Infections and pelvic inflammatory disease - a cause of pain and discharge

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Except for thrush, most vaginal and womb infections are sexually transmitted. These infections have potentially very serious long term effects, so you do need to chose your sexual partners carefully. Not all infections can be treated with antibiotics, furthermore you may not know you have a problem until its complication arises such as cancer and infertility. The problems in order of nastiness are:

  • AIDS
  • Hepatitis B or C
  • Wart viruses (herpes, human papilloma virus), which hugely increases the risk of cervical cancer. See Wikipedia:Human papillomavirus and Wikipedia:Herpesviridae.
  • Chlamydia: often there are no symptoms in the male. Chlamydia is thought to infect about 10% of sexually active young people. It is a major cause of infertility. It does this by blocking the fallopian tubes and causing inflammation of the lining of the womb. Often the first symptom is infertility.
  • Other bugs such as gram positive cocci, gram negative cocci, diplococci etc including haemolytic streptococci, gamma strep, gardnerella, E coli, acinetobacter iwoffii may also be present in the vagina. Gardnerella is usually immediately recognisable because it produces a distinctive fishy smell.
  • Group B Streptococcal infections are a particular problem in pregnancy and should be screened for - antibiotic cover may be needed at delivery.
  • Syphilis and gonorrhoea are really not such a problem any more because both are very sensitive to antibiotics and can easily be controlled. However because syphilis has such potentially serious effects on the unborn child, all pregnant women are routinely screened for syphilis. In the USA both partners must be syphilis and AIDS tested to get a marriage licence.

Clinical picture

There may be no symptoms.

There may be local symptoms such as discharge, soreness, irritation, pain and abnormal vaginal bleeding.

There may be general symptoms such as fever, severe illness and collapse.

Late symptoms include infertility, chronic pelvic pain and cancer.

Diagnosis

The best way to get diagnosed is to go to a sexually transmitted diseases (special) clinic to get vaginal swabs, cervical swabs and blood tests looking for antibody levels. Many of these bugs are difficult to culture and "hot" specimens give the best chance of success. Even so, these tests may fail to pick up the bugs.

I often refer patients to the London Clinic for their pelvic inflammatory diseases screening. This includes a high vaginal swab, cervical swab, urine testing and blood testing for antibody levels for the above bugs, but it does not include HIV and hepatitis testing, unless specifically requested.

  • Vaginosis profiles can be ordered through this website, these swabs you can do yourself from the vagina. They go into a special media to help preserve the bugs in transport. They are not perfect and cannot be expected to pick up nasties like HIV, herpes, hepatitis and chlamydia. I occasionally do these tests to look for yeast infections (such as candida) and bacterial infections.
  • Blood tests for antibody levels can be done for many infections. However these tell you about past and present infections. It is not possible to distinguish what has gone before from what is happening now.
  • PCR (polymerase chain reaction) is an extremely sensitive blood test for present infections and can certainly pick up HIV, hepatitis B and C, herpes virus and chlamydia.

Treatment

Some patients with acute PID need hospital admission not least of all to make sure there is nothing else going on. PID can mimic ectopic pregnancy, appendicitis, diverticulitis or any abdominal emergency.

  • Get rid of the bug. For some infections this is not possible or difficult because:
    • There is a viral infection. External warts can be treated by painting on podophylin, but there are no anti-viral remedies to cure HIV, hepatitis or cervical warts.
    • If there have been recurrent or long standing infections scar tissue may have formed. With any antibiotic there is a percentage kill: it is up to the immune system to knock off the last few bugs. If there is scar tissue, the blood supply is impaired and the bugs may survive.
    • There is constant re-infection. Contact tracing is necessary so all sexual partners are also identified and treated.
  • The immune system can be improved by good nutrition and nutritional supplements - see treatment of viral infection (the same principles apply with bacterial and fungal infections).

Is this allergy?

Allergy is the great mimic and can produce almost any symptom. Some women have chronic symptoms not because they have infection but because the vagina is acting as an allergic target organ. If you looked at a hay fever sufferer with his streaming eyes, sneezing, runny nose and raised temperature you might conclude he had a cold. Similarly a woman with inflammation of the vagina and discharge may be reacting allergically - the commonest allergen is yeast.

Is this hormone deficiency?

It is the female sex hormones which keep the tissues of the vulva and vagina plump and moist. After the menopause the tissues shrink and dry and this can cause soreness and irritation. Sometimes a small amount of oestrogen cream is justified to relieve this symptom, temporarily.

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