Infections – GyneClinics

Pelvic Infection (PID)

Pelvic inflammatory disease (PID) is a general term for infection of the upper genital tract, including the uterus, Fallopian tubes, and ovaries. It usually results from ascending infection from the cervix. It is a common and serious complication of some sexually transmitted diseases, especially chlamydia and gonorrhoea. It can damage the fallopian tubes and tissues in and near the uterus and ovaries. Untreated PID can lead to serious complications, including infertility, ectopic pregnancy, abscess formation and chronic pelvic pain.

Genital chlamydial infection (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) are currently the most common sexually transmitted infection diagnosed in the United Kingdom. However, several other organisms may be responsible, such as those commonly associated with bacterial vaginosis, e.g. Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus spp. and other anaerobes.
Sexually Transmitted Infections are common in younger people, new sexual partner, multiple sexual partners, lack of barrier contraception, lower socio-economic group, termination of pregnancy and in the first 3-4 weeks after insertion of intrauterine contraceptive device (IUCD)

Presentation

Diagnosis of acute PID made only on clinical signs and positive swab results is 65-90% as accurate when compared to laparoscopic diagnosis. Many episodes of PID go unrecognised, as women often have absent, mild, or atypical symptoms.

Symptoms

The following features are suggestive of PID

Lower abdominal pain – often on both sides.
Deep painful sexual intercourse – deep dyspareunia.
Abnormal vaginal bleeding (bleeding after sex, or heavy menstrual period or intermenstrual
Pus-like vaginal or cervical discharge.

Signs

Tenderness in the lower abdomen (usually on both sides).
Cervical discharge that is a mixture of pus and mucous and inflammation and reddeness of the cervex will be seen on speculum examination.
Tenderness when the cervix is moved during examination; and also tenderness in the region of the fallopian tudes and ovaries (adnexal) when internal pelvic vaginal examination is carried out, by the doctor.
High temperature- fever – above 38°C (but the temperature may be normal).

Investigations

Pregnancy test (pregnant women with PID should be admitted; ectopic pregnancy – pregnancy outside of the uterus – may be confused with PID).
Cervical swabs for chlamydia and gonorrhoea: a positive result supports the diagnosis of PID, but a negative result does not exclude PID.
Bllod test may show signs of inflammation – pointing to a diagnosis of possible PID.
Utrasound scanning may also be helpful, showing evidence of inflammation and swelling of the fallopian tubes and collection of inflammation tissue fluid.
Laparoscopy with direct visualisation of the Fallopian tubes is the best single diagnostic test, but is an invasive procedure and therefore not necessary, when the diagnosis is clear.
Urinalysis and urine culture: to exclude urinary tract infection; this may co-exist.

Management

Provide adequate pain relief.
If an intra-uterine contraceptive device – or coil – in present, this may need to be removed temporarily. The scientific evidence for whether an IUCD should be left in situ or removed is limited. Removal of the IUCD may be associated with better short-term clinical outcomes. The decision to remove the IUCD needs to be balanced against the risk of pregnancy in those who have had otherwise unprotected intercourse in the preceding seven days.
Refer to a Sexual Health clinic, for a full sexually transmitted infection screen (HIV, etc.), contact tracing and treatment of sexual partners.

Antibiotic treatment

The current outpatient treatment recommendation is ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by doxycycline 100 mg orally twice-daily and metronidazole 400 mg twice-daily, for 14 days.
Do not delay antibiotic treatment while waiting for the results of tests if PID is clinically suspected. It is likely that delayed treatment increases the risk of long-term complications, such as ectopic pregnancy, infertility and pelvic pain. Negative swabs do not exclude PID and therefore should not influence the decision to treat. Emphasise the importance of completing the course of antibiotics to reduce the risk of long-term complications.
Broad-spectrum antibiotic treatment to cover C. trachomatis, N. gonorrhoeae and anaerobic infection is recommended.
Other recommended regimes include:8
- Outpatient regimens:
  - Ofloxacin 400 mg orally twice-daily plus oral metronidazole 400 mg twice-daily, for 14 days.9 This is not recommended if the woman is at high risk of gonococcal PID because of increasing quinolone resistance of gonorrhoea. Levofloxacin may be used as a once-daily, convenient alternative to ofloxacin.
- Severely ill patients:
  - Intravenous (IV) therapy is recommended for patients with more severe clinical disease, e.g. pyrexia above 38°C, clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis or pregnancy.
  - Initial treatment with doxycycline, single-dose IV ceftriaxone and IV metronidazole, then change to oral doxycycline and metronidazole to complete 14 days of treatment.
  - There is no evidence-based recommendation for treatment in pregnancy, but an empiric regimen might include IM ceftriaxone plus oral or IV erythromycin, with the possible addition of oral or IV metronidazole 500 mg three times daily in clinically severe disease. Any risk of this regimen is justified on the basis of need to provide therapy and low risk to the fetus.
  - IV therapy should be continued for 24 hours after signs of clinical improvement.

Management of sexual partners

Although most infected male partners have no symptoms, infection rates of 26-36% for Chlamydia trachomatis have been reported among partners.
Patients should be advised to avoid unprotected intercourse until they, and their partner(s) have completed treatment and follow-up.
Screen for other sexually transmitted infections, ideally at a Sexual Health clinic. All sexual partners within the previous six months (or the most recent sexual partner if there have been no sexual contacts within the previous six months) should be notified and offered screening for sexually transmitted infections.
Sexual partners should be treated for chlamydial infection even if this is not identified on testing.
Treatment for gonorrhoea only needs to be offered if N. gonorrhoeae is identified in the woman with PID or in her partner.
Blind treatment for chlamydial infection and gonorrhoea should be given to partners who are unwilling to be screened.

Referral

Admission to secondary care (for IV antibiotics and/or further investigation) should be considered in the following situations:

Diagnosis is uncertain, e.g. where appendicitis or ectopic pregnancy cannot be excluded.
Severe symptoms or signs.
Deteriorating clinical condition.
No improvement with oral antibiotics within three days.
Inability to tolerate oral treatment, e.g. due to nausea and vomiting.
Presence of a tubo-ovarian abscess.
Pregnancy.
Immunodeficiency, e.g. HIV infection, immunosuppression therapy.

Complications

Infertility: the risk of infertility following PID is related to the number of episodes of PID and their severity.
Ectopic pregnancy.
Chronic pelvic pain.
Perihepatitis (Fitz-Hugh and Curtis syndrome): causes right upper quadrant pain. Occurs in up to 10-20% of women with PID.
Tubo-ovarian abscess.
Reiter’s syndrome (reactive arthritis) – inflammation of the joints
PID in pregnancy is associated with an increase in preterm delivery, and maternal and fetal morbidity. If this occurs around the time of birth, there could be neonatal chamydial infection – as perinatal transmission of C. trachomatis or N. gonorrhoeae can cause ophthalmia neonatorum. Also Chlamydial pneumonitis may also occur.

Prevention

Limited evidence suggests that screening for chlamydia and treating identified infection prior to IUCD insertion reduces the risk of PID. Routine prophylactic antibiotics prior to IUCD insertion are not recommended.

It has been recommended that testing for chlamydia be offered to women at increased risk of sexually transmitted infections and to all sexually active women aged under 25 years.

Non-infectious / Chemical Vaginitis?

Occasionally, a woman can have itching, burning, and even a vaginal discharge without having an infection. The most common cause is an allergic reaction or irritation from vaginal sprays, douches, or spermicidal products. Additionally, the skin around the vagina can be sensitive to perfumed soaps, detergents and fabric softeners.

Another non-infectious form of vaginitis results from a decrease in hormones because of menopause or because of surgery that removes the ovaries. In this form, the vagina becomes dry. This is referred to as atrophic vaginitis. The woman may notice pain, especially during sexual intercourse, as well as vaginal itching and burning.

Treatment of Vaginitis

The key to proper treatment of vaginitis is proper diagnosis. This is not always easy since the same symptoms can exist in different forms of vaginitis. You can greatly assist your doctor by paying close attention to exactly which symptoms you have and when they occur, along with a description of the colour, consistency, amount, and smell of any abnormal discharge. Do not douche before visiting your doctor as it will make accurate testing difficult or impossible. Some doctors ask that you abstain from sex for 24 hours before your appointment.

Because different types of vaginitis have different causes, the treatment needs to be specific to the type of vaginitis present. It is best to seek medical advice before self-treating with over-the-counter medications.

‘Non-infectious’ vaginitis is treated by changing the probable cause. If you recently changed your soap or laundry detergent or have added a fabric softener, you might consider stopping the use of the new product to see if the symptoms improve. The same instruction would apply to a new vaginal spray, douche, sanitary napkin or tampon. If the vaginitis is due to hormonal changes, oestrogen may be prescribed to help reduce symptoms.

Prevention of Vaginitis

There are certain things that you can do to decrease the chance of getting vaginitis. If you suffer from yeast infections, it is usually helpful to avoid garments that hold in heat and moisture. The wearing of nylon underwear, tights without a cotton panel, and tight jeans can lead to yeast infections. Good hygiene is also important. In addition, doctors have found that if a woman eats yoghurt that contains active cultures (read the label) she may get fewer infections.

Because they can cause vaginal irritation, most doctors do not recommend vaginal sprays or heavily perfumed soaps for cleansing this area. Likewise, douching may cause irritation or, more importantly, may hide a vaginal infection. Douching also removes the healthy bacteria that help keep the vagina clean. Removing these bacteria can result in, or worsen, vaginitis.

Safe sexual practices can help prevent the passing of infections between partners. The use of condoms is particularly important.

If you are approaching menopause, have had your ovaries removed or have low levels of estrogen for any reason, discuss with your doctor the use of oestrogen in the form of pills, creams, or vaginal rings to keep the vagina lubricated and healthy.

Good health habits are important. Have a cervical smear as often as advised. If you have multiple sexual partners, you should request screening for sexually transmitted infections.

Sexually Transmitted

There are several vaginal infections that are transmitted through sexual contact.

Trichomoniasis

Trichomoniasis is an sexually transmitted infection (STI) and the most common curable STI. It is caused by a tiny single-celled organism that infects the vagina, The time between exposure to trichomoniasis and the onset of symptoms is from 5 to 28 days. While some women don’t experience any symptoms, other women have symptoms such as a frothy yellowish-greenish vaginal discharge, a foul vaginal odor, pain during sexual intercourse, pain during urination, vaginal itching and general irritation and soreness of the vagina and vulva, and rarely pelvic pain. If you suspect you may have trichomoniasis, you should discontinue sexual intercourse and see your doctor immediately. If your doctor diagnoses trichomoniasis, your sexual partner(s), should be diagnosed and receive treatment. Sexual intercourse should not resume until both you and your partner are treated and symptom -free.

Chlamydia

Chlamydia is another sexually transmitted form of vaginitis. Unfortunately, most women with Chlamydia infection do not have symptoms, which makes diagnosis difficult. A vaginal discharge is sometimes present, but not always. More often, a woman might experience light bleeding, especially after intercourse, and she may have pain in the lower abdomen and pelvis. Chlamydial vaginitis is most common in young women (18 to 35 years) who have multiple sexual partners. If you fit this description, you should request screening for chlamydia from your doctor or local sexual health clinic. If left untreated, chlamydia can cause damage to a woman’s reproductive organs, and can make it difficult for a woman to become pregnant.

Viral Vaginitis

Several sexually transmitted viruses cause vaginitis, including the Herpes Simplex Virus (HSV) and the Human Papilloma Virus (HPV). The primary symptom of herpes is pain associated with lesions or sores. These sores are usually visible on the vulva or the vagina but occasionally are deep inside the vagina and can only be seen during a gynaecological examination.

HPV – sometimes referred to as genital warts – can cause warts to grow in the vagina, rectum, vulva or groin. These warts, when visible, are usually white to grey in colour, but they may be pink or purple. When warts are not visible, a cervical smear, or a more specialised HPV test may be the only way to detect the virus.

Bacterial Vaginosis (BV)

BV is the most common cause of vaginal discharge in women during their reproductive years. It is not an infection. Rather, BV develops when the normal balance of bacteria that colonize in the vagina gets thrown off by overgrowth. While there is not a definitive answer about what causes BV, a few factors are known to raise risk including having a new or multiple sexual partners, using vaginal douches, having an IUD, and failure to practice safe sex by not using a condom during every act of sexual intercourse. The most common symptom of BV a fish -like vaginal odor, as well as an abnormal vaginal discharge that is white or gray and that can be either watery or foamy.

What is Bacterial Vaginosis?

Although ‘yeast’ is the name most women think of when they think of vaginal infections, bacterial vaginosis (BV) is a very common type of vaginal infection in women of reproductive age. BV is caused by a combination of several bacteria. These bacteria seem to overgrow in much the same way as Candida do when the vaginal balance is upset. The exact reason for this overgrowth is not known.

BV is not transmitted through sexual intercourse but is more common in women who are sexually active. It is also not a serious health concern but can increase a woman’s risk of developing other sexually transmitted infections and may increase the risk of pelvic inflammatory disease (PID) following surgical procedures such as abortion and hysterectomy. BV may increase the risk of early labour and premature births in women who have the infection during pregnancy.

Symptoms of bacterial vaginosis

Up to 50% of women who have bacterial vaginosis do not have any symptoms, but if symptoms do appear, they can include:

white or discoloured, often grey, discharge
discharge that smells “fishy”, that is often strongest after sex
pain during urination
itchy and sore vagina.

Diagnosis of Bacterial Vaginosis

Your doctor can tell you if you have BV. He or she will examine you and will take a sample of fluid from your vagina. The fluid is viewed under a microscope. In most cases, your doctor can tell immediately if you have BV.

Treatment of Bacterial Vaginosis

Bacterial Vaginosis can be treated with medicine prescribed by your doct or. The most common medicines prescribed for BV are antibiotics called metronidazole and clindamycin . These may be taken orally or used as a vaginal cream or gel.

Prevention of Bacterial Vaginosis

Ways to prevent BV are not yet known. It is possible to reduce the risk of developing BV by not douching and not using scented soaps or vaginal deodorants.

Vaginal Infections (Vaginitis) & Bacterial Vaginosis

Vaginitis is a medical term used to describe various conditions that cause infection or inflammation of the vagina. Vulvo-vaginitis refers to inflammation of both the vagina and vulva (the external female genitals). These conditions can result from a vaginal infection caused by organisms such as bacteria, yeast or viruses, as well as by irritation from chemicals in creams, sprays, or even clothing that is in contact with this area. In some cases, vaginitis results from organisms that are passed between sexual partners.

Symptoms of Vaginitis?

The symptoms of vaginitis can vary depending on what is causing the infection. Some women have no symptoms at all. Some of the more common symptoms of vaginitis include:

abnormal vaginal discharge with an unpleasant odour
burning sensation during urination,
itching around the outside of the vagina,
discomfort during intercourse.

Vaginal Discharge

A woman’s vagina normally produces a discharge that can usually be described as clear or slightly cloudy, non-irritating, and odour-free. During the normal menstrual cycle, the amount and consistency of discharge can vary. At one time of the month there may be a small amount of a very thin or watery discharge; and at another time, a more extensive thicker discharge may appear. All of these descriptions could be considered normal.

A vaginal discharge that has an odour or that is irritating is usually considered an abnormal discharge. The irritation might be itching or burning, or both. The itching may be present at any time of the day, but it is often most bothersome at night. These symptoms are often made worse by sexual intercourse. It is important to seek medical advice if there has been a change in the amount, colour or smell of the discharge.

Common types of vaginitis

The six most common types of vaginitis are:

Candida or “yeast” infections
Bacterial vaginosis
Trichomoniasis vaginitis
Chlamydia vaginitis (see also under PID)
Viral vaginitis
Non-infectious

Although each of these types of vaginitis can have different symptoms, it is not always easy for a woman to work out which type she has. In fact, diagnosis can even be tricky for an experienced doctor. Part of the problem is that sometimes more than one type can be present at the same time. And, an infection may even be present without any symptoms at all. To help you better understand these six major causes of vaginitis, we will look briefly at each one of them and how they are treated.

Thrush – Vaginal Yeast Infection – Candida

Yeast is the most common cause of vaginal infection. A fungus causes vaginal yeast infections, which occur inside the vagina and in the vulvar area that surrounds the vagina. Three out of four women have at least one vaginal yeast infection during their lifetimes. The symptoms of va ginal yeast infections include vaginal itching; a thick, white vaginal discharge that may look like cottage cheese; pain during sexual intercourse; redness; burning; soreness; swelling; and general vaginal irritation. Not every woman experiences all these possible symptoms of vaginal yeast infection. Many women frequently experience yeast infections, so they are familiar with their symptoms and the course of treatment recommended for them. But if this is the first time you are having such symptoms, it’s important to see your doctor to get a formal diagnosis and rule out other possibilities.

What factors increase your risk of vaginal yeast infections?

Several things will increase your risk of contacting a yeast infection, including:

Recent treatment with antibiotics. For example, a woman may take an antibiotic to treat an infection, and the antibiotic kills her “friendly” bacteria that normally keep the yeast in balance. As a result, the yeast overgrows and causes the infection.
Uncontrolled This allows for too much sugar in the urine and vagina.
Pregnancy, which changes hormone levels.

Other factors Include: Oral contraceptives ( birth control pills), Disorders affecting the immune system, Thyroid or endocrine disorders and steroid therapy.

How are vaginal yeast infections treated?

Yeast infections are most often treated with medicine that you put into your vagina. This medicine may be in cream or pessary form and many are available over-the-counter. Medicine in a pill form that you take by mouth is also available.

What should I do to prevent vaginal yeast infections?

To prevent yeast infections, you should:

Wear loose clothing made from natural fibres (such as cotton, linen and silk).
Avoid wearing tight trousers.
Do not douche. (Douching can kill bacteria that control fungus.)
Limit the use of feminine deodorant.
Limit the use of deodorant tampons or pads to the times when you need them.
Change out of wet clothing, especially swimsuits, as soon as you can.
Avoid frequent
Wash underwear in hot water.
Eat a well-balanced
Eat yoghurt.
If you have diabetes, keep your blood sugar level as close to normal as possible.

If you get frequent yeast infections, seek medical advice. Certain tests may be needed to rule out other medical conditions.

Vaginal Discharge

Vaginal discharge is the term for fluid or mucus that comes from the vagina. Vaginal discharge is a common concern among women, and leads many women to see their doctors. Some amount of vaginal discharge is normal, unless it occurs with itching, burning, or other bothersome symptoms. Vaginal discharge is made by the skin cells of the vagina and cervix under the influence of the female hormone, oestrogen. Women who are menopausal normally have minimal vaginal discharge as a result of lower levels of oestrogen. In women who are premenopausal, it is normal to have about one-half to one teaspoon of white or clear, thick, mucus-like, and mostly odorless vaginal discharge every day. However, the amount and consistency of the discharge varies from one woman to another. The amount can also vary at different t imes during the menstrual cycle. It may become more noticeable at certain times, such as during pregnancy, with use of birth control pills/patch/vaginal ring, near ovulation, and in the week before the menstrual period.

Normally, discharge contains vaginal skin cells, bacteria, and mucus and fluid produced by the vagina and cervix. A normal discharge often has a slight odor and may cause mild irritation of the vulva. This discharge helps to protect the vaginal and urinary tract against infections and provides lubrication to the vaginal tissues.

ABNORMAL VAGINAL DISCHARGE

Vaginal discharge is common and normal. However, vaginal discharge with the following signs and symptoms is not normal and should be assessed by a doctor or nurse:

Itching of the vulva, vaginal opening, or labia
Redness, burning, soreness, or swelling of the vulvar skin
Foamy or greenish-yellow discharge
Bad odor
Blood-tinged vaginal discharge
Pain with intercourse or urination
Abdominal or pelvic pain

CAUSES OF ABNORMAL VAGINAL DISCHARGE

The most common causes of vaginal discharge include:

A vaginal infection (yeast or bacterial infection, trichomonas)
The body’s reaction to a foreign body (such as a forgotten tampon or condom) or substance (such as spermicide, soap).
Changes that occur after menopause can cause vaginal dryness, especially during sex, as well as a watery vaginal discharge or other symptoms.

Treatment — In some cases, it is possible to make a diagnosis and begin treatment immediately, based upon the examination. In other cases, the provider may recommend delaying treatment until test results are available. Sexual partners of women with a sexually transmitted infection, such as chlamydia, gonorrhea, or trichomonas, need evaluation and treatment. For other infections, such as yeast or bacterial vaginosis, the sexual partner does not need treatment. If treatment is needed, you should avoid having intercourse until the treatment is completed.

Can I treat myself? — Many women would prefer to avoid seeing their healthcare provider. However, self-treatment can delay getting the correct diagnosis, be costly, or even cause worsened symptoms. In most cases, a physical examination should be performed before any treatment is used. In particular, you should not douche to get rid of the discharge because douching can make the discharge worse if it is due to an infection.

SELF-HELP HYGEINE

Abnormal vaginal discharge may be more likely to develop in women who practice certain habits, such as those who use:

Douches
Pantyliners every day
“Feminine hygiene” sprays, powders, or rinses
Bubble baths or other scented bath products
Tight or restrictive synthetic clothing (eg, thongs, synthetic underwear)

Healthier practices include the following:

Use water or unscented non-soap cleanser to wash genitalia, use warm (not hot) water and the hand (not a washcloth)
Do not douche or use feminine hygiene products; if odor or discharge is bothersome, see your doctor
Avoid hot baths with scented products; plain warm water is preferred
Wear cotton underwear; avoid thongs and lycra underwear
Rinse genitals with water and/or pat dry after toileting;
avoid use of baby wipes or scented toilet paper