PID, Vag Discharge, UTI,STIs

Question 1

What is an abnormal vag discharge
State the principal causative organisms ( mention for vaginitis and mention for cervicitis)
State four associated symptoms with vag discharge

Answer 1

Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina
Abnormal vaginal discharge is defined as discharge that is different from usual with respect to colour/odour/consistency (e.g. discoloured or purulent).

Abnormal discharge is often associated with vulvar pruritus or pain with intercourse (dyspareunia), or painful or difficult urination (dysuria) or lower abdominal pain.
Abnormal vaginal discharge may be a sign of infection of the vagina (vaginitis) and/or the cervix (cervicitis) or upper genital tract infection.
The principal causative organisms are:
In vaginitis: Bacterial vaginosis, Trichomonas vaginalis (trichomoniasis) and Candida albicans (candidiasis).
In cervicitis: Neisseria gonorrhoeae (gonorrhoea) and Chlamydia trachomatis (chlamydia).

Question 2

What does a normal Vaginal discharge contain and what is the normal pH of the vagina
What causes the normal pH of the vagina
State four factors that can contribute to a change in the composition of Vaginal flora (risk factors )

Answer 2

Vaginal pH is about 4.0 (3.8-4.5) due to the presence of Lactobacillus and other organisms converting Glycogen to Lactic acid.
•Lactobacillus also produces Hydrogen Peroxide that inhibits growth of other bacteria.

Contains vaginal and cervical epithelial cells, normal bacteria flora, water, electrolytes and other chemicals
17 – 29 bacteria species: diphtheroids, streptococcus, staph epidermidis, Gardnerella vaginalis, E-coli
Anaerobes- Peptococcus, Peptostreptococcus, Bacteroides
White or may be grey odourless
Acidic PH. Vaginal pH is about 3.8 - 4.2 due to the presence of Lactobacillus and other organisms converting Glycogen to Lactic acid. Lactobacillus also produces Hydrogen Peroxide that inhibits growth of other bacteria.

Age(changes in hormonal status))
Sexual activity(Semen and inflammation and STI)) (or abuse)
Hormonal status
Hygiene
Immunologic status
Underlying skin diseases
Drug abuse ( antibiotics,et )
Sex with a New partner without protection
Stress
Antibiotics
Contraceptives

•

Question 3

In a case of vag discharge, you need to find out if it’s due to STI causes or due to non STI causes
What are the features of a normal vag discharge
What will you want to ask in the history of someone w vag discharge

Answer 3

No smell
Clear fluid or white fluid
No associated symptoms such as itching or abdominal pain

History:
Age ( patient at extremes of ages . In menopause, it could be a cancer. In children it could be assault)
Duration ( short if normal and cyclical if it’s related to menses . Discharge that comes 2-3 days after menses could be a PID. Long and not cyclical if abnormal )
Colour( clear, pale, white if normal. Whitish cottage cheese appearance which is clumpy in candida, yellowish in trichomoniasis, greyish in Vaginosis,blood stained or bloody discharge (endometrial or cervical cancer) )
Quantity( may be scanty in normal)
Consistency( light or thin in normal, thick in abnormal if not related to ovulation)
Odour( not offensive in normal and fishy smell or fishy smell that worsens after sex in vaginosis)
Are they sexually active( or in the past one month have you had sex)
Was it unprotected?
MultiplePartners?
Does your partner have an STI or experiences discharges too? Do you have a previous history of STIs?
(Make sure the discharge isn’t related to sex. If it is, it’s likely to be an STI not a non STI discharge)
Do you have a previous history of PID or have you been treated for an STI or a PID?
Any associated symptoms such as itching(vaginosis doesn’t really cause itching), dysuria, frequency, urgency (urinary symptoms likely to be a UTI) , dyspareunia, fever, nausea,vomiting, chills, lower abdominal pain(likely to be an STI cause)
Ask about comorbidities such as DM , HIV,any disease that can cause immunosuppression
Ask about a foreign body( do you have an IUD implant? And in kids ask if they’ve recently put something in there while playing. Think of this especially when you treat and the thing isn’t going. Pass a speculum and check for a foreign body. It’s likely to be a foreign body)
If a child, rule out sexual assault (note that STIs and non STI causes aren’t common in kids so if it’s coming then there’s a problem)
Birth control method
 Last menstrual period
 Douching practice
 Use of personal hygiene products
 Antibiotic use

Question 4

What is bacterial vaginosis and what causes it
How does it cause problems?
What’s re the characteristics of the discharge caused by BV?
State three risk factors that can predispose yoj to getting BV

Answer 4

Vaginosis refers to overgrowth of bacteria spec anaerobic bacteria in normal Vaginal flora. Loss of kactobacillus causes the overgrowth
This is an infection caused by a change in the vaginal flora, which refers to the community of organisms that live in the vagina. It is the most common cause of pathological vaginal discharge in women of childbearing age and accounts for 40–50% of cases. In BV, the vagina experiences a decrease in a bacterium called lactobacilli, and a relative increase in a multitude of anaerobic bacteria with the most predominant being Gardnerella vaginalis. This imbalance results in the characteristic vaginal discharge experienced by patients with BV. The discharge in BV has a characteristic strong fishy odor, which is caused by the relative increase in anaerobic bacteria.
Bacterial vaginosis

•
The discharge is typically thin and grey, or occasionally green. It sometimes is accompanied by burning with urination. Itching is rare. Thin, greyish white, homogenous, malodorous discharge (fishy and worse after sex), adherent on vaginal walls.
•No inflammation
•Associated with upper genital tract infections
The exact reasons for the disruption of vaginal flora leading to BV are not fully known. However, factors associated with BV include antibiotic use, unprotected sex, douching, and using an intrauterine device (IUD).

Usually caused by douching or applying hygiene products

Question 5

How is BV diagnosed and treated?(Pharma and non Pharma)

Answer 5

BV rarely causes itching. So discharge with itching is unlikely to be a BV especially if the other symptoms aren’t present. If there’s no sex history, shift towards candidiasis

Diagnosis:
Thorough hx and exam
Amsel criteria :
Homogenous whitish grey adherent discharge
pH more than 4.5
Clue cells on microscopy ( epithelial cells with bacteria around each cell)
Whiff test. At least three or more produces fishy pungent smell. Whiff test – 10% KOH gives Fishy smell in BV

Management:

Metronidazole, oral, 400mg 8 hourly for 5 days (contraindicated during the 1st trimester of pregnancy) Or
Metronidazole, oral, 2g stat. (contraindicated during the 1st trimester of pregnancy) Or
Secnidazole, oral, 2g stat. (contraindicated during the 1st trimester of pregnancy)
Timidazole 2g stat
 Treatment for Vaginitis due to trichomoniasis and bacterial vaginosis for pregnant women in the 1st trimester: Clindamycin cream, 2%, vaginal, One applicator full at bedtime for 7 days

Non Pharma
Make sure you treat partner as well if there’s one

Iron underwear before you wear it or hang in the sun
Sit on salt water the big big salt causing a hypertonic solution
2times daily for 20 minutes
Cotton panties
Advice against douching
Avoid douching with herbal or chemical preparations Avoid use of medicated soaps around genital area

Question 6

What is Vaginal candidiasis and what causes it
State four risk factors for getting candidiasis
Is it an STI
what are the characteristics of candidiasis discharge

Answer 6

Vaginal candidiasis results from overgrowth of candida albicans, or yeast, in the vagina. This is a relatively common infection, with over 75% of women having experienced at least one yeast infection at some point in their life. Risk factors for yeast infections include recent antibiotic use, diabetes mellitus, immunosuppression, increased estrogen levels, and use of certain contraceptive devices including intrauterine devices, diaphragms, or sponges. It is not a sexually transmitted infection.
Vaginal Candidiasis

•
Vaginal discharge is not always present in yeast infections, but when occurring it is typically odorless, thick, whitish cheese like discharge, and clumpy. Vaginal itching is the most common symptom of candida vulvovaginitis. Women may also experience burning, soreness, irritation, pain during urination, or pain during sex

C albicans, C tropicalis, C glabrata
•Normal inhabitants in 50% of women
•90% albicans
•Risk Factors: oral contraceptives, IUD, early coitarche, frequent intercourse, cunninglingus, diabetes, HIV or immunecompromised states, Long term antibiotics use, Pregnancy
•Thick, odorless discharge, ‘cottage cheese’
•Associated with burning sensation, itchiness, dyspareunia, vulvar dysuria
•75% of women have at least 1 episode of candidiasis in lifetime

Question 7

How is candida diagnosed and managed

Answer 7

Hx exam(general, pelvic exam )

High vaginal swab for microscopy, culture and sensitivity. Saline wet mount – clue cells in BV, Hyphae and budding yeast forms in Candida

Treatment for Vaginitis due to Candidiasis
Fluconazole, oral: Uncomplicated: 150mg stat. as a single dose; Complicated: 150mg 72 hourly for 3 doses; Recurrent: 150mg daily for 10 to 14 days followed by 150mg once weekly for 6 month OR
Clotrimazole, vaginal tablets, 200mg inserted into vagina at night for 3 days OR
Miconazole vaginal tablets, 200mg inserted into vagina at night for 3 days And Clotrimazole cream, vaginal, 1% or 2%, Apply twice daily for 3 to 7 days (for vulval irritation)
Nistatin cream especially for notorious ones

Non Pharma is the same throughout

Damp and tight fitting clothing
•Scented detergents and soaps
•Feminine sprays
•Poor hygeine

Question 8

What is trichomoniasis and how does it cause problems
Characteristics of discharges
Risk factors
What is the incubation period of trichomonas
How is it acquired

Answer 8

Trichomonas vaginitis the third most common cause of vaginitis, is caused by trichomonads. Fusiform shaped, flagellated protozoan
It is an infection acquired through sex that is associated with vaginal discharge. About 70% of affected people do not have symptoms when infected. When symptoms occur, they typically begin 5 to 28 days after exposure.
The discharge in Trichomonas is typically yellowish- green in color. It sometimes is frothy and can have a foul smell. Strawberry cervix is pathogmonomic. Symptoms can include itching in the genital area, a bad smelling thin vaginal discharge, burning with urination, and pain with sex.
Risk factors include tobacco use, unprotected intercourse with multiple sexual partners, and the use of an IUD.

Question 9

What is gonorrhea
State ten common risk factors
How is it spread
Characteristics of discharges

Answer 9

Gonorrhoea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. Gonorrhea is spread through sexual contact with an infected person. This includes oral, anal, and vaginal sex. It can also spread from a mother to a child during birth. Infected women may experience burning with urination, vaginal bleeding between periods, or pelvic pain. Gonorrhea can also cause pus-filled(yellow) vaginal discharge, but Gonorrhea is similarly asymptomatic in up to 50% of cases. If the vaginal discharge is accompanied by pelvic pain, this is suggestive of pelvic inflammatory disease (PID),
Gonorrhoea

Common risk factors for gonorrhea:
Sexual contact with a person who has gonorrhea. Sex with a new partner without protection.
Unprotected sex with someone from an area with high gonorrhea burden.
Sexually active people under 25 years of age. Unprotected sex with multiple partners.
Being birthed by a person with gonorrhea. Low socioeconomic status
History of HIV infection.

Question 10

What is chlamydia
What is the incubation period
Statesome common risk factors
How is it spread
Characteristics of discharges

Answer 10

Chlamydia infection, is a sexually transmitted infection caused by the bacterium Chlamydia trachomatis. Most people who are infected have no symptoms. When symptoms do appear they may occur only several weeks after infection; the incubation period between exposure and being able to infect others is thought to be on the order of two to six weeks. This infection causes pelvic inflammatory disease, which may result in future infertility or ectopic pregnancy. Symptoms may include abnormal vaginal bleeding or discharge, abdominal pain, painful sexual intercourse, fever, painful urination or the urge to urinate more often than usual (urinary urgency).

Inflammation of the cervix from chlamydia infection characterized by mucopurulent cervical discharge, redness, and inflammation

Question 11

State ten signs and ten symptoms of patients with Abn vag discharge

Answer 11

Symptoms
• Abnormal vaginal discharge - change in colour, odour, consistency or amount
Vulval itching
Vulval swelling
Pain on urination
Lower abdominal or back pain
Dyspareunia

 Signs
• Abnormal vaginal
discharge
Vulval swelling
Vulval erythema
Lower abdominal tenderness
Cervical excitation tenderness
Cervical mucopus or erosions (on speculum examination)
• • • •
•

Question 12

On pelvic exam, what do you expect to see if BV, if candida, if trichomoniasis, if due to gono or chlamydia

Answer 12

Physical Examination
The physical examination of pubertal and adult
women should include a complete pelvic examination.

Physical findings associated with cervicitis from STDs include excessive vaginal discharge, erythema, and edema of the cervix. Fever, cervical motion, or abdominal or adnexal tenderness may indicate upper genital tract infection

Physical findings in bacterial vaginosis include a homogeneous, frothy vaginal discharge that is grayish-white to yellowish-white in color. Vaginal pH higher than 4.5 with a litmus paper.

Vaginal candidiasis may present with a well- demarcated erythema of the vulva. A thick, adherent, cottage cheese–like vaginal discharge may be seen. The cervix usually appears normal.

In trichomoniasis, the vulva may appear erythematous and edematous. Look for a copious, frothy, homogeneous vaginal discharge that can be white, gray, yellow, or green
•
•

Question 13

State six ddx for abn vag discharge

Answer 13

Urinary Tract Infection
Atrophic vaginitis
Cervical polyp
Contact dermatitis
Fistula
Foreign body
Trauma
Cervical cancer
PID
Cervicitis
Herpes simplex
Chemical irritation

Question 14

State six investigations done for abn vag discharge

Answer 14

High vaginal swab for microscopy, culture and sensitivity. Saline wet mount – clue cells in BV, Hyphae and budding yeas forms in Candida – Large numbers of WBCs and protozoa seen for Trichomonas
Whiff test – 10% KOH gives Fishy smell in BV
In Vaginitis, Vaginal pH can be determined with litmus paper. Bacterial vaginosis - pH is 5.0-6.0
Vaginal candidiasis - pH is less than 4.5
T vaginalis infection - pH is 5.0-7.0
In Cervicitis, Nucleic acid amplification tests (NAATs) are preferred over the other tests, because they are highly sensitive and specific for diagnosing gonococcal and chlamydial infections.
STI rapid test kits for clamydia and gonorrhea
FBC
USS if pelvic pain is present

pH test – acid for Candida, base for BV and Trichomonas
•Cultures – often not necessary
•Gram staining- BV (clue cells)
•Pap smear ??

Question 15

How is gono and chlamydia treated
Also check flow chart for how to manage vag discharge for syndromic management

Answer 15

Treatment for Cervicitis due to gonorrhoea.
Cefixime, oral, 400mg stat. And Azithromycin, oral, 1g stat. OR
Ceftriaxone, IM, 250mg stat. And Azithromycin, oral, 1g stat.
Treatment for Cervicitis due to Chlamydia
Doxycycline, oral,100mg 12hourly for 7days (avoid in pregnant and nursing mothers)
Or Erythromycin, oral, 500mg 6 hourly for 7 days
Or Azithromycin, oral, 1g stat. (recommended in pregnancy)

Treatment of the partner
When the patient is treated for vaginitis or cervicitis, the partner receives the same treatment as the patient, whether or not symptoms are present.

Question 16

State ten complications of vag discharge including maternal or fetal complications

Answer 16

PID
Ectopic Pregnancy
Infertility
Endometritis
Systemic disease resulting from the spread of gonorrhea may occur

During pregnancy, bacterial vaginosis and trichomoniasis are associated with an increased risk of:
Premature rupture of membranes
Preterm labor Low birth weight Preterm delivery.

Question 17

What is PID
What will you call infection of the upper genital tract due to intra peritoneal Manipulation?
What is it called in pregnancy?
What about in males?

Acute PID is a polymicrobial infection involving a mixture of aerobic and anaerobic bacteria clinically
appearing as a single complex infection.
True or false
Infection of the ovaries is called?
Infection of the myometrium is called ?

Answer 17

Clinical manifestations due to infection of the upper GIt (internal os of cervix, uterus, ovaries, Fallopian tubes) in a woman. No history of intra peritoneal manipulation ( laparotomy, laparostomy ( opening abdominal cavity), laparoscopy is creating wholes and putting cameras there to see what is there ) and isn’t related to pregnancy

The areas involved include:
Endometrium  endometritis
Myometrium  myometritis
Parametrium  parametritis
Fallopian tubes  salpingitis
Ovaries  oophoritis

So it means :
A man cannot have PID
A pregnant woman can’t have PId

Infections of upper genital tract ( internal os of cervix, uterus, ovaries, Fallopian tubes) due to intra peritoneal manipulations are called peritonitis. Usually bacterial peritonitis

Infections of upper genital tract in a pregnant woman-
chrorion, amniotic fluid infection - chrorioamnioitis
Depending on part infected(cervicitis,etc)
Parametritis- fat and connective tissues surrounding the uterus

Males- BPH, prostitis, prostatic CA

Infection of lower genital tract-
Vaginitis or vaginosis difference(Vaginosis is an imbalance of bacteria in the vagina, while vaginitis is inflammation of the vagina.
Bacterial vaginosis is a common vaginal infection caused by an imbalance of bacteria in the vagina. )
, infection of the vulva, infection of cervix ( cervicitis)

Question 18

State six causative organisms of PID

Answer 18

klebsiella, Staph , pseudomonas aureogonosa, mycoplasma ominis , neisseria gonorrhea, chlamydia trachomatis, group B strept

Major organisms implicated are:
Sexually transmitted organisms Endogenous vaginal flora
Major ones Neisseria gonorrhoeae
Chlamydia trachomats
Aerobes Group-B streptococcus
Non-haemolytic streptococcus
Coagulase –ve staphylococcus
Others Mycoplasma hominis Anaerobes Peptococcus
Peptostreptococcus
Bacteroides spp.
Clostridium spp.
ActinomyceS

Question 19

What is the mode of transmission leading to a PID
State four

Answer 19

Second most common- Haematogemous spread( infection from blood moves to upper GI )

Most common- Ascension of infections ( bacteria moving from lower genital tract to upper genital tract). I think sexual transmission of infections falls here
Continuity or contiguous direct contact by Peritoneal surgeries, infection from appendicitis to upper genital tract (GI)(Pelvic infection secondary to spread of a primary infection Appendicitis
{ Diverticulitis{ Tuberculous peritonitis { Actinomyosis))

Lymphatic spread ( lymphatic vessels transmit bacteria throughout body)

The
remaining 15% follow procedures that break the cervical mucus barrier, allowing the vaginal flora the
opportunity to colonize the upper genital tract. Such procedures include:
 Endometrial biopsy
 Endometrial curettage
 IUD insertion
 Hysteroscopy
This occurs when there is ascending infection from
the endocervix to the higher reproductive tract. It
is a recognized complication of chlamydia and less
frequently of gonorrhoea, but they are often not
isolated and other implicated organisms include
Mycoplasma genitalium as well as those in the vagi nal microflora.

Question 20

State the signs and symptoms of PID
What do you expect to see on examination

Feverish is low grade fever
Fever > 37.5 in children
True or false

Answer 20

The diagnosis of PID is usually made clinically.

SYMPTOMS
Bilateral lower abdominal pain(Character of the pain - gradual onset constant dull and could be severely painful mild to severe pain non radiating )

Intermenstrual bleeding (IMB)
Postcoital bleeding (PCB)
Breakthrough bleeding
New onset vaginal discharge(offensive, from brown, yellow, greenish discharge. Usually appears 3-5 days after having unprotected sex. )
Fever and chills ,vomiting,50%)
Deep dyspareunia
Urethritis
Proctitis
lower bilateral abdominal pain, dyspareunia, altered vagi nal discharge and IMB or PCB. Systemic symptoms
of infection may be present.

SIGNS
Elevated temperature (Fever is a symptom not a sign (>38˚C)
Rebound tenderness in lower
abdomen
Right upper quadrant tenderness
(possible Fitz-Hugh Curtis in 10%
of patients)
Purulent endocervical discharge
Cervical excitation motion tenderness
Adnexal tenderness on bimanual
examination ± mas

Characteristic clini cal findings include lower abdominal and cervical motion tenderness and cervicitis

Question 21

What is the criteria for admission for PID

Answer 21

Criteria of admission of person with PID **
Vomiting such that they can’t take oral meds
Is patient hemodynamically stable
Adolescents PID are managed intra hospital
Will patient be able to follow up with treatment? If no start IVs
Very high temp above 38 degrees
When you’re not certain of diagnosis
If patient doesn’t respond to OPD treatment
If patient has something something
Patient with immunosuppression
Patient with IUD
Patient with peritonitis

OPD:
Not severely I’ll
Can tolerate orals
Not in intensive pain
Temps not higher than 38 degrees

Question 22

What is the gold standard for diagnosing PID
State four investigations done for PID

Answer 22

Investigations-
Gold standard for diagnosing PID- laparoscopy. To check for fluid in the pouch of Douglas
lab: FBC to check for leucocytosis,increased neutrophils , take secretions for C/S,(check HVS),FBS
Imaging: pelvic ultrasound (but preferably is trans Vaginal ultrasound since that will give you a better picture of the pouch of Douglas) to check for fluid in the pouch of Douglas

Question 23

State ten risk factors for PID

Polymicrobial infection of upper GT in a non Gravid uterus not associated with intra peritoneal manipulations with clinical presentations of what what

Neiserria Gonorr is a gram negative diclococcus. Same as chlamydia and live inside cells of epithelium
True or false

Answer 23

Risk factors of PID:
Age 16-25. Cuz they are sexually active
Multiple sexual partners
STIs
Unprotected sex
History of offensive Vaginal discharge
Frequent history of lower abdominal pain
Undertreated STIs and undertreated PIDs
Menstrual periods
Previous history of PID
Previous history of STI
Illiteracy
Prosititution
Hookups
Intrauterine contraceptive devices
Immunosuppression
Low socioeconomic standard
Socio cultural practices such as early
Marriages
Having a partner with multiple sexual partners
Previous history of septic abortions
The four procedures Baba mention po oned in the beginning

Question 24

Which bacteria is asymptomatic in PID

Answer 24

Which bacteria is asymptomatic in PID:
Chlaymdia trachomatis
Gonirrhea is what shows symptoms. Incubation period of gonorrhea is 3days to 1 week( confirm)
Charact of bacteria that makes them infectious ( virulence, multiplication, colonization, ability to show symptoms, ability to cause infection, ability to kill

Question 25

Management of PID

Answer 25

Mgt-
1. Determine if patient needs admission or not so you’ll admit depending on the clinical scenario
2. If admission,.Pain meds- first line para, or diclo or morphine if you can’t do diclo
3.Antipyretics- first line para
4. Wide bore cannulas and iv fluids
Take Samples for labs such as malaria, FBC and other things that can cause the fever and do IV hydration
5. Do pelvic scan
6. Give antibiotics. So you do poly pharmacy. Since you can’t wait for the c/S, give empirical antibiotics ( treating for Gono)
7. 3rd generation cepha - 2g stat IV cefritraxone or 4th generation if 3rd generation isn’t there,
8. 500mg tds IV metronidazole
9. Azithromycin 1g stat or doxycycline 100mg bd for 2 weeks
10. Take secretion for C/S high Vaginal swab

Pharmacological treatment
A. For Pelvic inflammatory Disease (mild cases)
1st Line Treatment
y Ciprofloxacin, oral, 500 mg 12 hourly for 3 days And
Evidence Rating: [B]
y Doxycycline, oral, 100 mg 12 hourly for 14 days And
y Metronidazole, oral, 400 mg 12 hourly for 14 days

B. For Pelvic inflammatory Disease (severe cases)
y Ceftriaxone, IM, 250 mg daily for 3 days And
y Doxycycline, oral, 100 mg 12 hourly for 3 days And
y Metronidazole, IV, 500 mg 8 hourly for 3 days
Then
y Doxycycline, oral, 100 mg 12 hourly for 14 days And
y Metronidazole, oral, 400 mg 12 hourly for 14 days

Why are you doing 4th or 3rd generation cephalo : cuz it can go intracellular and are bacteriocidal cuz they interfere with protein synthesis then you cause destabilization of cell membrane so it can’t Protect itself. 3rd generation can also enter into the epithelium cells.
Bacterio something -Stops bacterial proliferation
Bacteriocidal- kills bacteria

Check for comorbidities of patients and treat

Question 26

State six complications of PID
What is Vaginal douching
State two causes of a smelly vagina

Answer 26

Early-sepsis, septic shock,generalized peritonitis,

Late- tubo-ovarian abscess, infertility(due to removal or tying of tubes due to ectopic pregnancy) , ectopic pregnancy(chlamydia trachomatis causes adhesions of tubes by secretions and reduces lumen of tubes ), recurrent PID or chronic lower abd pain,
Fitz-Hugh-Curtis syndrome (FHCS), (or perihepatitis, is a chronic manifestation of pelvic inflammatory disease (PID). [1] It is described as an inflammation of the liver capsule, without the involvement of the liver parenchyma, with adhesion formation accompanied by right upper quadrant pain.)

Vaginal douching- excessive washing of vagina will rid the vagina of the normal PH and is a risk factor for candidiasis. Cuz acidity restricts the candidiasis from causing infection m. Douching removes the cells that cause the acidity and causes candidiasis proliferation
lactobacillus are part of normal flora of vagina so they can’t cause an infection there

Smelly vagina:
Dehydration 3.8-5.0 ph of vagina
Cells responsible for Vaginal pH1

Question 27

What are UTIs
What is the length of the urethra and males and females
Why do women have more UTIs than men
Why are pregnant women susceptible to UTI

Answer 27

Clinical manifestation due to Colonization by bacteria of the lower Urianry tract . UTI is defined as the presence of at least 100,000 organisms per milliliter of urine in an asymptomatic patient, or as more than 100 organisms/mL of urine with accompanying pyuria (> 7 white blood cells [WBCs]/mL) in a symptomatic patient. A diagnosis of UTI should be supported by a positive culture for a uropathogen, particularly in patients with vague symptoms. [1]
Asymptomatic bacteriuria
Asymptomatic bacteriuria is commonly defined as the presence of more than 100,000 organisms/mL in 2 consecutive urine samples in the absence of declared symptoms.

Cm of urethra in women- 4.8-5.1cm or 3.5-5cm
Cm of urethra in men- 17-20cm or 7 inches

Why women have more UTIs than men:
Wider surface area of the vagina or genital so bacteria can easily be colonized and can easily get into the external orifice urethra
Shorter urethra : men have longer so their urine flushes the thing out before the bacteria gets to the external orifice
Women retain more urine cuz they don’t like using public what what do they get it more

Pregnancy:
UTIs are more common in pregnancy due to dilation of upper renal tract and urinary stasis. Hormonal and mechanical changes can promote urinary stasis and vesicoureteral reflux. These changes, along with an already short urethra (approximately 3-4 cm in females) and difficulty with hygiene due to a distended pregnant belly, help make UTIs the most common bacterial infections during pregnancy. The high levels of progesterone cause smooth muscle relaxation and reduced peristalsis in the renal collecting system. The decreased detrusor tone of the bladder leads to incomplete emptying and increased capacity.
Pyelonephritis can cause pre term labour

Question 28

State two signs of acute cystitis
State four organisms implicated in UTIs

Answer 28

Acute cystitis-
Pollakiuria (Pollakiuria means frequent, abnormal urination during the day. frequent urination like very frequent) , having urge to pee but when you go it doesn’t come or it comes small but you feel you haven’t peed all

Organisms cystitis-
1.Why E. coli is more common -cuz it’s part of the normal flora of the lower GIT tract . Fecal contamination of perineum with other things that’s why it’s more common .

Proteus mirabilis (PM) is a Gram-negative rod-shaped bacterium and widely exists in the natural environment, and it is most noted for its swarming motility and urease activity. PM is the main pathogen causing complicated urinary tract infections (UTIs), especially catheter-associated urinary tract infections.
Pseudomonas
2.Klebsiela
Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterococcus faecalis and Staphylococcus saprophyticus.

3. Urea plasma urealyticum
   Ureaplasma urealyticum

Question 29

State ten risk factors for UTI

Answer 29

The pregnancy itself
If woman is immunocompromized
If woman has DM
Sexual activities
Personal hygiene
Long term antibiotic use
History of previous infection ( in previous pregnancy or outside pregnancy)
Renal stones
Poly cystic kidneys
Congenital anomalies of renal tract
Neuropathic bladder
Post partum risks mainly associated with catheterization:
Prolonged labour
Prolonged 2nd stage
C/S
Pre eclampsia

Immunosuppression
Pre-existing diabetes
Sickle cell anemia
Neurogenic bladder
Recurrent or persistent UTIs before pregnancy
Tobacco use
Age < 20 years
Late presentation for prenatal care

Question 30

State the signs and symptoms of UTI
What do you expect to see on clinical exam

Answer 30

Dysuria
Urinary urgency and frequency
A sensation of bladder fullness or lower abdominal discomfort
Suprapubic tenderness or LAP
Flank pain and costovertebral angle tenderness (may be present in cystitis but suggest upper UTI)
Bloody urine
Fevers, chills, and malaise (may be noted in patients with cystitis, but more frequently associated with upper UTI)

Exam:
Renal angle tenderness-Examination- right flank tenderness (palpate first then put hand on kidneys location and ball the other one into a fist then you hit on the other hand)

Pelvic examination is recommended in all symptomatic patients (with the exception of third-trimester patients with bleeding) to rule out vaginitis or cervicitis. In patients with cystitis, tenderness can often be elicited with isolation of the bladder on pelvic examination.
Patients with pyelonephritis have fever (usually > 38°C), flank tenderness upon palpation, and an ill appearance. Flank tenderness occurs on the right side more frequently, and is present in more than half of patients. Pain may also be found suprapubically with palpation.
Assessment of the fetal heart rate on the basis of gestational age should be included as part of the evaluation. Often, owing to maternal fever, the fetal heart rate is elevated to more than 160 beats/min.

The presence of toxic fever, chills, nausea, and vomiting suggests pyelonephritis rather than cystitis;
The clinician may appreciate signs of dehydration, such as dry mucous membranes and tachycardia. Clammy extremities and symptomatic orthostasis suggest poor vascular tone due to gram-negative bacteremia rather than simple cystitis.
Most adult women with simple lower UTI have suprapubic tenderness.
Pelvic examination should be performed to exclude vaginitis, cervicitis, or pelvic tenderness (eg, cervical motion tenderness, which suggests pelvic inflammatory disease).

Question 31

State six complications of UTI

Answer 31

Complications may include the following:
Perinephric cellulitis and abscess
Septic shock
Renal dysfunction (usually transient, but as many as 25% of pregnant women with pyelonephritis have a decreased glomerular filtration rate)
Hematologic dysfunction, including anemia or thrombocytopenia
Hypoxic fetal events due to maternal complications of infection that lead to hypoperfusion of the placenta
Preeclampsia [20]
Preterm labor, and possible subsequent preterm delivery, leading to increased infant morbidity and mortality

Question 32

State six investigations done for UTI
Why is mid stream urine preferred?

Answer 32

a.Urine C/S( gold standard), Urine dipstick(what are you looking for in this? ) Ten things looked for in b. urine R/E
1.colour of urine hematuria in very bad or complicated UTI
2. Leociocyte esterase or number of leukocytes (up to plus 1. If you find traces of leukocytes the person may be asymptomatic)
3. Presence of bacteria in urine
4. Ketones ( increased means dehydration)
5. Epithelial cells ( high means compromised epithelium due to dehydration or colonization of bacteria )
6. Yeast and other things
7. Presence of proteins

c. FBC-
Increased number of reticulocytes or immature neutrophils ( left shift. Immature WBCs move toward the left when there’s an infection. )
Leucocytosis with neutrophilia

Percentages that indicate bacterial infection:
30-40 lymphocytes
70 neutrophils

Infections that you do polypharmacy:
TB
HIV
PUD
Leprosy
STI

ESR- acute inflammatory markers
CRP- acute inflammatory markers

Ultrasound to rule out other causes such as a congenital abnormality, renal calculi, hydronephrosis (A condition characterised by excess fluid in a kidney due to a back-up of urine.Hydronephrosis is caused by a blockage in the tube that connects the kidney to the bladder (ureter). Possible causes include a kidney stone, an infection, an enlarged prostate, a blood clot or a tumour)

Midstream urine-
Whiles urinating you make patient take sample after first part of urine has come. Patient doesn’t stop urinating but the midstream is a true reflection of what’s in the bladder cuz the first urine removes the bacteria from the ureters

Question 33

Why is a pyelonephritis more likely in second or third trimester
What are the differences between a cystitis and a pyelonephritis

Answer 33

Pyelonephritis:
Pregnancy pushes bladder up as it progresses and causes obstructive uropathy that’s why pyelonephritis is more likely in second and third trimester

Right ureter prone to obstructions and right kidney pyelonephritis why?
Calistea and urethral dilitations are common on right side and this causes stasis and leading to pyelonephritis
Sigmoid colon pushes uterus

What differentiates UTI(low grade fever and localized manifestations such as dysuria, urgency, frequency, hematuria, proteinuria and suprapubic pain ) from pyelonephritis ( presents with systemic features fever(high grade ), chills and vomiting,renal angle tenderness. More likely to end in sepsis)

Question 34

How are UTIs managed?(asymptomatic pyelo and in patient pyelo
State four drugs for UTI and other drugs that are toxic in pregnancy and why

Answer 34

Pyelonephritis-
Asymptomatic-OPD
5-7days with metronidazole 400mg tds or
2-3rd gen cephalosporins Cefuroxime 500mg bd 5-7 days or Amxiclaf 1g bd for 5-7 days
Tab Pmol tds for fever
Oral hydration in house
Review and so urine R/E on review date

Inpatient mgt
Forget sickle cell in pyelonephritis mgt
Antibiotics-broadSpevtrum beta lactam such as ceftriaxone 2g daily 48hrs . Max is 4g ,Cefuroxime,iv metro 500mg tds 24-48hrs before you switch to orals
Pmol 1g tds
Iv hydration 3-4litres
Vitals 4hrly

No cipro in pregnancy (why?) cuz it can cause skeletal problems and no tetracyclines too cuz it can cause permanent staining of teeth and problems with skeletal development
Why won’t you give sulfonamides in third trimester?(Co-trimoxazole is a combination of trimethoprim and sulfamethoxazole and is in a class of medications called sulfonamides)
It increases risk of Kernicterus in neonates due to displacement of protein binding bilirubin
Why should you be careful if gentamicin in pregnant women? It puts patient at risk of ototoxicity so you monitor levels to minimize this risk
What Is Ototoxicity? Certain medications can damage the ear, resulting in hearing loss, ringing in the ear, or balance disorders.

Why will you avoid trimethoprim in first trimester?
It is a folate antagonist