Vaginitis

Bacterial vaginitis (BV) is a common infection usually caused by an opportunistic pathogen within the normal resident flora that multiplies to abnormally high numbers. This overgrowth of a bacterial population normally found in relatively low numbers is due to any number of factors, including the following:

A number of bacteria can account for bacterial vaginitis, none of which produce the infection alone. Typically a number of bacteria, usually anaerobes, interact to produce an infection. The bacterium Gardnerella vaginalis in combination with other anaerobic bacteria accounts for about 30% of vaginitis cases. Gardnerella vaginalis is a tiny, gram-negative coccobacillus that is normally present in either the urinary or reproductive tract of 20% to 40% of healthy women. In women of reproductive age, the normal vaginal pH is 3.8 to 4.4, with readings in the neutral range in young girls and elderly women. When the vaginal pH reaches the range of 5 to 6, Gardnerella vaginalis can interact with anaerobes such as those in the genera Bacteroides and Peptostreptococcus to cause bacterial vaginitis. This type of infection is sometimes called nonspecific vaginitis because different anaerobes are reacting with Gardnerella to cause the infection. This type of infection is characterized by a frothy, fishy smelling vaginal discharge that may be small in volume but may contain millions of organisms.

Diagnosis can be made by microscopic examination of wet mounts made from vaginal discharge. Vaginal epithelial cells are referred to as “clue cells” and will be covered with many of the coccobacilli in the case of a vaginitis infection. BV can lead to pelvic inflammatory disease and also may increase the risk of transmitting or acquiring HIV.

There are a number of preventive measures that can be taken to help women avoid bacterial vaginitis, and they include the following:

Treatment of vaginitis usually involves a two-pronged approach: First, the use of antibiotics to bring the infection under control and second, the use of live bacterial cultures such as those found in yogurt as a douche to replace the normal lactobacillus flora that may have been killed by the antibiotics. Antibiotics such as metronidazole, ampicillin, and tetracycline have proven effective against the anaerobes that work with Gardnerella to produce the infection.

Toxic Shock Syndrome (TSS)

Toxic shock syndrome (TSS) is usually considered a blood-borne infection and is discussed in detail in Chapter 14 (Infections of the Circulatory System). However, one of the areas of the body especially prone to an infection causing TSS in women is the reproductive tract, specifically the vagina. The bacteria most often associated with TSS originating in the vagina is Staphylococcus aureus, and between 5% and 15% of women normally have S. aureus among their vaginal microflora. This type of infection normally manifests itself when use of a tampon causes a lesion in the vagina. The menstrual flow blood accumulates in the absorbent material of the tampon, which provides ideal growing conditions for the bacteria. As the bacteria multiply they produce exotoxin C, which can travel into the bloodstream through the lesion in the tissue of the vagina, causing a systemic reaction. Manifestations of TSS include the following:

The most effective treatment is the immediate use of the antibiotic nafcillin. In severe cases, death can occur as a result of shock. Recurrence of a TSS infection is possible, especially during subsequent menstrual cycles. To prevent recurring infections, the prophylactic use of antibiotics and the cessation of use of tampons have proven to be effective.

Group B Streptococcal Infection

Streptococcus is a genus of spherical gram-positive bacteria capable of causing infections in many parts of the body, including the reproductive system. Streptococci are also part of the normal flora of the skin, mouth, upper respiratory tract, intestine, and reproductive tract of humans. Numerous strains of Streptococcus have been identified, with types A, B, C, D, and G being most likely to cause serious infections. Streptococcal infections are communicable diseases that develop when the organism overgrows, or invades other parts of the body and contaminates blood or tissue.

Group B strep, or GBS, is Streptococcus agalactiae and most often affects pregnant women, infants, the elderly, and chronically ill adults. The organism emerged in the 1970s and since then has been the primary cause of life-threatening illness and death in newborns. GBS exists in the reproductive tract of 20% to 25% of all pregnant women, but only 2% of them develop an invasive infection. If the organisms gain access to the amniotic fluid, the results include sepsis, pneumonia, or meningitis in the newborn infant. Unfortunately, 40% to 73% of the women with the organism present will transmit the bacteria to their babies during delivery.

Two or three newborns per 1000 live births will end up with a GBS infection and up to 50% of these infants will die. Of the infants infected about 75% develop early-onset infections, sometimes evident within a few hours of birth and always apparent during the first week of life. Others develop late-onset GBS between the ages of 7 days and 3 months, when these babies develop meningitis. Women at high risk of giving birth to infants with GBS infection include those having:

The Centers for Disease Control and Prevention (CDC, Atlanta, GA) recommends that pregnant women should be tested for group B strep in her vagina and rectum at 35 to 37 weeks of pregnancy. To prevent group B strep from being passed to the newborn, women with positive tests should receive intravenous (IV) antibiotics at the time of labor or when the water breaks. GBS has also been linked to a history of breast cancer in women carrying the organism.

Endometritis

Endometritis affects the uterus and can be caused by a number of different organisms. Escherichia coli and group B streptococci are among those frequently associated with the infection. This particular infection is most likely to occur after childbirth or an abortion because of the trauma to the lining of the uterus, which makes it susceptible to microbial attack. The trauma may occur during a pelvic examination or delivery, when instruments are inserted into the uterus. Symptoms of endometritis include the following:

Treatments with cephalosporins have proven to be effective.

Mastitis

Mastitis typically occurs in the mammary glands of nursing mothers, although in rare circumstances this condition can occur outside of lactation. Mastitis occurs when bacteria enter the breast through a break or crack in the skin of the nipple, or through the opening to the milk ducts. The organism most frequently associated with the infection of the breast is S. aureus. Symptoms include the following:

Penicillin is frequently the antibiotic of choice when treating this infection.

Risk factors for developing mastitis include the following:

Pelvic Inflammatory Disease (PID)

On occasion bacteria from the vagina can travel upward and infect the uterus, fallopian tubes, and ovaries, causing pelvic inflammatory disease. PID is a collective term for any extensive bacterial infection of the pelvic organs, including the uterus, fallopian tubes, and/or ovaries. The infection may lead to tissue necrosis with or without abscess formation. Pus may be released into the peritoneum, that is, the abdominal lining. Although normally caused by sexually transmitted pathogens, organisms such as Mycoplasma hominis, which is a common component of the vaginal flora, have been known to cause opportunistic infection of the pelvic organs. PID infections may be asymptomatic; however, they often exhibit the following:

If damage occurs to parts of the pelvic organs such as the fallopian tubes (salpingitis), there is increased risk of infertility or a more dangerous condition called an ectopic pregnancy, in which the fertilized egg implants in the fallopian tube instead of the uterus. The administration of tetracyclines and cephalosporins has proven effective in treating these infections.

Candidiasis

Vaginal candidiasis, or simply vaginal yeast infection, is caused by the organism Candida albicans. This organism is a yeastlike fungus that is often part of the normal vaginal flora; however, it can become an opportunistic pathogen when the competing microflora is suppressed by antibiotics or other factors such as the use of oral contraceptives, pregnancy, or menstruation. C. albicans is the most common cause of vaginitis in women, with about 75% of all women experiencing at least one episode in their lifetime. Symptoms of the infection are vaginal itching and a thick, white, or yellowish-green, yeasty smelling discharge. Diagnosis of an infection usually involves microscopic examination of scrapings from the infected area and isolation of the fungus in culture. A number of antifungal drugs such as nystatin, clotrimazole, miconazole, and oral administration of ketoconazole are effective at treating vaginal candidiasis.

Trichomoniasis

Trichomoniasis is transmitted primarily through sexual intercourse; however, there have been cases of transfer by other means. Although a relatively rare occurrence, there are confirmed cases of children becoming infected due to contact with contaminated linens and toilet seats. The organism that causes the infection is Trichomonas vaginalis (Figure 16.2), a large flagellate with an undulating membrane. The organism is thought to be part of the normal microflora, where it feeds on bacteria and cell secretions. The optimal pH for growth of this organism is 5.5 to 6.0, and so it is only when the pH of vaginal secretions is disturbed that conditions favor the growth of this protozoan. Successful competition with the normal flora will result in the overgrowth of Trichomonas to an infectious level. Other conditions such as bacterial antibiotic therapy, diabetes, and physical lesions may also favor an infection with this protozoan. Symptoms of infection include the following:

Diagnosis is accomplished by direct microscopic examination of the discharge to identify the presence of the organisms. The organism can also be isolated and grown in laboratory media. The drug of choice for treatment is metronidazole, administered orally.

Epididymitis

Epididymitis, or inflammation of the epididymis, usually represents a complication of urethritis or prostatitis. In a young man this condition is usually a complication of a sexually transmitted infection caused by pathogens such as Neisseria gonorrhoeae and Chlamydia trachomatis. On the other hand, in older patients the condition is usually caused by uropathogens, and typically is a complication of urinary obstruction or prostate surgery. Symptoms include the following:

Other symptoms may include:

Treatment requires antibiotics and medication for pain relief. Complications of acute epididymitis include abscess formation, testicular infarction, development of chronic pain, and infertility.

Balanitis

Balanitis is the inflammation of the glans penis, and if this infection involves the foreskin and prepuce it is referred to as balanoposthitis. The most common complication of this infection is the inability to retract the foreskin from the glans penis. Men at highest risk are uncircumcised men who have poor personal hygiene. In the United States balanitis is a common condition affecting 11% of adult men seen in urology clinics, and 3% of children. Although caused mostly by bacteria, several other microorganisms can cause this condition, including the following:

The most common symptoms of balanitis are discharge from the penis, and a red, itchy and moist penis. Treatment depends on the microbe causing the condition and may be an antibiotic or an antifungal agent. Because anaerobic conditions are necessary for the growth of the organisms causing the infection, simple exposure to air and local cleansing is most often effective.