Genitourinary tract infections Notes

NOTES NOTES GENITOURINARY TRACT INFECTIONS GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ▪ Infections of genital/urinary tract CAUSES ▪ Mostly bacteria RISK FACTORS ▪ Recent sexual activity ▪ High-risk sexual behavior ▪ Previous genitourinary tract infections COMPLICATIONS ▪ Pelvic inflammatory disease, infertility, pyelonephritis, epididymitis, prostatitis, sepsis, abscesses SIGNS & SYMPTOMS ▪ Abdominal pain, altered vaginal/urethral discharge, dysuria, fever DIAGNOSIS LAB RESULTS ▪ Vaginal/urethral discharge microscopy ▪ Nucleic acid amplification tests (NAATs) OTHER DIAGNOSTICS ▪ Clinical examination TREATMENT MEDICATIONS ▪ Antibiotic therapy PELVIC INFLAMMATORY DISEASE osms.it/pelvic-inflammatory-disease PATHOLOGY & CAUSES ▪ Infection, inflammation of upper genital tract (uterus, ovaries, fallopian tubes) in individuals who are biologically female ▪ Common pathogens: Chlamydia trachomatis, Neisseria gonorrhoeae, vaginal flora bacteria (e.g. Gardnerella vaginalis); often polymicrobial ▪ Bacterial vaginosis (alteration in vaginal flora) present in ⅔ of PID cases ▫ Anaerobic bacteria replace lactobacilli in vagina → enzyme production → degradation of cervical mucus, antimicrobial agents → infections spread ▪ Associated syndromes ▫ Endometritis, salpingitis, oophoritis, peritonitis, perihepatitis (liver capsule inflammation), tubo-ovarian abscess ▪ Vaginal mucosa colonization → disruption of endocervical canal barrier → pathogens ascend to upper genital structures → inflammation OSMOSIS.ORG 753

RISK FACTORS ▪ More common in individuals who are biologically female, < 25 years old, sexually active ▪ Multiple sexual partners ▪ Partner with sexually transmitted disease (STD) ▪ Personal history of PID/STD ▪ Unprotected sexual intercourse ▪ Cervix instrumentation (e.g. abortion) COMPLICATIONS ▪ Recurrent PID, hydrosalpinx (fluid-filled fallopian tubes), pyosalpinx (infected fallopian tube filled with purulent matter), chronic pelvic pain, infertility, ectopic pregnancy, ovarian cancer SIGNS & SYMPTOMS Acute symptomatic PID ▪ Bilateral lower abdominal/pelvic pain ▫ Abrupt onset during/after menstruation ▫ Constant, aching ▫ Worsens during sexual intercourse/ movement ▪ Abdominal/pelvic organ tenderness ▪ Feeling of pelvic fullness ▪ Intermenstrual/postcoital bleeding ▪ Dysuria ▪ Low-grade fever ▪ Rebound tenderness, fever, ↓ bowel sounds (severe) Chronic PID ▪ Low-grade fever, weight loss, abdominal pain Perihepatitis (Fitz-Hugh–Curtis syndrome) ▪ Right upper quadrant pain, tenderness DIAGNOSIS DIAGNOSTIC IMAGING Pelvic/abdominal ultrasound ▪ Fluid-filled fallopian tubes with cogwheel sign (thickened loops on cross-section) ▪ Endometrium changes (e.g. wall thickening) 754 OSMOSIS.ORG ▪ Tubo-ovarian abscess (thick walls, multilocular cyst) LAB RESULTS ▪ Vaginal discharge microscopy ▫ Saline microscopy, Gram stain ▫ ↑ leukocytes ▫ Clue cells (epithelial cells surrounded by bacteria) in bacterial vaginosis ▪ Nucleic acids amplification tests (NAATs) ▫ C. trachomatis, N. gonorrhoeae ▪ Tissue biopsy ▫ ↑ plasma cells, neutrophils (inflammation) ▪ Leukocytosis, ↑ C-reactive protein (CRP), ↑ erythrocyte sedimentation rate (severe) OTHER DIAGNOSTICS ▪ Speculum exam ▫ Mucopurulent cervical discharge (positive swab test) TREATMENT MEDICATIONS Broad-spectrum antibiotic therapy ▪ Inpatient (parenteral) ▫ Cefoxitin/cefotetan (cephalosporin) + doxycycline (tetracycline) ▫ Clindamycin (lincosamide) + gentamicin (aminoglycoside) ▪ Outpatient ▫ Ceftriaxone/cefoxitin (cephalosporin) + doxycycline (tetracycline) ▪ Pelvic abscess ▫ Clindamycin/metronidazole + doxycycline Antiemetic medication ▪ E.g. metoclopramide Antipyretic medication ▪ E.g. acetaminophen OTHER INTERVENTIONS ▪ Prevention ▫ Barrier contraception (e.g. condoms) ▫ Abstinence

Chapter 125 Genitourinary Tract Infections Figure 125.1 An MRI scan of the pelvis in the sagittal plane demonstrating a right-sided pyosalpinx. URETHRITIS osms.it/urethritis PATHOLOGY & CAUSES ▪ Inflammation of urethra; more common in individuals who are biologically male with sexually transmitted diseases ▪ Common coinfection with other STDs ▪ Incubation period: 4–8 days CAUSES ▪ Infectious urethritis (most common) ▫ Gonococcal: Neisseria gonorrhoeae ▫ Non-gonococcal: Chlamydia trachomatis (most common), Mycoplasma genitalium ▪ Non-infectious urethritis ▫ Chemical irritation (e.g. soaps, spermicides) ▫ Trauma RISK FACTORS ▪ Individuals who are biologically male, young ▪ Multiple sexual partners ▪ Partner with sexually transmitted disease (STD) ▪ Unprotected sexual intercourse COMPLICATIONS ▪ Reactive arthritis related to C. trachomatis, gonococcal conjunctivitis, epididymitis, prostatitis, penile lymphangitis, periurethral abscess SIGNS & SYMPTOMS ▪ Sometimes asymptomatic ▪ Dysuria ▪ Urethral pruritus, discharge (mucoid, watery, purulent) ▪ Inflammation/edema of urethral meatus OSMOSIS.ORG 755

DIAGNOSIS LAB RESULTS ▪ Diagnosis criteria (≥ one) ▫ Mucopurulent/purulent urethral discharge ▫ ≥ one leukocyte per oil immersion field in Gram stain of urethral discharge ▫ Positive leukocyte esterase, ≥ 10 leukocytes per high-power field (firstcatch urine) ▪ NAATs ▫ C. trachomatis, N. gonorrhoeae ▪ Urethral discharge microscopy (e.g. Gram stain) OTHER DIAGNOSTICS ▪ Clinical examination ▫ Gonorrhoea: purulent discharge ▫ Chlamydia: isolated dysuria ▫ Herpes simplex virus (HSV): dysuria + painful genital ulcers 756 OSMOSIS.ORG TREATMENT MEDICATIONS Antibiotic therapy ▪ Gonococcal urethritis ▫ Ceftriaxone (cephalosporin) + azithromycin (macrolide) ▪ Non-gonococcal urethritis ▫ Azithromycin or doxycycline (tetracycline) ▫ Azithromycin/moxifloxacin (persisent) OTHER INTERVENTIONS ▪ Prevention ▫ Barrier contraception (e.g. condoms) ▫ Abstinence