GENITAL INFECTIONS

Dr.B.BOYLE
 GENITAL INFECTIONS
FEMALE MALE
Vaginal Infections Prostatitis
Infections of the Epididymitis
female pelvis
Orchitis
Post-Gynaelogical
Surgery Infections Urethritis (Previous
Pelvic Inflammatory Lecture)
Disease(Previous Balanitis
lecture)
 Vaginal Infections
Normal Flora
Candidiasis (Previous lecture)
Trichomoniasis (Previous lecture)
Bacterial Vaginosis
Staphylococcal Infection
Foreign Body Vaginitis
Herpes Simplex Virus (Previous lecture)
Human Papillomavirus (Previous lecture)
 Normal Vaginal Flora(p-p)
Variety of bacteria, primarily obligate and
facultative anaerobes
More that 105 lactobacilli per ml of vaginal
material recovered from 75% of women
Primarily Lactobacillus crispatus, Lactobacillus
jensonii
Viridans Streptococci and S.epidermidis found in
50% of women
One sixth of women have large numbers~105-6 of
Bacteroides and Prevotella spp.
Gardnerella vaginalis in 30-90% of women
Staphylococcus aureus in 5% of women
Yeasts carried in 15-20% of healthy women
 Vaginal Secretion
Endocervical secretions combine sloughed
epithelial cells and normal bacteria to form
physiologic discharge, occasionally give rise to
leukorrhoea
Often increased during pregnancy or with the use
of oral contraceptives
Floccular and no bubbles present
Lactobacillus spp. Prevents growth of other
organisms particulary anaerobes by the Hydrogen
peroxidase system
Bacterial Vaginosis
Described by Gardner and
Dukes 1955
Predominant symptom
-Vaginal odour
Perivaginal irriation is
much milder than
candidiasis or
trichomoniasis
90% mild to moderate
discharge, often visible
Labia and vulva non-
erythematous
Discharge:
grayish,thin,homogenous
containing small bubbles
 Bacterial Vaginosis
Diagnosis(3/4) Guide
Ph greater than 4.5(90%)
Homogenous white ,
smoothly adherent vaginal
discharge
Positive whiff test (limited
value)
Clue cells:direct Some clue cells seen in 90% of women
microscopy of discharge
with BV
reveals vaginal epithelial
cells studded with tiny In normal women predominant type of
coccobacilli, edge of cells
or obliterate the nucleus bacteria is large rods(Lactobacilli spp.)
 Bacterial Vaginosis
Gardnerella Vaginalis is isolated from 92-98%
of women with BV, however also isolated from
asymtomatic females
Risk factors: higher in those with more sexual
partners(male and female) , Higher in those
with STI, symptoms often appear in women
shortly after becoming sexually active, 80%
partners have organism isolated, higher in
those who douche or use intrauterine devices
however is seen in virgins
Because of the association with STI`s , those
screened in STI`s clinics are also screened for
G.vaginalis
 Gardnerella Vaginalis
Faculative anaerobic, gram variable
organism
Has been shown to consume ammonia
produced by anaerobes
Has phospholipase A2 activity
Produces B-haemolysis on human blood
agar or blood agar with gelatin added, small
pinpoint colonies
 Bacterial Vaginosis-
Pathophysiology
BV is actually a synergistic infection involving
not only G.vaginalis but certain anaerobic
bacteria as well
Evidence
Numbers of anaerobes are dramatically
increased in women with BV (Bacteroides and
Prevotella spp. Etc)
Asymtomaic carriers
Odour due to aromatic amines produced by
anaerobes (Volatilised at basic Ph hence
positive whiff test)
Reduction in Lactobacilli spp., allow G.vaginalis
AND anaerobes to thrive
 Bacterial Vaginosis-
Treatment
BV not considered a benign condition
Treatment oral or intravaginal gel of
metronidazole 5-7 days or clindamycin
intravaginal cream
Metronidazole first choice as part of
recovery is recolonization with
Lactobacillus spp.
 Bacterial Vaginosis-
Complications
Amnionitis and Premature labour and delivery
Late term miscarriage
Postpartum fever, endometritis and salpingitis
(particulary following abortion)
Wound infection and vaginal cuff infection post
hysterectomy
Occassionally septicaemia associated with these
conditions
 Other vaginal Infections
Staphylococcus Spp.and Toxic shock
Syndrome
Secondary anaerobic infections associated
with foreign bodies such as tampon,
contraceptive devise(diaphragm, condom
etc)
In childrem a variety of objects produces
foul odour , scanty discharge with blood
Bartholin`s Gland Abscess
Bartholin`s Gland Abscess
 Age related
Neonates may acquire trichomonal or candidal
vulvovaginitis after passage through the birth
canal, can be treated
Vaginal discharge after neonatal period is
abnormal and should be promptly investigated
N.gonorrhoeae and C.trachomatis produce
vulvovaginitis as prepubscent vagina not
cornified, require through investigation ,
including possibility of sexual abuse
 Infections of the female
Pelvis
Intra-amniotic Post-abortion
Infection Syndrome Infections
Post Partum Infections after
Endometritis Gynaecological
Puerperal Ovarian Procedures
vein
Thrombophlebitis Pelvis Inflammatory

Episiotomy
Disease
Infections
 Intra-amniotic Infection
Syndrome
Chorioamnionitis
Is clinically detectable infection of the uterus
and it`s contents during pregnancy
1-2% of women with full term pregnancy and
25% of women with preterm labour
Most cases are ascending in origin, occurring
after prolonged rupture of membranes
Few cases from transplacental spread of
bacteremia e.g Listeria monocytogenous
Rare cases after diagnostic amniocentesis etc
Risk factors: PROM, MVE, young age, Low SE
group, nullparity and Bacterial vaginosis
 Organisms isolated
Gardnella vaginalis E.coli
Mycoplasma hominis Group B Streptococci
anaerobes Enterococci
Aerobic Gram
negative bacilli
 Presentation
Maternal Fetal
Fetal Heart rate
Fever abnormalities(TC ,DV)
Tachycardia PPROM 25%
subclinical infection
Uterine tenderness
Preterm labour and
Uncommom: foul intact membranes 5-
smelling or grossly 10% and another 10%
purulent Amniotic subclinical
Causes arrest of progress
fluid of labour
Diagnosis : clinical
mostly
 Management
Antibiotics started as soon as suspected not
postpartum
Delivery essential to cure
Antibiotic administration reduces frequency of
neonatal pneumonia, bacteremia and cures
maternal infection
As Group B Streptococci and E .coli most
common isolates from newborn, combination of
Ampicillin or Penicillin and Gentamicin used if
delivered vaginally
 Post-partum Endometritis
Postpartum infection of the uterus
Most common cause of puerperal fever
Predominant predictor: Caesearan section
particularly after labour or premature
rupture of membranes
Rates vaginal delivery 0.9-3.9%
Caesearan section rate: 10-50%
Secondary risk factors include BV
 Cause of PP Endometritis
It is a polymicrobial Infection
Endometrial isolates: Group B Streptococci,
enterococci, G.vaginalis, E.coli, Prevotella
bivia, Bacteroides spp and
Peptostretococcus
Blood isolates: Group B Streptococcus and
G.vaginalis most common
 Presentation
Fever on 1st or 2nd day postpartum
Lower abdominal pain
Uterine tenderness
Leucocytosis
Blood cultures should be taken positive in up to
20%
If late onset and at risk test for Chlamydia
infection
Treatment: INTRAVENOUS ANTIBIOTICS
 Treatment failures
If fever persists despite appropriate
antimicrobial therapy consider wound or
pelvic abcess, puerperal ovarian vein
thrombophlebitis and non-infectious fever(
drug-fever, breast engorgement)
Pyosalpinx
Actinomyces Gram /Culture
Actinomyces Infection
 Puerperal Ovarian Vein
Thrombophlebitis
Syndrome resulting from acute thrombosis
of one or both ovarian veins in the
postpartum period
1/2000 deliveries or 1-2 cases per 100
patients with PP infection
Onset variable but usually 2-4 days after
delivery
 Puerperal Ovarian Vein
Thrombophlebitis
Temperature , Tachycardia
Lower abdominal pain often on right side
Previous diagnosis of PPE not responding to
antimicrobial therapy
to 2/3 have a rope-like mass
Ileus and respiaratory distress may be present
Therapy: antimicrobial therapy and Heparin
Female Anatomy
 Episiotomy Infections
Uncommon Infection
0.1% become infected, higher rate if 3rd or 4th
degree extensions
4 types
Simple Episiotomy Infection (skin and
superficial fascia)
Superficial fascia infection without necrosis
Infection of the superficial fascia with
necrosis(necrotizing fascitis)
Myonecrosis (deep fascia)-C.perfringens
 Post abortal Infection
Ascending Process
More common if retained products of
conception or operative trauma
Risk factors: greater duration of pregnancy,
technical difficulties and unsuspected presence
of STI
Symptoms: Fever, chills, abdominal pain,
vaginal bleeding and passage of tissue
Onset: usually 4 days after procedure
Temp, TC, abdominal tenderness
 Post abortal Infection
C.perfringens has a characteristic presentation
in PAI, massive intravascular hemolysis
producing jaundice, severe anaemia
Treatment is removal of infected material and
antibiotics
Use of Prostaglandin E 2 is contraindicated in
the presence of pelvic infection
Prevention and Prophylaxis
Pyometrum
 Infection after
Gynaecological Procedures
E.coli, Klebsiella, Proteus, Enterobacter spp,
B.fragilis and enterococci are the most common
causes of postop infection in 5 days post op
Risk Factors: Duration of Surgery, Abdominal
approach, age-premenopausal, bacterial
vaginosis for abdominal surgery
4 forms: Pelvic celluitis, cuff celluitis, cuff
abscess, pelvic abscess
Role of Prophylaxis
Tuboovarian Abscess
 Genital Infections in Men
Prostatitis Epididymitis
Acute bacterial Non-specific
Chronic bacterial Sexually Transmitted
Chronic Pelvic Pain Orchitis
Syndrome Viral
Granulomatous Bacterial
Prostatic Abscess
Host Defences in the Male
Organisms that ascends through the urethra
cause most infections of the urogenital ducts
and accessory sex organs
Flushing gives some protection
Prostatic antibacterial factor (zinc containing
polypeptide) secreted by prostate
Presence of leucocytes
Immunoglobulins
Those with secretory dysfunction may have
increased Ph of prostatic fluid, reduced
calcuim, citric acid changes in prostatic fluid
enzymes
 Prostatitis
50% of men will experience symptoms at
some stage of their lives
 Acute Bacterial Prostatitis
Causes: Enterobacteriaceae, Pseudomonads
and Enterococci
Urinary frequency , dysuria
Lower UT obstruction due to odema of prostate
Signs of systemic toxicity are common
Lower abdominal pain, suprapubic discomfort
Exquisite tenderness on PR exam
 Acute Bacterial Prostatitis
Urinalysis : pyuria, C/S POSITIVE
Bacteremia may also be present
Antimicrobial therapy penetrate prostate
Complications: Prostatic abscess, Prostatic
infarction, chronic bacterial prostatitis and
granulomatous prostatitis
Chronic Bacterial Prostatitis
Present with recurrent bacterial urinary tract
infections caused by the same organism,
asymptomatic inbetween
Prostate normal on rectal exam
Urinary localization studies establish diagnosis
Causes: most important gram negative
rods(Enterobacteriaceae and Pseudomonads)
Treatment: Ciprofloxacin or trimethoprim(
achieve good concs in prostatic tissue)
Patients may require suppressive therapy
Chronic Bacterial Prostatitis
Urinary Tract Localization Using Sequential
Urine Cultures

Specimen Symbol Descripition

Voided Bladder VB1 Initial 5-10ml

cfu
1 VB3>>VB1
Voided Bladder VB2 Midstream 10 fold
2 specimen
Expressed EPS Secretions
Prostatic expressed from
secretion prostate by
digital massage
Voided Bladder VB3 First 5-10ml
3 after Prostatic
massage
 Granulomatous Prostatitis
Most cases follow an episode of acute bacterial
prosatitis
Tuberculosis prosatitis secondary to
tuberculosis elsewhere in the genital tract
Iatrogenic following those who receive
intravesical Calmette-Guerin bacillus
treatment for transitional cell carcinoma of
bladder
Crytococcosis
 Prostatic Abscess
Rare
Most patients are diabetics,
immunocompromised, inappropriate treated
acute prostatitis, urinary tract obstruction,
foreign body
Ascending route: common uropathogens,
S.aureus
Febrile, irritative voiding
But fluctant area on prostate or seEn on US,
MRI
Treatment : Drainage and antimicrobial
therapy
 Non-Specific Bacterial
Epididymitis
Most common cause in men over 35 years is
gram negative rods in 2/3 and gram positive in
20%
Often recent history of urinary tract
manipulation (weeks or months after) or
urology pathology
Occurs if patient was bacteriuric
TB: most common male manifestation ,
heaviness, swelling, beadlike vas deferens,
sinuses
Treatment: antimicrobials to cover gram
negative rods and Gram positive cocci, local
measures , if TB , antituberculosis therapy
 Sexually Transmitted
Epididymitis
Most common type in young men
C.trachomatis and N.gonorrhoeae major
pathogens
C.trachomatis 1-45 days post exposure, 10
days average
Patient most be evaluated for other STI`s
 Viral Orchitis
Most cases of orchitis are viral
Mainly mumps
Mumps rarely cases orchitis in prepubertal
males but 20% of postpubertal males with
mumps
Testicular pain and swelling 4-6 days after
parotiditis, 70% unilateral (contra 1-9 days)
May be systemically unwell
Resolve 4-5 days in mild cases
50% testes undergo some atrophy, but rarely
results in infertility
Coxsackie B virus also
 Bacterial Orchitis
Usually contiguous spread to give
Epididymoorchitis
E.coli, Klebsiella pneumoniae, Pseudomonas
aeruginosa, Staphylococci or Streptococci
Acutely ill: high fever, marked swelling and
pain of affected testes, nausea , vomiting
Tender, hydrocoele, skin oedematous and
erytematous
Complications: infarction of testis, Abscess
formation and scrotal pyocele