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Although sexually transmitted diseases are a major public health problem at the international level, the relationship between contraception and pelvic infection is seldom examined. Numerous STDs are more difficult to diagnose, more frequent, and more serious in women than in men. Differential diagnosis between pelvic infection and other intraabdominal syndromes has been a concern for practitioners for years, and many pelvic infections are probably never diagnosed. Lower abdominal pain and sensitivity as well as fever, leucocytosis, accelerated sedimentation rate, inflammatory annexial mass evident on sonography, and microorganisms in the pouch of Douglass and presence of leucocytes in the peritoneal fluid are diagnostic criteria. Apart from errors in treatment resulting from errors in diagnosis, pelvic infections are often inadequately treated, especially in the initial phase before symptoms are confirmed. The exact incidence of pelvic infections in the US is unknown, but pelvic inflammatory disease (PID) accounted for over 200,000 hospitalizations per year between 1970-75. PID carries grave risks of subsequent ectopic pregnancy, chronic pelvic pain, and infertility which is more likely as the number of acute episodes increases. The female genital tract has diverse microenvironments propitious for growth of microorganisms of different types, aerobic and anaerobic. Each anatomic site has specific features conditioning bacterial growth. Histological modifications during the menstrual cycle and pregnancy affect the microbial flora. Except in the case of gonorrhea, it is not known how many female lower genital tract infections spread to the upper tract. Since 1970, several studies have domonstrated a growing diversity of cervical and vaginal flora in asymptomatic subjects. The principal risk factors for PID have been well described in the literature. All contraceptive methods except the IUD provide some degree of protection against PID. Even among IUD users the risk of PID is probably not greater than among women with a comparable risk of exposure to STDs. The protective effect of condoms has been recognized since the era of Casanova, but it is difficult to quantify. Studies describing the protective effects of spermicides used one against pelvic infection are very rare, and protective effects have usually been demonstrated only in vitro. Surfactants such as nonoxynol probably have viricidal properties against herpes simplex. Condoms and diaphragms have been seen to exercise a protective effect independent of spermicide, with relative risks of .6 and .4 compared to nonouse of contraception. There is as yet no consensus on changes in risk of PID during oral contraceptive (OC) use, but several studies have shown OCs to have a protective effect. Risks of PID in IUD users apparently stem from contamination during insertion or of the thread during prolonged use, but both possibilities remain controversial. The use of women not using contraception as controls in studies of relative risks of PId may not be appropriate because their sexual behavior and risks of exposure to STDs may differ. At the moment of ovulation, when the mucus is most receptive, IUDs do not place any barrier in the way of ascension of sperm and bacteria to the upper genital tract.
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PMID:[Contraception and pelvic infection in women]. 1234 Dec 41

The real prevalence of pelvic inflammatory disease (PID) is unknown since many women are either asymptomatic or have atypical symptoms. It is often difficult to detect, manage, and prevent PID. Since PID has obstetric, gynecologic, and contraceptive-related causes, its prevalence is quite high. About 70% of PID hospital admissions in sub-Saharan Africa are a result of reproductive tract infections (RTIs) while this figure is 34% in Asia and 31% in developed countries. Only 10-20% of lower RTIs ascend into the upper genital tract and an even smaller percentage of women with PID develop chronic sequelae. Still, just 1 episode carries an increased risk of a tubal infertility, ectopic pregnancy, chronic pelvic pain, considerable pain during coitus, a new episode, and menstrual irregularities. Neisseria gonorrhoea and Chlamydia trachomatis are the most common causative organisms of PID. In Africa, the risk factors for PID are the same as they are for sexually transmitted diseases (STDs): multiple sex partners, young age at first intercourse, high frequency of coitus, and a high rate of acquiring new partners. The largest percentage of women with RTIs are monogamous women who are infected and constantly reinfected by their promiscuous husbands. The primary means to prevent PID are promotion of safer sexual behavior and condom usage. Secondary measures include accessible, acceptable, and effective STD services and education and counseling during case management. WHO suggests that STD treatment become part of the primary health care system. It has developed flow charts on syndromic diagnosis for urethral discharge in men and genital ulcer disease in women. Health workers should assume increased PID risk if the partner has had a history of urethral discharge and/or treatment for gonorrhea or nongonococcal urethritis. Partner notification is also needed for case management, but stigmatization in some countries poses a problem. WHO also recommends use of drugs which have a 95% STD cure rate.
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PMID:Pelvic inflammatory disease. 1234 39

Douching has been linked to gonococcal or chlamydial cervicitis and pelvic inflammatory disease (PID) in retrospective studies. The authors conducted a 1999-2004 prospective observational study of 1,199 US women who were at high risk of acquiring chlamydia and were followed for up to 4 years. Cervical Neisseria gonorrhoeae and Chlamydia trachomatis were detected from vaginal swabs by nucleic acid amplification. PID was characterized by histologic endometritis or pelvic pain and tenderness plus one of the following: oral temperature >38.3 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital tract infection. Associations between douching and PID or gonococcal/chlamydial genital infections were assessed by proportional hazards models. The 4-year incidence rate of PID was 10.9% and of gonococcal and/or chlamydial cervicitis was 21.9%. After adjustment for confounding factors, douching two or more times per month at baseline was associated with neither PID (adjusted hazard ratio = 0.76, 95% confidence interval: 0.42, 1.38) nor gonococcal/chlamydial genital infection (adjusted hazard ratio = 1.16, 95% confidence interval: 0.76, 1.78). Frequency of douching immediately preceding PID or gonococcal/chlamydial genital infection was not different between women who developed versus did not develop outcomes. These data do not support an association between douching and development of PID or gonococcal/chlamydial genital infection among predominantly young, African-American women.
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PMID:Douching, pelvic inflammatory disease, and incident gonococcal and chlamydial genital infection in a cohort of high-risk women. 1563 69

Controversy surrounds the association between bacterial vaginosis (BV) and pelvic inflammatory disease (PID). Women (N = 1,140) were ascertained at five US centers, enrolled (1999-2001), and followed up for a median of 3 years. Serial vaginal swabs were obtained for Gram's stain and cultures. PID was defined as 1) histologic endometritis or 2) pelvic pain and tenderness plus oral temperature >38.8 degrees C, leukorrhea or mucopus, erythrocyte sedimentation rate >15 mm/hour, white blood cell count >10,000, or gonococcal/chlamydial lower genital infection. Exploratory factor analysis identified two discrete clusters of genital microorganisms. The first correlated with BV by Gram's stain and consisted of the absence of hydrogen peroxide-producing lactobacillus, Gardnerella vaginalis, Mycoplasma hominis, anaerobic gram-negative rods, and, to a lesser degree, Ureaplasma urealyticum. The second, unrelated to BV by Gram's stain, consisted of Enterococcus species and Escherichia coli. Being in the highest tertile in terms of growth of BV-associated microorganisms increased PID risk (adjusted rate ratio = 2.03, 95% confidence interval: 1.16, 3.53). Carriage of non-BV-associated microorganisms did not increase PID risk. Women with heavy growth of BV-associated microorganisms and a new sexual partner appeared to be at particularly high risk (adjusted rate ratio = 8.77, 95% confidence interval: 1.11, 69.2). When identified by microbial culture, a combination of BV-related microorganisms significantly elevated the risk of acquiring PID.
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PMID:A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease. 1609 89

The most common site of Neisseria gonorrhoeae infection is the urogenital tract. Men with this infection may experience dysuria with penile discharge, and women may have mild vaginal mucopurulent discharge, severe pelvic pain, or no symptoms. Other N. gonorrhoeae infections include anorectal, conjunctival, pharyngeal, and ovarian/uterine. Infections that occur in the neonatal period may cause ophthalmia neonatorum. If left untreated, N. gonorrhoeae infections can disseminate to other areas of the body, which commonly causes synovium and skin infections. Disseminated gonococcal infection presents as a few skin lesions that are limited to the extremities. These legions start as papules and progress into bullae, petechiae, and necrotic lesions. The most commonly infected joints include wrists, ankles, and the joints of the hands and feet. Urogenital N. gonorrhoeae infections can be diagnosed using culture or nonculture (e.g., the nucleic acid amplification test) techniques. When multiple sites are potentially infected, culture is the only approved diagnostic test. Treatments for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections include cephalosporins and fluoroquinolones. Fluoroquinolones should not be used in patients who live in or may have contracted gonorrhea in Asia, the Pacific islands, or California, or in men who have sex with men. Gonorrhea infection should prompt physicians to test for other sexually transmitted diseases, including human immunodeficiency virus.
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PMID:Diagnosis and treatment of Neisseria gonorrhoeae infections. 1673 55

This article reviews the epidemiology of sexually transmitted disease (STD) disparities for African American communities in the United States. Data are reviewed from a variety of sources such as national case reporting and population-based studies. Data clearly show a disproportionately higher burden of STDs in African American communities compared with white communities. Although disparities exist for both viral and bacterial STDs, disparities are greatest for bacterial STDs such as gonorrhea, chlamydia, and syphilis. Gonorrhea rates among African Americans are highest for adolescents and young adults, and disparities are greatest for adolescent men. Although disparities for men who have sex with men (MSM) are not as great as for heterosexual populations, STD rates for both white and African American MSM populations are high, so efforts to address disparities must also include African American MSM. Individual risk behavior and sociodemographic characteristics of African Americans do not seem to account fully for increased STD rates for African Americans. Population-level determinants such as sexual networks seem to play an important role in STD disparities. An understanding of the epidemiology of STD disparities is critical for identifying appropriate strategies and tailoring strategies for African American communities. Active efforts are needed to reduce not only the physical consequences of STDs, such as infertility, ectopic pregnancy, chronic pelvic pain, newborn disease, and increased risk of HIV infection, but also the social consequences of STDs such as economic burden, shame, and stigma.
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PMID:Epidemiology of STD disparities in African American communities. 1897 96

Gonorrhea (Neisseria gonorrhoeae) is a common sexually transmitted infection in women, with a heavy burden on female and neonatal health, because sequelae occur, such as female infertility, ectopic pregnancy, neonatal ophthalmitis and infection, and chronic pelvic pain. Prompt and appropriate antibiotic treatment can cure infection and avoid complications. However, adequate treatment is not easy, because early and rapid identification of gonorrhea is interfered with by many factors, including the complicated mixed microflora of the vagina and cervix, non-user-friendly culture systems, and lack of immediate availability of results, even with a combination of subjective complaint and high clinical suspicion. A PubMed search was conducted using the major headings of "gonorrhoea and diagnostic tool" and "Neisseria gonorrhoeae and diagnostic tool", before the end of 2010. Recently available methods for the diagnosis of gonorrhea infection in women were included, including traditional tools and advanced technology. Traditional tools such as microscopic examination and microbial culture have been used broadly; unfortunately, they have relatively lower specificity or sensitivity, and most importantly, "see-and-treat" is impossible for these infected women. Advances in technology, such as antigen detection by immunoassay and nucleic acid amplification tests (NAATs), have achieved major progress in the diagnosis of gonorrhea, because of their accuracy, convenience and time-saving aspects. However, NAATs are expensive, making their acceptance impossible in developing countries. Detection of pathogens including N. gonorrheae using microarray chips is viewed as a possible solution, because it is a relatively rapid, easy, inexpensive and sensitive tool, which makes an "identify-and-treat" or point-of-care policy possible. A rapid and affordable tool with high sensitivity and specificity for detection of gonorrhea in developing countries is still not available at the time of writing. To make a point-of-care policy possible, advanced technology for aiding diagnosis of gonorrhea is encouraged and appreciated.
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PMID:Are we satisfied with the tools for the diagnosis of gonococcal infection in females? 2203 33

Pelvic inflammatory disease (PID) is the most significant complication of sexually transmitted infections in childbearing-age women and it represents an important public health problem because of its long-term sequelae (chronic pelvic pain, tubal infertility, ectopic pregnancy). Prior to the mid 1970s PID was considered a monoetiologic infection, due primarily to Neisseria gonorrhea. Now it is well documented as a polymicrobial process, with a great number of microrganisms involved. In addition to Neisseria gonorrhea and Chlamydia trachomatis, other vaginal microrganisms (anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram negative rods, Streptococco agalactie, Mycoplasma genitalium) also have been associated with PID. There is a wide variation in PID clinical features; the type and severity of symptoms vary by microbiologic etiology. Women who have chlamydial PID seem more likely than women who have gonococcal PID to be asymptomatic. Since clinical diagnosis is imprecise, the suspicion of PID should be confirmed by genital assessment for signs of inflammation or infection, blood test and imaging evaluation. Laparoscopic approach is considered the gold standard. According to the polymicrobial etiology of PID, antibiotic treatment must provide broad spectrum coverage of likely pathogens. Early administration of antibiotics is necessary to reduce the risk of long-term sequelae.
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PMID:Pelvic inflammatory disease (PID) from Chlamydia trachomatis versus PID from Neisseria gonorrhea: from clinical suspicion to therapy. 2300 48

Evaluation of the nonpregnant patient presenting to the emergency department with vaginal bleeding requires the emergency physician to be aware of the potential for a variety of underlying causes. Patients with vaginal bleeding may have non-life-threatening problems such as fibroids, endometriosis, or treatable sexually transmitted diseases such as gonorrhea and chlamydial infection. However, care must be taken to differentiate these from more serious causes of pelvic pain and bleeding such as ectopic pregnancy, hemorrhagic cyst, ovarian torsion, and rare complications from fibroids such as intraperitoneal hemorrhage. Abnormal bleeding unrelated to structural problems could have an anovulatory or ovulatory cause.
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PMID:Emergency evaluation and management of vaginal bleeding in the nonpregnant patient. 2313 8

Neisseria gonorrhoeae causes urogenital, anorectal, conjunctival, and pharyngeal infections. Urogenital tract infections are most common. Men with gonorrhea may present with penile discharge and dysuria, whereas women may present with mucopurulent discharge or pelvic pain; however, women often are asymptomatic. Neonatal infections include conjunctivitis and scalp abscesses. If left untreated, gonorrhea may cause pelvic inflammatory disease in women, or it may disseminate, causing synovial and skin manifestations. Urogenital N. gonorrhoeae infection can be diagnosed using culture or nucleic acid amplification testing. Urine nucleic acid amplification tests have a sensitivity and specificity comparable to those of cervical and urethral samples. Fluoroquinolones are no longer recommended for the treatment of gonorrhea because of antimicrobial resistance. A single intramuscular injection of ceftriaxone, 250 mg, is first-line treatment for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections. This dosage is more effective for common pharyngeal infections than the previously recommended dose of 125 mg. Ceftriaxone should routinely be accompanied by azithromycin or doxycycline to address the likelihood of coinfection with Chlamydia trachomatis. Azithromycin may be used as an alternative treatment option for patients with previous allergic reactions to penicillin, but because of the likelihood of antimicrobial resistance, its use should be limited. Gonococcal infection should prompt physicians to test for other sexually transmitted infections, including human immunodeficiency virus. Because of high reinfection rates, patients should be retested in three to six months. The U.S. Preventive Services Task Force recommends screening for gonorrhea in all sexually active women at increased risk of infection. It also recommends intensive behavioral counseling for persons with or at increased risk of contracting sexually transmitted infections. Condom use is an effective strategy to reduce the risk of infection.
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PMID:Diagnosis and management of gonococcal infections. 2315 46


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