Chapter 7 Gynaecological Infections
Inflammation in the lower gynaecological tract
Under normal conditions, the vulva, vagina and ectocervix are the habitat of various types of infective agents, but they are a threat only if normal defence mechanisms are altered.
Defence mechanisms
Glycogen is produced by vaginal epithelium influenced by oestrogens and is converted to lactic acid by Doderlein’s bacillus (a type of B. acidophilus). This maintains the vaginal pH between 3 and 4 which inhibits most other organisms.
This is a considerable physical barrier to infection. Continual desquamation of the superficial kerato-hyalin layer and glycogen production, both dependent upon ovarian oestrogen action, combat bacteria. In children and postmenopausal patients, the epithelium lacks oestrogen stimulation and is thin and easily traumatised or infected.
The vaginal canal is only a potential space kept closed by the surrounding muscles and provides another physical barrier. This, however, alters following sexual activity and pregnancy.
4. Glandular secretions from the cervix and Bartholin’s glands maintain an outward fluid current helping to clear the canal of debris. In addition, cervical secretion contains immunoglobulins, especially IgA, and there are varying numbers of polymorphs, lymphocytes and macrophages.
Vulval inflammation
Vulval inflammation is not uncommon but is usually an extension of infection from the vagina. A mild reaction may arise because of physical and anatomical conditions in the area, such as (a) moistness and (b) proximity of urethra and anus.
The area is not only naturally moist but also warm, particularly in obese patients. The folds of fat harbour moisture, and chafing occurs between them. The proliferation of bacteria is encouraged. Urinary incontinence and unsuspected glycosuria may add to this. It is important to test the urine for sugar in all patients.
Incidental factors may intensify any reaction resulting from these conditions, for example, the wearing of nylon underwear which is heat-retaining and non-absorptive. Chemical factors such as washing underclothes with detergents, and using toilet powders, perfumes and deodorants, which intensify the reaction, may be associated with this. The clinical result is irritation and itching leading to scratching. Continual itch-scratch-itch leads to maceration of the skin and may invite infection. Careful attention to personal hygiene is essential. Obese patients should be encouraged to lose weight and all the incidental factors mentioned above should be avoided.
Search for lice or scabies should be made where appropriate.
One of the complications of vulvar inflammation is obstruction of the duct of Bartholin’s gland. Cystic dilatation and abscess formation are apt to follow. The condition occurs during a woman’s sexual life. Any organism, staphylococcal, coliform or gonococcal, may be found.
The gland lies partly behind the bulb of the vestibule and is covered by skin and the bulbospongiosus muscle. The duct is 2 cm long and opens into the vaginal orifice lateral to the hymen.
Treatment
Marsupialisation (Gk. marsipos, a bag). The cyst or abscess is widely opened within the labium minus and drained, and its walls sutured to the skin leaving a large orifice, which it is hoped will form a new duct orifice and allow conservation of the gland. A ribbon-gauze pack is inserted for 48 h by some surgeons.
Vaginal discharge and infection
A small amount of vaginal discharge is normal in adult life and may be excessive in the presence of cervical ectopy. Cervical ectopy is where the glandular epithelium from the endocervix is visible on the ectocervix.
Composition
The vaginal discharge is composed of tissue fluid, cell debris, carbohydrate, lactobacilli and lactic acid. The pH is about 4.5, a degree of acidity that inhibits the growth of organisms other than the lactobacilli.
Source of vaginal discharge
Vulva: Greater vestibular glands, glands of vulval skin.
Vagina: Mainly desquamated epithelial cells which liberate glycogen. The lactobacilli metabolise the glycogen to lactic acid. Vaginal transudate (secretion from tissues and capillaries of the mature vagina) is often described; vaginal epithelium is certainly not water resistant (like transitional epithelium). There are no mucosal glands.
Cervix: Alkaline mucous secretion which becomes copious and watery during ovulation.
Clinical features
Volume: The need to wear a pad or tampon continuously suggests excessive discharge.
Onset: Onset can be associated with the end of a pregnancy, the contraceptive pill, a course of antibiotic.
Colour: Normal discharge is white but stains yellow or pale brown on clothing or pads. A greenish-yellow colour suggests pyogenic infection, commonly accompanied by an unpleasant odour. Red or dark brown suggests blood.
Irritation: Any discharge can in time excoriate the vulva, but often Candida and Trichomonas cause itching.
Complaints of vaginal discharge
Women will complain under the following conditions.
There is often little correlation between symptoms and signs. Some women will complain of what is really normal; and gynaecologists regularly observe heavy and purulent discharge in women who deny any symptoms at all.
Examination
Leucorrhoea
This means an excessive amount of normal discharge – a very subjective assessment. The patient will complain of constantly having to change her clothes but there will be no irritation and appearance will be normal. The smell will be the normal vulval odour (from the action of commensal bacteria on the secretions of the apocrine sex glands); microscopy will reveal normal appearances and culture will grow only lactobacilli.
The patient should be reassured and given an explanation of normal physiology. No local treatment is necessary.
Vaginal discharge
Candida albicans
This is yeast and exists in two forms – slender branching hyphae or as a small globular spore which multiplies by budding.
Source of Infection
This organism may exist as a normal commensal in the rectum and small numbers may be found in the vagina. Sexual transmission is also possible. Symptomatic infection is most likely to arise when there are predisposing conditions, examples of which are given below:
Clinical Features
The patient is usually between 20 and 40, when oestrogen support of the epithelial glycogen content is at its highest. The complaint is of irritant discharge and dyspareunia. Examination reveals an inflamed and tender vagina and vulva with white plaques resembling curdled milk adhering to the vaginal wall and vulva. Removal of the plaque reveals a red inflamed area. Pre-pubertal or postmenopausal infection is less common.
Treatment
A single 500 mg clotrimazole pessary, with external application of 1% clotrimazole cream, offers convenient therapy. Routine treatment of partners is unlikely to reduce recurrence rates. In persistent or recurrent infection, confirmation of the diagnosis by culture and determination of sensitivity to treatment are important.
Bacterial vaginosis
For a long time, a large number of cases of vaginitis were labelled non-specific because of disagreement regarding the infective agent. These cases were characterised by a non-irritating, foul-smelling discharge. The discharge contains a mixture of bacteria.
Clinical Features
The patient complains of a foul-smelling discharge, and examination confirms both the discharge and the odour. In appearance, the discharge is thin, greyish and sometimes shows bubbles. A vaginal smear reveals the presence of ‘clue’ cells. Gram staining is usually negative but can be variable.
Pus cells tend to be few in number. Lactobacilli are also scanty but frequently many other bacteria are present. The pH of the fluid is raised. Although the main complaint is of malodorous discharge, some patients will have pruritus, frequency, dysuria and dyspareunia.
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