REPRODUCTIVE TRACT

INFECTIONS
By
Dr Patrick Okonta
FWACS, FMCOG, MPH, FICS
Department of Obstetrics & Gynaecology
Delta State University Teaching Hospital,
Oghara, Delta State
 Lecture objectives
• Review the female reproductive tract and
susceptibility to infections

• Describe the clinical entities associated with

infections in the female reproductive tract

• Discuss the common reproductive tract

infections
 Lecture outline
• Introduction
– Review the anatomy of the female reproductive tract
– Magnitude of reproductive tract infections.
• Clinical entities associated with reproductive tract
infections
– PID -STI
– Post abortal sepsis -Puerperal sepsis
– Pelvic peritonitis -Pelvic abscess
• Common organisms infecting the female
reproductive tract.
 Introduction
• RTI refers to basically 3 different types of
infections that affect the RI
– Endogenous infections:
• most common worldwide
• Results from overgrowth of normal flora eg BV,
candidiasis
– Iatrogenic infections:
• Following a medical procedure eg TOP, IUCD insertion,
childbirth
– Sexually transmitted infections
Introduction
Burden of reproductive tract infections
• WHO estimates that each year 499 million new cases of
curable STI.
• Post abortal sepsis, puerperal sepsis is a major cause of
maternal mortality in developing countries.
• 536 million people are estimated to be living with incurable
herpes simplex virus type 2 (HSV-2) infection.
• Approximately 291 million women have a human
papillomavirus (HPV) infection at any given point in time.
• The burden of STIs is greatest in low-income countries.
 Clinical entities associated with
reproductive tract infections
Pelvic Inflammatory disease
• Ascending infection of the upper Genital tract involving the
endocervix, endometrium, fallopian tubes, ovary and overlying
peritoneum.
• Estimated gynae admissions related to PID
– 40% in Africa
– 15 -37% in South East Asia
• NG and Chlamydia infections maybe 10-100 times more common in
low-income communities than high-income communities
• Risk of infertility
– 15-23% after one episode of PID,
– 50-60% after 3 episodes
– Rates higher where antibiotics tx is not available
• Ectopic pregnancy
– 6-10 times greater in women who have had PID
 Clinical entities associated with
reproductive tract infections
Sexually Transmitted Infections
• STIs are infections that are spread principally by
sexual intercourse, including cunnilingus,
anilungus, fellatio, anal intercourse.
• However may also be spread by other forms of
intimate physical contact such as kissing, mouth-
breast contact.
• Some of these infections can also be transmitted
through the birth canal, lactation and placenta
 Clinical entities associated with
reproductive tract infections
– Post abortal sepsis

– Puerperal sepsis

– Pelvic peritonitis

– Pelvic abscess
 Microbiology of common organisms
infecting the female reproductive tract.
Neisseria Gonorhoea
• Gram –ve intracellular diplococcus
• Oxidase +ve
• Ferments glucose
• Incubation period 3-5 days
• Rapidly killed by drying, sunlight, heat and most
disinfectants
• Culture medium- Thayer-martin or Transgrow
media
• Transport medium is Stuart’s or Amies
 Neisseria Gonorhoea (contd)
• Affects columnar epithelium – urethra, cervix,
Bartholins glands, rectum.
• Can also cause ophthalmia neonatorum,
pharingitis ,disseminated arthritis, meningitis
and endocarditis
• In males, can cause in addition to urethritis,
prostatitis and epididymotitis
 Neisseria Gonorhoea (contd)
• Vulvo- vaginitis in prepubertal girls due to the
non keratinized membranes of the vagina
• Co-infection with Chlamydia in 20 – 40 % of
cases
• Without treatment 10 -17% will develop pelvic
infection.
• Tissue damage is through direct tissue
invasion
 GONORRHOEA - Diagnosis
• Isolation of NG from specimen taken from
– Urethra, cervix, anal canal, and/or pharynx
• Microscopy (Giemsa stain)- intracellular, gm
neg diplococcus
• Culture medium: Thayer martins or Transgrow
media. Note: NG is a very delicate organism
• Transport media: Stuarts transport medium
 GONORRHOEA - Treatment
• Important to have an idea of the antibiotic sensitivity
pattern in the locality
– Most NG infections are resistant to penicillin and
tetracyclines
• Generally uncomplicated infection can be treated with
any of these
– Ciprofloxacin, 500 mg orally, as a single dose (Contra
indicated in pregnancy)
– Ceftriaxone, 125 mg by intramuscular injection, as a single
dose
– Cefixime, 400 mg orally, as a single dose
– Spectinomycin, 2 g by intramuscular injection, as a single
dose
– Kanamycin, 2 g by intramuscular injection, as a single dose
(WHO recommendation 2003)
 GONORRHOEA - Treatment
DISSEMINATED GONOCOCCAL INFECTION
• Ceftriaxone, 1 g by intramuscular or intravenous
injection, once daily for 7 days
– (alternative third-generation cephalosporins may be
required where ceftriaxone is not available, but more
frequent administrations will be needed)
OR
• Spectinomycin, 2 g by intramuscular injection,
twice daily for 7 days.
– There are some data to suggest that therapy for 3
days is adequate
(WHO recommendation 2003)
 CHLAMYDIA INFECTION
• Organism:
– Obligate intracellular organism
– Contains RNA and DNA
– Has a cell wall
– Divides by binary fission
– 15 serotypes A to L; A-C cause trachoma, D-K cause
genital infections, L cause LGV
– All except the L serotype attach only to columnar
epithelium without deep tissue invasion
– Damage to tissue is via cell-mediated immune
response
 CHLAMYDIA INFECTION
Clinical features
• Mainly asymptomatic in females (about 80%)
• Females may present with features of acute
PID , mucopurulent cervical discharge.
• Complications of PID- infertility or ectopic
pregnancy
• Males have a less purulent or non purulent
urethra discharge. Commonest cause of non
gonoccocal urethritis in males
CHLAMYDIA INFECTION - Diagnosis
• Serology – detection of antibody against
chlamydia estimation, ELISA
• Cell culture using Mc Coy cells
• PCR and Ligase Chain Reaction (LCR)- more
specific but expensive
Specimens
– Blood
– Cervical smears
– Vaginal swabs
– Urine (first pass urine) for Nucleic Acid Amplification
tests NAAT
 CHLAMYDIA INFECTION – Treatment
Uncomplicated Chlamydia infection
• Doxycycline, 100 mg orally, twice daily for 7 days
or
• Azithromycin, 1 g orally, in a single dose

Alternative regimen
• Amoxycillin, 500 mg orally, 3 times a day for 7 days
or
• Erythromycin, 500 mg orally, 4 times a day for 7 days
or
• Ofloxacin, 300 mg orally, twice a day for 7 days
or
• Tetracycline, 500 mg orally, 4 times a day for 7 days
(WHO 2003)
Note : Doxycyline and other tetracyclines are contraindicated during
pregnancy and lactation
 Herpes Simplex infection
• HSV type I causes oral herpes, while type II
causes genital herpes. However type I can also
cause genital ulcers.
• High incidence of relapse/recurrence and thus a
source of distress to infected women
• Primary herpes presents up to 3 weeks after
infection
– Affects the vulva, vagina, cervix and mons pubis
– Initial vulval parasthesia painful multiple visicles
burst heal without scarring in 21 days
 Herpes Simplex infection
• Other symptoms
– Fever, dysuria, vaginal discharge and inguinal
lymphadenopathy.
• After primary infection the virus remains
dormant in the pelvic dorsal root ganglia
• Recurrences are triggered by
– Stress; trauma; fever; menses; immunosuppression
• Viruses are shed during primary infection and
recurrent infections
Herpes Simplex infection- diagnosis
• Serology- antibody estimation; a rise in IgM
followed by IgG is most convincing of recent
infection
• Cell Culture
• Cervical smear (Pap smear) – characteristic
multinucleated giant cells, inclusion bodies
• PCR techniques
 Treatment
Recommended regimen for first clinical episode
• Acyclovir,
– 200 mg orally, 5 times daily for 7 days or
– 400 mg orally, 3 times daily for 7 days
Recommended regimen for recurrent infection
• Acyclovir,
– 200 mg orally, 5 times daily for 5 days or,
– 400 mg orally, 3 times daily for 5 days, or
– 800 mg orally, twice daily for 5 days
Recommended regimen for suppressive therapy
• Acyclovir, 400 mg orally, twice daily, continuously
Other drugs for treatment of Herpes
– Valaciclovir
– famciclovir
 GENITAL WARTS-HPV Infection
• More than 70 strains identified
• Most genital infections caused by HPV 6 & 11
which have little oncogenicity, while HPV 16 &
18 linked to cervical cancer
• Infection usually established asymptomatically
• Incubation period unclear ? 8-12 weeks
• Affects the vulva, perineum, vagina, cervix,
rectum. Can also affect the lips and mouth
 GENITAL WARTS-HPV Infection
• Presents as multiple raised frond-like skin lesions
• Growth of warts is increased during pregnancy,
immunocompromised patients, use of OCPs.
• Large florid vulval warts may be an indication for
CS delivery- can cause obstructed labour and
primary PPH from large perineal and vulval tears
• Neonatal giant laryngeal papilloma may result
from maternal HPV infection
 Diagnosis
• Clinical diagnosis
• Pap smear- multinucleated giant cells with
intranuclear inclusions (non specific for viral
infections)
• Cell culture
• Elisa
 Treatment
Chemical
• Podophyllin 10–25% in compound tincture of benzoin, applied carefully to the
warts, avoiding normal tissue. External genital and perianal warts should be
washed thoroughly 1–4 hours after the application of podophyllin. Treatment
should be repeated at weekly intervals

• Podophyllotoxin 0.5% solution or gel, twice daily for 3 days, followed by 4 days of
no treatment, the cycle repeated up to 4 times (total volume of podophyllotoxin
should not exceed 0.5 ml per day)

• Imiquimod 5% cream applied with a finger at bedtime, left on overnight, 3 times a

week for as long as 16 weeks. The treatment area should be washed with soap and
water 6–10 hours after application. Hands must be washed with soap and water
immediately after application

• Trichloroacetic acid TCA 80–90%, applied carefully to the warts, avoiding normal
tissue, followed by powdering of the treated area with talc or sodium bicarbonate
(baking soda) to remove unreacted acid. Repeat application at weekly intervals .
 Treatment
Surgical
• Cryotherapy with liquid nitrogen, solid carbon dioxide, or a
cryoprobe. Repeat applications every 1–2 weeks

• Electrosurgery

• Carbon dioxide laser

• Surgical excision with knife

• Cervical warts must be investigated with colposcopy to rule

out early invasive ca cervix
 Prevention
• Barrier contraceptives
• HPV vaccination
– Gardasil
• targets HPV 6, 11, 16, & 18
• 3 doses
– Cervarix
• Targets 16 & 18
– Vaccination recommended for females aged 9-25 yrs
not exposed to HPV
– Primarily targeted for the prevention of Ca cervix
 Trichomoniasis
• Caused by a flagellated protozoon – T vaginalis
• Responsible for up to 35% of vaginitis
• Associated with adverse pregnancy outcomes, particularly
premature rupture of membranes, pre-term delivery and
low birth weight.
• Can cause symptomatic non-gonoccocal, non chlamydial
urethritis in some male
• Maybe asymptomatic for some months before causing
symptoms
• Symptoms /signs
– Yellowish or greenish thin frothy vaginal discharge, malodorous,
– Pruritus vulvae
– Examination: punctate haemorrhagic spots maybe seen on the
cervix
 Trichomoniasis (contd)
Diagnosis
– Microscopy of wet saline mount of discharge shows flagellated
protozoan

Treatment
• Metronidazole
– 2 g orally, in a single dose or
– 400 mg or 500 mg orally, twice daily for 7 days
OR
• Tinidazole
– 2 g orally, in a single dose or
– 500 mg orally, twice daily for 5 days
• Metronidazole is generally not recommended for use in the
first trimester of pregnancy, however in confirmed cases of
TV short cause can be used to avert the dangers of TV
 Bacteria Vaginosis
• Commonest cause of vaginal discharge
• Caused mainly by gardnerella vaginalis
– Other org. Include Bacteriodes, Mobiluncus, and
Mycoplasma species
– These are normal commensals in the vagina
– BV results from the overgrowth of normal vaginal
commensals that increase in conc thousand fold
– Increase in vaginal pH (4.5 – 7.0) due to reduction of
Lactobacilli
– Women with BV are at increased risk of 2nd trimester
miscarriage, PROM, preterm delivery, post abortal
endometritis and PID
 Bacteria Vaginosis
• Diagnosis (Amsel criteria)
– Profuse vaginal discharge, yellowish or grey; fishy
smell, watery (thin)
– Vaginal pH > 4.5
– Positive whiff (Amine) test
• Fishy smell on addition of alkali (10% potassium hydroxide)
to vaginal discharge
• Presence of ‘Clue cell’
– Vaginal epithelial cells covered with bacterial cells at the borders
• Treatment
– Metronidazole (as in TV)
– Clindamycin 300mg orally bd x 7 days
 CANDIDIASIS
• Common cause of vaginal discharge
• Not really a STI as candida is normal vaginal flora
• About 80%- 90% of candidiasis is caused by the C.
Albicans strain. Other strains include
• C. Glabrata; C. Krusei; C. Tropicalis; C. Stellaloides
• Predisposing factors:
– Immunosuppression - HIV
– Steriods - DM
– Vaginal douching - Increased E2 (OCP)
– Pregnancy - Dermatosis
– Broad spectrum antibiotics
 CANDIDIASIS
Clinical features
• Pruritus valvae
• Vaginal discharge
– Thick, curd like, whitish-creamy
• Vaginal discomfort

Diagnosis
• Clinical diagnosis
• Wet saline prep: spores and psuedohyphae
• Culture : Sabouraud’s or Nickerson’s media
• Normal vaginal pH
 CANDIDIASIS
• Treament
– Generally topical treatment better than systemic treatment.
– Vaginal ovules and creams
• Imidazole group: Clotimazole, Micanazole, Tioconazole
– miconazole /clotrimazole, 200 mg intravaginally, daily for 3 days
– Clotrimazole 500 mg intravaginally, as a single dose
– Tioconazole 300mg intravaginally, as a single dose
• Nystatin 100,000 units pv daily x14 days
– Oral treatment
• fluconazole, 150 mg orally, as a single dose
• ketoconazole
• Itraconazole
• Recurrent candidiasis
– Treat sexual partner
– Prolonged treatment
– Investigate and correct predisposing factors
 SYPHILIS
• Caused by a spirochaete- Treponema Pallidum
• Incubation period 10 -90 days
• If untreated passes through the primary
phase; secondary phase, latent phase and
tertiary phase
• Can be transmitted vertically. Vertical
transmission can be as high as 80% in the
primary and secondary phases
 Clinical features
• Primary Syphilis
– Painless ulcer (chancre) on the cervix mainly or the
vulva. Also can appear on the lips and anal area
– In males the ulcer appears on the penis
– Ulcer develops 2-6 weeks after infection
– Ulcer usually solitary, but may be multiple, rubbery
– Associated inguinal lymphadenopathy- enlarged
painless and discrete
– Ulcer disappears without treatment
 Clinical features
• Secondary syphilis
– Signs and symptoms due to dissemination and
proliferation of treponemes and the deposition of
immune complexes
– Affects skin, mucous membranes and muco-
cutaneous junctions
• Maculopapula rash, non itchy, symmetrical, involving
the palms and soles, trunks
• Condylomata lata
• Systemic symptoms- fever, generalised
lympahdenopathy, malaise, headache
 Clinical features
• Latent syphilis
– Asymptomatic
• Tertiary syphilis
– Neuro-Syphilis
• Meningovascular syphilis presenting as stroke
• Tabes dorsalis
• General paresis of the insane
– Cardiovascular syphilis
• Thoracic aortic aneurysm
• Aortic regurgitation
– Syphilitic gumma
• Chronic punched-out ulcers with central healing
 Diagnosis
• Dark-field microscopy
• Non treponema test.
– VDRL test- quick and cheap, but cross reaction with
other treponema infections
– Rapid plasma reagin RPR
• Treponema tests
– TPHA : Treponema pallidum heamagglutination test
– TPPA :Treponema pallidum particle agglutination
– TPI : Treponema pallidum inhibition test
 Treatment
Early syphilis (primary, secondary, or latent syphilis < 2 yrs duration)

• Benzathine benzylpenicillin, 2.4 million IU IM at a single session.

or
• Procaine benzylpenicillin, 1.2 million IU IM, daily for 10 consecutive
days

Alternative regimen for penicillin-allergic non-pregnant patients

• Doxycycline, 100 mg orally, twice daily for 14 days

or
• Tetracycline, 500 mg orally, 4 times daily for 14 days

Alternative regimen for penicillin-allergic pregnant patients

• Erythromycin, 500 mg orally, 4 times daily for 14 days

 Treatment
• LATE LATENT SYPHILIS
– (infection of more than two years’ duration
without evidence of treponemal infection)
Recommended regimen
• Benzathine benzylpenicillin, 2.4 million IU by
IM, once weekly for 3 consecutive weeks
 RTI causative agents - Bacteria
BACTERIA INFECTION GENITAL SITE

Neisseria Gonoccocus Neisseria Gonorrhoea Bartholins glands

Urethra
Cervix
Fallopian tubes
Chlamydia Trachomatis Lymphogranuloma Vulva
venerum LGV Urethra
Chylamidia infection Cervix
Fallopian tubes
Haemophylus Ducreyi Chanchroid- soft Vulva
chancre
Treponema Pallidum Syphilis Vulva, multiple genital
entry sites
Gardnella vaginalis Bacterial vaginosis Vagina

Klebsiella Donavani Granuloma Inguinale vulva

 Causative agents - Viruses
VIRUS INFECTION GENITAL SITE

HIV HIV infection/AIDS Multiple genital sites

Herpes Simplex virus II Genital herpes Multiple genital sites

Human Papilloma virus Genital warts- Multiple sites- vulva,

HPV Condylomata accuminata perinuem, cervix

Pox virus Mulluscum Contagiosum Vulva

Hepatitis virus Hepatitis Multiple entry sites

 Causative agents - contd
Protozoan Infection Genital site

Trichomonas Vaginalis Trichomoniasis Vagina

Parasite Infestation Genital site

Phthirus Pubis (Crab louse) Pediculosis pubis Pubic hair

Sarcoptes Scabiei Scabies vulva

Fungal Infection Genital site

Candida Candidiasis Vagina, vulva