Chapter 74: Pelvic Infections

INTRODUCTION

Infections in the pelvic organs and surrounding structures compose a heterogeneous group of diseases. They primarily affect sexually active women and men. Many of the pathogens implicated are sexually transmitted, so an important facet of management is partner notification and treatment, as well as patient education regarding safe sexual practices. Among sexually transmitted infections, major syndromes that will be discussed are genital ulcer disease, vaginitis, cervicitis, pelvic inflammatory disease (PID), urethritis, prostatitis, and epididymitis.

Some of the organisms described in this chapter, such as Treponema pallidum, Neisseria gonorrhoeae, Chlamydia trachomatis, and herpes simplex virus 2, are transmitted from the mother to the fetus. The acronym TORCHES is used to describe certain important fetal or newborn infections acquired from the mother. There are several versions of this acronym. The following is a commonly used one: T = Toxoplasma; O = other (including parvovirus, human immunodeficiency virus, and Zika virus); R = rubella; C = cytomegalovirus; HE = herpes simplex virus 2; and S = syphilis. A more complete list of organisms vertically transmitted from mother to child can be found in Part 12, Table XII–10.

GENITAL ULCER DISEASE

Definition

Genital ulcer disease manifests as a breach in the skin or mucosa of the genitalia, usually caused by a sexually transmitted infection. Of these infections, herpes simplex virus type 2 (HSV-2) is the most common etiology in most geographic areas, followed by syphilis and chancroid. The most important noninfectious cause is Behçet’s disease.

Pathophysiology

The mechanisms by which ulcers are produced by pathogens are incompletely understood, and there are different mechanisms of injury depending on the pathogen. In chancroid, a cytotoxin secreted by Haemophilus ducreyi may be important in epithelial cell injury.

Clinical Manifestations

Although the various lesions may have a characteristic appearance, it is important to note that local epidemiology is an important consideration because lesions may appear in an atypical fashion. The appearance of the ulcer, whether it is painful, and the nature of the associated lymphadenopathy may be clues in the etiology of the ulcer. Figure 74–1 shows several vesicles on the shaft of the penis of a patient with genital herpes. The vesicular lesions are typically painful. The vesicles can then progress to form shallow ulcers. Figure 74–2 shows the chancre of primary syphilis. It is a painless lesion with a shallow base and a firm, rolled edge. Table 74–1 describes the important clinical features of genital ulcer lesions, their diagnostic procedures, and treatment.