Infections of the Lower Reproductive Tract

• Urinary tract infections (UTIs) are one of the most common infections of the lower genitourinary tract treated by clinicians
• Approximately 50% of women will be diagnosed with a UTI during their lives and at an incidence of approximately 1% per year in adult women; 5% will have recurrent episodes
• Urethritis


  Discomfort or pain at the urethral meatus or a burning sensation throughout the urethra with micturition
• Cystitis


  Pain in the midline suprapubic region and/or frequent urination
• Factors that increase risk of UTIs

  • Sexually active women
  • Obesity
  • Increasing age
  • Anatomic or neurologic abnormalities
  • Diabetes mellitus
  • Sickle cell disease
• UTIs are more common in women than men due to the shorter length of the urethra and its proximity to the vagina and rectum
• Diagnosis of UTI


  1. Clean voided midstream urine sample for urinalysis and microscopic examination

  2. Hematuria, leukocytes, leukocyte esterase, or nitrates in the absence of a vaginal infection are indicative of a UTI

  3. Microscopic bacteruria without the presence of inflammatory cells or in the presence of squamous epithelial cell is most likely contamination

  4. Urine collected via catheterization to distinguish contamination from true infection

  5. Urine culture to confirm diagnosis, but not required in uncomplicated cases
• Organisms that commonly cause UTIs

  • Escherichia coli
  • Staphylococcus saprophyticus
  • Proteus mirabilis
  • Klebsiella pneumoniae
  • Enterococcus
• If the urine culture is negative, the diagnosis should be reconsidered
• In patients with symptoms consistent with urethritis, organisms such as Chlamydia trachomatis and Neisseria gonorrhoeae should be considered and screened for using a midstream collection
• Another etiology of urethritis is herpes simplex virus (HSV) infection
• In patients with symptoms of cystitis, but a negative culture, the diagnosis of overactive bladder or painful bladder syndrome (interstitial cystitis) should be entertained
• Treatment of uncomplicated UTIs

  1. Oral antibiotics such as trimethoprim-sulfamethoxazole, nitrofurantoin, or a fluoroquinolone for 3 to 7 days

  2. Follow-up culture sensitivities to ensure adequate treatment of pathologic organisms

  3. Ampicillin or cephalexin have also been used, but beta-lactams have become less effective

  4. Local sensitivities of common organisms should be known
• Patients with symptoms consistent with pyelonephritis are usually treated as an inpatient with IV antibiotics
• Outpatient management has been studied and is used increasingly in reliable patients without other medical issues
• A 14-day antimicrobial therapy should be completed for pyelonephritis
• Vulvitis


  The most common cause is candidiasis, which usually presents with vulvar erythema, pruritus, and small satellite lesions
• Causes of ulcerated vulvar lesions

  • Herpes
  • Syphilis
  • Chancroid
  • Lymphogranuloma venereum
• Up to 25% of patients with genital ulcers will not have a laboratory-confirmed diagnosis
• Crohn's disease can have linear "knife cut" vulvar ulcers as its first manifestation, preceding gastrointestinal or other systemic manifestations by months to years
• Behçet disease leads to tender and highly destructive vulvar lesions that often cause fenestrations in the labia and extensive scarring
• Syphilis


  A chronic systemic infection caused by the spirochete Treponema pallidum, transmitted primarily through direct sexual contact
• Primary syphilis


  • Initial lesion is a painless, red, round, firm ulcer approximately 1 cm in size with raised edges known as a chancre
  • Develops approximately 3 weeks after inoculation and is usually associated with concomitant regional adenopathy
• Secondary syphilis


  • Systemic disease that occurs as T. pallidum disseminates, typically with flu-like symptoms, fever, myalgias, and a maculopapular rash on the palms and soles
  • Moist papules and mucous patches can also occur
• Latent syphilis


  Infection enters a latent phase that can last for years, further divided as early (acquired <1 year) or late (acquired >1 year)
• Tertiary syphilis


  • Characterized by granulomas (gummas) of the skin and bones, cardiovascular syphilis with aortitis, and neurosyphilis with meningovascular disease, paresis, and tabes dorsalis
• Diagnosis of syphilis


  1. Screening with nontreponemal anticardiolipin antibody tests like VDRL or RPR

  2. Positive results must be confirmed with specific treponemal antibody studies like FTA-ABS or TPPA

  3. Primary, secondary, tertiary, and neurosyphilis can be diagnosed by presenting signs and symptoms
• Treatment of syphilis


  1. Penicillin remains the drug of choice

  2. Primary, secondary, or early latent syphilis can be treated with benzathine penicillin G 2.4 million units IM one time

  3. Late latent or latent of unknown duration syphilis requires penicillin G 2.4 million units IM weekly for 3 weeks

  4. Alternative regimens for penicillin-allergic patients include doxycycline, tetracycline, ceftriaxone, or azithromycin, but close follow-up is essential

  5. Neurosyphilis requires aqueous crystalline penicillin
• Penicillin G 2.4 million units IM weekly for 3 weeks


  Treatment for late latent or latent of unknown duration syphilis
• Doxycycline 100 mg orally twice a day for 14 days, tetracycline 500 mg orally four times a day for 14 days, ceftriaxone 1 g IM or IV daily for 10 to 14 days, or azithromycin 2 g single oral dose


  Alternative regimens for penicillin-allergic, nonpregnant patients with primary or secondary syphilis
• Penicillin remains the only recommended treatment in pregnancy, with sufficient evidence demonstrating efficacy for preventing maternal syphilis transmission to the fetus and for treating fetal infection
• Aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hours for 10 to 14 days

  Treatment for neurosyphilis
• Procaine penicillin 2.4 million units IM once daily plus probenecid 500 mg orally four times a day both for 10 to 14 days


  Alternative treatment for neurosyphilis
• Some authorities further recommend following the recommended or alternative neurosyphilis treatment with benzathine penicillin 2.4 million units weekly IM for 3 weeks after completion of either regimen
• Jarisch-Herxheimer reaction


  Acute febrile reaction frequently accompanied by fever, chills, headache, myalgia, malaise, pharyngitis, rash, and other symptoms that usually occur within the first 24 hours (generally within the first 8 hours) after any therapy for syphilis
• The Jarisch-Herxheimer reaction might induce preterm contractions or cause fetal distress in pregnant women, but this should not prevent or delay therapy
• Herpes simplex virus (HSV) infections are quite common in the perioral and genital regions
• Although only about 5% of women report a history of genital herpes infection, as many as 25% to 30% have antibodies on serologic testing
• After this initial herpes outbreak, recurrent episodes can occur as frequently as one to six times per year
• Subclinical or asymptomatic shedding can occur and is more frequent during the first 6 months after acquisition and immediately before or after recurrent outbreaks