女性生殖系统炎症及STD(2).ppt

女性生殖系统炎症及STD1.女性生殖系统炎症n妇科最常见的疾病之一。n生理防御机制被破坏，机体免疫功能降低、内分泌改变、内源性菌群失调或外源性致病菌侵入时，均可导致炎症发生。2.女性生殖系统生理防御炎症机制：解剖学特点：复层鳞状上皮；大阴唇自然合拢；阴道前后壁紧贴；阴道的自净作用：雌激素，上皮增厚，糖原，乳酸;阴道的生态平衡：正常菌群，乳杆菌（需氧菌，兼性厌氧菌，厌氧菌，支原体，念珠菌）宫颈粘液栓，阴道部复层磷状上皮，内口紧闭;子宫内膜周期性剥脱，分泌液中有乳铁蛋白、溶菌酶;输卵管的蠕动及粘膜细胞的纤毛摆动；生殖道免疫系统：淋巴组织及淋巴细胞，中性粒细胞、巨嗜细胞、补体、细胞因子3.宫颈炎 Cervicitis:宫颈阴道部和宫颈管黏膜受各种病原体感染而导致的一系列病理改变。概述：发病于生育年龄，妇科最常见的疾病之一，约半数以上已婚妇女患过宫颈炎。急性宫颈炎 Acute cervicitis，少见，多与急性盆腔炎伴发，以宫颈黏膜炎为主，难治愈，易导致慢性宫颈炎。慢性宫颈炎 Chronic cervicitis 4.急性宫颈炎 Acute cervicitis病原体：淋病双球菌、沙眼衣原体。临床表现：白带增多，脓性或血性，腰酸及下腹坠痛，伴发盆腔炎及全身不适。黏液脓性宫颈炎（mucopurulent cervicitis，MPC），最常见，宫颈管可见脓性或黏液脓性分泌物，触血（+）。治疗：全身用药（抗生素），局部冲洗，禁电烙等。5.慢性宫颈炎（chronic cervicitis）较为常见的妇科炎症疾病病因：多由急性宫颈炎未治疗或治疗不彻底转变而来。病原体：主要为葡萄球菌、链球菌、大肠埃希菌及厌氧菌，其次为淋病奈瑟菌、沙眼衣原体、HPV、HSV等。6.病例：女，40岁，阴道分泌物增多，伴腰酸，偶有性生活后出血2年。检查外阴正常，宫颈肥大，度糜烂，接触出血。问题：考虑什么病，进一步做什么检查，选择哪种治疗方法？病 例7.1.宫颈糜烂（cervical erosion）宫颈外口处的 宫颈阴道部呈细颗粒状红色区，最常见，“宫颈住状上皮异位”（columnar ectopy）;(生理性宫颈糜烂，青春期、妊娠期、避孕药）;度（1/3）度（1/3-2/3)度(2/3);宫颈糜烂深度:单纯型,颗粒型(腺上皮过度增生,间质增生)乳头型(间质过度增生).2.宫颈肥大 cervical hypertrophy 慢性炎症刺激腺体、间质增生宫颈肥大结缔组织增生宫颈硬韧,多光滑.病 理 Pathology8.病 理 Pathology3.宫颈息肉 cervical polyp慢性炎症颈管粘膜增生突出外口息肉,恶变率1%,子宫腺肉瘤鉴别。4.宫颈腺囊肿 Naboth cyst（宫颈腺管为新生的鳞状上皮等阻塞）:青白色小囊泡。5.宫颈管粘膜炎 endocervicitis（颈管内粘膜及黏膜下组织炎症）9.临床表现主要白带增多，白色黏液状，脓性或血性白带。症状于月经期、性交后加重（出血）。沿宫骶韧带向盆腔扩散则伴腰酸坠痛。诊断：临床症状与体征；直观不难诊断；关键在于与宫颈上皮内瘤变、早期宫颈癌鉴别。辅助检查方法有：阴道脱落细胞学检查、阴道镜检查及活检。10.宫颈糜烂治疗:局部治疗为主1.物理疗法：治疗效果最好；电熨、激光、冷冻、红外线凝结、微波。破坏糜烂面单层柱状上皮，待其坏死脱落后为新生的复层鳞状上皮覆盖。月经干净后3-7天治疗；排除恶性病变、急性生殖道炎症；治疗后8周内禁性生活、盆浴及阴道冲洗；阴道分泌物增多，甚至大量排液及出血；可致感染、宫经管狭窄及不孕；定期复查，防止并发症。2.药物治疗：硝酸银、铬酸。3.宫颈锥切术：并发非典型增生者，宫颈环形电切（loop electrosurgical excision procedure，LEEP）11.治疗:n宫颈息肉：摘除，病理；n宫颈管黏膜炎：抗感染药物全身治疗为主；增生严重者宫腔镜电切；n宫经腺囊肿：不处理；物理治疗；LEEP。12.SummarynAcute infection of the cervix may be Neisseria gonorrhoeae，Chlamydia trachomatis，herpes simplex virus，human papilloma virus in origin.It may present with vaginal discharge,but also asymptomatic.Routine dual therapy for gonococcal and chlamydial infections is necessary.Chronic cervicitis causes a chronic persistent vaginal discharge.Cervical swabs,colposcopy and cervical biopsy are all helpful in diagnosis.Destruction of the inflamed columnar epithelium by cauterization or cryotherapy may produce a cure.13.盆腔炎 Pelvic inflammatory disease,PID概念：女性内生殖器及其周围的结缔组织、盆腔腹膜炎性病变的总称,包括子宫内膜炎、输卵管卵巢炎、盆腔结绨组织炎、盆腔腹膜炎和输卵管卵巢脓肿等，输卵管炎和输卵管卵巢炎常见。临床较为常见，严重危害妇女健康水平，是输卵管妊娠、不孕及慢性盆腔痛的主要因素。14.常见致病菌:外源性病原体：淋病双球菌、沙眼衣原体内源性病原体：寄居于阴道的菌群（链球菌、葡萄球菌、大肠杆菌、厌氧菌（脆弱类杆菌）、支原体）15.感染途径：沿生殖道粘膜上行蔓延：病原体沿外阴、阴道侵及宫颈黏膜、子宫内膜、输卵管黏膜蔓延到卵巢及盆腹腔。淋菌奈瑟菌、衣原体及葡萄球菌，为非妊娠期、非产褥期盆腔炎的主要感染途径；经血液循环传播：病原体自其他系统经血液循环感染生殖器（结核）；经淋巴系统蔓延：病原体经外阴、阴道、宫颈及宫体创伤处的淋巴管侵入盆腔结缔组织及内生殖器其他部分。链球菌、大肠埃希菌和厌氧菌按此方式播散，是产褥期、流产及宫腔操作时的主要传播途径。直接蔓延：盆腔其他脏器直接蔓延至内生殖器，阑尾炎可直接引起右输卵管卵巢炎甚至盆腔腹膜炎。16.病 因宫腔内手术操作后 流产或产后 不良卫生习惯 经期护理不当 不洁性生活；多个性伴侣；性生活临近器官感染蔓延17.急性盆腔炎的病理：急性子宫内膜炎 acute endometritis 急性子宫肌炎 acute myometritis 急性输卵管炎 acute salpingitis 输卵管积脓 pyosalpinx 输卵管卵巢脓肿 tubo-ovarian abscess 急性盆腔结缔组织炎 acute inflammation of connective tissue 急性盆腔腹膜炎 acute peritonitis败血症 septicemia 脓毒血症 pyaemia18.临床表现：1.发热、下腹痛、阴道异常分泌物增多为常见症状；月经异常；下腹包块。2.重症患者可表现为急性病容，体温升高，心率加快，下腹部可有压痛、反跳痛，甚至腹胀、肠鸣音减弱或消失。妇科检查示阴道和宫颈充血、水肿，阴道分泌物脓性、有臭味，宫颈口有脓栓，穹隆触痛明显，宫颈举痛，子宫增大、压痛，活动受限，子宫两侧可有条索状或片状增厚，合并输卵管脓肿或盆腔脓肿时可触及包块，腹膜刺激征阳性。3.辅助检查：血常规、尿常规、ESR、CRP、培养及镜检（宫颈分泌物、后穹隆穿刺液、血）、腹腔镜、阴道分泌物、PCR、血清抗体。B超、CT、MRI。诊断：根据病史、症状、体征及辅助检查急腹症鉴别：急性阑尾炎、异位妊娠、卵巢囊肿蒂扭转 19.治疗：n一般治疗：休息、半卧位、支持治疗（饮食、补充液体、纠正电解质紊乱及酸碱失衡）、避免不必要的检查。n抗生素治疗：主要治疗手段；联合、足量、足疗程（14日以上）。n手术治疗：主要用于抗生素治疗无效的输卵管卵巢脓肿或盆腔脓肿；指征有：药物治疗无效、脓肿持续存在、脓肿破裂。20.慢性盆腔炎nFrozen pelvis，冰冻骨盆：部分慢性盆腔炎患者盆腔粘连严重，盆腔脏器活动差。21.SummarynPelvic inflammatory disease includes endometriosis，salpingitis，oophoritis，myometritis，parametritis and pelvic abscess Acute lower abdominal pain,vaginal discharge,fever,pelvic tenderness and adnexal mass are symptoms and signs of acute pelvic inflammatory disease.Hospital admission is required for severe cases,for bed rests,intravenous antibiotics and analgesia.Combination antibiotic therapy is started immediately and is reviewed when bacteriological culture results are available.Treatment is given at least for 14days.Chronic infection may be relatively asymptomatic or may provoke complaints of chronic pelvic pain and dyspareunia.There are three major sequelae of PID-ectopic pregnancies,chronic pain,and infertility.The majority of these infections require specific therapy.22.又称结核盆腔炎，好发于输卵管（90%100%）,近年发病率呈上升趋势，常继发于其他部位的结核，约10%的肺结核患者伴有生殖结核，潜伏期一般为110年。生殖器结核 Genital tuberculosis23.病 理输卵管结核 子宫内膜结核、宫颈结核 卵巢结核 盆腔腹膜结核 24.临床表现月经失调 menstrual dysfunction 下腹坠痛 全身症状 不孕 infertility 25.诊断：需详细病史、症状、体征；辅助检查：子宫内膜活检，X-ray（胸、腹、输卵管造影），腹腔镜，细菌培养等。注意：鉴别肿瘤等 治疗：1、抗结核治疗；2、手术。诊断及治疗26.Summary nInfection of the genital tract with Mycobacterium Tuberculosis is almost always secondary to a primary lesion elsewhere，usually in the lungs.The clinical symptoms and signs of pelvic tuberculosis are similar to the chronic sequence of nontuberculous acute pelvic inflammatory disease.The fallopian tube is the most commonly affected site in the pelvis.The diagnosis may be established by specimen which may be from menstrual discharge,from curetage or biopsy.The therapy of genital tuberculosis,with or without extragenital lesions,is primarily that of continuous,long-term,combined drug therapy for 6 to 9 months.General therapeutic measures,including adequate diet and rest,should not be neglected.If surgery is necessary,patients older than 40 years should have a total hysterectomy with bilateral salpingo-oophorectomy.27.Non-specific vulvitis 非特异性外阴炎nNon-specific vulvitis will occur if there is sufficient vaginal discharge，feces or urine from any cause to keep the vulval skin continually moist.In vulval dermatitis of long standing there may be some thickening and pigmentation of the skin,but the skin soon recovers when the cause is removed.28.Bartholinitis 前庭大腺炎Abscess of Bartholin glandnThe most common cause of enlargement of Bartholin glands is csytic dilation of Bartholin duct.Subsequently,symptomatic enlargement of Bartholin glands may be related to adenitis of abscess formation.Bartholin abscess is treated by marsupialization which involves eversion and suturing of the cyst wall,so allowing it to drain.29.Bacterial vaginosis,BV细菌性阴道病nBacterial vaginosis results when high concentrations of anaerobic bacteria replace the normal H2O2-producing lactobacillus species in the vagina.The classic criteria for the diagnosis of bacterial vaginosis are(1)A homogeneous vaginal discharge is present.(2)The vaginal discharge has a Ph equal to or greater than 4.5.(3)The vaginal discharge has an aminelike odor when mixed with potassium hydroxide.whiff test.(4)Microscopic examination of the discharge reveals typical“clue cells”.The recommended regimen of treatment is oral metronidazole.400 mg twice daily for 7 days.30.Vulvovaginal candidiasis,vvc外阴阴道念珠菌病nVulvovaginal candidiasis is produced by a ubiquitous,airborne,gram-positive fungus.The vast majority of cases are caused by Candida albicans.The usual symptoms are vulval pruritus and vaginal soreness.Candida species are part of the normal flora of approximately 25%of women,being a commensal saprophytic organism on the mucosal surface of the vagina.When the ecosystem of the vagina is disturbed,Candida becomes an opportunistic pathogen.Treatment is with clotrimazole vaginal pessary,together with clotrimazole cream if vulvitis is present,or with oral flubonazole.31.Trichomonal vaginitis滴虫性阴道炎nTrichomonal vaginitis is the most prevalent nonviral,nonchlamydial sexually transmitted disease of women.There are a yellowish-green vaginal discharge,and a characteristic strawberry cervix due to the prominent appearance of blood vessels in Trichomonal vaginitis.Treatment is with metronidazole.The asymptomatic female who has trichomonas identified in the lower female genital urinary tract definitely should be treated.32.Senile vaginitis 老年性阴道炎nSenile vaginitis is due to the long-term effect of low estrogen level that results in the vaginal skin thin and easily traumatized,and lacking in glycogen.Treatment is with metronidazole and estrogen.The possibility of a carcinoma should be remembered in this age group,particularly if the discharge is blood-stained.33.Sexually transmitted disease,STD性传播疾病n是指 通过性行为或类似性行为而传播的疾病。传统的性病包括梅毒、淋病、软下疳、性病淋巴肉芽肿和腹股沟淋巴肉芽肿。1975年WHO将以性行为为主要传播途径及可经性行为传播的20余种疾病列为现代意义的性传播疾病，病原体包括细菌、病毒、螺旋体、支原体、衣原体、真菌、原虫及寄生虫8类。目前我国重点监测的STD包括淋病、梅毒、AIDS、尖锐湿疣、非淋菌性尿道炎、生殖器疱疹、软下疳和性病性淋巴肉芽肿，前3种为传染病法中的乙类传染病。34.淋病 Gonorrhea概述：淋病奈瑟菌（neisseria gonorrhoeae）目前世界上发病率最高的性病，主要侵袭粘膜，以生殖、泌尿系统粘膜的柱状上皮与移行上皮为主。35.感染途径：主要性接触；极少间接接触，幼女感染。临床表现：多数泌尿系症状伴有生殖器感染症状，及全身淋病表现。诊断：病史；细菌培养。治疗：以青霉素首选。淋 病36.Summary nSexually transmitted disease is used to denote disorders spread principally by intimate contact.Gonorrhea is caused by a gram-negative intracellular diplococcus.It causes cervicitis,urethritis,pelvic inflammatory disease and acute pharyngitis in women.Single-dose efficacy is a major concern.Patients infected with neisseria gonorrhoeae should be screened for other STDs.37.梅毒 Syphilis概念：经典性病，由梅毒螺旋体(苍白密螺旋体,treponema pallidum,TP)感染引起生殖器、淋巴结及全身病变的性传染病。分-期。硬下疳,chancre 感染途径：性行为传染，垂直传播。诊断：性病接触史，血清血检查。治疗：苄星penicillin，罗红霉素。38.二期梅毒39.Summary nSyphilis is a chronic complex systemic disease produced by the spirochete treponema pallidum.Dark-field microscopy rather than normal light microscopy is used for detection of syphilis.The characteristic chancre of primary is a red,round ulcer with firm,well-formed,raised edges,with a nonpurulent clean base and yellow-gray exudate.Penicillin is first choice for all stages of syphilis.40.生殖道沙眼衣原体感染 Chlamydial trachomatis简介：国外较常见，为新生儿肺、眼感染主要原因，亦是非淋菌性尿道炎的主要原因，不孕妇女感染率较高。途径：以性接触为主。表现：宫颈炎最常见。诊断：细胞学检查。治疗：四环素、红霉素等。41.Summary nChlamydia trachomatis is not uncommon Chlamydia trachomatis is not uncommon for women with chlamydia infection to be for women with chlamydia infection to be asymptomatic.Women with cervical asymptomatic.Women with cervical infection generally have a mucopurulent infection generally have a mucopurulent discharge with hypertrophic cervical discharge with hypertrophic cervical inflammation.Salpingitis may be inflammation.Salpingitis may be unassociated with symptoms.Diagnosis and unassociated with symptoms.Diagnosis and treatment of chlamydial infections are treatment of chlamydial infections are frequently based on the clinical frequently based on the clinical symptom.symptom.42.病毒感染简介：逐渐成为感染的主要原因，导致新生儿畸形，诱发肿瘤发生，直接接触传染。包括：单纯疱疹病毒(HSV)、巨细胞病毒(CMV)、人乳头瘤病毒(HPV)，其中尖锐湿疣为重要的STD之一，经典性病。43.反复发作，恶变趋势。病原体：HPV（HPV6、11、16、18）-人乳头瘤病毒 human papilloma virus表现：外阴、阴唇、尿道口、宫颈、肛周搔痒，疣状突起，菜花样。诊断：注意与假性湿疣、外阴肿瘤等鉴别病理、细胞学、分子生物学等;挖空细胞(koilocytosis).治疗：激光、冷冻、药物、手术。尖锐湿疣 Verruca acuminata,condyloma acuminata44.图45.Summary nHPV is responsible for condyloma acuminata of the vagina,cervix,vulva,perineum,and perianal aereas as well as for dysplasia and cancer.The typical lesion is an exophytic or papillomatous condyloma.The presence of koilocytes is pathognomonic for HPV infection.Diagnosis includes pap smears,biopsy and colposcopy.Treatment does not eradicate the virus.Podophyllin（鬼臼脂）,trichloroacetic acid cryotherapy and electrocautery are the main physical or chemical destructive techniques.46.AIDS-获得性免疫缺陷综合症acquired immunodeficiency syndrome简述：为HIV(human immunodeficiency virus)感染，是一种逆转录RNA病毒，表现为艾滋病相关综合症。实验室血清血诊断。47.Summary nHIV is believed to be responsible for severe deficiencies in cell-mediated immunity,leading to unusual opportunistic infections,malignancy and eventually death.The diseases caused by the HIV are known as acquired immunodeficiency syndrome(AIDS).There are three methods of contracting HIV:intimate sexual contact,use of contaminated needles or blood products,and perinatal transmission from mother to child.Antiretroviral therapy may delay progression to advanced disease.48.Genital herpes,生殖器疱疹nHerpes simplex virus(HSV)has an affinity for infection mucocutaneous tissues of the lower genital tract.The majority of symptomatic women have severe vulvar pain,tenderness,and inguinal adenopathy.However,subclinical primary herpes infection is common.Oral acyclovir has been shown to be beneficial in reducing the duration of herpetic ulcerative lesions and in reducing the time that the virus can be isolated from these lesions.49.本课重点慢宫颈炎的病理、分型、分度。急性盆腔炎的病理、治疗原则。STD的概念。其他女性生殖系统炎症的病因或病原体。常见STD的病原体。50.