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Women's Health Unit I > 2 STIs > Flashcards

2 STIs Flashcards

1
Q

What are the five P’s of taking a sexual history?

A

Partners
• Men, women, both
• How many in past year
• Last time you had sex

Practices - sites of exposure

Prevention of pregnancy

Protection from STIs

Past hx of STIs - them and partners

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2
Q

What population accounts for half of all new STIs?

A

Youth (ages 15-24)

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3
Q

Special populations for STIs

A

Youth (15-24)

MSM

Pregnant women

HIV-infected patients

Individuals entering correctional facilities

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4
Q

General term for disorders of the vagina caused by infection, inflammation, or changes in the normal vaginal flora

A

Vaginitis

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5
Q

Sx of vaginitis

A

Vaginal discharge

Odor

Pruritis and/or discomfort

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6
Q

Most common causes of vaginitis

A

Candida vulvovaginitis

Bacterial vaginosis

Trichomoniasis

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7
Q

Is vulvovaginal candidiasis considered an STI?

A

Nope

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8
Q

What is the prevalence of vulvovaginal candidiasis?

A

Common - exact prevalence difficult to determine

Highest among women in their reproductive years

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9
Q

Causative organism of vulvovaginal candidiasis?

A

Usually C. albicans

Can be caused by other Candida sp or yeast (ie C. glabrata - resistant to fluconazole)

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10
Q

Clinical presentation of vulvovaginal candidiasis

A

Sx: PRURITIS, external dysuria, vulvar soreness, dyspareunia, and abnormal vaginal discharge

PE: white, THICK, CURD-LIKE discharge (adherent to vaginal walls)

May see vulvar erythema, edema, fissures, or excoriations

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11
Q

Risk factors for vulvovaginal candidiasis

A

DM

Abx use

Increased estrogen levels

Immunosuppressed

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12
Q

How is vulvovaginal candidiasis diagnosed?

A

Clinically

If necessary:
• 10% KOH wet mount - budding yeast, hyphae, or pseudohyphae
• Normal vaginal pH (<4.5)
• MAYBE vaginal culture (not likely to happen)

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13
Q

How do you treat vulvovaginal candidiasis?

A

Indicated for relief of symptoms

Uncomplicated:
• Short course (1-3 days) of topical azole (ie Clotrimazole) OR
• Oral fluconazole 150mg PO x1

Complicated:
• Longer duration (7-14d) topical azole OR
• Oral fluconazole 150mg q72h x 2-3 doses
• Maintenance rx for recurrent

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14
Q

What makes a case of vulvovaginal candidiasis complicated?

A

Severe Sx

Recurrent infection

Nonalbicans sp

Pregnancy (use topical azole, not fluconazole)

Poorly controlled DM

Immunosuppression

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15
Q

Do you need to treat partners of patients with vulvovaginal candidiasis?

A

No data to support tx of partner(s) unless male partner has Sx of balanitis

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16
Q

Is Bacterial Vaginosis considered an STI?

A

No but sexual activity is a major risk factor

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17
Q

Most common cause of vaginal discharge in women of childbearing age

A

Bacterial vaginosis

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18
Q

Replacement of “healthy” vaginal flora (Lactobacillus sp) with overgrowth of anaerobic bacteria

A

Bacterial vaginosis

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19
Q

What is the causative organism(s) of bacterial vaginosis?

A

Cause is usually polymicrobial (so culture not helpful)

Often associated with Gardnerella vaginalis, Mobiluncus sp., Prevotella sp.

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20
Q

Clinical presentation of bacterial vaginosis

A

Asymptomatic in 50-75%

Symptomatic: vaginal discharge and/or vaginal odor - THIN, white or gray with STRONG “FISHY SMELL”

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21
Q

Risk factors for bacterial vaginosis

A

Sexual activity (esp with new or multiple sex partners)

Presence of other STIs

Race/ethnicity (African-Am, Mexican-Am)

Douching (regularly)

Smoking

Lack of condom use

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22
Q

What is Amsel’s Criteria?

A

Clinical diagnostic criteria for BV

Presence of at least 3….

  1. Thin, white, homogenous discharge
  2. CLUE CELLS on SALINE wet mount (vs. KOH for candida)
  3. Vaginal fluid pH >4.5
  4. (+) whiff test 🤮🤮🤮
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23
Q

What is a (+) “whiff test”

A

Presence of a fishy odor when a drop of 10% KOH is added to a sample of vaginal discharge

Indicative of BV

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24
Q

Who should be treated for BV?

A

Patients with SYMPTOMS - may be identified on Pap smear but only symptomatic patients need meds

Pregnancy if SYMPTOMATIC

Tx of sex partners not recommended

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25
What is the treatment regimen for BV?
Metronidazole 500mg PO BID x 7 days**** or Metronidazole gel 0.75% intravaginally QD x 5 days or Clindamycin cream 2% intravaginally QHS x 7 days
26
Complications of BV
Increases risk of acquiring and transmitting HIV Increases risk of acquiring HSV-2, N. gonorrhoeae, C. trachomatis, and T. vaginalis BV is more common among women with PID (independent risk factor?)
27
What is the CDC recommendation for women diagnosed with BV?
All women with BV should be offered testing for HIV and other STIs
28
Most common non viral STI worldwide
Trichomoniasis Most have minimal or no symptoms (70-85%)
29
Causative organism for Trichomoniasis
Trichomonas vaginalis Flagellated protozoan Coexistence of T. vaginalis and BV pathogens is common
30
Clinical presentation of trichomoniasis
Asymptomatic in most Sx: • Malodorous, FROTHY, YELLOW-GREEN vaginal discharge, +/- vulvar irritation • Burning, pruritis, dysuria, or dyspareunia • Postcoital bleeding can occur (b/c of cervical involvment) PE: • Punctate hemorrhages on vagina/cervix (STRAWBERRY CERVIX) • Vaginal pH >4.5
31
How is trichomoniasis diagnosed?
**Saline wet mount shows MOTILE ORGANISMS (be quick!) **Nuclei acid amplification test (NAAT) is now the gold standard (highly sensitive and specific) Culture - may take up to 7 days, not widely available Rapid antigen and DNA probes ?
32
Complications of trichomoniasis
If untreated —> urethritis or cystitis PID (esp if with HIV) Cervical neoplasia Infertility Increased risk of acquiring/transmitting HIV
33
Complications of trichomoniasis in PREGNANCY
Increased risk of premature rupture of membranes, premature delivery, low birth weight
34
Treatment of Trichomoniasis
Treat both asymptomatic and symptomatic partners Metronidazole 2g single dose (safe in pregnancy) • Avoid alcohol for at least 72 hours Abstain from sex until patient and partner both treated (wait at least 7 days) Test for other STIs incl HIV
35
Do you need repeat testing for Trichomoniasis?
Repeat testing within 3 months following initial treatment Why? Reinfection rates up to 17% have been reported
36
Who should be screened for trichomoniasis?
All HIV infected women annually and at their prenatal visits Consider in high prevalence settings (STI clinics, correctional facilities) Consider asymptomatic persons at high risk of infection
37
Most frequently reported infectious disease in the US
Chlamydia
38
Prevalence of chlamydia is highest in ...
Persons age ≥ 24 years
39
Majority of women with chlamydia are...
Asymptomatic (at least 85%)
40
Patients with chlamydia are frequently co-infected with ....
Gonorrhea
41
Clinical presentation of chlamydia
Change in vaginal discharge +/- intermenstrual or postcoital bleeding Frequency and dysuria PE: Classic findings of cervicitis • Mucopurulent endocervical discharge • FRIABILITY, erythema, edema
42
Diagnosis of chlamydia
Nucleic acid amplification testing (NAAT) is test of choice Can be with vaginal swab (preferred), endocervical swab, or urine
43
Complications of chlamydia
PID Ectopic pregnancy Infertility Chronic pelvic pain Complications in pregnancy: Increased risk for premature rupture of membranes, premature delivery Transmittable to neonate (conjunctivitis)
44
Treatment for chlamydia
Treat patient AND partner(s) Azithromycin 1g PO single dose OR Doxycycline 100mg PO BID x 7 days If pregnant: • Use Azithromycin, not Doxy • Test of cure recommended Avoid sex until 7 days after treatment Test for other STIs Repeat testing for reinfection at 3 months
45
Who should be screened for chlamydia?
Annual screening of all sexually active women <25 years old ``` Older women with risk factors: New or multiple sex partners Sex partner recently treated for an STI No or inconsistent condom use outside of mutually monogamous relationship Hx of prior STI Exchange of sex for drugs/money ```
46
2nd most commonly reported communicable disease in the US
Gonorrhea Majority of patients asymptomatic, often co-infected with chlamydia
47
What is of increasing concern with gonorrhea?
Antimicrobial resistance
48
Causative organism for gonorrhea
Neisseria gonorrhoeae
49
Clinical presentation of gonorrhea
Change in vaginal discharge +/- intermenstrual or postcoital bleeding Frequency and dysuria Clinical findings of cervicitis: • Mucopurulent endocervical discharge • Cervix friable, erythematous, edema
50
How is gonorrhea diagnosed?
NAAT - vaginal (preferred) swab, endocervical swab, or urine Culture helpful when abx resistance is suspected
51
Complications of gonorrhea
PID, ectopic pregnancy, infertility, and chronic pelvic pain DISSEMINATED GONOCCAL INFECTION (DGI) In pregnancy: Risk of preterm birth, low birth weight, infection Transmittable to neonate (ophthalmia neonatorum)
52
How do you treat gonorrhea
Treat patient and sex partner(s) Ceftriaxone 250mg IM PLUS Azithromycin 1gm PO single dose In pregnancy, same tx but test of cure is recommended if alt given Avoid sex for 7 days post treatment Test for other STIs Repeat testing for reinfection at 3 months
53
Who should be screened for gonorrhea?
Same as for chlamydia
54
Any combo of endometriosis, salpingitis, turbo-ovarian abscess, or pelvic peritonitis initiated by a sexually transmitted agent which ascends into the upper genital tract
Pelvic Inflammatory Disease (PID)
55
Majority of PID is caused by....
N. gonorrhoeae or C. trachomatis or BV associated pathogens Emerging: Mycoplasma genitalium
56
______ women with a hx of PID have trouble getting pregnant
1 in 8
57
Risk factors for PID
Women with multiple partners (highest risk) Younger age (<25) Partner with an STI Hx of prior PID or STI IUD - risk is primarily limited to the first 3 weeks after insertion Disruption of the normal vaginal flora
58
Sx of PID
Lower abdominal pain - onset during or shortly after menses is particularly suggestive Abnormal vaginal discharge Abnormal uterine bleeding Dyspareunia Fever
59
PE findings for PID
Abdominal or uterine/adnexal tenderness Cervical motion tenderness (CHANDELIER SIGN) Purulent endocervical discharge and/or vaginal discharge
60
DDx for PID
Ectopic pregnancy Septic/incomplete abortions Acute appendicitis Diverticular disease Adnexal torsion
61
How do you evaluate someone for PID?
``` Hx and PE PREGNANCY TEST***** Vaginal wet mount - check for WBCs NAATs for C. trachomatis, N. gonorrhoeae, M. genitalium HIV screening, testing for syphilis CBC, ESR, CRP U/A ``` If unsure - pelvis U/S, CT/MRI
62
Presumptive clinical dx of PID can be made if...
Sexually active young woman (esp women at high risk for STIs) Pelvic or lower abdominal pain Evidence of cervical motion, uterine, or adnexal tenderness on exam
63
Additional findings that can support the clinical diagnosis of PID
Oral temp >101F Abnormal cervical or vaginal mucopurulent d/c or cervical friability Presence of abundant numbers of WBCs on wet mount Elevated ESR, CRP Documentation of cervical infection with C. trachomatis or N. gonorrhoeae
64
How do you treat PID?
As soon as presumptive Dx is made! Empiric, broad coverage ``` Ceftriaxone 250mg IM single dose*** PLUS Doxycycline 100mg BID x 14 days +/- Metronidazole 500mg PO BID x 14 days ``` CLOSE FOLLOW-UP 48-72 hours
65
Who should be hospitalized for PID?
Pregnant women Lack of response or tolerance to oral meds (within 72 hours) Concern for non adherence to therapy Inability to take oral meds due to N/V Severe clinical illness (high fever, N/V, severe pain) Complicated PID with pelvic abscess Surgical emergencies cannot be excluded
66
Complications of PID
Infertility Chronic pelvic pain Risk of ectopic pregnancy ***PERIHEPATITIS (Fitz-Hugh-Curtis Syndrome)
67
What is Fitz-Hugh-Curtis syndrome?
Perihepatitis - RUQ pain and adhesions
68
How do you manage PID
Abstain from sex until therapy completed, Sx resolve, and partners have been adequately treated Repeat testing for those (+) for chlamydial or gonococcal PID in three months
69
Most common STI in the US
HPV - at least 80% of sexually active adults are exposed to HPV in their lifetime
70
How is HPV transmitted?
Through contact with infected skin or mucosa (doesn’t have to be intercourse
71
Why subtypes of HPV are most likely to cause Condylomata Acuminata?
6 and 11
72
Risk factors for condyloma acuminata
Sexual activity Smoking Immunosuppression (assoc with more serious types) Association with malignancy
73
Clinical presentation of condyloma acuminata
Typically asymptomatic but may be pruritic Found on: vulva, penis, groin, perineum, perianal skin and/or suprapubic skin Can also involve cervix, urethra, and anal canal Soft, flesh-colored, smooth or plaque-like Single or multiple, flat (or dome-shaped), CAULIFLOWER LIKE
74
How are anogenital warts diagnosed?
Visualize warts on PE - consider anoscopy, speculum exam Biopsy may be considered if dx uncertain
75
DDx for condyloma acuminata
Condyloma Lata (syphilis) Molluscum contagiosum Squamous cell carcinoma
76
Treatment for condyloma acuminata
Cyto-destructive (Podofilox, Trichloracetic acid, or Bichloracetic acid) Immune-mediated (Imiquimod, Sinecatechins) Surgical (cryotherapy, laser, electrocautery, excision)
77
Prevent and patient ed for HPV
HPV VACCINE!!!! Correct, consistent condom use lowers chances HPV can infect areas not covered by condom Limit number of partners Common for warts to recur after treatment Duration of viral persistence after warts have resolved is unknown
78
Most cases of recurrent genital herpes are caused by....
HSV-2 Chronic, lifelong viral infection
79
How is HSV transmitted
Mucosal surfaces, both genital and oral secretions Many infected have minimal or no symptoms - 70% of transmission occurs during times of asymptomatic HSV shedding Average incubation period after exposure is 4 days (2-12 days)
80
Clinical presentation of primary infection of genital herpes
``` Painful genital ulcers*** Dysuria Fever Tender Inguinal LAD HA ``` In some, may be very mild, or even asymptomatic
81
CLinical presentation of recurrent HSV infection
Prodromal symptoms before eruption Symptoms tend to be less severe than primary infection
82
How is genital herpes diagnoses?
Virologic tests • Viral culture (highest yield in early stages) • PCR (more sensitive) ``` Serologic tests (detects HSV-1 and HSV-2) • Limitation = false-neg results more frequent early on ```
83
Should you screen the general population for HSV?
Nope
84
How do you treat first clinical episode of genital herpes
Valacyclovir (valtrex), famciclovir (famvir), or acyclovir (Zovirax) 7-10 day regimen, start within 72 hours
85
How long is the treatment regimen for episodic recurrence of genital herpes?
1-5 days
86
How do you suppress genital herpes?
QD or BID dosing of antivirals Reduces frequency of recurrences and risk of transmission to partner Periodically reassess need
87
What counseling should you give to genital herpes patients
Help patients cope Counsel to prevent sexual transmission • Disclosure of HSV status to partners • Use of condoms • ID any concerns/misconceptions Educate potential for clinical recurrence Educate about vertical transmission

Women's Health Unit I (2 decks)

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