STI/RTI

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1 Mohammed Kamal Aldahdouh Alaa Hani Rustom Mahmoud Wael Qandeel

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Reproductive tract infection ( RTI ) are infections that affect the reproductive tract, which is part of the Reproductive System. 2

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For females, reproductive tract infections can be in either the upper reproductive tract (fallopian tubes, ovary and uterus), and the lower reproductive tract (vagina, cervix and vulva). 3

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for males these infections are at the penis, testicles, urethra,epididymis or the sperm tube 4

The three types of reproductive tract infections are: :

The three types of reproductive tract infections are: Endogenous infections Iatrogenic infections Sexually transmitted infections. 5

Endogenous infections:

Endogenous infections Probably the most common RTIs worldwide. They result from an overgrowth of organisms normally present in the vagina . Endogenous infections include bacterial vaginosis and candidiasis . These infections can be easily treated and cured . 6

Iatrogenic infections :

Iatrogenic infections Occur when the cause of infection (a bacterium or other micro-organism) is introduced into the reproductive tract through a medical procedure such as menstrual regulation, induced abortion, the insertion of an IUD or during childbirth. Because iatrogenic infections may affect the upper reproductive tract of women, they can result in extremely serious consequences. The uterus, endometrium, fallopian tubes, and ovaries can all be involved . Pelvic inflammatory disease (PID) may develop and cause severe abdominal pain, pelvic abscess , menstrual disturbances, ectopic pregnancy, spontaneous abortion, premature birth, and infertility . 7

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If a woman has recently undergone a transcervical procedure , the following symptoms may indicate the presence of an iatrogenic infection : Pain in the pelvic region Sudden high fever Chills Menstrual disturbances Unusual vaginal discharge Pain during intercourse 8

Unsafe abortion :

Unsafe abortion Although a variety of medical procedures can lead to the development of iatrogenic infections, unsafe abortion poses a particularly common risk. The vast majority of unsafe abortions take place in the developing world, and complications occur after 10-50% of them. Unsafe abortions are often sought if abortion is illegal, safe procedures are difficult to access or afford, or the woman is ashamed to seek care because she is young, unmarried, or the victim of sexual assault or coercion. 9

Sexually transmitted infections (STIs) :

Sexually transmitted infections (STIs) Caused by viruses, bacteria, or parasitic microorganisms that are transmitted through sexual activity with an infected partner . About 30 different sexually transmitted infections have been identified, some of which are easily treatable, many of which are not. HIV, the virus that causes AIDS, is perhaps the most serious sexually transmitted infection as it eventually leads to death. STIs affect both men and women, and can also be transmitted from mothers to children during pregnancy and childbirth. 10

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11 SITE OF INFECTION NOMENCLATURE Urethra Urethritis Epididymis Epididimitis Testis Orchitis Glans penis Balanitis Glans penis + prepuce Balanoposthitis Urethra Urethritis Epididymis Epididimitis Testis orchitis Glans penis balanitis Glans penis + prepuce balanoposthitis

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External/Epidermis Ulcers , warts Vagina Vaginitis Cervix Cervicitis Uterus Endometritis Fallopian tubes Salpingitis Ovaries Tubo -ovarian abscess 12 SITE OF INFECTION NOMENCLATURE External/Epidermis Ulcers, warts Vagina Vaginitis Cervix Cervicitis Uterus Endometritis Fallopian tubes Salpingitis Ovaries Tubo-ovarian abscess

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Balanoposthitis:

Balanoposthitis Defined as the inflammation of the foreskin and glans in uncircumcised males . Candidal infection appears to be the most common cause of disease. Organisms that also have been identified : Bacteroides , Gardnerella Beta-hemolytic streptococci . 14 Balanoposthitis-candida

Urethritis:

Urethritis 15 Urethritis is inflammation of the urethra. T he main symptom is dysuria , which is painful or difficult urination . The disease is classified as either gonococcocal urethritis , caused by Neisseria gonorrhoeae , or non- gonococcal urethritis (NGU), most commonly caused by Chlamydia trachomatis . Other causes include: Ureaplasma urealyticum Trichomonas Adenovirus Uropathogenic Escherichia coli (UPEC) Herpes simplex

Epididymitis:

Epididymitis Epididymitis is the most frequent cause of acute onset scrotal pain in adults. In sexually active men, Chlamydia trachomatis is the most frequent causative microbe, followed by E. coli and Neisseria gonorrhoeae . In children, it may follow an infection in another part of the body (for example, a viral illness), or there may be an associated urinary tract anomaly . 16

Orchitis:

Orchitis Orchitis can be related to epididymitis infection that has spread to the testicles, often caused by the sexually transmitted diseases chlamydia and gonorrhea . It can also be seen during active mumps , particularly in adolescent boys. Also TB cause granulomatous orchitis . 17

Vaginitis :

Vaginitis Vaginitis is an inflammation of the vagina . It can result in discharge , itching and pain , and is often associated with an irritation or infection of the vulva . The three main kinds of vaginitis are Bacterial Vaginosis (BV ) Vaginal Candidiasis Trichomoniasis . The most common cause of bacterial vaginosis are Gardnerella , Mobiluncus , Bacteroides , and Mycoplasma .

Cervicitis:

Cervicitis STDs that can cause cervicitis include: Chlamydia Gonorrhea Herpes virus (genital herpes) Human papilloma virus (genital warts) Trichomoniasis Bacteria (such as staphylococcus and streptococcus ) and too much growth of normal bacteria in the vagina (bacterial vaginosis ), can also cause cervicitis.

Endometritis:

Endometritis Acute endometritis : It is characterized by the presence of microabscesses or neutrophils within the endometrial glands. The most common pathogen is Mycoplasma genitalium .

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Chronic endometritis : It is distinguished by variable numbers of plasma cells within the endometrial stroma . The most common organisms are: Chlamydia trachomatis Neisseria gonorrhoeae Streptococcus agalactiae Mycoplasma hominis Tuberculosis and various viruses.

Salpingitis:

Salpingitis It is an infection and inflammation in the fallopian tubes. The bacteria most associated with salpingitis are: N. gonorrhoeae Chlamydia trachomatis Mycoplasma Staphylococcus Streptococcus Ureaplasma urealyticum Anaerobic bacteria.

Pelvic inflammatory disease:

Pelvic inflammatory disease Pelvic inflammatory disease (PID) is one of the most serious complications of sexually transmitted diseases. It is an infection of the female upper genital tract that encompasses a broad category of diseases, including endometritis , salpingitis , salpingo-oophoritis , tubo -ovarian abscess (TOA) , and pelvic peritonitis . It is most commonly results from Chlamydia trachomatis or Neisseria gonorrhoeae infection of the cervix or vagina that then spreads into the endometrium, fallopian tubes, ovaries, and adjacent structures.

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Infection of the fallopian tubes may lead to scarring and adhesions (bands of scar tissue) that can obstruct the tubes, causing infertility . One of the most common complication is ectopic pregnancy .

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Trichomoniasis trich:

Trichomoniasis trich Trichomoniasis is a common STI that usually has very few symptoms caused by Trichomonas vaginalis For women, these parasites may infect the vagina , urethra, bladder or cervix. In men, the infection is usually in the urethra, or under the foreskin of uncircumcised men. It can be passed on via damp towels, washcloths, and bathing suits if someone has the parasite . 26

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Many people, particularly men, will not have symptoms of a trichomonas infection. If symptoms do appear, they usually appear within one week of infection 27 For women, symptoms may include: Discharge from the vagina Vaginal odour Pain during intercourse or urination Irritation or itchiness of the vagina For men symptoms may include: mild discharge irritation or redness at the top of the penis burning during urination Men may often become unknowing carriers of trich infections. Treatment is required to ensure that a trich infection is completely gone

Vaginal thrush Candidal vulvovaginitis :

Vaginal thrush Candidal vulvovaginitis Candidal vulvovaginitis is a very common vaginal infection- mostly caused by Candida albicans - which is irritating and annoying rather than harmful Candidal infection isn’t considered STD , but it is endogenous infections . Up to 75% of women will have thrush at some point in their lives. Up to half of these will have thrush more than once. Thrush most commonly affects women in their twenties and thirties, and those who are pregnant. 28

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The symptoms of vaginal thrush include vulval itching and irritation ,dyspareunia and dysuria ) . The signs of vulvovaginal inflammation include erythema (redness) of the vagina and vulva, vagina fissuring (cracked skin), oedema . Vaginal discharge , which is usually odorless. This can be thin and watery, or thick and white, like cottage cheese . 29 Vaginal discharge vulvovaginitis

Gonorrhea : the clap :

Gonorrhea : the clap Gonorrhea is a curable sexually transmitted disease . It is most common in young adults. The bacteria ( Neisseria gonorrhoeae ) that cause gonorrhea can infect the genital tract( mainly the mucous membranes of the urethra in males and the endocervix and urethra in females ), mouth or anus. Note also that 10% of infected males and 50% of infected females are asymptomatic. 30

Symptoms :

Symptoms Infection of the genitals can result in a yellow purulent (or pus-like) discharge from the genitals which may be foul smelling in both sexes . In Men : Stinging during urination Frequent urination Blood in the urine Swelling of the glands in the groin The head of the penis may turn red In women : Abnormal bleeding A burning sensation during urination Vaginal discharge General irritation of the outer area of the vagina Infection of the genitals in females with N. gonorrhea can result in pelvic inflammatory disease if left untreated, which can result in infertility. 31

Lymphgranuloma Venerum:

Lymphgranuloma Venerum LGV caused by Chlamydia trachomatis Serovars L1, L2, L3 . Primary lesion-painless papule or vesicle on genitals 5-21 days after exposure. Weeks to months after primary lesion heals- painful inguinal adenopathy-60% unilateral. Buboes form-overlying skin often gets purplish hue. Scarring of bubo may leave linear depression parallel to inguinal ligament=groove sign. Late sequellae include scarring; urethral, vaginal and anal strictures; and occaionally lymphatic obstruction.

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Lymphgranuloma Venerum

Syphilis:

Syphilis Treponema pallidium causes one of the most common STDs “ Syphilis ”. The symptoms of syphilis are the same in men and women. Primary stage of syphilis : One or more painless ulcers (know as chancres) appear at the place where the syphilis bacteria entered the body. Chancres may be difficult to notice and are highly infectious.

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Secondary : Mucocutaneous lesions, fever , pharyngitis, malaise, hepatitis, alopecia , lymphadenopathy. Condylomata lata in the vulva and moist lesions in the penis. Latent : Somewhat arbitrary division into – early latent (< 1 year) and late latent (> 1 year ) . The person will no longer experience any symptoms of the earlier stages, but their infection can still be diagnosed with a blood test. Tertiary : Gummas , cardiovascular (syphilitic aortic aneurysm), central nervous system. Congenital

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Primary syphilis : chancre Tertiary syphilis : gummas Secondary syphilis Condylomata lata Syphilitic rash

Chancroid :

Chancroid Haemophilus ducreyi is causing the sexually transmitted disease chancroid , a major cause of genital ulceration in developing countries characterized by painful sores on the genitalia. Another early symptom is dark or light green shears in excrement. Chancroid starts as an erythematous papular lesion that breaks down into a painful bleeding ulcer with a necrotic base and ragged edge.

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Chancroid in men Chancroid in women

Donovanosis Granuloma inguinale :

Donovanosis Granuloma inguinale Calymmatobacterium granulomatis is causing the sexually transmitted disease Donovanosis characterized by ulcerative genital lesions . In addition, the painless genital ulcers can be mistaken for syphilis. The ulcers ultimately progress to destruction of internal and external tissue, with extensive leakage of mucus and blood from the highly vascular lesions. Rarely, the vaginal wall or cervix is the site of the lesion.

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Donovanosis in men Donovanosis in women

Genital warts condylomata acuminatum :

Genital warts condylomata acuminatum Are usually flat, papular, or pedunculated growths on the genital mucosa Is a highly contagious STD caused by some sub-types of human papillomavirus ( HPV types 6 and 11 ). It is spread through direct skin-to-skin contact during oral , genital , or anal sex with an infected partner. Though usually painless , symptoms for genital warts include: Itching or burning sensation and occasional minor bleeding as a result of anal sex or bowel movement. 41

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Genital warts often occur in clusters and can be very tiny or can spread into large masses in the genital or penis area. In other cases they look like small stalks In women , genital warts can appear on the vulva, urethra, cervix, anus or thighs. In men , they can appear on the penis, scrotum, anus or thighs 42 Cervix Genital warts penis Genital warts

Cancers by HPV:

Cancers by HPV Carcinogenic types of HPV cause most cervical cancers and 70% are caused by HPV types 16 and 18. These types may also be linked to oral and penile cancers. Research has shown a strong link between anal cancer and HPV 16. 43

Herpes genitalis:

Herpes genitalis It was established that " HSV-2 was below the waist, HSV-1 was above the waist“ HSV is believed to be asymptomatic in the majority of cases. When symptomatic, the typical manifestation is clusters of genital sores consisting of inflamed papules and vesicles on the outer surface of the genitals resembling cold sores. In males , the lesions occur on the glans penis, shaft of the penis or other parts of the genital region, on the inner thigh, buttocks, or anus. In females , lesions appear on or near the pubis, labia, clitoris, vulva, buttocks or anus .

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Genital sore in men Genital sore in women

Scabies (Sarcoptes scabiei):

Scabies ( Sarcoptes scabiei ) Scabies can be transmitted sexually. It is very contagious with onset of symptoms 2-6 weeks after first exposure. The most obvious signs of scabies are pink-to-red bumps , which can look like pimples or bug bites, sometimes with scale or a scab on them.

Crab lice:

Crab lice ( A.k.a Phthirus pubis, and pubic lice) are parasitic insects notorious for infesting human genitals. The species may also live on other areas with hair, including the eyelashes. The main symptom is itching , usually in the pubic-hair area, resulting from hypersensitivity to louse saliva . In some infestations, a characteristic grey-blue or slate coloration appears ( maculae caeruleae ) at the feeding site, which may last for days.

Louse in pubic hair:

Louse in pubic hair

Jock itch:

Jock itch Jock itch is a superficial fungal infection of the skin on the groin , cuased by Tinea cruris People who wear tight clothing for extended periods, share clothing, participate in athletics, or are overweight or diabetic are more often affected.

Other pathogens:

Other pathogens They are STDs but don’t cause genital infections. The pathogen Its type The disease HIV Virus AIDS Hepatitis B Virus Hepatitis Campylobacter sp. Bacteria Enterocolitis Shigella sp. Bacteria Enterocolitis Salmonella sp. Bacteria Enterocolitis Enatmoeba histolyticum Protozoa Amebiasis Giardia lamblia Protozoa Giardiasis

Reproductive Tract Infections, Pregnancy and Children :

Reproductive Tract Infections, Pregnancy and Children Reproductive tract infections can cause many adverse pregnancy outcomes , including Spontaneous abortion . Premature rupture of membranes . Premature delivery and consequent low birthweight stillbirth. In addition ,many RTIs can be passed between mother and infant during pregnancy and childbirth and breastfeeding resulting in serious morbidity and even death for the neonate . ( Vertical Transmission ) 52

RTI of Pregnancy:

RTI of Pregnancy 53

Vertical Transmission:

Vertical Transmission 54

Prevention :

Prevention

Prevention is the Key:

Prevention is the Key Total abstinence / avoidance of vaginal, oral or anal sex is the best way of preventing most STD’s. Safe sex: 􀂃 delaying sexual activity (for adolescents); 􀂃 decreasing the number of sex partners; 􀂃 using condoms correctly and consistently . P rompt recognition and effective treatment of STIs

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Safe delivery practices Use aseptic technique Manage postpartum infection effectively Safe transcervical procedures Use aseptic technique Rule out infection prior to procedure Postabortion care Use aseptic technique Manage postabortion infection effectively Vaccines are available that protect against some viral STIs, such as Hepatitis A, Herpes simplex vaccine ,and some types of HPV. Vaccination before initiation of sexual contact is advised to assure maximal protection.