Upper Female Reproductive Tract and Infections

• Upper Female Reproductive Tract

  The tract between the vagina, pelvis, and abdomen in women
• Women experience more upper reproductive tract, pelvic, and abdominal infections compared to men because of the absence of a mucosal lining or epithelium between these spaces and the external body in the female patient
• Defenses such as ciliary movement creating flow and cervical mucus exist, but there is essentially an open tract between the vagina, the pelvis, and abdomen
• This can lead to ascending infections of the uterus, fallopian tubes, adnexa, pelvis, and abdomen
• This open ascending tract may also lead to the acquisition of toxic shock syndrome (TSS)
• The vaginal epithelium is easily abraded during intercourse, so transmission of systemic infections such as HIV and hepatitis B and C is more common from men to women than the converse
• Endometritis


  Infection of the uterine endometrium
• Endomyometritis


  Infection that invades into the myometrium
• Endometritis and endomyometritis are included in a spectrum of inflammatory disorders of the upper female genital tract that comprises pelvic inflammatory disease (PID)
• Risk factors for endometritis

  • Retained products of conception
  • Sexually transmitted infections (STIs)
  • Intrauterine foreign bodies or growths
  • Instrumentation of the intrauterine cavity
• Endometritis is seen most commonly after cesarean delivery, but also after vaginal deliveries and surgical pregnancy terminations
• Endometritis is an uncommon complication of minimally invasive transcervical gynecologic procedures such as hysteroscopy, endometrial ablation, endometrial biopsy, and intrauterine device (IUD) placement
• Antibiotic prophylaxis is recommended for cesarean sections, surgical terminations of pregnancy, and hysterosalpingography or sonohysterography in women with a history of pelvic infection or if dilated tubes are demonstrated
• Nonpuerperal endometritis is not commonly recognized but is probably coexistent with 70% to 80% of PID
• Chronic endometritis is often asymptomatic but is clinically significant because it leads to other pelvic infections and, uncommonly, endomyometritis
• Chronic endometritis is often a polymicrobial infection with a variety of pathogens, including skin and gastrointestinal flora in addition to the usual flora colonizing the lower reproductive tract
• Mycobacterium tuberculosis is a rare cause of chronic endometritis in developed countries but is a leading cause of infertility in endemic countries
• Chronic endometritis


  Can be suspected in patients with chronic irregular bleeding, discharge, and pelvic pain
• The diagnosis of chronic endometritis can be made in a nonpuerperal patient with endometrial biopsy showing plasma cells
• Treatment of severe endomyometritis unrelated to pregnancy


  Same as treatment for PID
• Treatment of postpartum endomyometritis

  1. Clindamycin 900 mg IV every 8 hours and gentamicin loaded with 2 mg/kg IV and then maintained with 1.5 mg/kg IV every 8 hours

  2. Single daily IV dosing of gentamicin (5 mg/kg every 24 hours) may be substituted for 8-hour dosing

  3. Single antibiotic agent treatment with cephalosporins such as cefoxitin 2 g IV every 6 hours
• Treatment continues until clinical improvement and afebrile status for 24 to 48 hours. Oral antibiotic therapy is not required following successful parenteral treatment
• Treatment of nonpuerperal infections where chlamydial infection may be the suspected cause

  Doxycycline should be added to the regimen for a total of 14 days
• Treatment of chronic endometritis

  10- to 14-day course of doxycycline 100 mg PO BID
• Pelvic inflammatory disease (PID)


  Infection of the upper female genital tract including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis
• PID is the most common serious complication of sexually transmitted infections (STIs)
• An estimated 750,000 to 1 million cases of PID occur annually in the United States
• The annual expense of initial treatment is estimated at $3.5 to $5 billion, which does not account for possible future treatment for the principal sequelae, including infertility and increased ectopic pregnancies
• PID is strongly associated with infertility. Infertility risk increases with the number of PID episodes: 12% with one episode, approximately 20% with two episodes, and 40% with three or more episodes
• The risk of ectopic pregnancy is increased as much as 7- to 10-fold and approximately 20% of women develop chronic pelvic pain during their lifetime
• Among sexually active women, the incidence of PID is highest in the 15- to 25-year-old age group (at least three times greater than in the 25- to 29-year-old age group)
• Risk factors for PID


  • Nonwhite and non-Asian ethnicity
  • Multiple partners
  • Recent history of douching
  • Prior history of PID
  • Cigarette smoking
• IUDs are considered a risk factor for PID when insertion occurs in the setting of concurrent chlamydial infection or gonorrhea, where the prevalence of STIs is high, and when aseptic conditions cannot be assured
• Barrier contraceptives have been shown to decrease the incidence of PID, and use of oral contraceptives appears to diminish the severity of PID
• Acute salpingitis


  Principal symptom is abdominal or pelvic/adnexal pain
• Fever is a less common symptom, seen in only 20% of women with PID
• Diagnostic criteria for PID

  • Pelvic or lower abdominal pain in sexually active young women or women at risk for STIs
  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness
  • Fever (>38.3°C)
  • Abnormal cervical or vaginal mucopurulent discharge
  • Abundant WBC on saline microscopy of vaginal secretions
  • Elevated erythrocyte sedimentation rate
  • Elevated C-reactive protein
  • Cervical Neisseria gonorrhoeae or Chlamydia trachomatis infections
• Cervical cultures are performed to find a causative organism but, because of the disease's polymicrobial nature, should not dictate the treatment regimen
• The definitive diagnosis is made via laparoscopy, endometrial biopsy, or pelvic imaging with PID findings
• The principal organisms suspected of causing PID are N. gonorrhoeae and C. trachomatis; these two organisms together account for approximately 40% of all PID cases