Infections of the Reproductive System

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Infections of the Reproductive System

WHY YOU NEED TO KNOW

HISTORY

Written as far back as 1825 bce, the Kahun gynecological papyrus contains a discourse on the female reproductive system including the diagnosis and treatment of various infections and diseases. In the more recent past, in 1980 an outbreak of toxic shock syndrome (TSS) occurred that was found to originate in the reproductive system. Hundreds of women using a specific brand of tampon were struck with TSS because of defects in the product design. The tampon was causing lesions when inserted, leading to excessive bleeding and irritation. The tampon was also designed with a very absorbent material to allow the woman to leave the tampon inserted for a longer period of time. The combination of bleeding and highly absorbent material created an ideal growth environment for Staphylococcus aureus, which produced large amounts of toxin that entered the bloodstream, causing TSS.

IMPACT

After the realization that some superabsorbent tampons increased the risk for developing TSS, Procter & Gamble voluntary recalled these products in September 1980.

With the advent of hormone therapy to help attenuate the negative factors associated with menopause, there is a new potential for vaginal infections in women. When the hormones cause chemical changes in the female reproductive system they can alter the pH in the vagina and also increase vaginal discharge, which keeps the area extra moist, thus favoring the growth of bacteria and/or fungus. The use of oral contraceptives also causes pH changes that favor the growth of certain infectious organisms. Circumcision in males is considered by many health professionals as an important measure to help improve hygiene in men and reduce the chance of infection of the genitalia.

FUTURE

Research today is revealing potential connections between reproductive system infections and the development of certain types of cancer. For example, mastitis, infection of the breast, has been suspected to be associated with the development of noninflammatory breast cancer. Some data appear to indicate a positive correlation, as noninflammatory breast cancer often appears after a severe infection of the breast. In addition, it has been shown that 90% of cervical cancer is linked to infections with human papillomavirus (HPV) and almost 80% of cases occur in low-income countries. Research on the prevalence and prevention of reproductive tract infections in developing countries is and will continue to be a major undertaking to develop more appropriate programmatic and policy responses for governments in low-income/developing countries.

Introduction

The human reproductive system consists of numerous organs and structures that are often closely associated with the urinary system (see Chapter 15, Infections of the Urinary System). Many texts will combine the two systems into the urogenital system. Although different in purpose and function these systems sometimes share the same organs/structures and therefore are susceptible to infections with the same microorganisms. This chapter specifically examines infections of the reproductive systems that are not sexually transmitted, as sexually transmitted infections are addressed in Chapter 17 (Sexually Transmitted Infections/Diseases).

The normal flora of the reproductive system varies greatly between the sexes; however, some typical resident flora in both reproductive systems include Streptococcus, Bacteroides, Mycobacterium, Neisseria, and some Enterobacteriaceae. Because of hormonal changes during the life of a woman, changes in the chemical environment in parts of the female reproductive system occur and will affect the resident flora, as well as the potential for infections. With the exception of the lower one third of the urethra, the healthy male reproductive system does not contain any resident flora and is normally sterile. In both the male and female systems, numerous defense mechanisms exist. They are in place to prevent infections within the organs and structures of the reproductive tract. These mechanisms include the following:

In spite of these preventive mechanisms, the reproductive system is rather susceptible to sexually transmitted infections, which are discussed in detail in the next chapter. Because of the unique structures and biochemical factors, the examination of infections of the reproductive system, exclusive of sexually transmitted diseases, is addressed separately for the female and male systems.

Types of Infections

These infections impact the health and reproductive capacity of women, men, their families, and their communities. Consequences of the infections include infertility, ectopic pregnancy, chronic pelvic pain, pelvic inflammatory disease, miscarriage, and increased risk of contracting sexually transmitted infections (see Chapter 17, Sexually Transmitted Infections/Diseases). Reproductive tract infections (RTIs) can be categorized as endogenous, iatrogenic, and sexually transmitted infections.

Infections of the Female Reproductive System

Because of the differences in structure, function, and systemic biochemical processes between males and females, the mechanisms of infection along with the targets and causative agents of infections differ considerably. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and the external genitalia (Figure 16.1). The mammary glands are part of the female system but they are not necessary for reproduction; they play a role only after birth.

Bacterial Infections

Several bacterial infections of women’s reproductive system may cause pain, irritation, or other symptoms. Some of these infections can lead to infertility or present a serious health risk. It is not uncommon for more than one infection to occur simultaneously. Unfortunately, having any one of the bacterial infections does not provide immunity against a future infection.

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.