Infections of the Uterus



Infections of the Uterus


Newton G. Osborne



Women are more likely to experience pelvic infections than men because there is an open tract between the vagina, the uterine cavity, and the abdomen by which pathogens can gain entry to the uterus, fallopian tubes, ovaries, and other pelvic and abdominal structures, especially during receptive sexual activity or when transvaginal surgical procedures are performed.

The uterus consists of a body (or corpus) and a neck (or cervix). The cervix is more susceptible to exogenous infection, especially in the sexually active woman, owing to direct contact with potentially infected sexual organs. The most common organisms associated with cervicitis, endocervicitis, cervical ulcers, and other infectious cervical lesions are sexually acquired pathogens like Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, mycoplasmas, human papilloma viruses, Trichomonas vaginalis, and herpes simplex viruses.

The body of the nonpuerperal uterus seems to be less susceptible to serious sequelae of infection than other components of the female reproductive system. The complex and abundant blood supply to the uterus partially protects it against endogenous infection. The cyclic regeneration, necrosis, and sloughing of the endometrium further protects the nonpregnant uterus against the establishment of infection during the reproductive years.

The main blood supply of the uterus originates from the uterine artery. Uterine and ovarian arteries form anastomoses bilaterally to provide a rich blood supply to the uterus. There is in addition an anastomotic arcade formed by the vaginal and uterine arteries.

The border between territories irrigated by uterine and ovarian arteries differs during the follicular and the luteal phase. There is a functionally determined shift in the territorial divide of the two vascular systems depending on the phase of the menstrual cycle.

The venous system copies the arterial system with one major exception: Some of the uterine veins join the ovarian outlet. Whereas most of the venous uterine blood is collected into the iliac veins, venous blood from the upper part of the uterus drains into the ovarian vein.

The ovarian drainage is faster than the uterine drainage. Substances secreted from the endometrium will reach the utero-ovarian venous blood and be transferred to the ovarian artery. This is how PG2-alpha induces luteolysis of the corpus luteum in domestic animals; it is metabolized 95% by one passage of the lungs. If the transfer system is interrupted, the corpus luteum does not regress for several months.

In women deprived of ovarian function, the border between the blood supply systems is approximately 1 cm from the tubal ostia. The cornual part of the uterus seems to be mainly supplied from the ovarian artery. During the follicular phase, a greater part of the uterus is supplied by the ovarian artery, whereas in the luteal phase most of the uterus is supplied from the uterine artery.

Intuitively, one would expect the complex uterine blood supply to have some effect on whether uterine infections remain localized or spread by hematogenous dissemination to contiguous pelvic structures to extrapelvic organs. It is most likely that the complex vascular network of the uterus, the ovarian cycle, and the endometrial cycle have important protective functions against uterine infection in addition to their more obvious physiologic functions.


Infections of the Uterine Cervix

The cervix acts as a barrier between the vagina, an area normally colonized with several species of bacteria, and the normally sterile upper genital tract, including the endometrium and fallopian tubes. Although the cervix is a major reservoir for bacteria found in the vagina, these organisms are usually there as mere commensals. Most infections of the cervix are caused by pathogens that are acquired during sexual activity. The sexual preferences and behaviors of individuals affect their risk of acquiring sexually transmitted infections as well as the sites and clinical presentation of these infections. Both endogenous and sexually acquired organisms in the cervix may result in secondary ascending infections in the nonpuerperal uterus or may be associated with infections of amniotic membranes, endometrial cavity, myometrium,
parametria, as well as with fetal and neonatal infections in pregnant patients.

Ectocervicitis is most frequently the result of infection with Candida albicans or with sexually acquired organisms such as herpes simplex virus, Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis. Most sexually acquired genital infections require direct contact or exchange of fluids for transmission. Although cervical infection with sexually acquired pathogens implies vaginal penetration, this activity is frequently only one of several forms of sexual expression. All sexually active patients should be examined with an awareness of the possibility of a sexually acquired infection in any area of the body. The examination for evidence of sexually acquired pathogens should not be limited to the vulva, vagina, cervix, and pelvic organs. It should also include the anus, the rectum, the oral cavity, the inguinal area, and the lymph nodes. The laboratory work should include hematologic and serologic tests in addition to microbiologic studies, including genital and extragenital cultures when appropriate.


Mucopurulent Cervicitis

The term mucopurulent cervicitis refers to the clinical diagnosis of active cervical infection. Definitive criteria to establish the diagnosis are gross visualization of yellow mucopurulent material and the presence of ten or more polymorphonuclear (PMN) leukocytes per microscopic field using 1,000× magnification to observe Gram-stained material obtained from the endocervix. Special care must be taken in obtaining cervical smears to establish a diagnosis of mucopurulent cervicitis. Initially, a large cotton swab is used to absorb the vaginal secretions from the upper vagina and wipe away the mucus from the exocervix. Next, a small white cotton swab is inserted in the endocervical canal. The small cotton swab is inspected for the presence of yellow purulent material. The swab is then rolled on a glass slide, and the slide is dried and Gram stained. The slide is scanned to identify strands of mucus-containing areas of inflammatory cells. If ten or more PMNs are seen at a magnification of 1,000× a positive diagnosis is made. If the patient is having her menstrual flow or if sperm or vaginal squamous cells are identified, the microscopic test is not valid. Endocervical leukocytes are a normal response to menstruation and to the presence of sperm in the endocervical canal.

Chlamydia trachomatis is the main cause of cervical abnormal discharge in most women with mucopurulent cervicitis. Neisseria gonorrhoeae seems capable of residing in the endocervical cells without always promoting a purulent response. In the nonpuerperal woman, infection of the upper genital tract is predominantly by direct spread along mucosal surfaces from an initial infection of the cervix. The presence of mucopurulent cervicitis should prompt the clinician to screen for Chlamydia trachomatis and Neisseria gonorrhoeae. The endocervical mucus resists upward bacterial spread, especially during the secretory phase of the menstrual cycle. However, instrumentation of an infected cervix at any phase of the menstrual cycle is likely to predispose to upper genital infection, including endometritis and myometritis.

Chlamydial or gonococcal cervicitis may be asymptomatic and yet be associated with tubal infertility. Symptomatic patients complain of abnormal vaginal discharge, intermenstrual or postcoital spotting, and dyspareunia. Most cases of chlamydial or gonococcal cervicitis persist if untreated. Infection may spread to the endometrium and fallopian tubes to culminate in silent or acute salpingitis.

During physical examination, certain signs may assist in making the diagnosis of chlamydial or gonococcal cervicitis. After absorbing the upper vaginal secretions and wiping away the mucus from the exocervix, the classic mucopus may be evident. In some cases the columnar epithelium of the endocervix is friable and bleeds on contact with a cotton-tipped swab. Tenderness may be elicited on palpation or motion of the cervix.

If the diagnosis of mucopurulent cervicitis is made, the patient should be treated for gonococcal and chlamydial cervicitis. Treatment is by intramuscular injection of a β-lactamase–resistant second-generation cephalosporin (125 mg ceftriaxone intramuscularly [IM], for example) followed by doxycycline (100 mg every 12 hours for 1 week). For women allergic to β-lactam antibiotics or to doxycycline, a single 1-g dose of azithromycin administered orally is effective for treatment of chlamydial infection. Since as many as 30% of patients with chlamydial cervicitis are coinfected with Neisseria gonorrhoeae, these women must also be treated with either ofloxacin (400-mg single dose orally), ciprofloxacin (500-mg single dose orally), or with spectinomycin (2-g IM single dose).


Infectious Ulcers

Genital ulcer disease is a common condition of women with HIV disease, but may be seen in women who are not infected with HIV. Most infectious ulcers of the cervix are caused by herpes simplex or an initial infection with Treponema pallidum. Ulcers secondary to infection with the agent of granuloma inguinale (Calymmatobacterium granulomatis), with the agent of chancroid (Haemophilus ducreyi), or because of lymphogranuloma venereum (L1, L2, or L3 strains of Chlamydia trachomatis) are very rarely seen on the cervix and for this reason will not be further discussed in this chapter.


Herpes Simplex Virus

Although primary infection with herpes is a local and systemic disease, recurrent herpes is a local disease. Frequently there is simultaneous involvement of the vulva, vagina, and cervix with both primary and recurrent infection, but recurrent infections are typically much less severe than the primary infection. Herpes simplex virus infection confined to the cervix is rare. Cervical infection is usually associated
with leukorrhea, occasional abnormal spotting, vaginal pain, and dyspareunia, but in some cases it may be asymptomatic. The appearance may be of discrete small ulcerations, very similar to the lesions seen on the vulva, or they may coalesce to form a large ulcer that may be confused with a chancre of the cervix. Although rapid diagnostic techniques are available, virus isolation in tissue culture remains the standard against which all other diagnostic procedures are compared.

Cervical infection with herpes is of special obstetric importance. Pregnant women with primary genital herpes, particularly in the second or third trimesters, have a high rate of major complications, including preterm labor, intrauterine growth restriction, congenital infection, and persistent viral shedding later in pregnancy. If lesions are present at the time of labor, a cesarean section should be performed to reduce the risk of neonatal herpes. Patients with cervical, vaginal, vulvar, or perineal herpetic lesions should be treated with acyclovir, 200 mg five times per day, ganciclovir, 1 g two times per day, or famciclovir, 250 mg three times per day. The therapeutic goal in pregnancy is to eliminate herpetic lesions or viral shedding prior to the time of labor and delivery. As mentioned, the presence of genital lesions at the onset of labor is an indication for cesarean section.


Syphilis

Treponema pallidum, the causative agent of syphilis, is one of the few pathogenic spirochetes that infect humans. Syphilis, the infection that most commonly comes to mind when the term “venereal disease” is used, is a chronic, systemic, and complex disease. Cervical chancre is second only to vulvar chancre in primary syphilis. The lesion may be confused with cervical erosion. It may present as an ulcer with an indurated base and elevated borders rounded by an edematous zone, or it will appear as a nonindurated erosion covered by a membranous exudate. When a chancre is present, the diagnosis of syphilis is established by demonstration of spirochetes with darkfield microscopy. Treatment is with weekly intramuscular injections of 2.4 million units benzathine penicillin until a total dose of 7.2 million units is delivered (a total of three injections). The rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-ABS) serologic tests are used in these cases to monitor the effectiveness of treatment.


Cervical Tuberculosis

Tuberculosis is endemic in underdeveloped countries. In many parts of the world, including the United States of America, the resurgence of tuberculosis is linked to the increasing incidence of HIV infection. The prevalence of active tuberculosis in homeless persons in the United States is estimated to be >6%, and estimates of latent infection range between 18% and 50%. Genital tuberculosis usually results from hematogenous spread of pulmonary tuberculosis. The genital organs most frequently affected are the fallopian tubes. Spread to the endometrium and cervix reflects the blood distribution of the tubes and corpus of the uterus. There is direct extension to the uterus in about 50% of cases where the fallopian tubes are involved, and to the cervix in up to 15% of these cases. Cervical tuberculosis is seen in approximately 1% of cases of congenital tuberculosis. When the cervix is involved, it is markedly irregular and may be ulcerated, giving the appearance of a malignant tumor. A biopsy of the cervix, however, will reveal granuloma with epithelioid cells surrounded by lymphocytes and Langhans-type giant cells. Mycobacterium tuberculosis may be recovered by culture in specialized media. Treatment of genital tuberculosis is similar to that required for pulmonary tuberculosis. The duration of treatment is between 6 and 9 months and includes administration of two to four anti-tuberculosis drugs (isoniazid, rifampin, ethambutol, and pyrazinamide). Management of pelvic tuberculosis should be carried out in consultation with an infectious diseases specialist.

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Jul 29, 2016 | Posted by in UROLOGY | Comments Off on Infections of the Uterus

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