8. Vulvar itch, vaginal discharge, and sexually transmitted disease Flashcards
1
Q
Describe history: Vulvar itch, vaginal discharge, and STDs (14)
A
- Vulvar Sx (burning or pruritus)
- Vaginal discharge (consistency, color, odor)
- Progression of Sx
- Previous investigations, including cultures, swabs, etc.
- Rx attempted, including antibiotics, antifungals, etc.
- Hygienic practices
- Dysuria (internal vs. external)
- Abdo pain
- Presence of IUD
- Prev. infections
- Menstrual Hx
- Sexual activity, including number of partners, new partners, barrier protection use
- Pregnancy Hx
- PM H x, including H x of diabetes
2
Q
Describe physical exam: Vulvar itch, vaginal discharge, and STDs (6)
A
- Inspect external genitalia
- Edema, excoriations, ulceration, condylomas, discharge on the perineum or introitus
- Assessment of inguinal and/or femoral lymph nodes: lymphadenopathy
- Speculum exam:
- Vaginal discharge and lesions, evidence of characteristic lesions (e.g., strawberry cervix of trichomoniasis), presence of cervical discharge
- Assess the presence of cervical and upper genital tract inflammation: Cervical motion tenderness, adnexal tenderness
- Assess the presence of systemic Sx: Fevers, abdo tenderness
- Perform perianal inspection, pharyngeal inspection
3
Q
Describe investigations: Vulvar itch, vaginal discharge, and STDs (7)
A
- Vaginal swabs
- Vaginal discharge sample wet mount
- Culture of the endocervix for gonorrhea or chlamydia infection
- Pap test (biopsy if any suspicious areas)
- UrineR&M, C&S
- Vaginal pH (using phenaphthazine paper)—may be altered by lubricating gel, semen, douches, or intravaginal medication
- CBC, specific blood tests (VDRL, treponemal tests, HSV PCR, HAV, HBV, HIV)
4
Q
Describe: Normal vaginal Discharge (3)
A
- Physiologic vaginal discharge (1–4 mL of fluid daily)
- pH of normal flora is acidic (4.0–4.5)
- Discharge may ↑at times (pregnancy, use of E contraceptives, mid-cycle).
- ↑mid- cycle due to ↑ cervical mucus → can be malodorous and can be accompanied by irritative Sx
5
Q
Describe: Vulvovaginitis (2)
A
- Inflammation of the vulva and vagina due to both infectious and noninfectious causes
- Sx of vaginitis are nonspecific → physical exam and lab findings are required to make a definitive Dx
6
Q
Name types of infectious vaginitis (4)
A
- Bacterial vaginosis (40% –50% of cases—most common cause of vaginitis in women of reproductive age)
- Vaginal candidiasis (20%–25% of cases)
- Trichomoniasis (15% –20% of cases)
- Other (less common):
- Atrophic vaginitis with 2° bacterial infection
- Foreign body with 2° infection
- Streptococcal vaginitis (group A)
- Ulcerative vaginitis TSS
- Idiopathic vulvovaginal ulceration related to HIV
7
Q
Name types of noninfectious vaginitis (5)
A
- Atrophic vaginitis
- Chemical or other irritant
- Allergic, hypersensitivity, and contact dermatitis
- Neoplastic
- Other:
- Traumatic vaginitis
- Postpuerperal atrophic vaginitis
- Desquamativein ammatoryvaginitis
- Erosive lichen planus
- Lichen sclerosis
- Lichen simplex chronicus
- Collagen vascular disease, Crohn disease
- Behçet syndrome
8
Q
Name causative agents: Bacterial vaginosis (4)
A
- G. vaginalis
- Bacteroides
- Peptostreptococcus
- M. hominis
9
Q
Why is it important to treat Bacterial vaginosis in pregnancy? (1)
A
↑ Risk of preterm birth
10
Q
Name signs and sx: Bacterial vaginosis (2)
A
- Predominant complaint of vaginal odor
- ↑ Risk with uterine manipulation
11
Q
Name Diagnostic Criteria: Bacterial vaginosis (4)
A
Amsel criteria (3 of 4):
- Thin homogeneous vaginal discharge
- Clue cells on N/S wet mount or Gram stain
- Positive Whiff test on KOH wet mount (presence of characteristically “ shy” [amine] odor)
- Vaginal pH > 4.5
12
Q
Name RX options: Bacterial vaginosis (3)
A
- Metronidazole 500 mg PO b.i.d. × 7d
- Metronidazole 5 g pv daily × 5d
- Clindamycin 5g pv × 7d
13
Q
Name causative agents: Vaginal candidiasis (3)
A
- C. albicans
- C. glabrata (less common)
- Associated with antibiotics use, DM, immunosuppression
14
Q
Name signs and sx: Vaginal candidiasis (3)
A
- Vulvar/vaginal pruritus
- Vulvar erythema, edema, fissures excoriations, external dysuria
- Thick occulent white discharge
15
Q
Name Diagnostic Criteria: Vaginal candidiasis (3)
A
- Normal vaginal pH (4–4.5)
- Hyphae and buds on saline wet mount (yeast)
- Positive yeast culture from the vagina (many asymptomatic women have vaginal yeast colonization)
16
Q
Name RX Options: Vaginal candidiasis (2)
A
- Fluconazole 150 mg PO once
- Clotrimazole 500 mg tablet p.v. ×1 or 5 g pv × 3d
17
Q
Name causative agents: Vaginal trichomoniasis (2)
A
- T. vaginalis
- Facilitates HIV transmission, associated with PROM
18
Q
Name signs and sx: Vaginal trichomoniasis (3)
A
- Dyspareunia
- Vaginal pruritus, vulvovaginal erythema “Strawberry” cervixon exam
- Timing: ↑ common during/ immediately after menses
19
Q
Name diagnostic criteria: Vaginal trichomoniasis (4)
A
- Trichomonas (motile agellum) seen on N/S wet mount
- High number of Polymorphonuclear leukocytes (PMNs) on saline microscopy
- Positive culture for T. vaginalis
- Vaginal pH 5–6.0
20
Q
Name rx options: Vaginal trichomoniasis (3)
A
- Metronidazole 2 g PO × 1
- Metronidazole 500 mg PO b.i.d. × 7 d
- *Must treat sexual partners simultaneously to prevent reinfection
21
Q
Who to Test for Gonorrhea and Chlamydia (5)
A
- Sexually active and < 25 yr
- In all patients who have a fever and lower abdo pain
- A symptomatic sexual partner
- A new sexual partner or more than one sexual partner
- Other STI diagnosed
22
Q
Name causative agent: Gonorrhea (1)
A
N. Gonorrhea (diplococci)
23
Q
Name signs and sx: Gonorrhea (12)
A
- Cervicitis, PID
- Mucopurulent discharge vagina
- Rectal pain and discharge
- Dysuria, dyspareunia
- Perihepatitis (Fitz-Hugh-Curtis)
- Lower abdo pain
- Abnormal vaginal bleeding
- Chorioamnionitis/endometritis
- Bartholinities
- Conjunctivitis
- Pharyngeal infection
- Disseminated infection (arthritis, dermatitis, endocarditis, meningitis)
24
Q
Name dx criteria: Gonorrhea (4)
A
- Nucleic acid testing from endocervical specimens (sensitivity 96% )
- Gram stain of cervical swab sample
- Culture from endocervix, pharynx, rectum, conjunctiva
- Usual incubation period is 2–7 d
25
Name rx options: Gonorrhea (6)
* **Recommended**: Cefixime 800 mg PO × 1
* **or**: Ceftriaxone 250 mg IM × 1 **plus** Azithromycin 1 g PO × 1
* **or** Doxycycline 100 mg PO b.i.d. × 7d
* **Alternative**
* Azithromycin 2 g PO × 1
* **or** Spectinomycin 2 g IM × 1
* **plus** Co-treatment for chlamydia
* **Mandatory reporting**
* Rx/F/U of partners with contact within 60 d of Sx onset
26
Name causal agent: Chlamydia (2)
* C. trachomatis
* Serotypes D, E, F, G, H, I, J, K (obligate intracellular bacteria)
27
Name signs and sx: Chlamydia (8)
* Majority of cases → asymptomatic
* Vaginal discharge
* Dysuria, dyspareunia
* Lower abdo pain
* Conjunctivitis
* Proctitis
* Reactive arthritis
* Incubation period can be up to 6 wk
28
Name dx criteria: Chlamydia (2)
1. Nucleic acid testing assay from endocervical, urethral, or urinary specimen
2. Throat and/or rectal culture of C. trachomatisc
29
Name rx options: Chlamydia (5)
* **Recommended:** Doxycycline 100 mg PO b.i.d. × 7 d
* **or** Azithromycin 1 g PO × 1b
* **Alternative** :
* Erythromycin 500 mg PO q.i.d. × 7 d
* **or** Erythromycin 250 mg PO q.i.d. × 14 d
* Mandatory reporting
* Rx/F/U of partners with contact within 60 d of Sx onset
30
Name repeat screening of Gonorrhea indications (8)
* All cases 6 mo post-Rx
* Test of cure with culture 3 to 7 d after initiation of treatment when:
* Gonococcal pharyngeal infection
* Patient treated with non recommended regimen, including known antimicrobial resistance
* Suspected treatment failure
* Uncertain compliance
* Reexposure to untreated partner
* PID or disseminated infection
* Pregnancy
31
Name STI RFs (11)
* Previous STI
* Sexually active \< 25 yr of age
* Sexual contact with person(s) with a known STI
* A new sexual partner or \> 2 sexual partners in the past year/serially monogamous patients
* IV drug use
* No contraception or sole use of a nonbarrier method
* Sex workers and their clients
* Street involvement, homelessness
* Victims of sexual assault/abuse
* Anonymous sexual partnering
* “Survival sex” (i.e., exchanging sex for money, drugs, etc.)
32
Name C. trachomatis Repeat testing indications (7)
* All cases 6 mo post-Rx
* Test of cure in 3 to 4 wk recommended when:
* Uncertain compliance
* Patient treated with nonrecommended regiment
* Pregnancy
* Test of cure at 3 to 4 wk is not recommended when:
* Standard treatment regimen has been completed
* Signs and Sx have resolved
* No reexposure to an untreated partner
33
Must consider ____ in any child diagnosed with gonorrhea and/or chlamydia after the immediate neonatal period.
Must consider **sexual abuse** in any child diagnosed with gonorrhea and/or chlamydia after the immediate neonatal period.
Suspected or known sexual abuse of children must be reported to child protection agencies.
34
What is the great imitator as it is associated with a variety of signs and Sx (1)
Syphilis
35
Describe signs and sx: Primary Syphilis (5)
* chancre (genital ulcer), regional
* LAD
* Ulcer is classically painless
* Resolves in 2–8 wk
* Incubation period: 3-90d
36
Name dx criteria: Primary Syphilis (1)
Dark field microscopy of serous fluid from genital lesions for observation of spirochetes
37
Name rx options: Primary Syphilis (2)
**1°, 2°, early latent:**
* Benzathine Penicillin G 2.4 million units IM × 1
* Doxycycline 100 mg PO b.i.d. × 28 d (if allergic to PCN)
38
Describe signs and sx: Secondary Syphilis (12)
* widespread symmetric maculopapular rash (palms and soles)
* fever
* malaise
* LAD
* mucous lesions
* condyloma lata
* alopecia
* meningitis
* headaches
* uveitis
* retinitis
* Incubation period: 2 wk to 6 mo
39
Name dx criteria: Secondary Syphilis (1)
Initial screening with non-treponemal antibody tests (VDRL and RPR)
40
Name rx options: Secondary Syphilis (2)
* Benzathine Penicillin G 2.4 million units IM×1b
* Doxycycline 100 mg PO b.i.d. × 28 d (if allergic to PCN)
41
Describe: Latent Syphilis (1)
* asx
* incubation period: 10-30 yr
42
Describe: Tertiary syphilis (6)
* aortic aneurysm
* aortic regurgitation
* coronary artery ostial stenosis
* Early \< 1 yr
* Late \> 1 yr
* Incubation period: 10-30 yr
43
Name dx criteria: Tertiary Syphilis and Latent (1)
If nontreponemal tests positive, perform confirmatory testing
44
Name Rx options: Late latent,CVS syphilis, and other syphilis not involving CNS (2)
* Benzathine Penicillin G 2.4 million units IM weekly × 3 dosesb
* Doxycycline 100 mg PO b.i.d.× 28 d (if allergic to PCN)
45
Describe: Neurosyphilis (3)
* form of 3°
* Argyll-Robertson pupil
* Incubation period: 2-20 yr
46
Name dx criteria: Neurosyphilis (1)
The treponemal tests remain positive for life, even after successful Rx.
47
Name rx options: Neurosyphilis (1)
Penicillin G 3–4 million units IV q4h × 10–14 db
48
Describe: Gumma syphilis (4)
* form of 3°
* tissue destruction in any organ
* The specific manifestations depend on the site involved.
* Incubation period: 1-46 yr
49
Name dx criteria: Gumma syphilis (1)
CSF samples should be taken in those with neurologic or ophthalmic Sx.
50
Name rx options: Gumma syphilis (1)
Sexual contacts (last 30 d): Benzathine Penicillin G 2.4 million units weekly × 3 doses
51
Name mode of transmission: Syphilis (3)
* direct sexual contact with infected lesions
* contact with infected blood
* vertical transmission (congenital syphilis)
52
Name syphilis forms that are considered infectious (3)
1°, 2°, and early latent phases are considered infectious (60% risk of transmission per partner)
53
Name Syphilis Follow-up Considerations (4)
* Test for other STIs, including HIV, HPV, hepatitis B, chlamydia, and gonorrhea
* Genital ulcers should be tested for HSV, chancroid, and/or lymphogranuloma venereum
* Immunization against HPV and hepatitis A and B if not already immunized
* Syphilis is reportable to public health (1°,2°,and early latent); sexual and perinatal contacts must be tested
54
Name signs and sx: Herpes HSV types 1 and 2 (11)
* Painful ulcerating genital lesions (80%)
* Atypical presentation (20% ) including genital pain, urethritis, cervicitis
* 1°outreak:
* Painful ulcerative genital lesions
* Systemic Sx (fever, myalgias)
* lymphadenopathy
* Aseptic meningitis (16% –26% )
* Extragenital lesions (10% –28% )
* 2°outreak:
* Residual latent sensory ganglion infection leads to late recurrence(s) in tissues innervated by sacral sensory nerves.
* Prodromal Sx: itching, burning, tingling, or discomfort
* Triggers: stress, illness, or certain medications
* Clinical Presentation: systemic sx (16%), ↓severity/durationof sx, meningitis (1% ), extragenital lesions (8%)
55
Name dx criteria: Herpes HSV types 1 and 2 (5)
* Cultures from HSV lesions (70% sensitive—ulcers, 94% —vesicles)
* HSV PCR : 100% specific
* Antibody response: early → IgM, followed by IgG
* 3–6 wk to seroconversion after 1° outbreak
* NAAT assay—vesicle fluid or ulcer swab (~100% sensitivity and specificity)
56
Name Measures to ↓ transmission of HSV (3)
* Counseling (i.e., HSV is not curable, potential for recurrent episodes, sexual transmission, asymptomatic shedding)
* Condom use
* Antiviral Rx to ↓ asymptomatic shedding and recurrent lesions NOTE: greatest RF for neonatal herpes → primary maternal genital HSV-1 or -2
57
For HSV, must inform which sexual partners? (1)
sexual partners from the preceding 60 d before Sx (due to risk of asymptomatic shedding)
58
Describe Rx of first episode of HSV (4)
* Urinary retention may be an indication for hospitalization
* Acyclovir 400 mg PO × t.i.d. ×7–10d
* Famciclovir 250 mg PO t.i.d. ×5–7d
* If severe: IV acyclovir 5 mg/ kg over 60 min q8h until improvement
59
Describe Rx of recurrent episode of HSV (episodic therapy) (3)
* Acyclovir 400 mg PO t.i.d. ×5d
* Valacyclovir 500 mg b.i.d. ×3d
* Famciclovir 125 mg PO b.i.d. ×5d
60
Name HSV Suppressive Rx for nonpregnant patients (6–9 yr) (3)
* Acyclovir 400 mg PO b.i.d. × 6–12 mo
* Famciclovir 250 mg b.i.d. × 6–12 mo
* Valacyclovir 500 mg daily × 6–12 mo
61
Name HSV suppressive Rx for pregnant patients (1)
Acyclovir 400 mg PO t.i.d., start- ing at 36 wk gestational age
62
Name causative agent: Chancroid (1)
H. ducreyi
Known cofactor in HIV transmission
63
Name signs and sx: Chancroid (3)
* Painful genital ulcers with granulomatous bases
* May progress to inguinal ulcers, painful inguinal LAD
Note: 50% of those exposed develop the disease (incubation period 5–14 d)
64
Name dx criteria: Chancroid (3)
* Culture of H. ducreyi
* Gram stain of GN coccobacilli with “school of sh” pattern
* Must also R/O T. Pallidum or HSV
65
Name RX options: Chancroid (5)
* Ciprofloxacin 500 mg PO × 1
* Erythromycin 500 mg PO t.i.d. ×7d
* Azithromycin 1 g PO × 1
* Ceftriaxone 250 mg IM × 1
* Must empirically treat all individuals with sexual exposure in the last 2 wk from onset
66
67
True or False
HPV is not reportable in Canada
True
68
Once genital warts are healed, what is recommended? (1)
routine F/U for cervical CA is recommended
69
Consider what in children presenting with genital warts? (1)
sexual abuse
70
Is C/S recommended in HPV? (1)
C/S is not indicated unless warts obstruct the birth canal
71
Name signs and sx: HPV (5)
* Hpv in infection is requently asymptomatic.
* HPV lesion:
* external genital warts (condyloma acuminata)—multifocal cauli ower-like exophytic fronds → ± pruritus or local discharge
* On cervix, vagina, vulva, or perianal
* D in size and number of warts with pregnancy
* Intraepithelial lesions on Pap smear → cervical involvement (LSIL, HSIL, invasive carcinoma)
* HIV : collaborative care with other specialists is required in patients with HIV due to ↑ risk of cervical CA.
* 90% of patients with external genital warts experience clearance within 2 yr with medical intervention.
72
Name DX criteria: HPV (6)
1. **pap test**
2. **HPV typing** not indicated for routine. Dx/management of visible genital warts. HPV typing is indicated \> 30 with ASCUS
3. **Coloscopy** if high grade squamous intraepithelial lesion (HSIL), atypical glandular cells or invasive carcinoma on Pap test or positive high-risk HPV subtype and negative cytology or persistent ASCUS or LSIL × 2 yr
4. **Anoscopy**: in patients with anal warts due to the risk of anal CA
5. **Urethroscopy** in patients with extensive urethral warts
6. **Suspect neoplasia if**:
* Pigmented lesion
* Bleeding
* Persistent ulceration
* Persistent pruritus
* Recalcitrant lesions
* Biopsy if lesion suspicious
73
What RX guarantees eradication of HPV? (1)
No RX
74
Name Patient applied RX for HPV (2)
* Imiquimod × 3/wk for up to 16 wk. Cream must be washed off after 6–8 h.
* Podophyllotoxin 0.5%, 0.5 mL q 12h × 3/wk for 6 wk
75
Name Provider-based RX for HPV (4)
* Cryotherapy (liquid nitrogen, CO2)
* Podophyllin resin 10% –25% for 1–4 h, repeated at weekly intervals
* Bi- or trichloroacetic acid (50% –80% solution) weekly for 4–6 wk
* CO2 laser ablation, excision
76
Name RX for extensive or resistant lesions of HPV (2)
* Excision with electrosurgery
* CO2 laser removal
77
Describe: Pelvic Inflammatory Disease (5)
* Ascending infection of the upper genital tract from the vagina and/or cervix.
* Sx range from asymptomatic to severe Sx.
* Up to two-thirds of cases go unrecognized.
* 10% to 15% of women of reproductive age will have at least one episode of PID.
* PID is the most common infectious cause of lower abdo pain in women.
78
Name signs and sx: Pelvic Inflammatory Disease (11)
* Fever \> 38.3°C
* Mucopurulent discharge
* Dyspareunia
* RUQ pain
* Dysuria
* Adnexal mass
* Vaginal bleeding
* Nausea/vomiting
* ↑ESR, CRP
* WBC \> 10,000/mm3
* Lab confirmation of cervical Dx of chlamydia and/or gonorrhea
79
Name Risk factors for PID (3)
* STI RFs
* IUDs
* Frequent vaginal douching
80
Most common causative agent in PID (12)
* C.trachomatis
* N.gonorrhea
* Other:
* E.coli
* Peptostreptococcus
* G. vaginalis
* Prevotella
* Bacteroides
* Streptococcus
* H. influenzae
* T.vaginalis
* M. genitalium
* M. hominis
81
Name acute complications of PID (5)
* Pelvic peritonitis
* Endometritis
* Salpingitis
* Tubo-ovarian abscess
* Sepsis
82
Name chronic complications of PID (5)
* Infertility
* Chronic pelvic or abdo pain
* Pelvic/Abdo adhesions
* Fitz-Hugh-Curtis syndrome
* EP
83
Name PID Minimum Triad (3)
Lower abdo pain + oneofthe following:
* Adnexal tenderness
* Cervical motion tenderness
* Uterine tenderness
84
Describe: Fitz-Hugh-Curtis Syndrome (2)
* Perihepatitis resulting in adhesions between the liver capsule and the abdo wall.
* Perihepatitis resolves with Rx of PID.
85
Describe: Inpatient Rx of PID (4)
1. Cefotetan 2 g IV q12h + doxycycline 100 mg PO b.i.d. until clinical improvement \> 24 h, then continue doxycycline PO only for a total of 14 d
2. Cefoxitin 2 g IV q6h + doxycycline 100 mg PO b.i.d. until clinical improvement \> 24 h, then continue doxycycline PO only for a total of 14 d
3. Clindamycin 900 mg IV q8h + gentamicin 2 mg/kg IV load, then 1.5 mg/kg IV q8h until clinical improvement × 24 h, then doxycycline 100 mg PO b.i.d. or clindamycin 450 mg PO q6h for a total of 14 d
4. Note: consider adding metronidazole 500 mg PO b.i.d. × 14 d to all the above regimens
86
Describe: Outpatient Rx of PID (4)
1. Ceftriaxone IM × 1 + either doxycycline 100 mg PO q12h × 14 d or azithromycin 1 g PO × 1 dose, then q weekly × 2 wk
2. Cefixime 800 mg PO × 1 dose + either doxycycline 100 mg PO q12h× 14d or azithromycin 1g PO × 1dose, then q weekly × 2 wk
3. Levofloxacin 500 mg PO b.i.d. × 14 d
4. Note: consider adding metronidazole 500 mg PO b.i.d. × 14 d to all the above regimens
87
Gold Standard Dx for PID (1)
Laparoscopy demonstrating abnormalities consistent with PID, including fallopian tube erythema and/or mucopurulent exudates
88
What to do with IUD if PID? (2)
* IUD: the device does not have to be removed during treatment of PID.
* If the patient prefers removal, it should not be removed until at least 2 doses of antibiotic Rx have been administered.
89
Name Criteria for Inpatient Rx in PID (10)
* Pregnancy
* Appendicitis/EP cannot be excluded
* Adolescence/poor compliance
* Inability to follow or tolerate an oral regimen
* If pelvic or tubo-ovarian abscess is suspected
* Patient previously failed to respond to outpatient Rx
* Patient is immunocompromised
* Dx is uncertain (i.e., need for laparoscopy)
* The patient has severe illness (vomiting, fever, pain)
* HIV-positive patient
90
Describe: Management of tubo-ovarian abscesses (Figure)
