

• From a mother who is infected to her baby; this can occur during pregnancy, at birth and through breastfeeding.

• Sharing unsterilised injection equipment that has previously been used by someone who is infected.

The course of the disease is erratic, associated with progressive loss of immune resistance. Death is almost inevitable but may be delayed for years with appropriate antiviral treatment.

Acquired immune deficiency syndrome (AIDS)

The progress of the disease can be roughly divided into six phases, but these phases are ill-defined, and variable in time of onset and duration:

2. Window period

3. Seroconversion

4. Asymptomatic period

5. HIV/AIDS-related illness

The duration of the different phases of HIV/AIDS is variable. It is not possible to predict the course of the disease in an individual. Factors affecting the course of HIV/AIDS include nutrition, emotional stress and access to health care. People infected with HIV can infect others at any phase of the disease.

Three conditions are particularly characteristic of the immunodeficiency state:

1. Kaposi sarcoma, usually an indolent growth in the skin, becomes aggressive.

2. Hairy leukoplakia of the tongue.

3. Lymphomas are common in AIDS patients and lymphoma of the brain is almost diagnostic.

Intercurrent infections frequently found in aids patients

Minor infections and infestations, which remain localised in normally immune persons and produce mild symptoms if any, spread rapidly and cause life-threatening clinical conditions in the AIDS patient whose immunity is seriously compromised.

Infective agents	Clinical results
Parasites
Pneumocystis carinii	Pneumonia
Cryptosporidium	Severe diarrhoea
Strongyloides stercoralis	Severe diarrhoea
Toxoplasma gondii	Chorio-retinitis
Viruses
Herpes	Pneumonia
J.C. virus	Leuco-encephalopathy
Bacteria
Species usually causing minor lesions, e.g. skin spots	Septicaemia
Fungi
Cryptococcus neoformans	Pneumonia, meningitis

Paediatric aids

Infection of the fetus or newborn from the mother can occur in utero, intrapartum or, through breastfeeding, post-partum. Zidovudine has been shown to reduce vertical transmission of HIV-1.

Treatment

Specialised knowledge and experience are essential.

Antiretroviral drugs are the mainstay of treatment

Combination therapy is used and for many patients can significantly control the disease within developing countries access to antiretroviral therapy may be limited. There is ongoing research to develop a vaccine.

Related

Gynaecology Illustrated