GYNECOLOGY

UPPER GENITAL TRACT INFECTIONS

Dr. Jennifer Co | MD2024
Disclaimer: Use at your own risk!!! rawr ○ N. gonorrhoeae
I. ENDOMETRITIS
■ 15% of women with cervical infection by this
● Infection of the uterine lining bacteria subsequently develops into acute PID
● Risk factors for isolated endometritis:
■ Lack of antibody titers against the outer
○ Douching in last 30 days (due to ascending) membrane protein of N. gonorrhoeae may explain
○ Current IUD in place why teenagers are more likely to develop PID
○ Douching in days 1-7 of menstrual cycle than women in late 20s
● Associated with infection with C. trachomatis and N.
■ Gonococci ascends to the fallopian tube and
gonorrhoeae among women with suspected PID selectively adheres to nonciliated
mucus-secreting cells → majority of damage
A. DIAGNOSIS & MANAGEMENT occurs to the ciliated cells from acute
Endometrial Biopsy - gold standard complement-mediated inflammatory response
● At least 1 plasma cell/x 120 field of endometrial stroma with migration of PMNs, vasodilation, and
combined with ≥ 5 neutrophils in the superficial transudation of plasma into the tissues →
endometrial epithelium/x 400 field inflammatory response causes cell death and
damage → repair with removal of dead cells and
fibroblast → scarring and tubal adhesions
○ C. trachomatis
■ More prevalent
■ 30% of women with acute cervicitis secondary
to chlamydia subsequently develop acute PID
■ May remain in the tubes for months after initial
colonization of the upper genital tract
■ Cell-mediated immune mechanisms appear to be
important in tissue destruction
■ Primary infection appears to be self-limited with
mild infection and little permanent damage
Note: Endometritis is under PID, hence, management is the same ■ Repeat exposures to chlamydia (e.g.,
asymptomatic untreated CT cervical infection)
II. PELVIC INFLAMMATORY DISEASE (PID)
→ autoimmune response to chlamydial heat
● Infection in the upper genital tract not associated with
shock protein → severe tubal damage even if CT
pregnancy or intraperitoneal pelvic operations
is no longer present and Fits-Hugh-Curtis
● Include infection of any or all of the ff:
syndrome (adhesions between the liver and
○ Endometrium (Endometritis)
diaphragm indicating prior peritonitis;
○ Oviducts (Salpingitis) - most characteristic/common
“violin-string”)
component of PID
■ Atypical or Silent PID
○ Ovary (Oophoritis)
● Asymptomatic or mild symptoms despite
○ Uterine wall (Myometritis)
ongoing inflammation of upper genital tract;
○ Uterine Serosa
gradual/indolent course
○ Broad ligaments (Parametritis)
● Sequelae: tubal factor infertility, ectopic
○ Pelvic Peritoneum
pregnancy
● Bacterial Vaginosis (BV)-associated microorganisms have
A. PATHOGENESIS AND ETIOLOGY
been isolated laparoscopically from the fallopian tubes of
PATHOGENESIS
women with BV and PID
● >99%: ascending infection
○ Not always sexually-transmitted: Candida and
from the bacterial flora of
BV-associated microorganisms
the vagina and cervix
● Other causative agents (part of normal flora): Mycoplasma
● <1%: transperitoneal
hominis and Ureaplasma urealyticum
spread from an infectious
○ M. hominis - commensal
material from a perforated
○ Rate of isolation of genital mycoplasmas from the
appendix or
cervix: 75%, and similar in populations of women who
intraabdominal abscess
are sexually active both with and without PID
● Rare af: hematogenous and lymphatic spread to the tubes
○ In women with acute PID, direct tubal cultures
and ovaries
demonstrated:
■ M. hominis in 4-17%
ETIOLOGY
■ U. urealyticum in 2-20%
● Polymicrobial Infection
○ Pathology is in the parametria and the tissues
● 2 classically sexually-transmitted organisms: N.
surrounding the tubes, not in the tubal lumen
gonorrhoeae and C. trachomatis (25 - 50% of the time: can
coexist in the same individual)

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 ○ Not highly pathogenic and the presence of genital ● Abundant WBCs in saline microscopy of vaginal
mycoplasma does not change the clinical secretions
presentation and clinical course of acute PID ● Elevated ESR
○ Both may colonize or persist in the endometrial cavity ● Elevated CRP
after complete recovery from acute PID ● Cervical discharge (mucopurulent)
● Endogenous Aerobic and Anaerobic Flora of the Vagina
○ Most common aerobic organisms: Definitive Diagnostic Criteria
■ Nonhemolytic Streptococcus, E. coli, GBS (Strep. ● Endometrial biopsy with histopathologic evidence of
agalactiae), Coagulase-negative Staphylococcus endometritis
○ Anaerobic organisms predominate over aerobes: ○ Not used as initial tool for diagnosis EXCEPT in Pelvic
Bacteroides spp., Peptostreptococcus, Peptococcus Tuberculosis
● Transvaginal sonography or MRI - thick fluid-filled tubes
Note: Regardless of the initiating event, the microbiology of ○ Earliest/easiest that can be done, more especially
PID should be treated as mixed/polymicrobial. TVS (remember, mahal ang MRI)
● Give broad-spectrum antibiotics to cover all organisms ● Laparoscopic abnormalities consistent with PID (gold
standard)
○ If you suspect PID in a patient, you don’t do
laparoscopy. It should be a “last resort” test, as you
wouldn’t want to subject your patient to anesthetic
risk and a very expensive procedure para sa
“suspected” lang

B. RISK FACTORS
● Age at first intercorse
○ Younger coitarche = more likely to have more sexual D. MANAGEMENT
partners down the line Objectives:
● Multiple partners ● Short-term: elimination of signs and symptoms and
● Lack of contraception eradication of infecting organisms
● Oral contraceptive use ● Long-term: reduction of tubal damage and preservation
● Intrauterine device (IUD) - The increase in risk for PID of fertility capacity
occurs only at the time of insertion and in the first 3 weeks
after placement i. OUTPATIENT THERAPY
● Previous tubal ligation - rare and less severe
● Previous PID - 25% subsequently develop another tubal
infection
● Transcervical penetration with instrumentation
(Iatrogenic) - e.g., Hysteroscopy, D&C
● Virulence factors

C. DIAGNOSIS
Minimum Criteria
Empirical treatment of PID should be initiated in sexually
active young women and others at risk for STIs if the ff. are
present and no other cause(s) for the illness can be identified:
● Uterine (or lower abdominal) tenderness, or
● Adnexal tenderness, or ● Management is the same as that of isolated endometritis
● Cervical motion tenderness ● Reexamine women within 48-72 hrs. of initiating
outpatient therapy
Additional Criteria for Diagnosing PID ● Hospitalization warranted if not responding
Increases the specificity of diagnosis; implies inflammatory in ● Reevaluate 4-6 weeks after therapy to assess resolution
nature of clinical symptoms and establish post-therapy baseline
● Oral Temperature >38℃
● Laboratory documentation of cervical chlamydia (CT) or
gonorrhea (GC) infection

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 ii. INPATIENT THERAPY Parenteral to Oral Shift:
Indications for Hospitalizing Patients with Acute PID: Symptoms have diminished and the woman afebrile for 24 hrs.
● Surgical emergencies (e.g., appendicitis) cannot be → switch to oral antibiotics → Doxycycline 100 mg BID x 14
excluded days or Clindamycin 450 mg QID x 14 days (alternative)
● Pregnant patients - not very common
● Patient does not respond clinically to oral antimicrobial E. SHORT-TERM SEQUELAE
therapy ● Perihepatitis
● Patients is unable to follow or tolerate an outpatient oral (Fitz-Hugh-Curtis
regimen syndrome)
● Patient has severe illness, nausea and vomiting, or high ○ “violin-string”
fever adhesions
● Patient has a tuboovarian abscess (TOA) ● Tubo-ovarian Abscess
○ Collection of pus
within a newly
created space
● Tubo-ovarian Complex
○ Collection of pus
within an anatomic
space created by
adherence of
adjacent organs
Abscess cavity → Low level
oxygen tension →
● No Metronidazole because anaerobic coverage is already Predominance of anaerobic organisms
accomplished by Cefotetan and Cefoxitin
● Cefotetan - not available in the PH Treatment:
Regimen A Clindamycin
● Doxycycline + IV Cefoxitin ● Stable in abscess environment
● Advantages: excellent for community-acquired infection ● Possess ability to penetrate human neutrophils
○ Doxycycline and cefoxitin - provide excellent Clindamycin + Aminoglycoside (Gentamicin)
coverage for: ● Standard for treatment of TOA
■ N. gonorrhoeae ● Does not treat Enterococcus (add Ampicillin should this
■ C. trachomatis organism be involved)
■ Penicillinase-producing N. gonorrhoeae
○ Cefoxitin
■ Peptococcus
■ Peptostreptococcus
■ E. coli
● Disadvantage: the two drugs are less than ideal for a
pelvic abscess or anaerobic infections
● Doxycycline should be included in the regimen of follow-up
oral therapy (2 weeks)
Parenteral to Oral shift after Clindamycin-Gentamicin
Regimen B
Regimen:
● Clindamycin + Aminoglycoside (Gentamicin)
● Advantage: excellent coverage for anaerobic infections Without TOA Clindamycin 450 mg QID x 14 days [or]
and facultative gram-negative rods Doxycycline 100 mg BID x 14 days
● Preferred for patients with an abscess (esp. Clindamycin),
With TOA Clindamycin 450 mg QID [or]
IUD-related infection, and pelvic infection after a Metronidazole 500 mg BID x 14 days +
diagnostic or operative procedure Doxycycline 100 mg BID x 14 days

Reassess:
Operative Treatment
● After 3 days of treatment
Indications:
● Continue regimen for at least 24 hours after substantial
● Life-threatening infections
improvement
● Ruptured tuboovarian abscesses
● With no improvement, consider:
● Persistent masses in older women for whom childbearing
○ wrong diagnosis
is not a consideration
○ resistant organism (e.g., enterococcus)
● Removal of a persistent symptomatic mass
○ mixed abscess, or rupture
Procedures:
○ septic thrombophlebitis
● Drainage of cul-de-sac abscess via percutaneous
drainage or a colpotomy incision

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● Unilateral Salphingooophorectomy - removal of one ovary ● Diagnosis is usually not made until a tuboovarian abscess
and uterus on one side is examined by a pathologist
● Total Abdominal Hysterectomy with Bilateral ● Histologic examination: “sulfur granules” with gram (+)
Salpingooophorectomy (TAHBSO) filaments

F. LONG-TERM SEQUELAE B. CLINICAL MANIFESTATIONS

Infertility ● Fever
● Incidence following acute PID varies from 6-60% ● Abdominal pain
depending on the severity of infection, number of ● Abnormal uterine bleeding
episodes of infection, and age of the woman ● Chronic endometritis with foul-smelling discharge
Ectopic Pregnancy ● Widespread adhesions, induration, and fibrosis
● 10-15% of pregnancies will be ectopic after ● Most cases have been described among women wearing
laparoscopically mild to moderate PID IUD >8 years
Recurrent PID ● High detection rate in pap smears of women with IUD
● Approx. 25% of women ● Extreme rarity of progression to upper tract infection
Chronic Pelvic Pain
● May be caused by a Hydrosalpinx, a collection of sterile C. TREATMENT
watery fluid in the fallopian tube; end-stage of a ● The decision to remove the IUD to treat the patient
pyosalpinx depends on the presence of clinical symptoms
○ Difficult to get pregnant ● TOA
○ For patients undergoing IVF, hydrosalpinx has to be ○ Surgery
removed because fluid is embryotoxic ○ Medical management for 12 weeks
● Develops in a woman with normal pelvic examination 4 to ■ Oral Penicillins
8 weeks following an acute infection ■ Doxycycline
● Pain from adhesions and resultant fixation ■ Fluoroquinolones
● May benefit from laparoscopy to establish the diagnosis
and rule out other diseases, such as endometriosis IV. PELVIC TUBERCULOSIS
● Conservative surgery via either Laparoscopy or ● Tuberculosis of the upper genital tract, primarily chronic
Celiotomy salpingitis and chronic endometritis, is a rare disease in
the US (edi sana ol nasa US)
G. SEXUAL PARTNER ● Primary site of infection: lungs
● Examine and treat sex partners ● Spread: hematogenous to the oviducts, endometrium, and
● Health education ovaries
● Culture discharge ● Typical patient presentation (daw): tachypneic, abdominal
● Empiric treatment: enlargement, amenorrheic
○ Cefixime 400 mg SD [or]
Ceftriaxone 250 mg SD A. CLINICAL MANIFESTATIONS
○ Doxycycline 100 mg BID for 7 days [or] ● Clinical features:
Azithromycin 1 g SD ○ Chronic salpingitis
○ Chronic endometritis
Primary Prevention - prevent exposure and acquisition of STIs ● The signs and symptoms are similar to the chronic
● Teaching adolescents safe sex practices sequelae of nontuberculous acute PID:
● Promoting the use of condoms and chemical barrier ○ Chronic abdominal and pelvic pain
methods ○ Ascites in advanced cases
Secondary Prevention ■ Wet-phase peritonitis - fluid content; (+) fluid
● Universal screening of women at high risk for chlamydia wave
and gonorrhea ■ Dry-phase peritonitis - adhesions inside
● Screening for active cervicitis ○ Fixed bilateral adnexal masses
● Increasing use of sensitive tests to diagnose lower GTI ○ Adnexal tenderness
(e.g., NAAT) ○ Infertility
● Treatment of sexual partners ○ Abnormal uterine bleeding
● Education to prevent recurrent infection
B. DIAGNOSTICS
III. ACTINOMYCES INFECTION Endometrial Biopsy
● Rare cause of upper genital tract infection ● Performed in the late secretory phase of the cycle (recall:
● Etiologic agent: Actinomyces israelii secretory/luteal phase occurs from Day 14-28)
● Portion of the endometrial biopsy should be sent for
A. DIAGNOSIS culture and animal inoculation
● Difficult to culture, must maintained in anaerobic ● The remaining portion should be examined histologically
environment for 2-3 weeks

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● Findings: classic giant cells, granulomas, caseous
necrosis
Laparotomy
● Pelvic TB may not be diagnosed until laparotomy or
celiotomy, when the characteristic changes may be
visualized
● Findings: distal ends of the oviducts remain everted;
“tobacco pouch”

When the diagnosis has been established:

● CXR
● IV Pyelogram
● Serial Gastric washing
● Urine TB culture

C. TREATMENT
Medical (always mauuna)
● 4 drugs initially
● De-escalate to 2-3 drugs based on culture results
Operative therapy (complication: fistula formation)
● Persistent pelvic mass
● Women with resistant organism (1 month medical therapy
→ unresponsive → do surgery)
● Women older than 40
● women whose endometrial cultures remain positive

MDR TB
● Infection from a strain of MTB that is resistant to 2 or
more agents including INH (Isoniazid)
● Tx: 5 drug regimen
○ 2nd line agents added: Ethionamide, Cycloserine,
Linezolid
● Note: XDR TB - Extensively Drug-resistant TB

Sequelae: Infertility, Chronic pelvic pain

● >50% of the endometrium is involved: the only option for
having kids is Adoption. IVF is not going to work anymore.
○ Endometrial lining becomes fibrotic, saan mo implant
yan?

Sources:
- Uploaded Moodle ppt (2023)
- Parbs Trans
- Live lecture w/ Dr. Co

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