Dc Dutta's Textbook of Gynecology, 6th edition

Pelvic Infection Defense Mechanisms

  • Spread of Infection: Infection in one pelvic organ frequently spreads to others due to free connections between lymphatics and blood vessels and direct communication from the peritoneal cavity to the vagina.

Vulval Defense

  • Anatomic Mechanisms:

    • Apposition of labia creating a protective cleft.

    • Presence of compound racemose type of Bartholin’s glands.

  • Physiologic Mechanisms:

    • Fungicidal action of undecylenic acid secreted by apocrine glands.

    • Natural resistance of vulval and perineal skin to infection.

Vaginal Defense

  • Anatomic Mechanisms:

    • Apposition of anterior and posterior walls.

    • Transverse rugae and stratified epithelium.

  • Physiologic Mechanisms:

    • Estrogen influences the resilience of vaginal epithelium.

    • Doderlein’s bacilli convert glycogen into lactic acid, maintaining acidic pH.

Phases of Life When Defense is Lost

  • Following Birth (10 days):

    • Multilayered epithelium present with significant glycogen.

  • Childhood to Puberty:

    • Thin epithelium and absence of glycogen.

    • Neutral to alkaline pH, higher risk of infection.

  • Menstruation: Increased pH and loss of cervix mucous protection.

  • Postabortion and Postpartum: Contaminated lochia increases infection risk.

  • Menopause: Withdrawal of estrogen causes defense loss, increasing infection susceptibility.

Causative Organisms of Pelvic Infection

  1. Pyogenic Organisms (Common):

    • Gram-positive: Staphylococcus.

    • Gram-negative: E. coli, Pseudomonas, Klebsiella, N. gonorrhoeae.

  2. Sexually Transmitted Diseases (STDs):

    • N. gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Herpes simplex virus, etc.

  3. Other:

    • Parasitic: Trichomonas vaginalis.

    • Fungal: Candida albicans.

    • Viral: Herpes simplex virus.

    • Tubercular: Mycobacterium tuberculosis.

Modes of Spread of Infections

  • Ascending Infections: Commonly from cervix to upper genital tract.

  • Pulmonary and Lymphatic Spread: Less common routes.

  • Direct Infection: Through adjacent organs.

Clinical Condition: Pelvic Inflammatory Disease (PID)

  • Definition: Infection of the upper genital tract including uterus, ovaries, and fallopian tubes.

  • Epidemiology:

    • Rising incidence due to increased STDs.

    • Primary risk group includes sexually active women, particularly younger than 25.

Symptoms & Signs of PID

  • Lower abdominal pain, purulent discharge, fever, irregular bleeding.

  • Cervical motion tenderness on examination.

Diagnostic Criteria (CDC-2006)

  • Minimum: Lower abdominal tenderness, adnexal tenderness.

  • Additional: Fever, purulent cervical discharge, elevated leukocytes.

Management of PID

  • Antibiotic Treatment: Early initiation of broad spectrum antibiotics is crucial.

  • Surgical Intervention: Indicated for severe cases.

  • Follow-Up: Regular monitoring for recurrent infections and ensuring treatment of partners.

Complications of PID

  • Immediate: Pelvic peritonitis.

  • Long-term: Infertility, chronic pelvic pain, risk of ectopic pregnancy, pelvic abscess.

Genital Tuberculosis

  • Incidence: Significant, particularly among women with infertility.

  • Symptoms: Often asymptomatic or non-specific.

  • Diagnosis: Requires histological examination, culture, PCR.

  • Treatment: Antitubercular chemotherapy recommended.

Key Points

  1. Defense mechanisms vary with life stages, particularly after childbirth and during menopause.

  2. PID is primarily related to microorganisms from sexual transmission, necessitating careful diagnosis and treatment.

  3. Certain preventive measures, including safe sexual practices and contraceptive use, help mitigate risks.