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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
Q

What is the treatment regimen for BV?

A

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

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26
Q

Complications of BV

A

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?)

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27
Q

What is the CDC recommendation for women diagnosed with BV?

A

All women with BV should be offered testing for HIV and other STIs

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28
Q

Most common non viral STI worldwide

A

Trichomoniasis

Most have minimal or no symptoms (70-85%)

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29
Q

Causative organism for Trichomoniasis

A

Trichomonas vaginalis

Flagellated protozoan

Coexistence of T. vaginalis and BV pathogens is common

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30
Q

Clinical presentation of trichomoniasis

A

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

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31
Q

How is trichomoniasis diagnosed?

A

**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 ?

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32
Q

Complications of trichomoniasis

A

If untreated —> urethritis or cystitis

PID (esp if with HIV)

Cervical neoplasia

Infertility

Increased risk of acquiring/transmitting HIV

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33
Q

Complications of trichomoniasis in PREGNANCY

A

Increased risk of premature rupture of membranes, premature delivery, low birth weight

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34
Q

Treatment of Trichomoniasis

A

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

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35
Q

Do you need repeat testing for Trichomoniasis?

A

Repeat testing within 3 months following initial treatment

Why? Reinfection rates up to 17% have been reported

36
Q

Who should be screened for trichomoniasis?

A

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
Q

Most frequently reported infectious disease in the US

A

Chlamydia

38
Q

Prevalence of chlamydia is highest in …

A

Persons age ≥24 years

39
Q

Majority of women with chlamydia are…

A

Asymptomatic (at least 85%)

40
Q

Patients with chlamydia are frequently co-infected with ….

A

Gonorrhea

41
Q

Clinical presentation of chlamydia

A

Change in vaginal discharge

+/- intermenstrual or postcoital bleeding

Frequency and dysuria

PE: Classic findings of cervicitis
• Mucopurulent endocervical discharge
• FRIABILITY, erythema, edema

42
Q

Diagnosis of chlamydia

A

Nucleic acid amplification testing (NAAT) is test of choice

Can be with vaginal swab (preferred), endocervical swab, or urine

43
Q

Complications of chlamydia

A

PID
Ectopic pregnancy
Infertility
Chronic pelvic pain

Complications in pregnancy:
Increased risk for premature rupture of membranes, premature delivery
Transmittable to neonate (conjunctivitis)

44
Q

Treatment for chlamydia

A

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
Q

Who should be screened for chlamydia?

A

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
Q

2nd most commonly reported communicable disease in the US

A

Gonorrhea

Majority of patients asymptomatic, often co-infected with chlamydia

47
Q

What is of increasing concern with gonorrhea?

A

Antimicrobial resistance

48
Q

Causative organism for gonorrhea

A

Neisseria gonorrhoeae

49
Q

Clinical presentation of gonorrhea

A

Change in vaginal discharge +/- intermenstrual or postcoital bleeding

Frequency and dysuria

Clinical findings of cervicitis:
• Mucopurulent endocervical discharge
• Cervix friable, erythematous, edema

50
Q

How is gonorrhea diagnosed?

A

NAAT - vaginal (preferred) swab, endocervical swab, or urine

Culture helpful when abx resistance is suspected

51
Q

Complications of gonorrhea

A

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
Q

How do you treat gonorrhea

A

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
Q

Who should be screened for gonorrhea?

A

Same as for chlamydia

54
Q

Any combo of endometriosis, salpingitis, turbo-ovarian abscess, or pelvic peritonitis initiated by a sexually transmitted agent which ascends into the upper genital tract

A

Pelvic Inflammatory Disease (PID)

55
Q

Majority of PID is caused by….

A

N. gonorrhoeae or C. trachomatis or BV associated pathogens

Emerging: Mycoplasma genitalium

56
Q

______ women with a hx of PID have trouble getting pregnant

A

1 in 8

57
Q

Risk factors for PID

A

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
Q

Sx of PID

A

Lower abdominal pain - onset during or shortly after menses is particularly suggestive

Abnormal vaginal discharge

Abnormal uterine bleeding

Dyspareunia

Fever

59
Q

PE findings for PID

A

Abdominal or uterine/adnexal tenderness

Cervical motion tenderness (CHANDELIER SIGN)

Purulent endocervical discharge and/or vaginal discharge

60
Q

DDx for PID

A

Ectopic pregnancy

Septic/incomplete abortions

Acute appendicitis

Diverticular disease

Adnexal torsion

61
Q

How do you evaluate someone for PID?

A 
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
Q

Presumptive clinical dx of PID can be made if…

A

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
Q

Additional findings that can support the clinical diagnosis of PID

A

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
Q

How do you treat PID?

A

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
Q

Who should be hospitalized for PID?

A

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
Q

Complications of PID

A

Infertility
Chronic pelvic pain
Risk of ectopic pregnancy
***PERIHEPATITIS (Fitz-Hugh-Curtis Syndrome)

67
Q

What is Fitz-Hugh-Curtis syndrome?

A

Perihepatitis - RUQ pain and adhesions

68
Q

How do you manage PID

A

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
Q

Most common STI in the US

A

HPV - at least 80% of sexually active adults are exposed to HPV in their lifetime

70
Q

How is HPV transmitted?

A

Through contact with infected skin or mucosa (doesn’t have to be intercourse

71
Q

Why subtypes of HPV are most likely to cause Condylomata Acuminata?

A

6 and 11

72
Q

Risk factors for condyloma acuminata

A

Sexual activity
Smoking
Immunosuppression (assoc with more serious types)

Association with malignancy

73
Q

Clinical presentation of condyloma acuminata

A

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
Q

How are anogenital warts diagnosed?

A

Visualize warts on PE - consider anoscopy, speculum exam

Biopsy may be considered if dx uncertain

75
Q

DDx for condyloma acuminata

A

Condyloma Lata (syphilis)
Molluscum contagiosum
Squamous cell carcinoma

76
Q

Treatment for condyloma acuminata

A

Cyto-destructive (Podofilox, Trichloracetic acid, or Bichloracetic acid)

Immune-mediated (Imiquimod, Sinecatechins)

Surgical (cryotherapy, laser, electrocautery, excision)

77
Q

Prevent and patient ed for HPV

A

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
Q

Most cases of recurrent genital herpes are caused by….

A

HSV-2

Chronic, lifelong viral infection

79
Q

How is HSV transmitted

A

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
Q

Clinical presentation of primary infection of genital herpes

A 
Painful genital ulcers***
Dysuria
Fever
Tender Inguinal LAD
HA

In some, may be very mild, or even asymptomatic

81
Q

CLinical presentation of recurrent HSV infection

A

Prodromal symptoms before eruption

Symptoms tend to be less severe than primary infection

82
Q

How is genital herpes diagnoses?

A

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
Q

Should you screen the general population for HSV?

A

Nope

84
Q

How do you treat first clinical episode of genital herpes

A

Valacyclovir (valtrex), famciclovir (famvir), or acyclovir (Zovirax)

7-10 day regimen, start within 72 hours

85
Q

How long is the treatment regimen for episodic recurrence of genital herpes?

A

1-5 days

86
Q

How do you suppress genital herpes?

A

QD or BID dosing of antivirals

Reduces frequency of recurrences and risk of transmission to partner

Periodically reassess need

87
Q

What counseling should you give to genital herpes patients

A

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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