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Genitourinary Infection and STDs

Genitourinary Infection and STDs



1. Normal vaginal secretionsÀÇ ±¸¼º

¨ç Vulva secretions from sebaceous , sweat, bartholin and skene glands

¨è Transdate from the vaginal wall

¨é Exfoliated vaginal and cervical cells

(¤¡) Superficial cells : estrogen stimulationÀÖÀ»½Ã

(¤¤) Intermediate cells : luteal phase¿¡ progesterone ÀڱؽÃ

(¤§) parabasal cells : hormone ÀÚ±Ø ¾øÀ»½Ã

¨ê Cervical mucus

¨ë Endometrial and oviductal fluids

¨ì Microorganisms and their metabolic products



2. normal vaginal flora

´ë°³ aerobicÀÌ¸ç Æò±Õ six different species°¡ Á¸ÀçÇϸç, °¡Àå ÈçÇϰԴ hydrogen peroxide producing lactobacilli´Ù. Normal vaginalÀÇ PH´Â 4.5¹Ì¸¸À̸ç ÀÌ´Â lacticacidÀÇ ÇÕ¼º¿¡ ÀÇÇØ À¯ÁöµÈ´Ù. Estrogen-stimulated vaginal epithelial cellsÀº glycogenÀÌ Ç³ºÎÇϸç, ÀÌ glycogenÀº monosaccharides·Î ºÐÇØµÇ°í, ´Ù½Ã lactobacilli¿¡ ÀÇÇØ lactic acids·Î º¯È­µÈ´Ù.



3. Bacterial Vaginosis(BV)

¨ç ¿øÀÎ : hydrogen-peroxide producing lactobacilli°¡ ¼Ò½ÇµÇ°í Gardnerella vaginalis and Mycoplasma hommins°°Àº anaerobic bacteriaÀÇ overgrowth¿¡ ÀÇÇÑ´Ù. Anaerobic bacteria´Â normal flora¿¡¼­´Â 1%¹Ì¸¸ÀÌ´Ù. BV¿¡¼­ÀÇ anaerobic bacteria´Â Á¤»óÀÇ ¾à 100-1000¹è°¡·®µÈ´Ù. Normal floraÀÇ º¯È­¸¦ ÃÊ·¡ÇÏ´Â °ÍÀÌ ¹«¾ùÀÎÁö´Â Àß ¸ð¸£³ª sexual intercourse³ª douche»ç¿ëµî¿¡ ÀÇÇÑ alkalizationÀÌ °¡¼³µÇ¾îÁø´Ù. ÀÏ´Ü normal hydrogen-peroxide-producing lactobacilli°¡ norma flora°¡ ȸº¹µÇ´Â °ÍÀº ¾î·Á¿ì¸ç µû¶ó¼­ Àç¹ßÀÌ ÈçÇÏ´Ù.

¨è Adverse sequelae : PID, post operative cuff infection after hysterectomy, abnormal cercical cytology, PROM, preterm labor and delivery, chorioamnionitis, post C/SEC endometritisÀÇ À§Ç輺ÀÌ Áõ°¡ÇÑ´Ù. ÇÏÁö¸¸ BVÀÇ sceening and treatment¿¡ ÀÇÇØ ÀÌ·¯ÇÑ sequelae°¡ °¨¼ÒÇÏ´Â Áö´Â ¸ð¸¥´Ù.

¨é Diagnosis

l Fishy vaginal odor (ƯÈ÷ coitus ÈÄ)

l Vagianl secretions are gray and thinly coat the vaginal walls

l PH > 4.5(usually 4.7-5.7)

l Çö¹Ì°æ»ó Clue cellsÁõ°¡Çϳª, leukocytes´Â ¾ø´Ù. Advanced BV¿¡¼­´Â epithelial cellsÀÇ 20%ÀÌ»óÀÇ clue cellsÀÌ´Ù.

l Vaginal secretion¿¡ KOH÷°¡Çϸé(Whiff test )fishy, amine-like odor°¡ ¹æÃâµÈ´Ù.

¨ê Treatment : anaerobeÀÇ ¼ºÀåÀ» ¾ïÁ¦Çϸ鼭µµ vaginal lactobacilliÀÇ ¼ºÀåÀ» ¾ïÁ¦ÇÏÁö ¸»¾Æ¾ß ÇÑ´Ù. Oral metronidazoleÀº mild to moderate G-I upset ¹× unpleasant taste°¡ Àֱ⠶§¹®¿¡ ºÎÀÛ¿ëÀûÀº Áú³»Ä¡·á°¡ ¼±È£µÇ±âµµ ÇÑ´Ù. »ó´ë³²ÀÚÀÇ Ä¡·á´Â therapeutic responseÀÇ Çâ»óÀÌ ¾ø±â ¶§¹®¿¡ ÃßõµÇÁö ¾Ê´Â´Ù.

(¤¡) Metronidazole : anaerobes¿¡°Ô´Â excellent activityº¸À̳ª, lactobacilli¿¡´Â poor activity º¸À̱⠶§¹®¿¡ BV Ä¡·á¿¡ choice´Ù 500mg ÇÏ·ç 2ȸ 7ÀÏ µ¿¾È»ç¿ëÇϸç, ¾àº¹¿ëÁß È¤Àº Ä¡·áÈÄ 24½Ã°£ µ¿¾È¿¡´Â ¾ËÄڿü·Ã븦 ±ÝÇØ¾ßÇÑ´Ù. ´Ù¸¥¹æ¹ýÀ¸·Î´Â 2g single dose»ç¿ëÇÏ´Â °ÍÀÌ ÀÖ´Ù. Cure rate´Â 7day regimenÀº 95%, single dose regimenÀº 84%´Ù.

(¤¤) Alternative regimens

l Metronidazole gel 0.75%À» ÇÏ·ç 2ȸ¾¿ Áú³»»ç¿ë

l Clindamycin cream 2%À» ÇÏ·ç Çѹø 7Àϵ¿¾È ÃëħÀü¿¡ Áú³»»ç¿ë

l Clindamycin 300mgÀ» ÇÏ·ç 2ȸ 7ÀÏ µ¿¾È »ç¿ë



4. Trichomonas Vaginitis

¨ç ¿øÀÎ : sexually transmitted, flagellated parasiteÀÎ Trichomonas vaginalis¿¡ ÀÇÇϸç, transmission rate°¡ ³ô¾Æ¼­ infected woman¿¡ ´Ü Çѹø ³ëÃâµÈ ³²ÀÚ ¾à 70%°¡ °¨¿°µÈ´Ù. AnaerobeÀ̸ç hydrogenÀ» »ý¼ºÇÏ¿© »ê¼Ò¿Í °áÇÕÇÏ°Ô ÇÔÀ¸·Î½á anaerobic environment¸¦ Á¶¼ºÇÑ´Ù. Á¾Á¾ BV¿Í µ¿¹ÝÇϸç Trochomonas vaginitisȯÀÚÀÇ ¾à 60%¿¡¼­ BV°¡ Áø´ÜµÈ´Ù.

¨è Diagnosis : local immune factors and inoculum size¿¡ µû¶ó Áõ»óÀÌ ´Þ¶ó¼­ smaller inoculum of trochomanadsȯÀÚ¿¡¼­´Â mildÇϸç, Á¾Á¾ asymptomaticÇÏ´Ù.

(¤¡) Vulva pruritiss µ¿¹ÝÇÒ ¼ö ÀÖ´Â profuse, purulent, malodorous vaginal discharge

(¤¤) Vaginal secretion may exude from the vagina

(¤§) OrganismÀÇ high concentrationÀÖ´Â °æ¿ì patch vaginal erythema and strawberry cervix(colpitis macularis)°¡ °üÂûµÉ ¼öÀÖ´Ù.

(¤©) Vaginal secretion PH´Â ´ë°³ 5º¸´Ù ³ô´Ù.

(¤±) Çö¹Ì°æ»ó motile trichomanads¸¦ º¸À̸ç, increased number of leukocytesº¸ÀδÙ.

(¤²) BV¿Í ÈçÈ÷ µ¿¹ÝµÇ±â ¶§¹®¿¡ clue cellsÀÌ º¸ÀÏ ¼öÀÖ´Ù.

(¤µ) Whiff test¿¡¼­ ¾ç¼ºÀÏ ¼öÀÖ´Ù.



¨é Morbidity : post op cuff cellulites, PROM, preterm deliveryÀÇ À§Ç輺ÀÌ Áõ°¡ÇÑ´Ù. STDsÀ̱⠶§¹®¿¡ ´Ù¸¥ STDs°¡·É neisseria gonorrhea, chlamydia trachomatis¿¡ ´ëÇÑ testµµ ½ÃÇàÇØ¾ßÇÑ´Ù. Syphilis and HIV¿¡ ´ëÇÑ serologic testingµµ °í·ÁÇÏ¿©¾ßÇÑ´Ù.

¨ê Treatment

(¤¡) metronidazoleÀÌ choiceÀ̸ç 500mgÀ» ÇÏ·ç 2¹ø 7Àϵ¿¾È »ç¿ë, ȤÀº 2g single dose»ç¿ë¿¡ ÀÇÇØ 95%ÀÇ cure rateº¸ÀδÙ.

(¤¤) Sexual partnerµµ °°ÀÌ Ä¡·áµÇ¾îÁ®¾ß ÇÑ´Ù.

(¤§) Metronidazole gelÀº BV¿¡´Â highly effectiveÇÏÁö¸¸ vaginal trichomoniasisÄ¡·á¿¡´Â »ç¿ëÇØ¼­´Â ¾ÈµÈ´Ù.

(¤©) 500mg ÇÏ·ç2ȸ 1ÁÖÀϰ£ÀÇ Ä¡·á¿¡ ¹ÝÀÀ¾ÈÇÏ¸é ´Ù½Ã Çѹø ÀçÂ÷ ½ÃÇàÇØº¸°í ±×·¡°í ¹ÝÀÀ ¾øÀ¸¸é single 2g dose·Î 3-5Àϰ£ Ä¡·áÇÑ´Ù.

(¤±) Ä¡·á¿¡ ¹ÝÀÀ¾ø´Â °æ¿ì´Â cultureÇØ¼­ metronidazole¿¡ ´ëÇÑ susceptibility¸¦ °Ë»çÇÑ´Ù.





5. Vulvovaginal candidiasis(VVC)

¨ç Incidence : ¿©¼ºÀÇ life time¿¡ ¾à 75%ÀÇ ¿©¼ºÀÌ Àû¾îµµ 1ȸ´Â VVC¸¦ °æÇèÇÑ´Ù. Candida albicans°¡ 85-99%¿¡¼­ ¿øÀÎÀ̸ç, Áõ»óÀº >10000/mlÀÇ organisa¿¡¼­ »ý±â¸ç, 1000/ml¹Ì¸¸ÀÎ °æ¿ì´Â Áõ»óÀÌ ¾ø´Ù.

¨è Pathogenesis : ½ÉÇÑ pruritis and inflammationÀ» º¸ÀÌ´Â °æ¿ì¿¡¼­µµ lower genital tract epithelium invasionÀÌ minimalÇÑ °ÍÀ¸·Î º¸¾Æ extracelluar toxin or enzymeÀÌ pathogenesis¿¡ ±â¿©ÇÏ´Â °Í°°´Ù. Hypersensitivity phenomenonµµ irritative symptoms°ú ¿¬°üÀÖ´Â °Í°°À¸¸ç, ƯÈ÷ chronic, recurrent disease¿¡¼­´Â ´õ¿í ±×·¸´Ù.

¨é Predisposing factor of symptomatic VVC : antibiotic use, pregnancy, DMµîÀÌ ÀÖ´Ù. Lactobacilli°¡ fugiÀÇ overgrowth¸¦ ¾ïÁ¦Çϳª, Ç×»ýÁ¦ÀÇ »ç¿ë¿¡ ÀÇÇØ lactobacilli³ª normal floraÀÇ °¨¼Ò¸¦ ÃÊ·¡µÇ¸é fungi overgrowth ¾ß±âÇÒ ¼öÀÖ´Ù. ÀӽŠ¹× ´ç´¢´Â cell mediated immunity °¨¼Ò¿Í ¿¬°üµÇ¾î candidiasis incidence¸¦ Áõ°¡½ÃŲ´Ù.

¨ê Diagnosis : Áõ»óÀº vaginal discharge ¿Í µ¿¹ÝµÇ´Â pruritusÀ̸ç, discharge´Â cottage cheese°°´Ù.

(¤¡) Discharge´Â waterly¿¡¼­ homogenouslhy thick±îÁö ´Ù¾çÇϸç, vaginal soerness, dyspareunia, vulvar burning, irritationµîÀ» º¸ÀÏ ¼öÀÖ´Ù.micturitiont½Ã¿¡ inflamed vulvar and vestibular epithelium¿¡ urineÀÌ exposeµÇ¸é external dysuria ¾ß±âÇÒ ¼öÀÖ´Ù.exam»ó¿¡¼­ labia and vulvar skin¿¡ erythema and edema¸¦ º¸Àθç, discrete pustulopapular peripheral lesionsÀÌ ÀÖÀ» ¼öÀÖ´Ù. Vagina´Â adherent, whitish discharge¸¦ °¡Á® erythematousÇÒ ¼öÀÖÀ¸¸ç, cervix´Â ´ë°³ Á¤»óÀÌ´Ù.

(¤¤) PH´Â ´ë°³ Á¤»óÀÌ´Ù.(<4.5)

(¤§) 80%ÀÇ case¿¡¼­ fungal element (budding yeast forms or mycelia)¸¦ È®ÀÎ ÇÒ ¼öÀÖ´Ù.

(¤©) Whiff test´Â normal

(¤±) PH°¡ Á¤»óÀ̸ç saline preparation Á¤»óÀ̸鼭 Çö¹Ì°æ»ó fungal element°¡ ¾Èº¸ÀÌ´Â °æ¿ì¿¡ Áø´ÜÀ» °¡Á¤ÇØ º¼ ¼ö ÀÖÀ¸¸ç È®ÁøÀ§Çؼ­´Â fungal cultureÇÑ´Ù.



¨ë Treatment

(¤¡) Azole drugs°¡ °¡Àå ÈçÈ÷ »ç¿ëµÇ¾îÁö¸ç nystatin º¸´Ù effectiveÇÏ´Ù.Ä¡·áÀ» ¸¶Ä£ ȯÀÚÀÇ ¾à 80-90%¿¡¼­ Áõ»ó¿ÏÈ­¿Í negative cultureº¸À̸ç, Azole»ç¿ëÇÑ °æ¿ì¿¡ Áõ»óÀº ´ë°³ 2-3Àϳ»¿¡ ¼Ò½ÇµÈ´Ù.

(¤¤) Fluconazole 150mg single oral dose°¡ VVCÀÇ Ä¡·á·Î °øÀεǾúÀ¸³ª Áõ»óÀÌ 2-3ÀÏ µ¿¾È »ç¶óÁöÁö ¾ÊÀ» ¼öÀÖÀ¸¹Ç·Î ±×µ¿¾È ´Ù¸¥ Ä¡·áÇÏÁö ¾Êµµ·Ï ±³À°ÇÑ´Ù.

(¤§) External irritative symptoms¿¡´Â 1% hydrocortisone cream°°Àº topical steroids°¡ Áõ»ó¿ÏÈ­¿¡ µµ¿òµÈ´Ù.

Table 15.1



6. Chronic vulvovaginal candidiasisÀÇ Áø´Ü ¹× Ä¡·á

¨ç ¼Ò¼öÀÇ ¿©¼º¿¡¼­´Â chronic , recurrent vulvovaginal candidiasisÀÇ ÀÇÇÑ persistent irritative symptomsÀÌ »ý±â°Ô µÈ´Ù. BurningÁõ»óÀº chronic VVCȯÀÚ¿¡¼­´Â itchingÀ¸·Î replaceµÇ°Ô µÈ´Ù. Áø´ÜÀº Çö¹Ì°æ È®ÀÎ ¹× culture·Î ÇÏ°Ô µÈ´Ù. ¸¹Àº ¿©¼ºÀÌ chronic vaginitis¸¦ VVC·Î ¿ÀÀÎÇϳª, ´ëºÎºÐÀº chronic dermatitis or atrophic dermatitis´Ù

¨è Ä¡·á´Â daily 400mg Ketoconazole ȤÀº daily 200mg fluconazoleÀ» Áõ»óÀÌ »ç¶óÁú ¶§±îÁö »ç¿ëÇϸç, prophylactic dose·Î ketoconazole 100mg daily ȤÀº fluconazole 150mg weekly·Î 6°³¿ù°£ »ç¿ëÇØÁØ´Ù.



7. inflammatory vaginitisÀÇ ¿øÀÎ, Áõ»ó, Ä¡·á

¨ç ¿øÀÎ : ¿øÀÎÀº Àß ¸ð¸£³ª normal floraÀÎ lactobacilli°¡ »ó´ëÀûÀ¸·Î °¨¼ÒÇϰí G(+)cocciÀÎ streptococci°¡ Áõ°¡ÇÑ´Ù.

¨è Áõ»ó : diffuse exudative vaginitis, epithelial cell exfoliation, profuse prulent vaginal discharge·Î Ư¡Áö¾îÁø´Ù. ÀÌ ÁúȯÀ» °¡Áø ¿©¼ºµéÀº purulent vaginal discharge, vulvovaginal burning or irritation and dyspareuniaº¸À̸ç, vulvar pruritus´Â less commonÇÏ´Ù.vaginal erythemaº¸À̸ç, ±×¿Í ¿¬°üµÇ¾î vulvar erythema, vulvovaginal ecchymotic spots, colpitis macularis°¡ ÀÖÀ» ¼öÀÖ´Ù. PH´Â 4.5º¸´Ù ³ô´Ù.

¨é Ä¡·á : initial therapy´Â 2% clindamycin creamÀ» ÇÏ·ç Çѹø 7ÀÏ µ¿¾È Áú³»»ç¿ëÇÏ´Â °ÍÀ̸ç, Àç¹ßÀÌ ¾à 30%¿¡¼­ »ý±ä´Ù. Àç¹ß ÇѰæ¿ì¶ó¸é ¾à 2ÁÖ°£ ´õ Ä¡·áÇÑ´Ù. Post menopausal women¿¡¼­ Àç¹ßÇϸé supplementary HRT¸¦ °í·ÁÇÑ´Ù.



8. Atrophic vaginitis ÀÇ Áõ»ó ¹× Ä¡·á

¨ç Æó°æ¿©¼ºÀº inflammatory vaginitis°¡ »ý±æ ¼öÀÖÀ¸¸ç, increased purulent vaginal discharge°¡ µ¿¹ÝµÉ ¼öÀÖ´Ù.°Ô´Ù°¡ vagina and vulva epitheliumÀÇ atrophy¿¡ ÀÇÇØ dyspareunia and post coital bleedingÀÌ ÀÖÀ» ¼öÀÖ´Ù.

¨è Exam»ó¿¡¼­´Â vaginal rugaeÀÇ ¼Ò½Ç°ú ÇÔ²² external genitalia atrophy¸¦ È®ÀÎÇÒ ¼öÀÖÀ¸¸ç, vaginal mucosa´Â ´Ù¼Ò friableÇÒ ¼öÀÖ´Ù. Çö¹Ì°æÇÏ¿¡¼­´Â parabasal epithelial cellsÀÌ predominentÇϸç leukocytes°¡ Áõ°¡µÇ¾îÀÖ´Ù.

¨é 1gÀÇ conjugated estrogen creamÀ» ¸ÅÀÏ Áú³»·Î 1-2ÁÖ°£ »ç¿ëÇϸé Áõ»óÀ» È£Àü½Ãų ¼öÀÖ´Ù.Àç¹ßÀ» ¹æÁöÇϱâ À§ÇØ systemic ERT¸¦ °í·ÁÇÑ´Ù.



9.CervicitisÀÇ ¿øÀÎ , Áø´Ü ¹× Ä¡·á

¨ç ¿øÀÎ :Cervix´Â squamous epithelium°ú glandular epitheliumÀ¸·Î ±¸¼ºµÇ¸ç, cervical inflammationÀÇ cause´Â affectedµÈ epithelium¿¡ ´Þ·ÁÀÖ´Ù. Áï ectocervical epitheliumÀº vaginal epitheliumÀÇ ¿¬ÀåÀ̸ç vaginitisÀÏÀ¸Å°´Â microorganism(trichomonas, candida, HSV)¿¡ ÀÇÇØ inflamedµÈ´Ù. ¹Ý¸é¿¡ Neisseria gonorrhea¿Í chlamydia trachomatis´Â glandular epithelium¸¸ infectÇÏ¿© mucopurulent endocervicitis(MPC)¸¦ ÀÏÀ¸Å²´Ù.

¨è Áø´Ü : MPCÀÇ Áø´ÜÀº purulent endocervical discharge(yellow or green)¿¡ ±âÃÊÇÑ´Ù.

(¤¡) Cotton swabÀ» endocervical canal¿¡ ³Ö¾ú´Ù »« ÈÄ mucopusÀÇ colorÈ®ÀÎÇÑ´Ù. °Ô´Ù°¡ glandular epithelium¿¡ edema , erythema, fiability°¡ Á¸ÀçÇÑ´Ù.ÀÌ·¯ÇÑ °ÍÀº ¾Ë±â°¡ ¾î·Á¿ì³ª catton swabÀ̳ª spatulumÀ¸·Î ectropionÀ» touchingÇÒ¶§ ½±°Ô bleedingÀÌ inducedµÊÀ» È®ÀÎ ÇÔÀ¸·Î½á ¾Ë ¼öÀÖ´Ù.

(¤¤) MucopusÀÇ gram stain¿¡ ÀÇÇØ Áõ°¡µÈ neutrophils(>30HPF)¸¦ È®ÀÎ ÇÒ ¼ö ÀÖ°í, intracellular G(-) diplococci´Â gonococcal endocervicitis¸¦ °¡Á¤ÇÒ ¼ö ÀÖ´Ù. ¸¸¾à gram stain¿¡¼­ gonococci°¡ negativeÀ̸é chlamydial MPC¸¦ °¡Á¤ÇÒ ¼ö ÀÖ´Ù.

(¤§) Gonorrhea and chlamydia¿¡ ´ëÇÑ test·Î¼­ cell culture, ELIZS, direct fluorescent antibody test°°Àº °ÍÀ» ½ÃÇàÇÑ´Ù. ¸¸¾à gonococci or chlamydia°¡ detectµÇÁö ¾ÊÀ¸¸é ¾à 50%¿¡¼­´Â ¿øÀÎÀ» ¾Ë ¼ö¾ø´Ù.

¨é Ä¡·á : sexual partnerµµ °°ÀÌ Ä¡·áµÇ¾îÁ®¾ßÇÑ´Ù.

Table 15.2



10. Pelvic inflammatory disease

¨ç ¿øÀÎ : endocervix¿¡ colonizingÇÏ¿© endometrium ,fallopian tube·Î ascedingÇÏ´Â microorganism¿¡ ÀÇÇÑ´Ù. ´ë°³ sexually transmitted microorganismÀÎ Neisseria gonorrhea, chlamydia trachomatis¿¡ ÀÇÇÏ¸ç ±×¿Ü¿¡µµ H. influenza, group A streptococci, pneumococci, BV microorganisms(prevotella, peptostreptococci, Gardnerella vaginalis)

¨è Áø´Ü

(¤¡) traditional triad : pelvic pain, cervical and adnexal motion tenderness, fever

(¤¤) lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chill, urinary symptoms°°Àº genitourinary smyptomsÀÌ ÀÖ´Â °æ¿ì PID¸¦ ¿°µÎ¿¡ µÎ¾î¾ßÇÑ´Ù. ¾î¶² ¿©¼º¿¡¼­´Â Áõ»ó¾øÀÌ PID°¡ »ý±æ ¼öÀÖ´Ù.

(¤§) Pelvic organ tenderness°¡ »ý±â´Âµ¥ , cervical motion tenderness´Â peritoneal inflammationÀ» ½Ã»çÇϸç, peritoneum strecting and traction¿¡ ÀÇÇØ painÀÌ À¯¹ßµÈ´Ù.

(¤©) Abdominal tenderness or rebounding tenderness°¡ ÀÖÀ» ¼öÀÖ´Ù.

(¤±) Vaginal and endocervical discharge¸¦ evaluationÇÏ´Â °ÍÀÌ Áß¿äÇϸç, Áõ°¡µÈ poly morphonuclear leukocytes°¡ wet smear¿¡¼­ º¸ÀÏ ¼öÀÖ´Ù.

(¤²) ¸¸¾à diagnosis°¡ ºÎÁ¤È®ÇÏ¸é ºÒÇÊ¿äÇÑ morbidity¸¦ ¾ß±âÇÒ ¼öÀֱ⠶§¹®¿¡ severeÇÑ °æ¿ì¿¡¼­´Â ´õ¿í Á¤¹ÐÇÑ °Ë»ç°¡ ÇÊ¿äÇÏ´Ù. Áï endometrial biopsyÅëÇÑ endometritisÁø´Ü, ÃÊÀ½ÆÄÅëÇÑ TOAÁø´Ü, visually salpingitis¸¦ È®ÀÎÇϱâ À§ÇÑ laparoscopyµîÀÌ ±×°ÍÀÌ´Ù.

¨é Ä¡·á :°¡´ÉÇÑ pathogens¿¡ ´ëÇÑ empiric, broad-spectrum coverage°¡ ¿ä±¸µÈ´Ù.

Table 15.4

¨ê ÀÔ¿ø±âÁØ ¹× Åð¿ø±âÁØ

(¤¡) ÀÔ¿ø±âÁØ

l Áø´ÜÀÌ ºÒ¸íÈ®ÇÒ½Ã

l pelvic abscess°¡ ÀǽɵɽÃ

l clinical disease°¡ severeÇÒ½Ã

out patient regimen¿¡ ´ëÇÑ compliance ³·À»°Å¶ó ¿¹»óµÉ½Ã

(¤¤) Åð¿ø±âÁØ

l 24½Ã°£ ÀÌ»ó ¿­ÀÌ ¿ÏÀüÈ÷ ¾ø¾îÁ³À»½Ã

l WBC°¡ Á¤»ó

l Rebounding tenderness°¡ ¼Ò½Ç

l ¹Ýº¹µÇ´Â ³»Áø¿¡¼­ pelvic organ tenderness°¡ »ó´çÈ÷ ¼Ò½ÇµÈ °æ¿ì

¨ë sexual partner : chlamydia or gonorrhea¿¡ ÀÇÇÑ urethral infection¿¡ ´ëÇØ Ä¡·áÇÏ¿©¾ß ÇÑ´Ù.

Table 15.2



11. Tubo-Ovarian Abscess(TOA)ÀÇ Áø´Ü ¹× Ä¡·á

¨ç Áø´Ü : acute PIDÀÇ end-stage processÀ̸ç, PIDÀÖ´Â ¿©¼º¿¡¼­ bimanual exam»ó¿¡¼­ pelvic mass°¡ ÀÖÀ» ½Ã Áø´ÜÇÒ ¼öÀÖ´Ù.pelvic organ agglutinationÀÌ ½ÉÇØ tube, ovary, bowelÀÇ palpable complex°¡ »ý±æ ¼öÀÖ´Ù.

¨è Ä¡·á : ¾à 75%ÀÇ È¯ÀÚ´Â antimicrobial therapy¿¡ ¹ÝÀÀÇÑ´Ù. ¸¸¾à medical therapy¿¡ ¹ÝÀÀ¾øÀ»½Ã´Â surgical exploration and drainage°¡ ¿ä±¸µÈ´Ù.





12.Genital ulcer disease

¨ç Á¾·ù : ¹Ì±¹¿¡¼­´Â HSV or syphilis°¡ °¡Àå ÈçÇϸç, chancroiÀº ´ÙÀ½À¸·Î °¡Àå ÈçÇÑ sexually transmitted genital ulcerÀÇ ¿øÀÎÀÌ´Ù. µå¹°Áö¸¸ lymphogranuloma venereum(LGV), granuloma inguinale(Donovanosis)µµ ¿øÀÎÀÌ´Ù. ÀÌ·¯ÇÑ diseaseµéÀº HIV infection °úµµ °ü·ÃµÈ´Ù. ±×¿Ü¿¡ infrequent and non infectiousÇÑ ¿øÀεé·Î¼­´Â abrasions,fixed drug eruption, carcinoma, Behcet¡¯s diseaseµîÀÌ ÀÖ´Ù.

¨è Áø´Ü : history and physical examÀº Á¾Á¾ ºÎÁ¤È®Çϸç, µû¶ó¼­ genital ulcerÀÖ´Â °æ¿ì ¸ðµç ¿©¼º¿¡¼­ syphilis serologic testÇØ¾ßÇÑ´Ù. Genital ulcerÀÖ´Â °æ¿ìÀÇ optimal W/UÀº dark field examination, direct immunofluorescence test for Treponema pallidum, culture or antigen test for HSV, culture for H.ducreyiµîÀÌ´Ù.ÀÌ·¯ÇÑ testing¿¡µµ ºÒ±¸Çϰí genital ulcerÀÇ 1/4ÀÎ ¿øÀÎÀ» ãÁö ¸øÇÑ´Ù.µû¶ó¼­ ´ëºÎºÐÀÇ clinicianµéÀº ulcer appearance¿¡ ±âÃÊÇÑ clinical impressionÀ¸·Î Áø´ÜÇÏ¿© Ä¡·á¸¦ °³½ÃÇÑ´Ù.



13. genital ulcerÀÇ clinical impression

¨ç Inguinal lymphadenopathyµ¿¹ÝÇÏÁö ¾Ê´Â nonpainful and minimally tender ulcer´Â syphilisÀ̸ç, ƯÈ÷ ulcer°¡ induratedµÈ °æ¿ì´Â ´õ¿í ±×·¸´Ù. Syphilis°¡ ÀǽɵǸé nontreponemal rapid plasma regain(RPR)test or venereal disease research laboratory(VDRL)test¸¦ ½ÃÇàÇϸç, È®ÁøÀ» À§ÇØ fluorescent treponemal Ab absorption (FTA ABS) or microhemagglutinin-Treponema Pallidum(MHA TP)¸¦ ½ÃÇàÇÑ´Ù. Nontreponemal testÀÇ °á°ú´Â disease activity¿Í correlationÀֱ⠶§¹®¿¡ quantitatively º¸°í µÇ¾î¾ß ÇÑ´Ù.

¨è Small ulcer¸¦ µ¿¹ÝÇÏ´Â groupted vesiclesÀÌ ÀÖ°í, ƯÈ÷ °ú°Å¿¡µµ ±×·¯ÇÑ º´º¯ÀÌ Á¸ÀçÇß¾ú´Ù¸é ÀÌ´Â genital herpesÀÇ pathognomonic findingÀÌ´Ù. ±×·³¿¡µµ ºÒ±¸Çϰí È®ÁøÀ» À§ÇÑ °Ë»ç°¡ ÇÊ¿äÇÏ´Ù. ÀÌ´Â genital herpes·Î Áø´ÜµÈ ¿©¼ºµéÀº ±×»ç½ÇÀÌ ¸Å¿ì traumatic Çϸç, self image¿¡ ¼Õ»óÀ» ÁÖ°í, »õ·Î¿î ¼º°ü°è ¸Î´Â °Í¿¡ Àå¾Ö¸¦ ÁÖ°í, child bearing¿¡µµ ¾Ç¿µÇâÀ» Áֱ⶧¹®ÀÌ´Ù. Culture°¡ most sensitive and specific testÀε¥, vesicle stage¿¡¼­´Â 100%, pustular stage¿¡¼­´Â 89%, ulcer stage¿¡¼­´Â 33%ÀÇ sensitivity¸¦ º¸ÀδÙ

¨é Extremely painfulÇÑ 1-3°³ÀÇ ulcers°¡ ÀÖÀ¸¸é¼­ tender inquinal lymphadenopathy¸¦ µ¿¹ÝÇÑ´Ù¸é Áø´ÜÀº chancroid´Ù. ƯÈ÷ adenopathy°¡ fluctuantÇÏ´Ù¸é ´õ¿í ±×·¸´Ù.

¨ê One or several ulcers¸¦ µ¿¹ÝÇÑ inguinal bubo(¼­Çý¼±Á¾)°¡ ÀÖÀ¸¸é chancroid°¡ °¡Àå ÀǽÉÀÌ µÇÁö¸¸, ¸¸¾à ulcer°¡ ¾ø´Ù¸é °¡Àå °¡´É¼ºÀÌ ÀÖ´Â Áø´ÜÀº LGV´Ù.



Fig 15.2





14. genital ulcerÀÇ Ä¡·á

¨ç Chancroid : ´ÙÀ½°ú °°Àº regimenµéÀÌ ÃßõµÇ¸ç Ä¡·á°³½Ã 3-7ÀÏ ÈÄ¿¡ ¼Ò½ÇÁ¤µµ¸¦ ´Ù½Ã Æò°¡Çϴµ¥, ´ë°³ 2ÁÖ³»¿¡ healedµÈ´Ù.

l Azithromycin 1g orally single dose

l Ceftriaxone 250mg IM single dose

l Erythromycin base 500mg orally ÇÏ·ç 4¹ø 7Àϵ¿¾È

¨è Herpes

l Genital herpesÀÇ first episodeÀÎ °æ¿ì´Â acyclovir 200mg orally ÇÏ·ç 5¹ø 7-10Àϵ¿¾È ȤÀº resolutionµÉ¶§±îÁö Ä¡·áÇÑ´Ù. ÇÏÁö¸¸ acyclovir´Â latent virus¸¦ ¹Ú¸êÇÏÁö ¸øÇϸç , subsequent risk, frequency, severity of recurrenceµî¿¡ ¿µÇâÀ» ÁÖÁö ¸øÇÑ´Ù.

l Acyclovir 400mg orally ÇÏ·ç 2¹ø¾¿ °è¼Ó Ä¡·áÇÏ´Â daily suppression therapy°¡ HSV recurrenceÀÇ ºóµµ¸¦ °¨¼Ò½Ã۱â´Â ÇÏÁö¸¸, viral shedding or potential for transmissionÀ» ¿ÏÀüÈ÷ ¹Ú¸êÇÏÁö ¸øÇÑ´Ù.

¨é Syphilis

l Parenteral penicillin G °¡ all stage of syphilisÄ¡·á¿¡ ¼±È£µÈ´Ù. Benzathine penicillin G 2.4million units¸¦ single dose IMÇÏ´Â °ÍÀÌ ¼ºÀο¡ À־ÀÇ primay, secondary, early latent syphilisÀÇ Ä¡·á¿¡ ÃßõµÈ´Ù. Ä¡·á 24½Ã°£³»¿¡ headche,myalgia°°Àº Áõ»óÀÌ ÀÖÀ» ¼ö Àִµ¥ À̸¦ Jarische-Herxheimer reactionÀ̶óÇÑ´Ù.

¨ê Latent syphilis: latent syphilis´Â treponema pallidum¿¡ infectedµÈ ÈÄ¿¡ seroreactiveÇÏÁö¸¸ disease evidence¾ø´Â periods¸¦ ¸»ÇÑ´Ù. Latent syphilisÀÖ´Â ¸ðµç ȯÀÚ´Â tertiary disease(aortitis, neurosyphilis, gumma, iritis)ÀÇ Áõ°Å°¡ ¾ø´ÂÁö evlautionÇØ¾ßÇÑ´Ù.

l 1³âÀÌ»ó Áö¼ÓµÇ´Â latent syphilis³ª unknown durationÀÇ °æ¿ì´Â Benzathine penicillin G 2.4million units¸¦ 1ÁÖ °£°ÝÀ¸·Î 3ȸ IM ÇÏ¿© ÃÑ 7.2 million units¸¦ »ç¿ëÇÑ´Ù. Quantative nontreponemal serologic tests¸¦ 6°³¿ù ¹× 12°³¿ù¿¡ ¹Ýº¹ÇÑ´Ù. 12-24°³¿ù ³»¿¡ ÃʱâÀÇ higher tiger(>1:32)°¡ Àû¾îµµ 4¹è(two dilutions)°¨¼ÒÇÏ¿©¾ßÇÑ´Ù.



15. Genital warts

¨ç ¿øÀÎ : condyloma accuminata´Â HPV infectionÀÇ manifestationÀÌ´Ù. ´ë°³ nononcogenic HPV typesÀÎ 6, 11ÀÌ genital wart¸¦ ÀÏÀ¸Å²´Ù.

¨è ºÎÀ§ : coitus¿¡ directÇÏ°Ô affectedµÇ´Â ºÎÀ§ÀÎ posterior fourchette, lateral areas on the vulva¿¡ ÁÖ·Î »ý±ä´Ù. ´ú ÈçÇϰԴ vulva, vagina, cervixÀüü¿¡ °ÉÃÄ ¹ß°ßµÉ ¼öÀÖ´Ù. Coitus¿¡ ÀÇÇÑ minor trauma¿¡ ÀÇÇØ basal layer of epithelium°ú infected maleÀÇ viral particlesÀÌ direct contactÇÏ°Ô µÇ¸é »ý±ä´Ù. InfectionÀº latentÇϰųª viral particlesÀÌ °è¼Ó replicationÇÏ¿© wart°¡ »ý±æ ¼öÀÖ´Ù. Exophytic genital warts´Â highly contagiousÇÏ¿© exposeµÈ °æ¿ì 75%ÀÇ ÆÄÆ®³Ê°¡ wart°¡ »ý±ä´Ù.

¨é Ä¡·á : Ä¡·á¸ñÀûÀº wart removalÀ̸ç, viral infectionÀ» ¹Ú¸êÇÏÁö´Â ¸øÇÑ´Ù. 1³â ¹Ì¸¸µÈ small wart°¡ Ä¡·á¿¡ ´õ¿í ¼º°øÀûÀÌ´Ù. Exophytic wartsÀÇ Ä¡·á°¡ HPV transmissionÀ» °¨¼Ò½ÃŰ´ÂÁö´Â ¸íȮġ ¾Ê´Ù. Ä¡·á ¹æ¹ýÀº wartsÀÇ size, number,expense, efficacy, convenience, potential side effects¿¡ µû¶ó ¼±ÅÃÇÑ´Ù. Recurrence´Â sex partner¿¡ ÀÇÇÑ reinfectionº¸´Ù´Â subclinical infectionÀÇ reactivation¿¡ ÀÇÇÑ´Ù. µû¶ó¼­ sex partnerÀÇ examÀÌ Àý´ëÀûÀ¸·Î ÇÊ¿äÇÑ °ÍÀº ¾Æ´Ï´Ù.ÇÏÁö¸¸ ¸¹Àº °æ¿ì¿¡¼­ sex partner°¡ exophytic warts¸¦ °¡Áö±â ¶§¹®¿¡ Ä¡·á¸¦ ÇÏ´Â °ÍÀÌ ÀÌ·Î¿ï ¼öÀÖÀ¸¸ç, warts transmission¿¡ ´ëÇØ »ó´ãÀ» ÇØÁÖ´Â °Íµµ ÀÌ·Î¿ï ¼öÀÖ´Ù.

Table 15.5





16. HIV infection

¨ç Áõ»óÀÇ ¹ßÇö :¿©¼º HIVȯÀÚÀÇ 50%°¡ IV drug usersÀ̸ç 36%´Â heterosexual transmission ¿¡ ÀÇÇÑ´Ù..HIVinfected ȯÀÚ¿¡¼­ÀÇ Áõ»óÀº ¹«Áõ»ó¿¡¼­ºÎÅÍ AIDS±îÁö ´Ù¾çÇÑ spectrumÀ» º¸À̸ç, °¨¿°µÈ ȯÀÚ¿¡¼­ AIDS°¡ developµÇ´Â Æò±Õ±â°£Àº ¾à 10³âÀÌ´Ù. (¼ö°³¿ù¿¡¼­ 12³â±îÁö ´Ù¾ç) ÇÑ¿¬±¸¿¡ ÀÇÇϸé HIV infected adultÀÇ 70-85%¿¡¼­ Áõ»óÀÌ »ý±â¸ç, AIDS´Â 12³âÀ̳»¿¡ ¾à 55-60%¿¡¼­ »ý°å´Ù. HIV induced altered immune function¿¡ ÀÇÇØ Tb, bacterial pneumonia, pneumocystis carinii pneumoniaµî¿¡ °É¸± À§Ç輺ÀÌ Áõ°¡ÇÑ´Ù.

¨è Áø´Ü

(¤¡) °¡Àå ÈçÇϰԴ HIV 1 antibody tests¸¦ ÀÌ¿ëÇÑ´Ù. Antibody testingÀº ELISA ³ª rapid assay°°Àº°ÍÀ» ÀÌ¿ëÇÏ´Â sensitive screening test·Î ½ÃÀÛÇÑ´Ù. Western blotµî¿¡ ÀÇÇØ È®ÁøµÈ °æ¿ì¶ó¸é positive anitibody test´Â HIV infected personÀÓÀ» ÀǹÌÇÏ¸ç ´Ù¸¥»ç¶÷¿¡°Ô virus¸¦ transmissionÇÒ¼ö ÀÖÀ½À» ÀǹÌÇÑ´Ù.

(¤¤) HIV Ab´Â infected µÈ ÈÄ 6°³¿ùÀ̳»¿¡ 95%À̻󿡼­ detectionµÈ´Ù. ´Ù¸¥ STDsƯÈ÷ genital ulcer°¡ ÀÖ´Â °æ¿ì¶ó¸é HIV testingÀ» ½ÃÇàÇØ¾ß¸¸ÇÑ´Ù.

(¤§) HIV positive ¿©¼º¿¡¼­ÀÇ initial evaluationÀº Tb, STDsµî°ú °°ÀÌ HIV¿Í ¿¬°üÀÖ´Â Áúȯµé¿¡ ´ëÇÑ screeningÀ̸ç, recommended vaccinationÀ» ½ÃÇàÇÑ´Ù.(HBV, pneumococcal, influenza) intraepithelial neoplasma´Â HPV infection°ú °ü·ÃµÇ¸ç ¸¸¾à HPV¿Í HIV°¡ coinfectedµÈ °æ¿ì¶ó¸é ´õ¿í ºóµµ°¡ Áõ°¡ÇÑ´Ù.

(¤©) CD4 T-lymphocytes count°¡ clinical progressionÀÇ best laboratory indicator´Ù. Áï CD4 T-lymphocytes count°¡ 200-500CD4-cells/ulÀΰæ¿ì´Â HIV related symptomsÀÌ more likely Çϸç medical interventionÀ» ÇÊ¿ä·Î ÇÒ ¼öÀÖ´Ù. CD4 T-lymphocytes count°¡ 200 cells/ul ¹Ì¸¸ÀÎ °æ¿ì´Â complicated HIV diseaseÀÇ risk°¡ ³ô´Ù.

¨é Ä¡·á

(¤¡) antiretroviral therapy(zidovudine, ZDV)°¡ CD4<500cell/ulÀÎ symptomatic womanÀ̳ª CD4<300 cell/ulÀ̸鼭 asymtomatic ÇÑ °æ¿ì¿¡ ÃßõµÈ´Ù. ZDV´Â advanced disease·ÎÀÇ progressionÀ» delay½ÃŰ´Â °Í °°´Ù.

(¤¤) 200 CD4-T cells/ul¹Ì¸¸ÀÇ È¯ÀÚÀ̰ųª constitutional symptomsÀ» º¸À̴ ȯÀÚµéÀº peumocystitis carinii pneumonia(PCP)prophylaxis°¡ ÇÊ¿äÇÏ´Ù. (trimethoprim/sulfamethoxazole or aerosol pentamidine)







17.Acute cystitis

¨ç Symptoms and signs : ±ÞÀÛ½º·´°Ô ½ÃÀ۵Ǵ ´Ù¾çÇÏ°í ½ÉÇÑ ¿äµµ°¨¿°Áõ»óÀ» º¸ÀδÙ. Áï, suprapubic or low back pain°ú ¿¬°üµÇ´Â dysuria, frequency, urgency¸¦ º¸ÀδÙ. Suprapubic tenderness°¡ ÀÖÀ» ¼öÀÖÀ¸¸ç, U/A¿¡¼­ pyuria°¡ ÀÖ°í, °¡²û hematuria°¡ ÀÖÀ» ¼öÀÖ´Ù.

¨è Cystitis riskÁõ°¡½ÃŰ´Â factors : sexual intercourse, diaphragm and spermicide»ç¿ë, delayed postcoital micturition, recent UTI history

¨é Pathogen : E.coli°¡ °¡Àå ÈçÇÑ pathogenÀÌ¸ç ¾à 80%¿¡¼­ °ËÃâµÇ¸ç,Staphylococcus saprophyticus°¡ ¾à 5-15%¿¡¼­ °ËÃâµÈ´Ù.

¨ê Pathophysiology : rectumÀ¸·Î ºÎÅÍÀÇ coliform bacteria°¡ vagina and urethra¿¡ colonization Çü¼ºÇÑ´Ù. ÀÌ·¯ÇÑ ÀÌÀ¯·Î ÇØ¼­ vaginal flora¿¡ ´ëÇÑ antimicrobial agent°¡ bacteriuria eradication¿¡ Áß¿ä ¿ªÇÒ ÇÑ´Ù.

¨ë Treatment

(¤¡) Vagianl secretion³»ÀÇ High concentration of trimethoprim and fluoroquinolones¿¡ ÀÇÇØ E.coli°¡ ¹Ú¸êµÊ°ú µ¿½Ã¿¡ vaginal flora¿¡ minimal alterationº¸ÀδÙ.

(¤¤) Uncomplicated cystitisÀÇ °æ¿ì´Â trimethoprim/sulfamethoxazole 160-180mgÀ» 12½Ã°£¸¶´Ù 3ÀÏ µ¿¾È ȤÀº trimethoprim´Üµ¶À¸·Î 100mgÀ» 12½Ã°£¸¶´Ù 3Àϵ¿¾È »ç¿ëÇÏ´Â °ÍÀÌ optimal choice´Ù

(¤§) FluoroquinoloneÁï ofloxacin 200mgÀ» 12½Ã°£ ¸¶´Ù 3ÀÏ µ¿¾È »ç¿ëÇÏ´Â °Íµµ highly effectiveÇÏ´Ù. ÇÏÁö¸¸ ´õ ºñ½Î±â ¶§¹®¿¡ recurrent infection, treatment failure, drug allergyÀִ ȯÀÚµîÀÇ °æ¿ì¸¦ À§ÇØ reserveÇØ¾ßÇÑ´Ù.

(¤©) ÀüÇüÀûÀÎ Áõ»óÀÌ ÀÖ´Â °æ¿ì¶ó¸é °£´ÜÇÑ °Ë»çÈÄ empirical therapy½ÃÀÛÇÏ¿©¾ß Çϸç, Áø´ÜÀº Çö¹Ì°æ °Ë»ç ȤÀº leukocyte esterase testing¿¡¼­ pyuriaÀÖÀ» ½Ã °¡Á¤Çغ¼ ¼öÀÖ´Ù. Urine culture´Â ÇÊ¿äÄ¡ ¾ÊÀ¸¸ç short course of antimicrobial therapy½ÃÇàÇØ¾ßÇÑ´Ù. Áõ»óÀÌ persist Çϰųª recurÇÏÁö ¾Ê´Â ÇÑ F/U visit or culture´Â ÇÊ¿äÄ¡ ¾Ê´Ù.



18. Recurrent cystitisÀÇ ¿øÀÎ ¹× Ä¡·á

¨ç Cystitis episodeÀÖ¾ú´ø ȯÀÚÀÇ ¾à 20%°¡ recurrent infection°®°Ô µÇ¸ç, ÀÌÁß ¾à 90%ÀÌ»óÀº exogenous reinfection¿¡ ÀÇÇÑ´Ù.

¨è Recurrent cystitisȯÀÚµéÀº ¹Ýµå½Ã resistant microorganismÀ» R/OÇϱâ À§ÇØ culture¸¦ ½ÃÇàÇÏ¿©¾ßÇÑ´Ù.

¨é ȯÀÚÀÇ Ä¡·á´Â ´ÙÀ½Áß ÇѰ¡Áö ¹æ¹ýÀ¸·ÎÇÑ´Ù.

(¤¡) Continuous prophylaxis

(¤¤) Postcoital prophylaxis

(¤§) Áõ»óÀÌ ½ÃÀ۵ǾúÀ» ¶§ ȯÀÚ¿¡ ÀÇÇÑ Ä¡·á°³½Ã

¨ê Post menopausal womanÀº reinfectionÀÌ ÀæÀ» ¼öÀÖÀ¸¸ç, À̰æ¿ì HRT or topical estrogen creamÀ» ¿¹¹æÀû Ç×»ýÁ¦¿Í °°ÀÌ »ç¿ëÇÏ´Â °ÍÀÌ helpfulÇÏ´Ù.



19. Urethritis

¨ç Symptoms and signs : urethritis¿¡ ÀÇÇÑ dysuria´Â more gradual onset of mild symtomsÀ» º¸À̸ç, abnormal vaginal discharge¿Í ¿¬°üÀÖÀ» ¼öÀÖÀ¸¸ç, concurrent cervicitis¿¡ ÀÇÇÑ bleedingÀ» º¸ÀÏ ¼öÀÖ´Ù. ȯÀÚ´Â ÃÖ±Ù »õ·Î¿î ÆÄÆ®³Ê¿Í °ü°è¸¦ °¡Á³¾úÀ» ¼öÀÖÀ¸¸ç, ¶ÇÇÑ lower abdominal painÀ» ÃÖ±Ù¿¡ °æÇèÇßÀ» ¼öÀÖ´Ù. Physical exma¿¡¼­´Â mucopurulent cervicitis ȤÀº vulvovagianl herpetic lesionÀ» º¸ÀÏ ¼öÀÖ´Ù. Chlamydia trachomatis, Neisseria gonorrhoeae, genital herpes°¡ acute urethritis¾ß±â ÇÒ ¼öµµ ÀÖ´Ù.U/A¿¡¼­ pyuriar°¡ ÀÖÀ¸³ª hematuria´Â rareÇÏ´Ù.

¨è Treatment : chlamydia and gonorrhea¿¡ ´ëÇÑ Ä¡·á´Â PID¿¡¼­¿Í µ¿ÀÏÇÏ´Ù.

¨é Vaginitis caused by Candida albicans or trichomonas : Á¾Á¾ dysuriaº¸À̸ç, ¼¼½ÉÇÑ Áú¹®À» ÇÔÀ¸·Î½á viginal discharge, pruritus, dyspareunia¿Í Á¾Á¾ ¿¬°üµÇ´Â dysuria¸¦ È®ÀÎ ÇÒ ¼öÀÖ´Ù. ´ë°³ urgency or frequency´Â ¾øÀ¸¸ç, pyuria and hematuriaµµ ¾ø´Ù.



20. Acute pyelonephritis

¨ç Áõ»ó : gram negative septicemia¿¡¼­ mild flank painÀ» µ¿¹ÝÇÏ´Â cystitis like illnessÀÇ ´Ù¾çÇÑ Áõ»óÀ» º¸ÀδÙ.

¨è ¿øÀÎ ¹× Áø´Ü : E.coli°¡ 80%¿¡¼­ ¿øÀαÕÀ̸ç, Çö¹Ì°æ°Ë»ç¿¡¼­ pyuria and G(-) bacteriaf¸¦ È®ÀÎÇÒ ¼öÀÖ´Ù. Pyelonephritis°¡ ÀǽɵǴ °æ¿ì¶ó¸é urine culture¸¦ ½ÃÇàÇØ¾ß Çϸç,¾à 15-20%¿¡¼­ ¾ç¼ºÀ¸·Î ³ª¿À±â ¶§¹®¿¡ ÀÔ¿øÈ¯ÀÚ¿¡¼­ blood culture¸¦ ¹Ýµå½Ã ½ÃÇàÇØ¾ßÇÑ´Ù.

¨é Ä¡·á

(¤¡) nausea and vomitingÀÌ ¾ø°í, severeÇÏÁö ¾ÊÀº°æ¿ì¶ó¸é OPD¿¡¼­ Ä¡·áÇÑ´Ù. RegimenÀº trimethoprim/sulfamethoxazole 160-180mgÀ» 12½Ã°£¸¶´Ù 10-14ÀÏ µ¿¾È Ä¡·áÇϰųª, quinolone Áï ofloxacin 200-300mgÀ» 12½Ã°£ ¸¶´Ù 10-14Àϵ¿¾È Ä¡·áÇÏ´Â °ÍÀÌ´Ù.

Nausea and vomitingÀÌ Àְųª, moderate to severe illnessÀ̰ųª, »ê¸ðÀǰæ¿ì´Â ÀÔ¿øÄ¡·áÇÑ´Ù. À̰æ¿ì regimenÀº ceftriaxone 1-2gÀ» daily, ampicillin 1gÀ» 6½Ã°£¸¶´Ù, ±×¸®°í gentamycin(ƯÈ÷ enterospecies°¡ ÀÇ½ÉµÉ ¶§)ȤÀº aztreonam 1gÀ» 8-12½Ã°£¸¶´Ù »ç¿ëÇÑ´Ù. Áõ»óÀº Ä¡·áÈÄ 48-72½Ã°£ ³»¿¡ resolveµÇ¾î¾ß ÇÑ´Ù. ¸¸¾à 72½Ã°£ ÀÌ»ó fever and flank painÀÌ Áö¼ÓµÉ½Ã´Â perinephric or intrarenal abscess or ureteral obstructionÀ» R/OÇϱâÀ§ÇØ ÃÊÀ½ÆÄ ³ª CT¸¦ ½ÃÇàÇÑ´Ù. F/U culture°¡ Ä¡·á ³¡³­ ÈÄ 2ÁÖ ÈÄ¿¡ ½ÃÇàµÇ¾î¾ßÇÑ´Ù.