Infections

Pelvic Pain

Pelvic pain is a common complaint. Its nature and intensity may fluctuate, and its cause is often obscure. Pelvic pain may originate in genital or extragenital organs; in some cases no disease can be shown. Causes include

*1 intense muscular contractions

*2 or cramps,

*3 inflammation or

*4 direct irritation of nerves, and

*5 psychogenic factors.

*6 Both smooth and skeletal

muscles can produce pain by strong or sustained contractions resulting from over distention or obstruction of a hollow viscus, ischemia, or tetany.

Nerves can be irritated by acute or chronic trauma, fibrosis, pressure, or intraperitoneal inflammation.

Psychogenic factors can cause pain or aggravate minor aches. Often pelvic pain has multiple causes.

In evaluating acute lower abdominal pain, prompt decisions must be made about which conditions are surgical emergencies; i.e., twisted ovarian cyst, ectopic pregnancy, ruptured tubo-ovarian abscess, appendicitis, and bowel perforation. A ruptured corpus luteum cyst and pelvic inflammation are usually treated medically.

The cause of pelvic pain can often be established by a thorough history, with special attention to type of discomfort; distribution and radiation of pain; time and suddenness of onset; circumstances at onset; duration of pain; associated symptoms; relation to various activities such as movement or defecation; frequency of recurrence; and relationship to the menstrual cycle, sleep, coitus, eating, and micturation. Physical and laboratory findings aid the diagnosis.

Vulvovaginitis

Infectious diseases and other inflammatory conditions affecting the vaginal mucosa and often secondarily involving the vulva; vaginal discharge is common

Etiology

Most vulvovaginitis and symptomatic vaginal discharges are caused by bacteria, usually Gardnella vaginas in combination with various anaerobes. Protozoa (Trichomonas vaginalis) cause 1/3 of all cases, Candida is a frequent cause in pregnant women and diabetics, and occasionally oral contraceptives increase susceptibility. Another major cause is

·1The human papillomavirus (HPV). Other less common causes are other bacteria (e.g., Neisseria gonorrhea, members of the Chlamydia and Mycoplasma groups, streptococci, Escherichia coli, and staphylococci),

·2foreign bodies,

·3viral infections (herpes simplex),

·4pinworms (Enterobius vermicularis),

·5fistulas, radiation, and

·6tumors of the genital tract.

·7Extensive vaginal and cervical adenosis, as found in some women exposed to diethylstilbestrol (DES), may produce excessive discharge.

·8Frequent douching, especially with chemicals, may disturb normal vaginal milieu.

·9Deodorant sprays,

·10laundry soaps and fabric softeners, and bath water additives may cause vulvar irritation. Tight, nonabsorbent underclothing, as well as poor hygiene, may foster fungal and bacterial growth.

·11Occasionally, sensitivity to spermicides, coital lubricants, or latex in a diaphragm or condom causes irritation.

Age groups must also be considered in determining etiology because of differences in estrogen and sexual activity.

In the reproductive years, when estrogen is present, vulvitis is usually secondary to vaginal infection, whereas in premenarchal and postmenopausal years, vulvitis alone is common.

Newborns may have a sterile mucoid discharge secondary to the maternal estrogen effect that subsides in < 2 wk; a small amount of bleeding may occur from this “estrogen withdrawal” effect.

·In children, E. coli is most commonly found with vulvitis; streptococci,

·staphylococci, and

·Candida are found less often. Occasionally, pinworms or N. gonorrhea cause infection.

·Bubble baths or soaps may cause irritation.

When discharge is present, especially with blood, a foreign body must be considered, as well as a DES-related tumor. Immature anatomy and poor hygiene contribute to infection; premenarchal girls have small labia minora, thin vaginal mucosa, and little cervical secretion.

Discharge is scant and usually alkaline in pH, with few bacteria.

The amount of discharge increases when estrogen production increases, up to a year or more before menarche.

In females of reproductive age, a milky-white, watery or mucoid discharge arises primarily from the cervix or as a result of desquamation of vaginal cells.

The amount and type of discharge vary with phase of the menstrual cycle and sexual stimulation and from transudation of vaginal fluid and Bartholin's gland secretion.

·Bacteria, chiefly lactobacilli and corynebacteria, and small numbers of fungi usually are present.

·The vaginal pH is normally 3.5 to 4.5; acidity tends to be decreased by menstrual blood, infected cervical mucus, or semen.

·The glycogen content is high, the vaginal mucosa is thick, and the labia are well developed.

·Elevated hormonal levels, as in pregnancy and oral contraceptive use, can change vaginal metabolism.

·Vaginal discharges due to infections are discussed below.

·In postmenopausal women, bacteria and fungi are the most common infecting agents, and Trichomonas is less common.

·Menopausal estrogen depletion due to aging, ovariectomy, or radiation of the pelvis, or temporarily low estrogen levels (similar to those during lactation) cause vulvar structures to regress and vaginal mucosa to thin.

Discharge becomes scant, and the pH rises to 4.5 to 5.5. The atrophic vaginal and vulvar epithelium is more easily traumatized and infected.

Dystrophies and tumors, symptomatic and asymptomatic, become increasingly common with aging. Folliculitis and other dermatologic disorders can affect the skin of the vulva. Foreign bodies, especially forgotten pessaries, can also cause discharge.

Symptoms, Signs, and Diagnosis

The most common complaint is of vaginal discharge, with or without vulvar irritation. Vaginal discharge is abnormal when the odor is offensive; when pruritus, irritation, or pain occurs; or when the amount distresses the patient.

The initial visit should include a complete physical examination and history, with attention to details of the discharge (color, consistency, presence of odor, duration, and symptoms). The type of discharge may suggest the cause, or it may be misleading.

The patient should be asked to describe when the discharge occurs in the menstrual cycle; whether it is recurrent; how it responded to previous therapy; whether vulvar itching, burning, pain, or lesion is present; and what aspect of the problem is most troublesome.

Questions should also

·concern sexual activity;

·contraceptive use;

·whether the sexual partner has had urethral discharge,

·pruritus,

·penile lesions,

·postcoital irritation, or

· therapy for infection;

· use of chemicals on the vulva or vagina;

·recent change in laundry products;

·any present or past venereal disease or parasitic infection;

·and whether anyone in the household has pubic itching.

After the general physical examination, the vulva is examined for redness, edema, and abnormal lesions.

A biopsy of discrete vulvar lesions should be performed; if much of the vulva is white and thickened or otherwise appears abnormal.

Examination should include searching for parasites, palpating enlarged nodes, culturing ulcers for viruses, and noting urethral and Bartholin's gland discharge.

In children, a culture may be obtained from the vulva or fourchette; if discharge is present, a vaginal culture should be done. The child should be checked for a foreign body and for pinworms.

Physiologic discharge is annoying because of the feeling of wetness and soiled clothing it produces, but it is not malodorous nor does it produce vulvitis.

Bacterial vaginosis tends to produce a white, gray, or yellowish turbid discharge with a foul or “fishy” odor that becomes stronger when the discharge becomes alkaline (e.g., after coitus or washing with soap). Vulvar pruritus or irritation may be present, but redness or edema is not usually marked.

Treatment and Nursing Care

Physiologic discharge requires only reassurance of normalcy. Occasionally, douching with water may reduce the amount of secretion and thus the discharge. Prepubertal girls should be instructed about perineal hygiene. Foreign bodies should be removed.

Specific causes of discharge require specific therapy.

Topical anti-inflammatory agents such as hydrocortisone 0.5% tid can be used until specific therapy is instituted after culture results have been obtained.

If labial adhesions have occurred secondary to previous inflammation of the labia, application of vaginal estrogen cream daily for 7 to 10 days usually opens the labia.

Povidone iodine douche 15 to 30 ml/L (2 tbsp/qt) of water may give relief until specific therapy is effective and may reduce recurrences of Candida.

Candida is treated topically with miconazole 2% or clotrimazole 1% cream, vaginal tablets, or suppositories for 3 to 7 days.

Trichomonas is treated with metronidazole 250 mg for 5 days. Ideally, the husband should also be treated..

Chlamydial infections are treated with doxycycline 100 mg bid or erythromycin 500 mg qid orally for 7 days.

Acute vulvitis: The cause should be treated as discussed above, and measures should be taken to reduce acute inflammation; e.g., wearing loose, absorbent clothing that allows air circulation and keeping the vulva clean (soaps should be avoided).

Intermittent use of ice packs reduces soreness and pruritus; sometimes compresses help.

Topical steroids are useful, and oral antihistamines may be helpful, especially at night when a sedative effect may be welcome. Symptomatic treatment with pain relievers and anesthetic ointments may be helpful.

Atrophic vaginitis is treated with estrogen replacement; many patients respond to oral estrogen given daily for 25 days.

If estrogen is used regularly, medroxyprogesterone acetate is needed to prevent endometrial hyperplasia. Symptoms will recur if the drug is stopped.

Some patients prefer estrogen vaginal cream (½ applicator [2.0 gm] every night for 1 mo, then ¼ applicator 2 or 3 times a week) to maintain a healthy, cornified vaginal epithelium. In some situations, the vaginal mucosa will respond to ½ these dosages.

Chronic vulvitis often leads to chronic inflammation. Occasionally it is due to poor hygiene, especially in elderly patients who are incontinent and bedridden; cleanliness improves the condition.

Skin conditions that can cause chronic vulvitis (e.g.. tinea versicolor) should be treated appropriately, and infection is treated with specific antibiotics. All substances that may cause chronic irritation should be removed.

Vulvar dystrophies can occur at any age but usually are seen in postmenopausal patients. Testosterone propionate 2% in petrolatum applied in small amounts bid is often beneficial.

Hyperplastic dystrophy usually produces a white or reddish area on the surface of the vulva. Initial treatment with fluorinated topical steroids relieves pruritus.

For long-term use, hydro-cortisone cream 0.5% prevents vulvar atrophy and contraction.

Surgical excision usually is not indicated.

Follow-up examinations with constant search for progressive change and possible malignancy are essential.

Atypical dystrophies should be removed. Biopsies should be performed on all dystrophies before treatment is begun.

Genital Candidiasis

Candida infection is suggested by moderate to severe vulvar itching and burning, with redness and possibly excoriation.

The thick, cheesy discharge that may be present tends to cling to the vaginal walls.

Symptoms usually increase in the week before menses.

Infection tends to recur in poorly controlled diabetics and patients routinely using tetracycline for acne.

Etiology

Yeast infections of the genital tract caused by Candida albicans are increasing in frequency, especially in women.

Uncommonly transmitted sexually, the infection usually spreads from the patient's normal skin or intestinal flora.

The increased incidence is primarily due to widespread use of broad-spectrum antibiotics and the large number of women taking oral contraceptives, although better diagnostic methods may also contribute.

Other predisposing factors include pregnancy, menstruation, diabetes mellitus, and use of immunosuppressive drugs and corticosteroids.

Symptoms and Signs

Women usually develop vulval irritation and vaginal discharge. Frequently the irritation is severe and the discharge scanty.

The vulva may be reddish and swollen, with excoriation and fissures.

The vaginal wall may be covered with a white, cheesy material or may appear normal.

Diagnosis

An immediate diagnosis can be made by taking smears from the vagina and examining them microscopically for C. albicans by Gram stain with potassium hydroxide.

Culture media should also be inoculated, as this increases the number of positive findings by 25% and confirms the presence of C. Albicans.

Treatment

Once the diagnosis and the underlying cause have been identified, predisposing conditions such as antibiotic therapy should be controlled to avoid recurrences.

Vaginal candidiasis can be treated locally with

1) clotrimazole one 100-mg vaginal tablet/day for 6 days or 200 mg/day for 3 days,

2) miconazole 200 mg/day intravaginally for 3 days,

Occasionally, oral contraceptives must be discontinued for several months during treatment.

Women who require antibiotics recurrently or for prolonged periods or have other unavoidable predispositions may require prophylaxis with any of the treatment regimens.

Trichomonas infection

Trichomonas infection is marked by a white, grayish-green, or yellowish discharge that may be frothy. It often appears shortly after menses. Itching is severe. Acute inflammation of the vagina with small “strawberry” spots may be found.

A watery discharge, especially if bloody, may suggest malignancy of the vagina or upper genital tract.

Cervical polyps or vaginal endometriosis may also produce this type of discharge, with bleeding after coitus.

A discharge may be related to atrophic vaginitis, radiation vaginitis, or a foreign body.

The atrophic vagina is fragile, and bleeding sites may be identified.

An acutely painful vulvar lesion suggests herpes infection or local abscess.

Chronic itching or vulvar discomfort suggests lichen sclerosus or carcinoma in situ. In chronic vulvitis, atypical dystrophies and malignancy should be ruled out by biopsy.

Using a water-lubricated speculum, the physician inspects the vagina, checks the pH, and obtains a specimen with a cotton-tipped applicator.

The specimen is diluted on 2 slides–one with 0.9% sodium chloride, the other with 10% potassium hydroxide; at the same time, the latter specimen is checked for released odor.

On microscopic examination, T. vaginalis can be seen as motile, unicellular flagellated organisms.

White cells and “clue” cells (epithelial cells with a granular appearance) with large numbers of bacteria suggest bacterial vaginosis.

In the potassium hydroxide preparation, mycelia and/or spores of Candida may be seen.

Cultures for Chlamydia trachomatis and N. gonorrhea may be indicated.

The cervix is inspected, a Papanicolaou (Pap) smear taken, and the remainder of the biannual examination performed.

Salpingitis

(Pelvic Inflammatory Disease [PID])

Infection of the fallopian tubes.

Although the term pelvic inflammatory disease (PID) is used by some to include infection of the cervix (cervicitis), the uterus (endometritis), or the ovaries (oophoritis), it should not be used as a catchall for pelvic pain of unknown origin.

Etiology and Pathogenesis

Salpingitis occurs predominantly in women under age 35 who are sexually active and results from microorganisms transmitted most commonly by intercourse, less often by childbirth (puerperal fever) or abortion.

Patients with intrauterine devices (IUDs) are especially vulnerable, probably because the transcervical appendage assists pathogen transport.

Salpingitis rarely occurs before

the menarche, after the menopause, or during pregnancy.

The cause may be a single organism or several organisms.

Chlamydia trachomatis has replaced Neisseria gonorrhea as the most common cause of PID, but numerous other aerobic and anaerobic organisms can also be present.

C. trachomatis may affect the lower or upper genital tract; often upper genital tract infections have a deceptively benign onset and seem quite mild.

Chlamydial organisms may remain in tubal mucosa for many months before manifestations of acute disease appear.

N. gonorrhea usually produces more acute, typical pelvic inflammation, with rapid onset and development of pelvic pain shortly after the start of a menstrual period.

Infection begins intravaginally in most cases.

The endocervical glands provide an optimal environment for organisms such as C. trachomatis and N. gonorrhea to flourish before spreading upward to produce a superficial endometritis and endosalpingitis.

Although symptoms and signs may predominate on one side, both tubes are probably affected.

The tubal infection produces a profuse exudate, leading to agglutination of mucosal folds, adhesions, and tubal occlusion.

Peritonitis, from spread of the exudate to the pelvic peritoneum, is common; the ovaries tend to resist infection but may also be invaded.

Symptoms and Signs

Acute salpingitis:

Onset is usually shortly after menses.

1) Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness, and discomfort that increases with cervical motion. Unless related to an IUD, involvement is usually bilateral

2) Vomiting may occur; bowel sounds are normal early, although paralytic ileus may ensue.

3) High fever, leukocytosis, and copious purulent cervical discharge have commonly been associated with PID, but low-grade fever, mild to moderate abdominal pain, irregular bleeding, and vaginal discharge may also signal the disease.

4) Chronic salpingitis may follow an acute attack with subsequent tubal and pelvic scarring and adhesions, chronic pain, menstrual irregularities, and possibly, infertility. An obstructed tube may distend with fluid (hydrosalpinx). In chronic interstitial salpingitis, the tube is enlarged as a result of a thickened wall.