14. Gynecological Infections Flashcards
Describe: Physiologic Discharge (5)
- clear, white, flocculent, odourless discharge
- pH 3.8-4.2
- smear contains epithelial cells, Lactobacilli
- increases with increased estrogen states: pregnancy, oral contraceptive pill OCP, mid-cycle, polycystic ovarian syndrome PCOS, or premenarchal
- if increased in perimenopausal/postmenopausal woman, consider investigation for other effects of excess estrogen (e.g. endometrial cancer)
Name non-physiologic causes of pruritis (9)
- genital tract infection
- vulvovaginitis: candidiasis, trichomoniasis, BV, polymicrobial superficial infection
- chlamydia, gonorrhea
- pyosalpinx, salpingitis
- genital tract inflammation (non-infectious)
- local: chemical irritants, douches, sprays, foreign body, trauma, atrophic vaginitis, desquamative inflammatory vaginitis, focal vulvitis
- neoplasia: vulvar, vaginal, cervical, endometrial
- systemic: toxic shock syndrome, Crohn’s disease, collagen disease, dermatologic (e.g. lichen sclerosis)
- intrauterine device IUD, OCP (secondary to progesterone)
Define: Vulvovaginitis (1)
Vulvar and vaginal inflammation
Describe clinical features: Vulvovaginitis (5)
- irritation
- pruritus
- discharge
- vulvar erythema
- vaginal bleeding (specifically due to Group A Streptococci and Shigella)
Name etiologies of vulvovaginitis (7)
- poor hygiene (proximity of anus to vagina)
- foreign bodies (most commonly tissue paper)
- irritation by perfumed soaps, chemicals, and tight clothing
- localized skin disorders: lichen sclerosis, condyloma acuminata
- trauma: accidental straddle injury, sexual abuse
- infectious
- pinworms
- Candida (if using diapers or chronic antibiotics)
- Group A streptococcus, S. aureus and Shigella
- discovery of STI should raise suspicion of sexual abuse
- other
- polyps, tumour (ovarian malignancy)
- psychosomatic vaginal complaints (specific to vaginal discharge)
- endocrine abnormalities (specific to vaginal bleeding)
- blood dyscrasia (specific to vaginal bleeding)
Name investigations: Vulvovaginitis (2)
- vaginal swab for culture (specifically state that it is a pre-pubertal specimen)
- pH, wet-mount, and KOH smear in prepubertal adults only
Describe link between vulvovaginal candidiasis and hygienic habits or wearing tight or synthetic clothing (1)
There is no high quality evidence showing a link
Describe treatment: Vulvovaginitis (3)
- enhanced hygiene and local measures (handwashing, white cotton underwear, no nylon tights, no tight fitting clothes, no sleeper pajamas, sitz baths, avoid bubble baths, use mild detergent, eliminate fabric softener, avoid prolonged exposure to wet bathing suits, urination with legs spread apart)
- A&D® dermatological ointment (vitamin A/D) to protect vulvar skin
- infectious: treat with antibiotics for organism identified
Name: Most common gynecological problem in prepubertal girls (1)
is non-specific vulvovaginitis, not yeast
Describe diagnosis and treatment of: Pinworms (2)
- Dx: Cellophane tape test
- Tx: Empirical treatment with mebendazole
Describe diagnosis and treatment of: Lichen Sclerosis (2)
- Dx: Area of white patches and thinning of skin (figure of 8)
- Tx: Topical steroid creams
Describe treatment of: Foreign Body (1)
Irrigation of vagina with saline, may require local anesthesia or an exam under anesthesia
Name organisms in vulvovaginitis: Candidasis (3)
- Candida albicans (90%)
- Candida glabrata (<5%)
- Candida tropicalis (<5%)
Describe pathophysiology or transmission: Candidasis (3)
Predisposing factors include:
- Immunosuppressed host (DM, AIDS, etc.)
- Recent antibiotic use
- Increased estrogen levels (e.g. pregnancy, OCP)
Describe discharge: Candidasis (3)
- Whitish
- “cottage cheese”
- minimal
Describe signs/symptoms: Candidasis (4)
- 20% asymptomatic
- Intense pruritus
- Swollen, inflamed genitals
- Vulvar burning, dysuria, dyspareunia
Describe pH: Candidasis (4)
≤4.5
Describe saline wetmount: Candidasis (1)
KOH wetmount reveals hyphae and spores
Describe treatment: Candidasis (3)
- Clotrimazole, butoconazole, miconazole, terconazole suppositories, and/or creams for 1, 3, or 7 d treatments
- Treatment in pregnancy is usually topical
- Fluconazole 150 mg PO in single dose (can be used in pregnancy)
Describe prophylaxis for recurrent infection: Candidasis (3)
includes
- boric acid
- vaginal suppositories
- luteal phase fluconazole
Is routine treatment of parter(s) recommended in: Candidasis (1)
Routine treatment of partner(s) not recommended (not sexually transmitted)
Name organisms: Bacterial Vaginosis (BV) (3)
- Gardnerella vaginalis
- Mycoplasma hominis
- Anaerobes: Prevotella, Mobiluncus, Bacteroides
Describe pathophysiology or transmission: Bacterial Vaginosis (BV) (1)
Replacement of vaginal Lactobacillus with organisms above
Describe discharge: Bacterial Vaginosis (BV) (3)
- Grey
- thin
- diffuse
Describe signs/symptoms: Bacterial Vaginosis (BV) (3)
- 50-75% asymptomatic
- Fishy odour, especially after coitus
- Absence of vulvar/vaginal irritation
Describe pH: Bacterial Vaginosis (BV) (1)
≥4.5
Describe saline wetmount: Bacterial Vaginosis (BV) (4)
- >20% clue cells = squamous epithelial cells dotted with coccobacilli (Gardnerella)
- Paucity of WBC
- Paucity of Lactobacilli
- Positive whiff test: fishy odour with addition of KOH to slide (due to formation of amines)
Describe treatment: Bacterial Vaginosis (BV) (3)
- No treatment if non-pregnant and asymptomatic, unless scheduled for pelvic surgery or procedure
- Oral: Metronidazole 500 mg PO bid x 7 d
- Topical:
- Metronidazole gel 0.75% x 5 d OD (may be used in pregnancy)
- Clindamycin 2% 5 g intravaginally at bedtime for 7 d
- Probiotics (Lactobacillus sp.): oral or topical alone or as adjuvant
What is Bacterial Vaginosis (BV) associated with? (3)
Associated with
- recurrent preterm labour,
- preterm birth
- postpartum endometritis
Is routine treatment of parter(s) recommended in: Bacterial Vaginosis (BV) (1)
Routine treatment of partner(s) not recommended (not sexually transmitted)
In the tx of bacterial Vaginosis (BV), need to warn patients on metronidazole not to do what? (1)
consume alcohol (disulfiram-like action)
Name organisms in vulvovaginitis: Trichomoniasis (1)
- Trichomonas vaginalis (flagellated protozoan)
Describe pathophysiology or transmission: Trichomoniasis (1)
Sexual transmission
Describe discharge: Trichomoniasis (4)
- Yellow-green
- malodourous
- diffuse
- frothy
Describe signs/symptoms: Trichomoniasis (4)
- 25% asymptomatic
- Petechiae on vagina and cervix
- Occasionally irritated, tender vulva
- Dysuria, frequency
Describe pH: Trichomoniasis (4)
≥4.5
Describe saline wetmount: Trichomoniasis (4)
- Motile flagellated organisms
- Many WBC
- Inflammatory cells (PMNs)
- Can have positive whiff test
Describe treatment: Trichomoniasis (3)
- Treat even if asymptomatic
- Metronidazole 2 g PO single dose or 500 mg bid x 7 d (alternative)
- Symptomatic pregnant women should be treated with 2 g metronidazole once
Is routine treatment of parter(s) recommended in: Trichomoniasis (1)
Treat partner(s) (sexually transmitted)
Name Centers for Disease Control (CDC) Notifiable Diseases (6)
- Chancroid
- Chlamydia
- Gonorrhea
- Hepatitis A, B, C
- HIV
- Syphilis
Name: Risk Factors for STIs (7)
- History of previous STI
- Contact with infected person
- Sexually active individual <25 yr
- Multiple partners
- New partner in last 3 mo
- Lack of barrier protection use
- Street involvement (homelessness, drug use)
Describe etiology: Chlamydia (1)
- Chlamydia trachomatis
Describe epidemiology: Chlamydia (2)
- most common bacterial STI in Canada
- often associated with N. gonorrhoeae
Describe clinical features: Chlamydia (6)
- asymptomatic (80% of women)
- muco-purulent endocervical discharge
- urethral syndrome:
- dysuria,
- frequency
- pyuria
- no bacteria on culture
- pelvic pain
- postcoital bleeding or intermenstrual bleeding (particularly if on OCP and prior history of good cycle control)
- symptomatic sexual partner
Describe investigations: Chlamydia (3)
- cervical culture or nucleic acid amplification test (can present in pharynx, rectum)
- obligate intracellular parasite: tissue culture is the definitive standard
- urine and self vaginal tests now available, which are equally or more effective than cervical culture
Describe tx: Chlamydia (4)
- doxycycline 100 mg PO bid for 7 d or azithromycin 1 g PO in a single dose. Doxycycline is contraindictated in the 2nd and 3rd trimesters of pregnancy
- also treat gonorrhea because of high rate of co-infection
- reportable disease, partners should also be referred for treatment
- test of cure for chlamydia required in pregnancy (cure rates lower in pregnant patients) s retest 3-4 wk after initiation of therapy
Describe screening: Chlamydia (3)
- high-risk groups
- during pregnancy
- when initiating OCP if sexually active (independent risk factor)
Name complications: Chlamydia (7)
- PID: low-grade salpingitis and adhesions resulting in tubal obstruction
- infertility
- ectopic pregnancy
- chronic pelvic pain
- Fitz-Hugh-Curtis syndrome (liver capsule inflammation)
- reactive arthritis (male predominance, HLA-B27 associated), conjunctivitis, urethritis
- perinatal infection: conjunctivitis, pneumonia
What does vaginal swabs test for? And cervical swabs? (2)
- Vaginal swab
- Tests for bacterial vaginosis, trichomoniasis, candida
- Cervical swab
- Tests for gonorrhea and chlamydia
Describe etiology: Gonorrhea (2)
- Neisseria gonorrhoeae
- symptoms and risk factors same as chlamydia
Describe investigations: Gonorrhea (2)
- Gram stain shows Gram-negative intracellular diplococci
- cervical, rectal, and throat culture (if clinically indicated)
Describe tx: Gonorrhea (2)
- single dose of ceftriaxone 250 mg IM plus azithromycin 1 g PO
- if pregnant: above regimen or 2 g spectinomycin IM plus azithromycin 1 g PO (avoid quinolones)
- also treat chlamydia, due to high rate of co-infection
- treat partners
- reportable disease
- screening as with chlamydia
Describe etiology: Human papillomavirus (2)
- most common viral STI in Canada
- >200 subtypes, of which >30 are genital subtypes
Name HPV types that are classically associated with anogenital warts/condylomata acuminate (2)
6 and 11
Name HPV types that are the most oncogenic (classically associated with cervical high grade squamous intraepithelial lesion HSIL) (2)
types 16 and 18
Name HPV types that are associated with increased incidence of cervical and vulvar intraepithelial hyperplasia and carcinoma
types 16, 18, 31, 33, 35, 36, 45 (and others)
Describe clinical features: Human papillomavirus (3)
-
latent infection
- no visible lesions, asymptomatic
- only detected by DNA hybridization tests
-
subclinical infection
- visible lesion found during colposcopy or on Pap test
-
clinical infection
- visible wart-like lesion without magnification (check pharynx too)
- hyperkeratotic, verrucous or flat, macular lesions
- vulvar edema
Describe investigations: Human papillomavirus (4)
- cytology
- koilocytosis: nuclear enlargement and atypia with perinuclear halo
- biopsy of lesions at colposcopy
- detection of HPV DNA subtype using nucleic acid probes (not routinely done but can be done in presence of abnormal Pap test to guide treatment
Describe tx patient-administered: Human papillomavirus (2)
- podofilox 0.5% solution or gel bid x 3 d in a row (4 d off) then repeat x 4 wk
- imiquimod (Aldara®) 5% cream 3x/wk qhs x 16 wk
Describe tx provider-administered: Human papillomavirus (5)
- cryotherapy with liquid nitrogen: repeat q1-2wk
- podophyllin resin in tincture of benzoin: weekly
- trichloroacetic acid (TCA) (80-90%) or bichloroacetic acid weekly x 4-6 wk; safe in pregnancy
- surgical removal/laser
- intralesional interferon
Describe: Genital Warts During Pregnancy (3)
- Condyloma tend to get larger in pregnancy and should be treated early (consider excision)
- C-section only if obstructing birth canal or risk of extensive bleeding
- Do not use imiquimod, podophyllin, or podofilox
Describe prevention: Human papillomavirus (2)
- vaccination: Gardasil®9, Gardasil®, Cervarix®
- condoms may not fully protect (areas not covered, must be used every time throughout entire sexual act)
Describe etiology: herpes simplex virus of vulva (1)
- 90% are HSV-2, 10% are HSV-1
Describe clinical features: herpes simplex virus of vulva (7)
- may be asymptomatic
- initial symptoms: present 2-21 d after contact
- prodromal symptoms: tingling, burning, pruritus
- multiple, painful, shallow ulcerations with small vesicles appear 7-10 d after initial infection (absent in many infected persons); lesions are infectious
- inguinal lymphadenopathy, malaise, and fever often with first infection
- dysuria and urinary retention if urethral mucosa affected
- recurrent infections: less severe, less frequent, and shorter in duration (usually only HSV-2)
Describe investigations: herpes simplex virus of vulva (3)
- viral culture preferred in patients with ulcer present; however decreased sensitivity as lesions heal
- cytologic smear (Tzanck smear) shows multinucleated giant cells, acidophilic intranuclear inclusion bodies
- HSV DNA PCR type specific serologic tests for antibodies to HSV-1 and HSV-2 (not available routinely in Canada)
Describe tx: herpes simplex virus of vulva (5)
- first episode: acyclovir 200 mg PO five times daily x 7-10 d, or famciclovir 250 mg PO tid x 7-10 d or valacyclovir 1 g PO bid x 7-10 d
- recurrent episode: acyclovir 400 mg PO tid x 5 d, valacylovir 1 g PO OD x 5 d or famciclovir 250 mg PO BID x 5 d
- daily suppressive therapy
- consider for >6 recurrences per yr or recurrence every 2 mo
- acyclovir 400 mg PO bid or valacyclovir 500 mg PO OD or valacyclovir 1 g PO OD or famciclovir 250 mg PO bid
- severe disease: IV acyclovir 5-10 mg/kg IV q8h x 2-7 d or until clinical improvement observed followed by oral antiviral therapy to complete 10 d of therapy total
- education regarding transmission: avoid sexual contact from onset of prodrome until lesions have cleared, use barrier contraception
Describe etiology: Syphilis (1)
- Treponema pallidum
Describe classification: Syphilis (5)
- Primary
- Secondary
- Latent
- Tertiary
- Congenital
Describe clinical features: Primary syphilis (4)
- 3-4 wk after exposure
- painless chancre on vulva, vagina, or cervix
- painless inguinal lymphadenopathy
- serological tests usually negative, local infection only
Describe clinical features: Secondary syphilis (5)
- 2-6 mo after initial infection
- nonspecific symptoms: malaise, anorexia, headache, diffuse lymphadenopathy
- generalized maculopapular rash: palms, soles, trunk, limbs
- condylomata lata: anogenital, broad-based, fleshy, grey lesions
- serological tests usually positive
Describe clinical features: Latent syphilis (1)
- no clinical manifestations; detected by serology only
Describe clinical features: Tertiary syphilis (4)
- may involve any organ system
- neurological: tabes dorsalis, general paresis
- cardiovascular: aortic aneurysm, dilated aortic root
- vulvar gumma: nodules that enlarge, ulcerate, and become necrotic (rare)
Describe clinical features: Congenital syphilis (1)
- may cause fetal anomalies, stillbirths, or neonatal death
Describe investigations: Syphilis (4)
- aspiration of ulcer serum or node
- darkfield microscopy (most sensitive and specific diagnostic test for syphilis): look for spirochetes
- non-treponemal screening tests (VDRL, RPR); non-reactive after treatment, can be positive with other conditions
- specific anti-treponemal antibody tests (FTA-ABS, MHA-TP, TP-PA)
- confirmatory tests; remain reactive for life (even after adequate treatment)
Describe tx: Syphilis (5)
- reportable disease, partners should be referred for treatment
- treatment of primary, secondary, latent syphilis of <1 yr duration
- benzathine penicillin G 2.4 million units IM single dose
- treatment of latent syphilis of >1 yr duration
- benzathine penicillin G 2.4 million units IM q1wk x 3 wk
- treatment of neurosyphilis
- IV aqueous penicillin G 3-4 million units IM q4h x 10-14 d
- screening
- high-risk groups
in pregnancy
Describe etiology: Bartholin Gland Abscess (3)
- often anaerobic and polymicrobial
- U. urealyticum, N. gonorrhoeae, C. trachomatis, E. coli, P. mirabilis, Streptococcus spp., S. aureus (rare)
- blockage of duct
Describe clinical features: Bartholin Gland Abscess (2)
- unilateral swelling and pain in inferior lateral opening of vagina
- sitting and walking may become difficult and/or painful
Describe tx: Bartholin Gland Abscess (5)
- sitz baths, warm compresses
- antibiotics: cephalexin x 1 wk
- incision and drainage using local anesthesia with placement of Word catheter (10 French latex catheter) for 2-3 wk (or as long as stays in situ)
- marsupialization under general anesthetic: more definitive treatment
- rarely treated by removing gland
Describe: Pelvic inflammatory disease (2)
- up to 20% of all gynecology-related hospital admissions
- inflammation of the upper genital tract (above the cervix) including endometrium, fallopian tubes, ovaries, pelvic peritoneum ± contiguous structures
Describe etiology: Pelvic inflammatory disease (5)
causative organisms (in order of frequency)
- C. trachomatis
- N. gonorrhoeae: gonorrhea and chlamydia often co-exist
- endogenous flora: anaerobic, aerobic, or both
- E. coli, Staphylococcus, Streptococcus, Enterococcus, Bacteroides, Peptostreptococcus, H. influenzae, G. vaginalis
- cause of recurrent PID
- associated with instrumentation
-
Actinomyces israelii (Gram-positive, non-acid-fast anaerobe)
- 1-4% of PID cases associated with IUDs
- others (TB, Gram-negatives, CMV, U. urealyticum, etc.)
Name risk factors: Pelvic inflammatory disease (5)
- age <30 yr
- risk factors as for chlamydia and gonorrhea
- vaginal douching
- IUD (within first 10 d after insertion)
- invasive gynecologic procedures (D&C, endometrial biopsy)
Describe clinical features: Pelvic inflammatory disease (4)
- up to 2/3 asymptomatic: many subtle or mild symptoms
- common: fever >38.3ºC, lower abdominal pain and tenderness, abnormal discharge (cervical or vaginal)
- uncommon: N/V, dysuria, AUB
- chronic disease (often due to chlamydia)
- constant pelvic pain
- dyspareunia
- palpable mass
- very difficult to treat, may require surgery
Describe investigations: Pelvic inflammatory disease (5)
- blood work
- β-hCG (must rule out ectopic pregnancy), CBC, blood cultures if suspect septicemia
- urine R&M
- speculum exam, bimanual exam
- vaginal swab for Gram stain, C&S
- cervical cultures for N. gonorrhoeae, C. trachomatis
- endometrial biopsy will give definitive diagnosis (rarely done)
- ultrasound
- may be normal
- free fluid in cul-de-sac
- pelvic or tubo-ovarian abscess
- hydrosalpinx (dilated fallopian tube)
- laparoscopy (gold standard)
- for definitive diagnosis: may miss subtle inflammation of tubes or endometritis
How to make Pelvic inflammatory disease diagnosis (10)
Must have
- Lower abdominal pain
Plus one of
- Cervical motion tenderness
- Adnexal tenderness
Plus one or more of
- High risk partner
- Temperature >38°C
- Mucopurulent cervical discharge
- Positive culture for N. gonorrhoeae, C. trachomatis, E. coli, or other vaginal flora
- Cul-de-sac fluid, pelvic abscess or inflammatory mass on U/S or bimanual
- Leukocytosis
- Elevated ESR or CRP (not commonly used)
Describe tx: Pelvic inflammatory disease diagnosis (10)
- must treat with polymicrobial coverage
Name indications of inpatient treatment of Pelvic inflammatory disease (7)
- Moderate to severe illness Atypical infection
- Adnexal mass, tubo-ovarian mass, or pelvic abscess
- Unable to tolerate oral antibiotics or failed oral therapy
- Immunocompromised Pregnant
- Adolescent (first episode)
- Surgical emergency cannot be excluded (e.g. ovarian torsion)
- PID is secondary to instrumentation
Describe tx regimen for inpatient management of pelvic inflammatory disease (3)
- Cefoxitin 2 g IV q6h + doxycycline 100 mg PO/IV q12h or
- Clindamycin 900 mg IV q8h + gentamycin 2 mg/kg IV/IM loading dose then gentamycin 1.5 mg/kg q8h maintenance dose
- Continue IV antibiotics for 24 h after symptoms have improved then doxycycline 100 mg PO bid to complete 14 d
- Percutaneous drainage of abscess under U/S guidance
- When no response to treatment, laparoscopic drainage
- If failure, treatment is surgical (salpingectomy, TAH/BSO)
Name indications of outpatient treatment of Pelvic inflammatory disease (4)
- Typical findings
- Mild to moderate illness Oral antibiotics tolerated
- Compliance ensured
- Follow-up within 48-72 h (to ensure symptoms not worsening)
Describe tx regimen for outpatient management of pelvic inflammatory disease (2)
- 1st line: ceftriaxone 250 mg IM x 1 + doxycycline 100 mg PO bid x 14 d or cefoxitin 2 g IM x 1 + probenecid 1 g PO + doxycycline 100 mg PO bid ± metronidazole 500 mg PO bid x 14 d
- 2nd line: ofloxacin 400 mg PO bid x14 d or levofloxacin 500 mg PO OD x 14 d ± metronidazole 500 mg PO bid x 14 d
- Consider removing IUD after a minimum of 24 h of treatment
- Reportable disease
- Treat partners
- Consider re-testing for C. trachomatis and N. gonorrhoeae 4-6 wk after treatment if documented infection
Name: Complications of Untreated PID (7)
- chronic pelvic pain
- abscess, peritonitis
- adhesion formation
- ectopic pregnancy
- infertility
- 1 episode of PID: 13% infertility
- 2 episodes of PID: 36% infertility
- bacteremia
- septic arthritis, endocarditis
Define: Toxic Shock Syndrome (1)
Multiple organ system failure due to S. aureus exotoxin (rare condition)
Name risk factors: Toxic Shock Syndrome (5)
- tampon use
- diaphragm, cervical cap, or sponge use (prolonged use, i.e. >24 h)
- wound infections
- post-partum infections
- early recognition and treatment of syndrome is imperative as incorrect diagnosis can be fatal
Describe clinical features: Toxic Shock Syndrome (6)
- sudden high fever
- sore throat, headache, diarrhea
- erythroderma
- signs of multisystem organ failure
- refractory hypotension
- exfoliation of palmar and plantar surfaces of the hands and feet 1-2 wk after onset of illness
Describe tx: Toxic Shock Syndrome (5)
- remove potential sources of infection (foreign objects and wound debris)
- debride necrotic tissues
- adequate hydration
- penicillinase-resistant antibiotics (e.g. cloxacillin)
- steroid use controversial, but, if started within 72 h, may reduce severity of symptoms and duration of fever
Name: Post-Operative Infections in Gynecological Surgery (1)
- pelvic cellulitis
Describe: Pelvic cellulitis (5)
- common post hysterectomy, affects vaginal vault
- erythema, induration, tenderness, discharge involving vaginal cuff
- treat if fever and leukocytosis with broad-spectrum antibiotics (i.e. clindamycin and gentamicin)
- drain if excessive purulence or large mass
- can result in intra-abdominal and pelvic abscess
