Natural defenseNatural defense mechanisms of themechanisms of the female genital tract:female genital tract:

1.1.Vulva :Vulva :a.a. inherent resistance of the skin of the inherent resistance of the skin of the

vulva and perineum.vulva and perineum.

b.b.apocrine gland secretions which are apocrine gland secretions which are bactericidal and fungicidal.bactericidal and fungicidal.

2.The vagina:2.The vagina:

a. Anatomical closure of the vaginaa. Anatomical closure of the vagina

Normally this canal is not patent ,the Normally this canal is not patent ,the anterior and posterior walls are in contact anterior and posterior walls are in contact with each other and this will protect with each other and this will protect against the ascend of infections to the against the ascend of infections to the genital tract(this canal opens only during genital tract(this canal opens only during coitus and childbirth).coitus and childbirth).

b.The epithelium which line the vagina:b.The epithelium which line the vagina:

-This is stratified sequamous epithelium.-This is stratified sequamous epithelium.

This type of epithelium is the thickest and This type of epithelium is the thickest and the most resistant to infection.the most resistant to infection.

c. The acidic pH of the vagina =4.5c. The acidic pH of the vagina =4.5 and this and this will prevent the proliferation of micro-will prevent the proliferation of micro-organismsorganisms

d. Normal flora of the vagina:d. Normal flora of the vagina: *The vagina contain may types of bacteria.*The vagina contain may types of bacteria.*The most important is the *The most important is the Doderlien’s bacilliDoderlien’s bacilli..*During reproductive life and under the influence of *During reproductive life and under the influence of

estrogen, there will be deposition of glycogen in estrogen, there will be deposition of glycogen in the epithelium of the vagina.the epithelium of the vagina.

*These lactobacilli will utilize glycogen and form *These lactobacilli will utilize glycogen and form lactic acid which cause the acidic PH of the lactic acid which cause the acidic PH of the vagina.vagina.

3. uterus:3. uterus: the periodic shedding of the the periodic shedding of the endometrium also protect against infections.endometrium also protect against infections.

Conditions which impair the defense Conditions which impair the defense mechanismsmechanisms

Age :Age :**Before puberty and after menopause, Before puberty and after menopause,

**there is no estrogen, there is no estrogen,

**so the epithelium of the vagina is thin and so the epithelium of the vagina is thin and lacks glycogen, lacks glycogen,

**so no lactic acid so no lactic acid →→ and alkaline pH and alkaline pH→→ predispose to infection.predispose to infection.

2. menstruation:2. menstruation: **The presence of blood, necrotic tissues & The presence of blood, necrotic tissues &

debris inside the genital tract forms a good debris inside the genital tract forms a good media for bacterial proliferation.media for bacterial proliferation.

3. During puerperium and after abortion:3. During puerperium and after abortion:a. The presence of raw placental site with

opened blood sinuses, so bacteria can get easily.

b.b.Mild lacerations of the vagina and uterus Mild lacerations of the vagina and uterus will break the continuity of the epitheliumwill break the continuity of the epithelium..

• c.c.wide opening of the birth canal causing wide opening of the birth canal causing

loss of the anatomical closure of the loss of the anatomical closure of the vaginavagina→→ascending infection.ascending infection.

dd..After delivery and abortion, the presence After delivery and abortion, the presence of discharge and lochia forms good media of discharge and lochia forms good media for infection.for infection.

Genital tract infections is eitherGenital tract infections is either::

1.Lower genital tract infection:1.Lower genital tract infection: **infections of the vulva.infections of the vulva. ** infections of the vagina. infections of the vagina.2.Upper genital tract infections, include:2.Upper genital tract infections, include: **infection of the uterine cavity----infection of the uterine cavity----endometritisendometritis**Infection of the oviducts-----Infection of the oviducts-----salpingitissalpingitis. . **Infection of the ovaries-----Infection of the ovaries-----oophoritis.oophoritis.**Infection of the cervix------Infection of the cervix------mucopurulant mucopurulant

cervicitiscervicitis

What is pelvic inflammatory What is pelvic inflammatory disease (PID)?disease (PID)?

*PID*PID is a general term for infection and is a general term for infection and inflammation of the upper reproductive inflammation of the upper reproductive organs of woman.organs of woman.

*It is often, though not always,

disease (STD).

a complication of

a sexually transmitted

PID may include infection and inflammation of:PID may include infection and inflammation of:

- - The fallopian tubes The fallopian tubes (salpingitis).(salpingitis).

-- The uterine lining The uterine lining (endometritis).(endometritis).

-- The ovaries The ovaries (oophoritis(oophoritis).).

A fallopian tube and ovary may form a pocket A fallopian tube and ovary may form a pocket of infection of infection (tubo-ovarian abscess).(tubo-ovarian abscess).

-PID may also infect the pelvic peritoneum -PID may also infect the pelvic peritoneum (pelvic peritonitis)(pelvic peritonitis) or inflammation around or inflammation around the liver (the liver (perihepaitis)perihepaitis)

-The diagnosis, treatment and follow up of PID -The diagnosis, treatment and follow up of PID are important because it can have serious are important because it can have serious long-term sequelae such as:long-term sequelae such as:

-Pelvic pain.-Pelvic pain. - Ectopic pregnancy- Ectopic pregnancy - Infertility. - Infertility. IncidenceIncidenceThe incidence of PID is unknown, as many The incidence of PID is unknown, as many

cases go un-noticed until investigations for cases go un-noticed until investigations for infertility are performed.infertility are performed.

Aetiology:Aetiology: -The infection is usually multi-factorial.-The infection is usually multi-factorial.-In about 80%of the cases it is caused by either:-In about 80%of the cases it is caused by either:*Neisseria gonorrhoeae.*Neisseria gonorrhoeae.*Chlamydia trachomatis.*Chlamydia trachomatis.

-Other organisms involved are-Other organisms involved are*gardnerella vaginalis.*gardnerella vaginalis. *anaerobes.*anaerobes. *Mycoplasmas and other organisms found in the *Mycoplasmas and other organisms found in the

vagina.vagina.-

Routs of infection:Routs of infection:

**PID results from micro-organisms PID results from micro-organisms transmitted during intercourse, transmitted during intercourse, instrumentation, abortion or delivery.instrumentation, abortion or delivery.

**So it is usually an So it is usually an ascending infectionascending infection through the vagina to the uterine cavity & through the vagina to the uterine cavity & tubes.tubes.

**It is usually bilateral.It is usually bilateral.

2.2.Infection can be transmitted from the Infection can be transmitted from the bowel as in acute appendicitis which bowel as in acute appendicitis which can cause right sided infection, and can cause right sided infection, and diverticulitis which can cause left sided diverticulitis which can cause left sided infection.infection.

3.3.Blood born infection is rare , it is seen Blood born infection is rare , it is seen in T.B.(tuberculosis) only.in T.B.(tuberculosis) only.

Risk factors for PID:Risk factors for PID:

1.Age:1.Age:

-It commonly occurs in women under -It commonly occurs in women under 25years (average age is 15-25years).25years (average age is 15-25years).

-It rarely occur before menarche or after -It rarely occur before menarche or after menopause.menopause.

-It rarely happened during pregnancy.-It rarely happened during pregnancy.

--So it is a disease of reproductive life.So it is a disease of reproductive life.

2. The presence of bacterial vaginosis.2. The presence of bacterial vaginosis.3.History of sexually transmitted diseases3.History of sexually transmitted diseases

4.Resent instrumentation of the uterus e.g. 4.Resent instrumentation of the uterus e.g.

-induced abortion.-induced abortion.

-hysterosalpingography.-hysterosalpingography.

5.Previous PID. 5.Previous PID.

6.insertion of IUCD in the last 6 weeks.6.insertion of IUCD in the last 6 weeks.

**It has been found that oral contraceptive It has been found that oral contraceptive pills reduce the risk of PID.pills reduce the risk of PID.

Pathology:Pathology:

11.As the infection ascend into the uterus, .As the infection ascend into the uterus, endometritis develops, plasma cells are endometritis develops, plasma cells are seen on endometrial biopsy.seen on endometrial biopsy.

22.The first stage of salpingitis involves .The first stage of salpingitis involves mucosal inflammation with swelling, mucosal inflammation with swelling, redness and de-ciliation.redness and de-ciliation.

33.Polymorph-nuclear cells invades the .Polymorph-nuclear cells invades the submucosa followed by mononuclear submucosa followed by mononuclear &plasma cells.&plasma cells.

44.Inflammatory exudates fills the lumen of the .Inflammatory exudates fills the lumen of the tube &adhesions develops between mucosal tube &adhesions develops between mucosal folds.folds.

55.The inflammation extends to the serosal .The inflammation extends to the serosal surface & pus exudes from the fimberia to surface & pus exudes from the fimberia to the ovaries & adnexae.the ovaries & adnexae.

66.in sever cases the tubes are fixed to adjacent .in sever cases the tubes are fixed to adjacent structures by fibrin exudates & adhesions.structures by fibrin exudates & adhesions.

77.With pelvic peritonitis all the organs are .With pelvic peritonitis all the organs are congested with multiple adhesions congested with multiple adhesions producing an inflammatory mass.producing an inflammatory mass.

88.Tubal or tubo-ovarian abscess may develop..Tubal or tubo-ovarian abscess may develop.

Clinical features of acuteClinical features of acute PID: PID:

1.Pain:1.Pain:-This is the most important presenting -This is the most important presenting

symptom.symptom.-Insidious or acute onset of lower abdominal -Insidious or acute onset of lower abdominal

and pelvic pain.and pelvic pain.-The pain is usually bilateral and only -The pain is usually bilateral and only

occasionally unilateral.occasionally unilateral.-There may be a sensation of pelvic pressure, -There may be a sensation of pelvic pressure,

with back pain radiating down one or both with back pain radiating down one or both legs.legs.

-The pain increase with movement and coitus-The pain increase with movement and coitus..

-Specific enquiry will reveals that the pain is -Specific enquiry will reveals that the pain is also present during menstruation also present during menstruation ((dysmenorrhae)dysmenorrhae) During coitus (During coitus (dyspareunia)dyspareunia)and during micturitionand during micturition(dysuria(dysuria).).

2.2. There is often an associated purulent There is often an associated purulent vaginal discharge.vaginal discharge.

33.Irregular vaginal bleeding in about 35%..Irregular vaginal bleeding in about 35%.

44.Those with sever infection complain of .Those with sever infection complain of nausea,vomitting, malaise and fever.nausea,vomitting, malaise and fever.

-In most cases, symptoms appears shortly -In most cases, symptoms appears shortly after the onset or cessation of mensesafter the onset or cessation of menses..

On examination:On examination:

1.Pyrexia:1.Pyrexia:

The temperature >38c in acute infection.The temperature >38c in acute infection.

2.Tachycardia.2.Tachycardia.

3.Abdominal tenderness and guarding 3.Abdominal tenderness and guarding usually involves both lower quadrants.usually involves both lower quadrants.

The abdomen may be some what distended.The abdomen may be some what distended.

4.The bowel sounds4.The bowel sounds may be hypoactive or may be hypoactive or absent.absent.

5-Pelvic examination5-Pelvic examination may demonstrate purulent may demonstrate purulent vaginal dischargevaginal discharge..

-Bimanual examination-Bimanual examination typically elicits extreme typically elicits extreme tenderness on movement of the cervix tenderness on movement of the cervix (cervical(cervical excitation sign positive).excitation sign positive).

-Bilateral adnexal tenderness-Bilateral adnexal tenderness or an adnexal or an adnexal mass may be palpable.mass may be palpable.

-In long standing cases, -In long standing cases, a tubo-ovarian massa tubo-ovarian mass extend to involve the pouch of Douglas and extend to involve the pouch of Douglas and poorly defined mass arise in the abdomen.poorly defined mass arise in the abdomen.

6-6-In sever cases with generalized peritonitis and In sever cases with generalized peritonitis and septicemia the patient present with features of septicemia the patient present with features of septic shock.septic shock.

Laboratory findings:Laboratory findings:

--LeukocytosisLeukocytosis is usually present; however, the is usually present; however, the WBC count may be normal.WBC count may be normal.

--EEndo-cervicalndo-cervical swab:swab:

A smear of purulent cervical material may A smear of purulent cervical material may demonstrate gram-negative kidney shaped demonstrate gram-negative kidney shaped diplococci in polymorphonuclear leukocytes.diplococci in polymorphonuclear leukocytes.

-These organisms may be gonococci, but definitive -These organisms may be gonococci, but definitive cultures on selectivecultures on selective mediamedia are advised. are advised.

--ESRESR is usually elevated. is usually elevated.

Ultrasound:Ultrasound: -Has limited value, only in case of tubo--Has limited value, only in case of tubo-

ovarian mass or abscess.ovarian mass or abscess.

-Also it is of value in following the -Also it is of value in following the progression or regression of an abscess progression or regression of an abscess after it has been diagnosed.after it has been diagnosed.

Culdocentesis:Culdocentesis:

-This test may be helpful in the diagnosis of -This test may be helpful in the diagnosis of pelvic infection.pelvic infection.

-The recto-uterine pouch of Douglas is -The recto-uterine pouch of Douglas is punctured with a long needle to obtain a punctured with a long needle to obtain a sample of the contents of the peritoneal sample of the contents of the peritoneal cavitycavity

-The vaginal skin washed with povidone- -The vaginal skin washed with povidone- iodine solution.iodine solution.

-Culdocentesis is indicated whenever -Culdocentesis is indicated whenever peritoneal material is needed for diagnosisperitoneal material is needed for diagnosis

-Cultures for aerobic and anaerobic -Cultures for aerobic and anaerobic organisms may be obtained.organisms may be obtained.

--Contraindications includesContraindications includes:-:-

*a cul-de-sac mass.*a cul-de-sac mass.

*a fixed retroverted uterus.*a fixed retroverted uterus.

LaparoscopyLaparoscopy:: This is the gold standard for diagnosis of This is the gold standard for diagnosis of PID but it is not routinely done for diagnosis PID but it is not routinely done for diagnosis of PID.of PID.It is only done if It is only done if 1.The clinical diagnosis is uncertain or 1.The clinical diagnosis is uncertain or 2.There is no improvement after 24-48 2.There is no improvement after 24-48 hours of i.v. antibiotics.hours of i.v. antibiotics.

Essential features of diagnosis Essential features of diagnosis of acute salpingitis: of acute salpingitis:

All of the following:All of the following:

11.Onset of lower abdominal and pelvic pain, .Onset of lower abdominal and pelvic pain, usually following onset or cessation of usually following onset or cessation of menses and associated with vaginal menses and associated with vaginal discharge.discharge.

2.2.Lower abdominal tenderness (bilateral).Lower abdominal tenderness (bilateral).

33.Cervical excitation sign positive..Cervical excitation sign positive.

44.Uterine and adnexal tenderness..Uterine and adnexal tenderness.

Plus one or more of the following:Plus one or more of the following:

1.1.Temperature Temperature above 38 C.above 38 C.2.2.Leukocyte count greater than Leukocyte count greater than 10,000/uL 10,000/uL or or

elevated c-reactive proteinelevated c-reactive protein..3.Inflammatory mass3.Inflammatory mass by examination or U/S. by examination or U/S.4.Gram-negative intracellular4.Gram-negative intracellular diplococcic in diplococcic in

cervical secretions.cervical secretions.5.Purulent material5.Purulent material from peritoneal cavity by from peritoneal cavity by

Culdocentesis or laparoscopy.Culdocentesis or laparoscopy.6.Elevated ESR6.Elevated ESR..

00

Complications of acute salpingitis:Complications of acute salpingitis: 1.1.Pelvic peritonitis or generalized peritonitis.Pelvic peritonitis or generalized peritonitis.

2.2.Sever pelvic cellulitis with Sever pelvic cellulitis with thrombophlebitis.thrombophlebitis.

33.Abscess formation (pyosalpinx, tubo-.Abscess formation (pyosalpinx, tubo-ovarian abscess, cul-de-sac abscess).ovarian abscess, cul-de-sac abscess).

4.4.Adnexal destruction and subsequent Adnexal destruction and subsequent infertility and intestinal adhesions and infertility and intestinal adhesions and obstruction.obstruction.

5.5.Rarely,dermatitis,gonococcal arthritis, or Rarely,dermatitis,gonococcal arthritis, or bacteremia with septic shock may occur.bacteremia with septic shock may occur.

Differential diagnosis:Differential diagnosis:

11.Ectopic pregnancy..Ectopic pregnancy. 22. appendicitis.. appendicitis. 3.3.Complications of ovarian cyst e.g. rupture, Complications of ovarian cyst e.g. rupture,

torsion or haemorrhage. torsion or haemorrhage. 44.Complications of early pregnancy e.g. .Complications of early pregnancy e.g.

inevitable abortion or septic abortion. inevitable abortion or septic abortion. 55.Degeneration of fibroid. .Degeneration of fibroid. 66.Endometriosis..Endometriosis. 77.Acute urinary tract infection. .Acute urinary tract infection. 88.Regional enteritis and ulcerative colitis..Regional enteritis and ulcerative colitis.

Thank youThank you

Treatment of acute PID:Treatment of acute PID:

-Because of the long term sequels it is -Because of the long term sequels it is important to start treatment as soon as important to start treatment as soon as clinical diagnosis is suspected.clinical diagnosis is suspected.

-The majority of women who present with -The majority of women who present with acute salpingitis have mild-moderate acute salpingitis have mild-moderate severity that usually respond to out patient severity that usually respond to out patient antibiotic therapy.antibiotic therapy.

Hospitalization is indicated for the Hospitalization is indicated for the following:following:

11.Women with sever disease..Women with sever disease.

22.When the diagnosis is uncertain..When the diagnosis is uncertain.

33.Pregnant women..Pregnant women.

44.Women with suspected pelvic abscess..Women with suspected pelvic abscess.

55.Women unable to tolerate out-patient .Women unable to tolerate out-patient therapy.therapy.

66.Women who have not respond to out-.Women who have not respond to out-patient therapy.patient therapy.

1. Outpatient therapy:1. Outpatient therapy:

Women with mild disease can be treated Women with mild disease can be treated with:with:

**antibioticsantibiotics

**Removal of IUCD (if present).Removal of IUCD (if present).

**Analgesics.Analgesics.

**Bed rest.Bed rest.

Antibiotics therapy:Antibiotics therapy:

..CeftriaxoneCeftriaxone 250mg,i.m. with 250mg,i.m. with probenecid probenecid 1g 1g orally, followed by 14days of orally, followed by 14days of doxycyclinedoxycycline 100mg,orally twice daily with or without 100mg,orally twice daily with or without metronidazolemetronidazole 500mg twice daily. 500mg twice daily.

If after 72 hours a response to therapy has not been If after 72 hours a response to therapy has not been seen the patient should be admitted for inpatient seen the patient should be admitted for inpatient therapy.therapy.

Inpatient therapy:Inpatient therapy:

-Inpatient therapy is prudent for patients with a -Inpatient therapy is prudent for patients with a temp. over 39c & for those who look toxic.temp. over 39c & for those who look toxic.

-Hospitalization of these patient is necessary -Hospitalization of these patient is necessary for therapy and for watching for signs of for therapy and for watching for signs of complications or deterioration.complications or deterioration.

-The following measures should be taken:-The following measures should be taken:

11.Maintain bed rest..Maintain bed rest.

22.Restrict oral feeding..Restrict oral feeding.

3.3.Administer i.v. fluid to correct dehydrationAdminister i.v. fluid to correct dehydration

4.4.Use naso-gastric suction in the presence of Use naso-gastric suction in the presence of abdominal distention or ileus abdominal distention or ileus

55.Antimicrobial therapy:.Antimicrobial therapy:

DoxycyclineDoxycycline 100 mg i.v. or orally twice daily ,plus 100 mg i.v. or orally twice daily ,plus cefoxitincefoxitin,2g i.v. 4 times daily for at least 24hours ,2g i.v. 4 times daily for at least 24hours after the patient shows clinical improvement, after the patient shows clinical improvement, followed by followed by doxycyclinedoxycycline 100mg orally twice daily 100mg orally twice daily to complete 14days of therapy.to complete 14days of therapy.

-If abscess is suspected metronidazole or -If abscess is suspected metronidazole or clindamycin should be used to cover anaerobesclindamycin should be used to cover anaerobes

6.6.explorative laparotomy should be explorative laparotomy should be performed if there is clinical suspicion of performed if there is clinical suspicion of abscess ruptureabscess rupture. .

7.7. Continual evaluation by the same clinician Continual evaluation by the same clinician is of paramount importance to maintain is of paramount importance to maintain accuracy and continuity of clinical accuracy and continuity of clinical observation.observation.

88. Patient with septicemia may develop . Patient with septicemia may develop septic shock, hypovoleamia,organ hypo septic shock, hypovoleamia,organ hypo -perfusion, renal impairment and DIC.-perfusion, renal impairment and DIC.

Such patient require treatment in intensive Such patient require treatment in intensive care unit.care unit.

Chronic PIDChronic PID: :

-Chronic inflammatory lesions usually are -Chronic inflammatory lesions usually are secondary to changes induced by secondary to changes induced by previous acute salpingitis but may previous acute salpingitis but may represent an acute re-infection.represent an acute re-infection.

-Adhesions of the peritoneal surfaces to the -Adhesions of the peritoneal surfaces to the adnexae as well as fibrotic changes in the adnexae as well as fibrotic changes in the tubal lumen are usually present.tubal lumen are usually present.

-It is usually the end result of incompletely -It is usually the end result of incompletely treated acute infection.treated acute infection.

Clinical features:Clinical features:

Recurrent infection usually has the same Recurrent infection usually has the same manifestation as acute salpingitis and a manifestation as acute salpingitis and a history of pelvic infection can be obtained.history of pelvic infection can be obtained.

1.Most of the patient are asymptomatic are 1.Most of the patient are asymptomatic are present with infertility.present with infertility.

2.Chronic pelvic pain is the commonest 2.Chronic pelvic pain is the commonest symptom in the form of:symptom in the form of:

-Dysmenorrhoea usually of congestive type. -Dysmenorrhoea usually of congestive type. -Deep dyspareunia due to pelvic adhesions.-Deep dyspareunia due to pelvic adhesions.3.Menorrhagia &polymenorrhoea due to pelvic 3.Menorrhagia &polymenorrhoea due to pelvic

congestion.congestion.

On examination:On examination:

-Most of the patients have no signs.-Most of the patients have no signs.-The uterus may be felt in fixed retroversion.-The uterus may be felt in fixed retroversion.-There is tenderness on movement of the -There is tenderness on movement of the

cervisx,uterus or adnexae.cervisx,uterus or adnexae.-There may be adnexal masses which are -There may be adnexal masses which are

either either tubo-ovarian masstubo-ovarian mass,, hydrosalpinx hydrosalpinx (the tubal ends closed and the tubes filled (the tubal ends closed and the tubes filled with fluid), or with fluid), or pyosalpinxpyosalpinx (the closed tubes (the closed tubes are filled with pus).are filled with pus).

Complications:Complications: -Hydrosalpinx.-Hydrosalpinx.-Pyosalpinx-Pyosalpinx-Tubo-ovarian abscess.-Tubo-ovarian abscess.-Infertility.-Infertility.-Ectopic pregnancy.-Ectopic pregnancy.-Chronic pelvic pain.-Chronic pelvic pain.

Prevention:Prevention:Prompt and adequate treatment of acute pelvic Prompt and adequate treatment of acute pelvic

infection is the essential preventive measure.infection is the essential preventive measure.

Treatment of chronic PID:Treatment of chronic PID:

There are no effective medical treatment.There are no effective medical treatment.

Long courses of antibiotics may be tried using Long courses of antibiotics may be tried using ampicillin, cephalosporin and tetracycline.ampicillin, cephalosporin and tetracycline.

Surgery is indicated for:Surgery is indicated for:

1.Persistent symptoms.1.Persistent symptoms.

2.Drainage of tubo-ovarian abscess.2.Drainage of tubo-ovarian abscess.

3.Fixed retroverted uterus which cause deep 3.Fixed retroverted uterus which cause deep dyspareunia.dyspareunia.

4.Treatment of infertility.4.Treatment of infertility.

Types of surgical treatment:Types of surgical treatment:

Conservative surgery :Conservative surgery :-For young patient of low parity.-For young patient of low parity.-Cutting of adhesions or re-opening of -Cutting of adhesions or re-opening of

closed tubes.closed tubes.-Drainage of pus.-Drainage of pus.Radical surgery:Radical surgery:For women over 45years and completed her For women over 45years and completed her

family, by total abdominal hysterectomy family, by total abdominal hysterectomy and bilateral salpingo-oophorectomy.and bilateral salpingo-oophorectomy.

Inflammation of the cervixInflammation of the cervix: :

The cervix consist of two distinct parts:The cervix consist of two distinct parts:

1.the ectocervix:1.the ectocervix:

which project into the vaginal vault and it is which project into the vaginal vault and it is

linen by stratified sequamous epithelium.linen by stratified sequamous epithelium.

2.The endocervix:2.The endocervix:

Which lie between the external and internal Which lie between the external and internal cervical os and it is lined by columnar cervical os and it is lined by columnar epithelium.epithelium.

-Acute inflammation of the cervix is known -Acute inflammation of the cervix is known as as mucopurulant cervicitismucopurulant cervicitis because it is because it is associated with mucopurulant discharge.associated with mucopurulant discharge.

-It is usually caused by chlamydial and -It is usually caused by chlamydial and gonorrhoeal infection.gonorrhoeal infection.

--On speculum examination:On speculum examination:The cervix is swollen with hyperaemia, The cervix is swollen with hyperaemia,

mucopurulant discharge and bleeding on touch.mucopurulant discharge and bleeding on touch.DiagnosisDiagnosis confirmed by endocervical swab. confirmed by endocervical swab. Treatment :Treatment : doxycycline 100mg twice daily for doxycycline 100mg twice daily for

7days, or erythromycin 500mg four times daily 7days, or erythromycin 500mg four times daily for 7days.for 7days.

Chronic cervicitisChronic cervicitis::

This is the end result of repeated acute infection or This is the end result of repeated acute infection or sometimes repeated injury to the cervix by sometimes repeated injury to the cervix by foreign body like pesseries or tampons.foreign body like pesseries or tampons.

pathology:pathology: -In chronic cervicitis there will be -In chronic cervicitis there will be cervical erosioncervical erosion

or called or called ectropian.ectropian.-This results from migration of columnar cells to -This results from migration of columnar cells to

the ectocervix , so part of the ectocervix will be the ectocervix , so part of the ectocervix will be covered by columnar epithelium in stead of covered by columnar epithelium in stead of sequamous epithelium so we have normal sequamous epithelium so we have normal epithelium in an abnormal place.epithelium in an abnormal place.

Clinical features:Clinical features:1.Can be asymptomatic and diagnosed by 1.Can be asymptomatic and diagnosed by

speculum examination.speculum examination.

2.The commonest symptoms is leukorrhoea 2.The commonest symptoms is leukorrhoea which is excessive normal vaginal which is excessive normal vaginal discharge , not offensive with no itching.discharge , not offensive with no itching.

3.Post-coital bleeding.3.Post-coital bleeding.

4.Low back pain and lower abdominal pain.4.Low back pain and lower abdominal pain.

5.Deep dyspareunia.5.Deep dyspareunia.

6.Sometimes cause infertility due to cervical 6.Sometimes cause infertility due to cervical hostility.hostility.

On examinationOn examination

The cervix usually hypertrophied with dark red The cervix usually hypertrophied with dark red areas on ectocervix.areas on ectocervix.

The presence of nabothian follicles which are The presence of nabothian follicles which are mucus-containing cysts up to 1cm in diameter mucus-containing cysts up to 1cm in diameter due to obestruction of the gland’s duct .due to obestruction of the gland’s duct .

Treatment:Treatment:

Antibiotics are useless and the best Antibiotics are useless and the best treatment is by treatment is by cauterization of the cervixcauterization of the cervix which is either:which is either:

1.Electrocautary1.Electrocautary by applying heat. by applying heat.

2.Cryocautary2.Cryocautary by applying cold. by applying cold.

3.Laser therapy.3.Laser therapy.

Surgical treatment: Surgical treatment:

This is indicated for patient with:This is indicated for patient with:1.1.Extensive cervical ectropian.Extensive cervical ectropian.22.No response to cauterization..No response to cauterization.33.Recurrent cervicitis..Recurrent cervicitis.This include either:This include either:1.Amputation of the cervix1.Amputation of the cervix..2.Cone excision2.Cone excision by removing a cone of tissues by removing a cone of tissues

contain the ectropian.contain the ectropian.3.Total abdominal hysterectomy3.Total abdominal hysterectomy for old women for old women

who completed her family.who completed her family.