Inflammatory Diseases of the Cervix (cervicitis)
• The cervix is covered by two epithelium: squamous and glandular epithelium. The causative agents of cervicitis caused by ectocervical squamous epithelium are agents that cause vaginitis (Trichomonas, Candida). N.gonorrhoeae and C.trachomatis cause mucopurulent endocervicitis because they only involve the glandular epithelium.
• The most common period of STD is the adolescence period.
• The most common STD agent is HPV.
Clinic and Diagnosis
► Endocervical yellow-green mucopurulent discharge is valuable in diagnosis.
► In the Gram stain of the discharge, neutrophil dominance is observed.
► While monitoring intracellular Gram (-) diplococcus establishes the diagnosis of N.gonorrhoeae, if it is not followed, the possible causative agent is chlamydia.
► Nucleic acid amplification test should be applied for the definitive diagnosis of both chlamydia and N.gonorrhoeae.
Chlamydia and N. gonorrhoeae most commonly attack the endocervix, but they cause the most severe damage to the tube.
Chlamydia is the most common causative agent of ectopic pregnancy and infertility.
Treatment
► Co-treatment should be done.
0 Gonorrhea endocervicitis
- Ceftriaxone + Azithromycin or
- Cefixime + Azithromycin (if Ceftriaxone cannot be used)
■ It should not be preferred in treatment due to the development of resistance against fluoroquinolones.
0 Chlamydia endocervicitis
- Azithromycin: Azithromycin can be used safely in pregnant women.
- Doxycycline
- Erythromycin
- Ofloxacin
- Levofloxacin
Metronidazole has no place in gonorrhea and chlamydial endocervicitis.
Pelvic Inflammatory Disease (PID)
· • PID is a bacterial infection of the upper genital tract (endometritis, myometritis, parametritis, salpingitis, oophoritis, pelviperitonitis). All PIDs are polymicrobial and contain Gram positive and negative aerobic and anaerobic bacteria. The primary pathogens in PID are N.gonorrhoeae and C.trachomatis.
• Mycoplasma can also cause PID and produce a clinical similarity to chlamydial PID. Anaeropic microorganisms that cause bacterial vaginosis are often isolated in the vagina in women with PID. These pathogens include Prevotella, peptostreptococci, Gardnerella. Less frequently, respiratory pathogens such as H. influenzae, group A streptococci and pneumococci may cause PID by colonizing the lower genital tract.
Risk Factors for PID
• Vaginal douche
• Single
• Substance use
• Multiple partners
• Low socioeconomic level
• New sexual partner
• Young age (10-19 years.)
• Having other sexually transmitted diseases
• Presence of urethritis or gonorrhea in the partner
• Having had a previous PID attack
• Not using a mechanical and/or chemical barrier contraceptive method
• Gonorrhea or chlamydia positivity in endocervical tests
- PID can develop in three ways:
► ascendant spread (90%) (vaginal inf., interventions)
► Direct spread from adjacent infected tissues (appendicitis, diverticulitis)
► Hematogenous spread (tuberculosis)
clinic
► Pelvic pain
► Uterine and/or adnexal tenderness with cervical movements {This is the most important finding.)
► Fever
Diagnosis
► Symptoms
0 Not required for diagnosis and some cases may be asymptomatic.
► Findings
0 Pelvic tenderness
0 Leukorea and/or mucopurulent endocervicitis
► Additional criteria that increase the diagnostic value
0 Endometritis findings in endometrial biopsy
Height at CRP or ESR
0 fever higher than 38 degrees
0 Leukocytosis
0 Test positive for gonorrhea or chlamydia
► Criteria with high diagnostic value
0 Tubuovarian abscess appearance on ultrasonography
0 Salpingitis appearance in laparoscopy
► Recurrent infection, infertility, ectopic pregnancy and chronic pelvic pain
Treatment
► When PID is suspected, treatment should be started. It is applied as an outpatient or hospitalized according to the condition of the case.
► Hospitalization indications for pelvic inflammatory disease
0 Pregnancy
0 Adolescent period
0 Substance abuse
0 advanced disease
0 suspected abscess
0 uncertain diagnosis
0 Generalized peritonitis
0 Fever > 38.3°C
0 unsuccessful outpatient treatment
0 History of recent intrauterine intervention
0 Leukocytes > 15,000 /mm3
0 Nausea-vomiting that prevents oral intake
► Outpatient treatment
0 [Cefoxitin (IM) or Ceftriaxone (IM)]+ [Doxycycline (oral) or Azithromycin (oral)]
► Inpatient Treatment
0 Regimen A: [Cefoxitin (IV) or Cefotetan (IV)] + Doxycycline (IV)
0 Regimen B: Clindamycin (IV) + [Gentamycin (IM/IV) or Ceftriaxone (IV)]
Co-treatment is absolutely necessary.
Tuba-Ovarian Abscess (TOA)
• TOA usually occurs unilaterally and multilocularly following an acute attack of PID. It can happen after the first PID attack. The ovary is usually involved at an ovulation site and abscess formation begins.
Clinic
► It is very variable. It ranges from asymptomatic to acute abdomen and septicemic shock. Pelvic and abdominal pain (90%), fever (60-80%), nausea, vomiting, and tachycardia are common symptoms, and pelvic examination is often not performed due to abdominal defense, but an adnexal mass (bilateral, painful adnexal masses are typical) can sometimes be palpated. The findings of a ruptured tubo-ovarian abscess are similar to acute abdomen.
Diagnosis
► USG is the imaging method that should be preferred for the diagnosis of tubaovarian abscess in patients with PID, and the presence of an adnexal mass suggests TOA. Diagnosis can also be used on CT with or without contrast.
Treatment
► If there is no response to medical treatment, percutaneous drainage can be performed with CT or USG. Percutaneous drainage under antibiotic pressure can also be considered as the first line of treatment. BSO and hysterectomy can also be performed in those who do not expect fertility.
► Laparotomy is absolutely necessary in case of progression and rupture of TOA, and endotoxic shock such as hypotension and oliguria in the patient.
Genital Tuberculosis
• Almost all cases develop secondary to pulmonary tuberculosis. 5% of patients with pulmonary tuberculosis also have genital tuberculosis. The bacillus comes from the pulmonary focus via the blood to the tuba and uterus. It spreads directly from the tubes to the pelvic peritoneum, endometrium, ovary, and cervix.
Tubal involvement is the most common in genital tuberculosis, and endometrial involvement is the second most common.
• Endosalpingitis develops in the exudative phase, followed by caseous degeneration and ulceration. In the long term, perisalpingial adhesions and tubercles form. Endometrial involvement can lead to menstrual irregularities and secondary amenorrhea. The most common complaints in patients are infertility and chronic pelvic pain.
The disease with the worst prognosis in terms of fertility is genital tuberculosis.
Toxic Shock Syndrome (TSS)
• It is caused by Staphylococcus aureus. It can be seen at any age; however, it is most commonly seen in adolescents and young people aged 10-30 years. Vaginal tampons are responsible for 99% of toxic shock syndrome in menstruating women. There is no increased risk in IUD use.
► Major diagnostic criteria;
✓ Hypotension
✓ Orthostatic syncope
✓ Systolic BP< 90 mmHg
✓ Diffuse macular erythroderma
✓ Fever ≥ 38.8°C
✓ Late skin desquamation (after 1-2 weeks), especially on the hands, palms and soles