16 - Gynecologic Infections (old deck) Flashcards
Causes of vaginal discharge?
Vaginitis
- BV
- VVC
- trichomoniasis
- other (atrophic, FOB)
Cervicitis/urethritis
- chlamydia
- gonorrhea
Physiologic discharge
Why does the vaginal mucosa produce glycogen?
Nutrients for many vaginal ecosystem species -> converted to lactic acid
- decreases in menopause
Vaginal mucosa is made of?
Stratified squamous epithelium
Actions of vaginal stratified squamous epithelium?
Secretory Estrogen responsive Homeostatic Produces glycogen Vaginal pH
Low vaginal pH =
4-4.5
What is the predominant microorganism of the vagine?
Lactobacilli
- lactic acid
- hydrogen peroxide
Lower reproductive tract flora
Aerobes
Gram pos
- lactobacillus
- diphtheroids
- staph aureus
- staph epi
- GBS
- e. Faecalis
- staph spp
Gram neg
- E. Coli
- klebsiella spp
- proteus spp
- enterobacter spp
- acinetobacter spp
- citrobacter spp
- pseudomonas spp
Lower reproductive tract flora
Anaerobes
Gram pos cocci
- peptostreptococcus spp
- clostridium spp
Gram pos bacilli
- lactobacillus
- propionibacterium
- eubacterium
- bifidobacterium
- actinomyces iraelii
Gram neg
- prevotella
- bacteroides
- bacteroides fragilis
- fusobacterium
- veillonella
Yeast
- candida albicans and others
Things that offset balance of the microflora?
Antibiotics Douchbags Semen FOB Hypoestrogenized (atrophic) - menopause - pregnancy - contraception
3 main causes of vaginitis?
Bacterial vaginitis (BV) - 40-50%
Candida vulvovaginitis - 20-30%
Trichomonas - 15-20%
Categories of vaginitis?
Inflammatory
- desquamative vaginitis
- trichomonas
- candida
- atrophic vaginitis
- GAS
- FOB
- irritants
- mucosal erosive disease
Non-inflammatory
- BV
- candida
MC cause of bacterial vaginosis?
BV
S/s of BV?
Profuse grey milky discharge
Strong, fishy odor
- esp after sex
What causes BV?
Sift in normal flora
- overgrowth of anaerobes
(Not listing them again)
- reduction/loss of lactobacilli
Risk factors for BV?
Oral sex Douchbags Black race Cigarettes Sex during menses Intrauterine device Early age of sex New/multi partners WSW sex
BV diagnosis requires?
Min 3 of:
- Homogenous discharge
- pH >4.5
- pos “whiff” test
- clue cells on wet prep
Acute BV tx?
Metronidazol (flagyl)
Metronidazole gel (metrogel vaginal)
Clindamycin cream
Doses and shit on slide 32 (original deck)
Recurrence of BV?
Recurrence is common (50% w/in 12 mo)
Probiotics have benefit ofr recurrence of chronic BV (not acute)
Should you treat the partner for BV?
Doesnt help women w recurrent sx
Consequences of BV?
- Increased risk of STI infections
- turbo-ovarian abscess
- PID
- persistence of HPV
- endometritis
- vaginal cuff cellulitis (post hysterectomy)
- premature rupture of membranes
- postpartum fever
- post-abortion infection/sepsis
Pt presents w chronic/recurrent BV you should?
Revisit pt hx
Perform speculum exam
Obtain NAAT and KOH/Wet prep
Chronic/recurrent BV tx?
No prior long term tx: - metronidazol (oral or vaginal) - tinidazol (oral) - cindamycin (vaginal) (Treat for 2 wks)
w hx of long term tx - metronidazol (oral or vaginal) - tinidazol (oral) - cindamycin (vaginal) (Suppress w weekly/biweekly x 6 months)
What is the goal of tx of chronic BV?
If cannot cure the goal is to control rather than eliminate
Adverse pregnancy outcomes of BV?
PROM
Preterm delivery
Intra-amniotic infection
Post-partum endometritis
- all pregnant women should be treated
- high risk pregnancy should be screened
2nd MCC of vaginitis?
Vulvovaginal candidiasis
Symptoms of vulvovaginal candidiasis?
Vaginal burnin/itching Irritation Post-voiding dysuria Odorless thick white discharge - “cottage cheese”
Cases of vulvovaginal candidiasis?
C. Albicans - 80-92%
C. Galbrata
Diagnosis of vulvovaginal candidiasis?
Vulvovaginal erythema
PH <4.5
Budding yeast/pseudohyphae on KHO
Culture
Risk factors of vulvovaginal candidiasis?
H estrogen Immunosuppression Environmental (tight clothes, condoms etc) DM Antibiotic use
Topical agents for candidiasis?
Big ass chart on 221 (review deck)
Risk factors for recurrent vulvovaginal candidiasis?
Most women dont have risk factors
- its a host issue not a bug issue
But they are:
- OCP
- diaphragm
- DM
- abx use
- pregnancy
- immunosuppression
- tight clothing
Recurrent vulvovaginal candidiasis?
> /= 4 episodes in 1 yr
5% of women
- get a culture
What to do if your pt has recurrent vulvovaginal candidiasis?
Revisit pt hx
Speculum exam
NAAT and KOH wet prep
Get a fungal culture w sensitivities
Tx for recurrent vvc?
Tx:
- local intravaginal therapy 7-14 days
- fluconazole PO
Suppressive:
- oral fluconazol weekly x 6 months
Tx for VVC external irritation?
Topical mid-potency steroid
3rd MCC of discharge
trichomoniasis - 10-20% of cases
S/s of trichomoniasis?
50% asymptomatic
But:
- frothy green-yellow discharge
- odor is strong or “musty”
- dyspareunia
- occasionally dysuria
Diagnosis of trichomoniasis?
Frothy discharge Strawberry 🍓 cervix PH >4.5 Trichomonads on wet prep NAAT
Gold standard for trichomoniasis?
NAAT
Tx for trichomoniasis?
Metronidazole either/or - 2gm PO - 500 mg BID x 14 days Tinidizole - 2gm PO
Test of cure at 1 and 6 months
Most prevalent STI?
HSV
1 and 2
Why are HSV 1 and 2 so easy to spread?
Only 10-20% know they have it
70% transmission from asymptomatic viral shedding
S/s of HSV?
Prodrome:
- tingling
- itching
- burning
- paresthesias
Painful burning
Vesicles/ulcers
HSV 1st infection symptoms?
Fever
Ha
Malaise
Inguinal lymphadenopathy
HSV transmission?
Toilet seats
Saliva
Direct contact
HSV risk to fetus?
Initial infection = greatest risk
- mom has no antibodies
Genital warthogs are?
HPV
- types 6, 11
Transmission of HPV?
Contact
Inanimate objects
- (like the back seat of a volkswagon?)
Birth canal -> larynx
Genital warts diagnosis?
Clinical
- acetic acid application
Biopsy if unresponsive to tx
Rx for genital warts?
Provider applied:
- podophyllin
- trichloroacetic acid (TCA)
- bichloroacetic acid (BCA)
- cryotherapy
Pt applied:
- podofilox
- imiquimod (no preggos)
Surgical:
- tangential scissor excision
- tangential shave excision
- curettage
- electrosurgery
Primary syphilis is?
Treponema pallidum -> bacterial spirochete
Primary syphilis transmission?
Contact
Transplacental
Clinical diagnosis for syphilis?
Clinical:
- Isolated painless chancre (ulcer)
- hard, smooth, raised rounded borders
- > actively sheds spirochetes
Screening:
- RPR
- VRDL
- FTA-ABS (confirmation)
Where does syphilis present?
Cervix Vagina Vulva Mouth Anus
Untreated syphilis?
Chancre heals in 6 wks Infection remains (dun dun dunnnnnn)
Tx for syphilis?
PCN 2.4 million units IM
Secondary syphilis presentation?
Bacteremia - 6 wks - 6 mo after chancre - 1/3 of cases Rash (hallmark) Fever, malaise Lymphadenopathy Exanthem (sheds spirochetes) Condylomata lata
Hallmark rash of secondary syphilis?
Maculopapular rash of:
- palms
- soles
- mucous membranes
- sometimes whole body
What is condylomata lata?
Broad, pink or gray-white highly infectious plaques
- in warm, moist areas of bodies
Tx for secondary syphilis?
PCN 2.4 million units IM
Latent syphilis timelines?
Early latent
- 1st yr following 2ndary w/o tx
Late latent
- > 1yr after initially infection
What is tertiary syphilis?
Can be up to 20 yrs after latency
Presentation can be:
- cardiovascular
- CNS
- musculoskeletal involvement
What if the syphilis pt has PCN allergy?
PCN is the only proven tx
- may need to desensitized
What is jarisch-herxheimer reaction?
Occurs in 50% of 1st degree syphilis
90% of 2nd degree syphilis
Caused by release of endotoxin when large #s of organisms are killed by antibiotics
- persistence fever, malaise and HA
Tx of syphilis:
< 1y
and
latent, tertiary and cardiovascular syphils
<1 yr
- bnezathine PCN G once
Late latent, tertiary and cardi
- benzathing PCN G IM weekly x 3
Syphilis tx needs?
Follow up
- after 6 months
If retreatment is req weekly PCN inj x 3 weeks
Chancroid is aka?
Haemophils ducreyi
Clinical presentation of chancroid?
Erythematous papule -> pustule -> ulcerates w/in 48hrs
Edges of ulcer = irregular w erythematous non-indurated
Ulcer red and granular, soft
PAINFUL
Chancroid tx?
Azithromycin 1 gm PO
Or
Ceftriaxone 250mg IM
Sx of chlamydia?
Asymptomatic
- 70% of women
- 50% of men
Urethritis
cervicitis
Dx for chlamydia?
Culture
Antigen test
PCR
Tx for chlamydia?
Azithromycin 1gm po x 1
Doxy x 7 days
Test of cure if pregnant
S/s of gonorrhea (clap)
asymptomatic
- most women
- 5% of men
Urethritis
Cervicitis
Dx for gonorrhea?
Gram stain
Culture
DNA/nucleic acid PCR
Tx for gonorrhea?
Primary
- ceftriaxone + azithromycin
Secondary
- cephalosporin PO/IM + azithromycin
Tertiary
- cephlosporin PO/IM + doxy
What is no longer recommended for gonorrhea?
Quinolones
What is PID?
Upper GI tract inflammation/infection
MC organisms for PID?
Chlamydia trachomatis N. Gonorrhea BV microflora (anaerobes) Genital mycoplasmas - M. Homiminis - U. Urealyticum - M. Genitalium
PID sequelae
Infertility
Ectopic pregnancy
Chronic pelvic pain
PID risk factors?
Douchbags Single status Substance abuse Multiple sex partners Lower socioeconomic status Recent new sex partners Younger age (10-19) STI Sexual partner w urethritis or gonorrhea Previous infection of PID Not using mechanical or chemical contraceptive barriers
clinical PID symptoms
Silent infection
- not clinical dx
Woman w tubal-factor infertility who lacks hx compatible w upper tract infection
Often has antibodies to:
- chlamydia
- gonorrhea
Prior tubal infection signs:
- adhesions
- hydrosalpinx
Acute PID clinical symptoms?
Usually develop during/soon after menstruation
- lower abd/pelvic pain
- yellow vaginal discharge
- heavy menstrual bleeding
- fever/chills
- anorexia
- N/V/D
- dyspareunia
- UTI sx
PID diagnostic criteria
Minimum
- uterine/adnexal or cervical motion tenderness
- lower abdominal pain
More specific
- > 101* F
- mucuopurulent cervical discharge/friability
- WBC on saline microscopy
- elevated ESR/CRP
- lab diagnosis STI
Most specific
- US, MRI, laparoscopic-
PID inpatient criteria?
Pregnant Adolescent Drug addict Severe disease Suspected abscess Uncertain diagnosis Generalized peritonitis Temp >38.3 Failed therapy Recent intrauterine instrumentation WBC > 15,000 N/V preclude oral therapy
PID tx?
GC/Chlamydia abx
Inpatient
- cefoxitin IV and doxy IV
Outpatient (all x 2 wks)
- ceftriaxone IM
- doxy PO
What if PID pt has concomitant trich or recent instrumentation?
Add metronidazole 500mg BID x 2 wks
Wht is tubo-ovarian abscess?
PID complication (10%) Rupture leads to peritonitis, sepsis
How to distinguish TOA from endometritis/saplingitis?
Presence of tender inflammatory adnexal mass
- US
- CT
- MRI
- laproscopy
Tx for TOA?
Broad spectrum IV abx
- 85% response rate
Surgery if no improvement x 24-48hrs
Toxic shock syndrome
Exotoxin from s. Aureus
2 days post surgery/mensturation
Super absorbent non-Cherokee hair tampons
Triad of TSS?
Fever, Malaise, Diarrhea
Diffuse macular rash
Orthostatic hypotension
Thats like a fivead but what do i know. I’m not a doctor
Tx for TSS?
Abx
Systemic support
TSS diagnostic criteria?
Major and minor
Major criteria for TSS?
HOTN Orthostatic syncope Diffuse macular erythoderma Temp < 38.8 Late skin desquamation
Minor criteria TSS?
Organ system involvement
- GI: Diarrhea/vomiting
- mucous membranes involvement
- muscular: myalgia, creatinine
- renal: BUN and creatinine, WBC in urine
- Heme: platelet <100k
- Hepatic: SGOT, STPT bilirubin H
- CNS: alter LOC
Knock knock
Who’s there?
Chlamydia, go get checked out
