Daring Aidil Akbar Internal Genital Infection

INTERNAL GENITAL
INFECTION
Dr. Aidil Akbar, SpOG
Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
CERVICITIS
Cervicitis —> an inflammation of the
uterine cervix
Characteristically:
(1) a visible, purulent or mucopurulent
endocervical exudate in the
endocervical canal or on an
endocervical swab specimen and/or
(2) sustained, easily induced
endocervical bleeding when a cotton
swab is gently passed through the
cervical os.
Etiologi
The most common —> Chlamydia trachomatis and
Neisseria gonorrhea.
Other etiologic organisms —> Trichomonas vaginalis

and herpes simplex virus (HSV), especially primary
type 2 HSV
Noninfectious
• local trauma
• radiation
• chemical irritation
• systemic inflammation
• malignancy
Symptoms and Signs of
Cervicitis
• Cervicitis is often asymptomatic in gonorrhea,
chlamydia, and T vaginalis infections
• When present, symptoms are often nonspecific and
may include increased vaginal discharge, dysuria,
urinary frequency, and intermenstrual or postcoital
bleeding.
• Most patients with herpes simplex virus (HSV)
infection are asymptomatic. However, the first
episode of genital herpes is frequently highly
symptomatic and is marked by painful ulcerations
associated with fever, myalgia, headache, and
general malaise
• Dysuria, vaginal discharge, and urethral discharge
are also common symptoms
Diagnosis of Cervicitis
Speculum examination
• The cervix is erythematous, edematous, or easily friable

• Classic mucopurulent cervicitis is present if thick,
yellow-green pus is visible in the endocervical canal (the
cervical os) or on an endocervical swab specimen
• Note cervical warts or ulcerations
Bimanual examination
• To assess tenderness or enlargement of the cervix,
uterus, and adnexa
• Cervicitis or pelvic inflammatory disease (PID) is
suspected if the patient has cervical motion tenderness
Cervicitis
Chlamydia
Chlamydia
trachomatis
Neisseria
gonorrhoeae
Differential Diagnosis
Treatment of Cervicitis
Chlamydial cervicitis
Azithromycin 1 g oral (PO) in a single dose, OR Doxycycline 100 mg PO twice daily for
7 days
Effective alternative agents to azithromycin and doxycycline for the treatment of

chlamidia include erythromycin, levofloxacin, and ofloxacin, as follows
Erythromycin base 500 mg PO four times daily for 7 days, OR
Erythromycin ethylsuccinate 800 mg PO four times daily for 7 days, OR
Levofloxacin 500 mg PO once daily for 7 days, OR
Ofloxacin 300 mg PO twice daily for 7 days
These patients should also be treated concurrently for gonococcal infection in areas
with high gonorrhea prevalence or if the individual’s personal risk is high. In women
who defer presumptive treatment, the need for therapy depends on the results of
sensitive tests for chlamydia and gonorrhea.
Treatment of Cervicitis
Gonococcal cervicitis
For uncomplicated gonococcal infections of the cervix
Ceftriaxone 250 mg administered intramuscularly (IM) in a single dose, PLUS
Azithromycin 1 g PO in a single dose or doxycycline 100 mg PO twice daily for 7 days
Cefexime 400 mg in a single dose, PLUS
Azithromycin 1 g PO in a single dose or doxycycline 100 mg PO twice daily for 7 days
Trichomoniasis
metronidazole 2 g PO in a single dose or tinidazole 2 g PO in a single dose for T
vaginalis infections. Alternatively, metronidazole 500 mg PO twice daily for 7 days can
be given.
ENDOMETRITIS
Endometritis —> inflammation of the
endometrial lining of the uterus. In
addition to the endometrium, inflammation
may involve the myometrium and,
occasionally, the parametrium
Endometritis:
• pregnancy-related endometritis
• endometritis unrelated to pregnancy—>
pelvic inflammatory disease (PID).
Patofisiologi
• usually results from an ascending infection from the lower
genital tract.
• Acute —> the presence of neutrophils within the endometrial

glands
• In the nonobstetric population —> pelvic inflammatory
disease and invasive gynecologic procedures
• In the obstetric population —> postpartum infection is the
most common predecessor
• Chronic —> the presence of plasma cells and lymphocytes

within the endometrial stroma
• in the obstetric population —> associated with retained
products of conception after delivery or elective abortion
• In the nonobstetric population —> infections (eg, chlamydia,
tuberculosis, bacterial vaginosis) and the presence of an
intrauterine device
Etiologi
Polymicrobial —> 2-3 organisms
it arises from an ascending infection from organisms found
in the normal indigenous vaginal flora.
Commonly isolated organisms:

• Ureaplasma urealyticum
• Peptostreptococcus
• Gardnerella vaginalis
• Bacteroides bivius
• group B Streptococcus
• Chlamydia has been associated with late-onset
postpartum endometritis
• Enterococcus is identified in up to 25% of women who
have received cephalosporin prophylaxis
Diagnosis
Diagnosis usually is based on clinical findings, as
follows:
• Fever
• Lower abdominal pain
• Foul-smelling lochia in the obstetric population
• Abnormal vaginal bleeding
• Abnormal vaginal discharge
• Dyspareunia (may be present in patients with PID)
• Dysuria (may be present in patients with PID)
Malaise
PID caused by Chlamydia tends to be indolent, with no

significant constitutional symptoms
Faktor risiko
The following factors increase the risk for
endometritis in general:
• Presence of an intrauterine device: the vaginal part
of the device may serve as a track for the
organisms to ascend into the uterus
• Presence of menstrual fluid in the uterus
• Associated cervicitis secondary to gonorrhea or
Chlamydia infection
• Associated bacterial vaginosis
• Frequent douching
• Unprotected sexual activity
• Multiple sexual partners
PELVIC INFLAMMATORY DISEASE
Infection of the uterus, fallopian tubes, and

adjacent pelvic structures that is not associated
with surgery or pregnancy
Etiology and Pathogenesis
-acquisition of a vaginal or cervical infection

-direct ascent of micro-organisms from the vagina and cervix
ORGANISMS MOST COMMONLY ISOLATED :
Neisseria gonorrhoeae and Chlamydia trachomatis

Gardnerella vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, herpes simplex virus-2
(HSV-2), Trichomonas vaginalis, cytomegalovirus, Haemophilus influenzae, Streptococcus
agalactiae
Symptoms
lower abdominal pain
abnormal vaginal discharge
abnormal uterine bleeding
dysuria
dyspareunia
nausea
vomiting
fever
Gonococcal PID - dramatic symptoms of fever and peritoneal irritation

Diagnosis
Antibiotics
Antibiotics
TUBO OVARIAN ABSCESS
Tubo-Ovarian Abscess (TOA) is usually a
consequence of pelvic inflammatory disease (PID)
Pelvic abscesses are classically polymicrobial with
predominance of anaerobic bacteria
Women with TOA most commonly present with lower
abdominal pain and with unilateral or bilateral
adnexal masses
Fever and leukocytosis may be absent
Abscess rupture causes severe pain with chills,
fever, and progressive peritonitis
Treatment
Treatment of a patient with an abscess should include

parenteral antimicrobial therapy until the patient has been
afebrile for at least 24 hours, preferably 48 to 72 hours
Surgery is rarely required
If antibiotic treatment fails, then abscess drainage alone
typically will suffice. Often this is possible percutaneously by
a radiologist with CT guidance and should be considered
initially for abscesses larger than 8 cm.
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INTERNAL GENITAL

Dr. Aidil Akbar, SpOG

Other etiologic organisms —> Trichomonas vaginalis

• The cervix is erythematous, edematous, or easily friable

Effective alternative agents to azithromycin and doxycycline for the treatment of

Erythromycin base 500 mg PO four times daily for 7 days, OR

Erythromycin ethylsuccinate 800 mg PO four times daily for 7 days, OR

Levofloxacin 500 mg PO once daily for 7 days, OR

Ofloxacin 300 mg PO twice daily for 7 days

Ceftriaxone 250 mg administered intramuscularly (IM) in a single dose, PLUS

Azithromycin 1 g PO in a single dose or doxycycline 100 mg PO twice daily for 7 days

Cefexime 400 mg in a single dose, PLUS

Azithromycin 1 g PO in a single dose or doxycycline 100 mg PO twice daily for 7 days

• Acute —> the presence of neutrophils within the endometrial

• Chronic —> the presence of plasma cells and lymphocytes

Commonly isolated organisms:

PID caused by Chlamydia tends to be indolent, with no

Infection of the uterus, fallopian tubes, and

-acquisition of a vaginal or cervical infection

ORGANISMS MOST COMMONLY ISOLATED :

Neisseria gonorrhoeae and Chlamydia trachomatis

Gonococcal PID - dramatic symptoms of fever and peritoneal irritation

Treatment of a patient with an abscess should include

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