24.3 Infections of the Female Reproductive Tract: Burden & Screening, Syndromic Management, Vaginitis and Cervicitis, Pelvic Inflammatory Disease & Tubo-Ovarian Abscess, Genital Tuberculosis and Toxic Shock

Why this area matters

TOS area O asks you to:

• identify infections of the female reproductive tract, including STIs, and their complications such as PID;
• explain their burden;
• recognize their course, severity and long-term effects on women's health;
• choose screening tools;
• apply treatment based on risk and benefit.

STIs are rising among young Filipinos together with HIV. Untreated chlamydia and gonorrhea cause tubal infertility and ectopic pregnancy. Genital TB remains a cause of infertility in the Philippines because pulmonary TB is so common. Social hygiene clinics provide confidential testing and treatment.

Screening and the syndromic approach

• Screening for asymptomatic infection:
  • chlamydia and gonorrhea by nucleic acid amplification tests (NAAT) of vaginal or cervical swabs or urine, in sexually active women under 25 and older women at risk;
  • syphilis, HIV and hepatitis B at the first prenatal visit and in women at risk;
  • cervical screening for HPV-related disease;
  • partner notification and treatment prevents reinfection.
• Syndromic management (WHO, used in DOH social hygiene clinics): where laboratory tests are unavailable or results would come too late, the patient is treated at the first visit for the common causes of her syndrome.
  • Vaginal discharge: treat vaginitis (bacterial vaginosis, trichomoniasis and candidiasis by findings). Add cervicitis treatment (gonorrhea and chlamydia) if the risk assessment or speculum findings suggest it.
  • Lower abdominal pain with cervical motion or adnexal tenderness: treat as PID.
  • Genital ulcer: treat syphilis and chancroid, and herpes if vesicles are present.
  • Every syndromic visit includes counseling, condoms, partner management and offers of HIV and syphilis testing.
• Limitation: vaginal discharge is a poor predictor of cervical infection. Syndromic management overtreats some women and misses asymptomatic infections, which is why NAAT screening is preferred where available.

Vaginitis and cervicitis

• The vaginitis triad: bacterial vaginosis, candidiasis and trichomoniasis are compared in the STI section. Normal vaginal pH is 4.5 or less, kept low by lactobacilli.
• Atrophic vaginitis in postmenopausal women causes dryness, dyspareunia and spotting, with a pH above 4.5 and parabasal cells. Treat with vaginal estrogen.
• Cervicitis:
  • a mucopurulent discharge and a friable cervix that bleeds easily;
  • usually chlamydia or gonorrhea;
  • treated presumptively with doxycycline for chlamydia, plus ceftriaxone if gonorrhea is likely;
  • partners are treated as well.
• Postoperative and post-abortion infections:
  • Vaginal cuff cellulitis or abscess after hysterectomy: prevented with cefazolin prophylaxis.
  • Infected abortion: treat with broad-spectrum IV antibiotics and prompt evacuation of retained tissue.
  • IUD-associated PID: the risk is mainly in the first 3 weeks after insertion. The IUD may usually stay in if the patient improves.

Pelvic Inflammatory Disease (PID)

An ascending polymicrobial infection extending from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, and adjacent pelvic structures.

• Etiology: Initiated by sexually transmitted pathogens—Neisseria gonorrhoeae (Gram-negative intracellular diplococcus) and Chlamydia trachomatis (obligate intracellular bacterium)—followed by secondary ascending invasion by endogenous vaginal anaerobes (Bacteroides, Prevotella), facultative Gram-negative rods, and Mycoplasma genitalium.
• Clinical Diagnosis: Based on the presence of lower abdominal or pelvic pain in a sexually active woman with no other identifiable cause, plus at least ONE of the following minimum clinical criteria on bimanual examination:
  1. Cervical Motion Tenderness ("Chandelier sign"): Exquisite pain elicited by moving the cervix during bimanual exam.
  2. Uterine Tenderness.
  3. Adnexal Tenderness (unilateral or bilateral).
  • Supportive Criteria: Oral temperature $> 38.3^\circ\text{C}$ ($101^\circ\text{F}$), abnormal mucopurulent cervical discharge, cervical friability, abundant WBCs on saline wet mount of vaginal secretions, elevated ESR or C-reactive protein, and laboratory confirmation of cervical gonococcal or chlamydial infection.
• Complications:
  • Tubo-Ovarian Abscess (TOA): Purulent inflammatory mass involving the fallopian tube and ovary; risk of rupture leading to life-threatening generalized peritonitis and septic shock.
  • Fitz-Hugh-Curtis Syndrome (Perihepatitis): Fibrous inflammation of the liver capsule causing right upper quadrant pain that worsens with inspiration; laparoscopy reveals pathognomonic "violin-string" adhesions between the anterior liver surface and abdominal wall.
  • Long-term Sequelae: Chronic pelvic pain, a 6- to 10-fold increased risk of ectopic pregnancy (due to tubal endothelial deciliation and scarring), and tubal factor infertility (classically about 12% after one episode, 25% after two and 50% after three).
• Evidence-Based Antimicrobial Regimens:
  • Outpatient Regimen (Mild to Moderate PID):
    • Ceftriaxone 500 mg IM single dose (covers N. gonorrhoeae), PLUS
    • Doxycycline 100 mg orally twice daily for 14 days (covers C. trachomatis), PLUS
    • Metronidazole 500 mg orally twice daily for 14 days (covers anaerobes and concurrent bacterial vaginosis).
  • Inpatient Regimen (Severe illness, pregnant, TOA, failed outpatient therapy):
    • Ceftriaxone 1 g IV every 24 hours PLUS Doxycycline 100 mg orally or IV q12h PLUS Metronidazole 500 mg orally or IV q12h; OR
    • Cefotetan 2 g IV q12h (or Cefoxitin 2 g IV q6h) PLUS Doxycycline 100 mg orally or IV q12h; OR
    • Clindamycin 900 mg IV q8h PLUS Gentamicin loading dose 2 mg/kg IV followed by 1.5 mg/kg q8h.

Tubo-ovarian abscess

• Presentation: an adnexal mass, high fever and severe pain in a woman with PID. It is confirmed on ultrasound or CT. Actinomyces is linked to long-term IUD use.
• Management:
  • admission and IV antibiotics with anaerobic coverage (for example ceftriaxone, doxycycline and metronidazole, or clindamycin plus gentamicin);
  • drainage (image-guided or laparoscopic) for abscesses of about 7 to 8 cm or more, or with no response in 48 to 72 hours;
  • emergency laparotomy for rupture (sudden worsening pain, peritonitis and septic shock).

Genital tuberculosis

• Spread: genital TB spreads from a primary focus, usually the lungs, by blood. It involves the fallopian tubes in almost all cases, then the endometrium in about half, and less often the ovaries and cervix.
• Presentation:
  • infertility (the most common complaint);
  • menstrual disturbance and secondary amenorrhea from intrauterine adhesions (Asherman syndrome);
  • chronic pelvic pain;
  • occasionally a pelvic mass or ascites.
• Diagnosis:
  • premenstrual endometrial biopsy for histology (caseating granulomas), AFB culture and Xpert MTB/RIF;
  • hysterosalpingography may show beaded, rigid "pipe-stem" or "tobacco-pouch" tubes, but HSG can flare the disease and is used carefully;
  • check the chest X-ray and for HIV.
• Treatment: standard anti-TB therapy (2HRZE/4HR). Tubal damage usually persists, so many women need IVF to conceive. The risk of ectopic pregnancy is high.

Menstrual toxic shock syndrome

• Cause: superabsorbent tampons or retained vaginal devices allow TSST-1-producing S. aureus to multiply.
• Features:
  • high fever, hypotension and a diffuse sunburn-like erythroderma that desquamates 1 to 2 weeks later, especially on the palms and soles;
  • vomiting and diarrhea;
  • multiorgan involvement;
  • blood cultures are usually negative.
• Treatment: remove the device, resuscitate, and give an anti-staphylococcal antibiotic plus clindamycin to suppress toxin production.