Upper genital tract infection

كلية الطب ? جامعة بابل المرحلة الخامسة
د-نسرين مالك
Gynaecology

Genital Tract Infections
(II) -Upper genital tract infection:-
Include the infection of the cervix, uterus, fallopian tubes, and ovaries with pelvic infection.

1-Chlamydia trachomatis :-
Chlamydia is a common sexually transmitted infection .C. trachomatis is a small gram-negative bacterium with unique biologic properties that distinguish it from all other living organisms, as it an obligate intracellular organism that has a distinct life-cycle that consists of two major phases: The small elementary bodies attach and penetrate into cells, changing into the metabolically active form, called the reticulate bodies within six to eight hours . These forms create large inclusions within cells. The reticulate bodies then reorganize into small elementary bodies, and within two to three days the cell ruptures, releasing newly formed elementary bodies. Release of the elementary bodies initiates the replicative process, since this is the form which can infect new epithelial cells. The long growth cycle explains why prolonged courses of treatment are necessary.

Chlamydial infection most frequently affect the women under 25 years of age, and is often asymptomatic but can still result in subclinical PID and subsequent complications. For this reason screening programs for this age group have been developed and there is some evidence that they reduce the rates of PID. Testing is also indicated in women with other risk factors, including a new sexual partner, or those with symptoms that include altered vaginal discharge, intermenstrual or postcoital bleeding or abdominal pain. Examination is often normal, but cervicitis with mucopurulent discharge may be present. Infection at other mucosal sites occurs as in gonorrhoea (although it is thought to a lesser extent) and similarly neonates born to mothers with cervical infection may develop conjunctivitis. A reactive arthritis that is typically monoarticular affecting the weight-bearing joints may occur, but is more common in men .
Occasionally, patients with chlamydia infection develop perihepatitis, (an inflammation of the liver capsule and adjacent peritoneal surfaces ) this is called (Fitzhugh-Curtis syndrome). .It’s also possible to get a chlamydia infection in the anus. In this case, the main symptoms are often discharge, pain, and bleeding from this area.

Physical examination:- Is often unremarkable, mucopurulent cervical discharge, cervical friability, and cervical edema can be noted, cervical ulcers also may be seen.

Diagnosis:- NAAT tests are widely available for C. trachomatis, and some test simultaneously for N. gonorrhea with the option to add on testing for Trichomonas vaginalis (TV) in women with indicative symptoms. These tests offer high levels of sensitivity and specificity, and in women the optimal genital specimen is a vulvovaginal swab that may be self-taken by the woman without compromising diagnostic accuracy

Treatment:-For uncomplicated genital chlamydia, equally effective treatment regimens include azithromycin or doxycycline; the benefit of the former is that it is single dose and well tolerated. Simultaneous treatment of current and recent sexual partners is required.

2-Gonorrhea :-
Gonorrhea is a sexually transmitted infection (STI). It’s caused by infection with the bacterium Neisseria gonorrhoeae. It tends to infect warm, moist areas of the body, including the urethra, eyes, throat, vagina, anus, and female reproductive tract (the fallopian tubes, cervix, and uterus).Gonorrhea passes from person to person through unprotected oral, anal, or vaginal sex. People with numerous sexual partners or those who don’t use a condom are at greatest risk of infection. The best protections against infection are abstinence, monogamy (sex with only one partner), and proper condom usage. The most concerning complications of gonorrhea relate to female reproduction. The resultant scarring from PID may lead to infertility or ectopic pregnancy.

Clinical manifestations:-
1-Cervical infection :- The most common site of mucosal infection with N. gonorrhoeae is the cervix. Approximately 50 percent of infected women with cervical infection are asymptomatic. Symptomatic infection typically manifests as vaginal a mucopurulent discharge. On examination, the cervix may appear normal or show signs of frank discharge. The cervical mucosa is often friable, and evidence of concurrent upper genital tract disease (abdominal pain, dyspareunia) may be present.
2-Urethritis(painful urination) , other sites of infection are anorectal infection and proctitis ,Oropharyngeal infection, conjunctivitis.
3- Other mucosal sites of infection :- Bartholin s glands can also become infected with N. gonorrhoeae
4- Pelvic inflammatory disease .
5-Fitz-Hugh Curtis syndrome (perihepatitis).

Diagnosis:-
1-NAAT tests are highly sensitive and specific, and if N. gonorrhoea is identified it is important to obtain a sample for culture and sensitivity testing as there has been a development of widespread antimicrobiological resistance that requires careful surveillance.

2-Gram stain :- The use of Gram stain for the diagnosis of cervical gonorrhea, which appear as intracellular Gram negative diplococci

Screening for other STIs is crucial, particularly for C. trachomatis, as dual infection is common.
Treatment:- Dual treatment of uncomplicated infection is presently with a parenteral third generation cephalosporin plus azithromycin; the recent addition of azithromycin to treatment regimens is
an attempt to delay the emergence of further drug resistance.

Cervicitis:-Mucopurulent cervicitis is a clinical diagnosis based on detecting purulent mucus in the cervix and is often accompanied by contact bleeding .It can be confused with a benign ectropion ,but the later dose not bleed heavily unless swabbed very vigorously. Women with cervicitis may present with post coital bleeding, or complain of a purulent vaginal discharge .Many however are asymptomatic. Cervicitis is often caused by sexual transmissible agent , with the male partner having NGU .Test for Chlamydia and gonorrhea should be performed. If ulceration present, test for herpes simplex.
Treatment is the same as for chlamydia. Chronic cervicitis produce scaring .Nabothian follicles are mucus –containing cysts up to 1 cm in diameter ,which are often present following chronic cervicitis.

Note:-Any patient presented with any one of sexual transmitted diseases should be do screening for other sexual transmitted diseases for her and for the partner, and treat both .

References:-1-Margaret Kingston, Genitourinary problems Gynecology by Ten Teachers, 2 0th Edition ,9,177-195.
2-Jonathan D.C. Ross, Acute Pelvic Infection,Dewhurst’s Textbook of Obstetrics & Gynaecology Ninth Edition ,2018;45: 611-620.